Emergency Nursing: BLS

Prepared by:
Ms. Cherry Ann G. Garcia, RN
Basic life support (BLS)

• A means of providing oxygen to

the brain, heart and other organs
until help arrives

• Also known as
CARDIOPULMONARY
RESUSCITATION
Basic life support (BLS)

• An adult is a person above age 8

• A child is any person age 1 to 8

years old

• An infant is anyone under 1 year

Basic life support (BLS)
• The BLS follows the A-B-C principle

– A= airway

– B= breathing

– C= circulation
Basic life support (BLS)

• Causes of cardiac arrest

– Respiratory arrest
– Direct injury
– Drug overdose
– Cardiac arrhythmias
 Basic life support (BLS)
ADULT

• STEPS in CPR: First STEP

– ASSESSMENT: determine Unresponsiveness
– Assess for 5-10 seconds
– Shake the victim’s shoulder and ask: “are you
okay”
 Basic life support (BLS)
ADULT

• STEPS in CPR: Second Step

– Survey the area
 Basic life support (BLS)
ADULT

• STEPS in CPR: Third Step

– Call for HELP
– Activate emergency medical system

– Note: for child and infant this is done LAST

 Basic life support (BLS)
ADULT

• STEPS in CPR: Fourth step

– Place Victim in Supine position on a flat firm
surface

– Log roll the patient when moving

 Basic life support (BLS)
ADULT

• STEPS in CPR: Fifth step

– OPEN the airway

– Head tilt-Chin Lift method

– Jaw thrust maneuver if neck injury is suspected

 Basic life support (BLS)
ADULT

• STEPS in CPR: Sixth step

– Assess BREATHING
• Place ear over the nose and mouth
• Look for chest movement
• Perform for 3-5 SECONDS
 Basic life support (BLS)
ADULT

• STEPS in CPR: Sixth step

– Assess BREATHING
• If breathing: place on side if no neck injury; DO
NOT move if with neck injury

• If NOT BREATHING: deliver INITIALLY 2 rescue

breath via mouth to mouth
• Then deliver 10-12 breaths/minute
 Basic life support (BLS)
ADULT

• STEPS in CPR: Seventh step

– Assess CIRCULATION
• Check for the carotid pulse on the side close to
you for 5-10 SECONDS
• If with (+) pulse ; continue giving 10-12
breaths/minute
 Basic life support (BLS)
ADULT

• STEPS in CPR: Seventh step

– Assess CIRCULATION
• If withOUT pulse: START Chest Compression
• Correct hand placement: LOWER HALF of sternum
one hand over the other with fingers interlacing
• Depress: 1 ½ to 2 INCHES
80-100 compressions/min
 Basic life support (BLS)
ADULT
• STEPS in CPR: Seventh step
– Assess CIRCULATION
• If withOUT pulse: START Chest Compression
• ONE-rescuer: 15 chest: 2 breaths

• TWO-rescuer: 5 chest: 1 breath

• DO FOUR cycles and re-assess for pulse

Basic life support (BLS)
CHILD
1-8 years old
• AIRWAY: assess unresponsiveness
and keep airway patent by HTCL or JT
• BREATHING: assess for airflow and
chest movement
• If breathing: maintain patent
airway
• If NOT breathing : deliver 2
rescue breaths by mouth to
mouth
• DELIVER 20 breaths/minute
Basic life support (BLS)
CHILD
1-8 years old
• CIRCULATION: assess the carotid pulse
• If with pulse: continue to deliver 15-
20 breaths/minute
• If WITHOUT pulse: start chest
compression
• Correct hand placement: lower half of
sternum using heel of ONE HAND
• DELIVER: 1 to 1 ½ inches
80- 100 chest
compressions/min
5:1 (do 20 cycles  EMS)
 Basic life support (BLS)
INFANT
Less than 1
• Determine unresponsiveness
• AIRWAY: Place head of infant in NEUTRAL
position
• BREATHING: assess for rise-fall of chest
and airflow
– If breathing: maintain patent airway
– If NOT breathing: initiate 2 rescue
breathing via mouth to mouth and nose
– DELIVER 20 breaths/min SLOWLY
 Basic life support (BLS)
INFANT
Less than 1
• CIRCULATION: assess for pulse: The
BRACHIAL pulse is utilized!!
– If with pulse: continue to deliver 20
breaths/min
– If WITHOUT pulse, start chest compression
– Correct hand placement: just below the
nipple line in the sternum using 2-3 fingers
of one hand!!
– DELIVER: ½ to 1 inch depth
100 chest com/min
5:1 ratio (do 20 cycles EMS)
 AIRWAY Obstruction
• Incomplete
– Crowing sound is heard
encourage to cough

• Complete
– Clutching of the neck
– Ask: “Are you choking?”
– Perform Heimlich’s
 AIRWAY Obstruction

• Complete
– If patient becomes unconscious:
• Place supine on flat surface
• Perform tongue-jaw lift maneuver
• FINGERSWEEP to remove object
• Open airway and attempt ventilation
• Perform Heimlich while supine
• Reattempt ventilation
• SEQUENCE: TJL finger-sweep
rescue breaths Heimlich’s TJL
 AIRWAY Obstruction

Pediatric consideration
CHILD: NEVER DO Blind Finger
sweep
 AIRWAY Obstruction

Pediatric consideration

INFANT: never DO blind finger-sweep

Give five back blows in the
interscapular area and turn the infant
with head lower than trunk then
deliver chest thrust below the nipple
line
 AIRWAY Obstruction

Obstetric considerations:
Hand is placed over the middle part
of sternum: backward chest
thrust

If unconscious: place pillow below

the RIGHT abdomen to displace
uterus
 Shock
• An abnormal physiologic state
where an imbalance exists
between the amount of circulating
blood volume and the size of the
vascular bed.
 Pathophysiology of Shock

1. Cellular effects of shock

• In the absence of oxygen, the cell will undergo
Anaerobic metabolism to produce energy source
and with it comes numerous by-products like lactic
acid
• The cell will swell due to the influx of Na and H20,
mitochondria will be damaged, lysosomal enzymes
will be liberated, and then cellular death ensues.
 Pathophysiology of Shock

2. Organ System Responses

• When the patient encounters precipitating causes
of shock, the circulatory function diminishes
there is decreased cardiac output Hypotension
and decreased tissue perfusion will result
 Shock Stages
3 STAGES:

• Compensatory stage
• Progressive stage
• Irreversible stage
 Shock Stages
THE COMPENSATORY STAGE OF SHOCK

• In this stage, the patient’s blood pressure is within

normal limits.
• Patient’s blood is shunted from the kidney, skin and GIT
to the vital organs- brain, liver and muscles
• Manifestations of cold clammy skin, oliguria and
hypoactive bowel sounds can be assessed.
• Medical management includes IVF and medication
• Nursing management includes monitoring of tissue
perfusion & vital signs, reduction of anxiety,
administering IVF/ordered medications and promotion of
safety
 THE PROGRESSIVE STAGE OF SHOCK

• In this stage, the mechanisms that regulate blood pressure

can no longer compensate and the mean arterial pressure
falls.
• The overworked heart becomes dysfunctional. Heart rate
becomes very rapid (as high as 150 bpm)
• Blood flow to the brain becomes impaired, the mental
status deteriorates due to decreased cerebral perfusion
and hypoxia.
• Laboratory findings will reveal increased BUN and
Creatinine. Urinary output decreases to below 30 mL/hour.
 THE PROGRESSIVE STAGE OF SHOCK

• Decreased blood flow to the liver impairing

the hepatic functions. Toxic wastes are not
metabolized efficiently, resulting to
accumulation of ammonia, bilirubin and lactic
acids.
• The reduced blood flow to the GIT causes
stress ulcers and increased risk for GI
bleeding.
• Hypotension, sluggish blood flow, metabolic
acidosis (due to accumulation of lactic acid),
and generalized hypoxemia can interfere
with normal blood function.
 THE IRREVERSIBLE STAGE OF SHOCK

• This stage represents the end point where there is

severe organ damage that patients do not respond
anymore to treatment. Survival is almost impossible to
maintain.
• Despite treatment, the BP remains low, anaerobic
metabolisms continues and multiple organ failure results.
• Medical management is the use of life supporting drugs
like epinephrine and investigational medications.
 Assessment of Shock
Assessment Findings
Skin : Cool, pale, moist in hypovolemic and cardiogenic
shock
: Warm, dry, pink in septic and neurogenic shock
Pulse
• Tachycardia, due to increased sympathetic stimulation
• Weak and thready
Blood pressure
• 1. Early stages: may be normal due to compensatory
mechanisms
• 2. Later stages: systolic and diastolic blood pressure drops.
 Assessment of Shock
Assessment Findings
Respirations: rapid and shallow, due to tissue anoxia and
excessive amounts of CO (from metabolic Acidosis)
Level of consciousness: restlessness and apprehension,
progressing to coma
Urinary output: decreases due to impaired renal perfusion
Temperature: decreases in severe shock (except septic shock).
 Management of Shock
Nursing Interventions
• Management in all types and phases of shock
includes the following:
• Basic life support
• Fluid replacement
• Vasoactive medications
• Nutritional support
 Management of Shock
A. Maintain patent airway and adequate ventilation.
B. Promote restoration of blood volume; administer fluid and
bloodreplacement as ordered
C. Administer drugs as ordered
D. Minimize factors contributing to shock.
E. Maintain continuous assessment of the client.
F. Provide psychological support: reassure client to relieve
apprehension, and keep family advised
G. Provide Nutritional support
 Hypovolemic Shock
This is the MOST common form of shock characterized
by a decreased intravascular volume
Risk factors: external Fluid Losses
• Trauma, Surgery, Vomiting, Diarrhea,
Diuresis, DI
Risk factors: internal fluid shifts
• Hemorrhage, Burns, Ascites,
Peritonitis, Dehydration
 Hypovolemic Shock
• Decreased blood volume decreased venous
return to the heart decreased stroke volume
decreased cardiac output decreased tissue
perfusion
• Assessment findings: cold clammy skin,
tachycardia, mental status changes, tachypnea
Hypovolemic Shock
• MEDICAL MANAGEMENT:
– The major medical goals are to
restore intravascular volume, to
redistribute the fluid volume, and
to correct the underlying cause of
fluid loss promptly
Hypovolemic Shock
• NURSNG MANAGEMENT:
– Primary prevention of shock is the most
important intervention of the nurse.
– General nursing measures include- safe
administration of the ordered fluids and
medications, documenting their
administration and effects. The nurse must
monitor the patient for signs of
complications and response to treatment.
Oxygen is administered to increase the
amount of O2 carried by the available
hemoglobin in the blood.
 Cardiogenic shock
This shock occurs when the heart’s ability to contract and to
pump blood is impaired and the supply of oxygen is
inadequate for the heart and tissues
• Risk factors: Coronary factor- Myocardial infarction
• Risks factors: NON coronary:
– Cardiomyopathies
– Valvular damage
– Cardiac tamponade
– Dysrhythmias
•
Cardiogenic shock
Precipitating factors will cause decreased cardiac
contractility Decreased stroke volume and cardiac output
leading to 3 things:
• Damming up of blood in the pulmonary vein will
cause pulmonary congestion
• Decreased blood pressure will cause decreased
systemic perfusion
• Decreased pressure causes decreased
perfusion of the coronary arteries leading to
weaker contractility of the heart
 Cardiogenic shock
ASSESSMENT FINDINGS: Angina, hemodynamic instability,
dysrhythmias
• MEDICAL MANAGEMENT:
– The goals of medical management are to limit further myocardial
damage and preserve and to improve the cardiac function by
increasing contractility.
• NURSING MANAGEMENT:
– The nurse prevents cardiogenic shock by early detection of
patients at risk.
– Safety and comfort measures like proper positioning, side-rails,
and reduction of anxiety, frequent skin care and family education.
 Circulatory
• This is also called shock
distributive shock. It occurs when
the blood volume is abnormally displaced in the
vasculature.
– Septic Shock
– Neurogenic Shock
– Anaphylactic Shock
 Circulatory shock
• Massive arterial and venous dilation allows
pooling of blood peripherally maldistribution of
blood volume decreased venous return
decreased stroke volume decreased cardiac
output Decreased blood pressure decreased
tissue perfusion.
 Circulatory shock
• Risk factors for Septic Shock
– Immunosuppression
– Extremes of age (<1 and >65)
– Malnourishment
– Chronic Illness
– Invasive procedures
 Circulatory shock
• Risk factors for Neurogenic Shock
– Spinal cord injury
– Spinal anesthesia
– Depressant action of medications
– Glucose deficiency
 Circulatory shock
• Risk factors for Anaphylactic Shock
– Penicillin sensitivity
– Transfusion reaction
– Bee sting allergy
– Latex sensitivity
 SEPTIC SHOCK
This is the most common type of circulatory shock and is caused
by widespread infection.
The HYPERDYNAMIC PHASE
– High cardiac output with systemic vasodilatation.
– The BP remains within normal limits.
– Tachycardia
– Hyperthermic and febrile with warm, flushed skin and
bounding pulses
 SEPTIC SHOCK
The HYPODYNAMIC or irreversible phase
– LOW cardiac output with VASOCONSTRICTION
– The blood pressure drops, the skin is cool and pale, with
temperature below normal.
– Heart rate and respiratory rate remain RAPID!
– The patient no longer produces urine.
 SEPTIC SHOCK
• MEDICAL MANAGEMENT:
– Current treatment involves identifying and eliminating
the cause of infection. Fluid replacement must be
instituted to correct Hypovolemia, Intravenous
antibiotics are prescribed based on culture and
sensitivity.
 SEPTIC SHOCK

• NURSING MANAGEMENT:
– The nurse must adhere strictly to the principles of ASEPTIC
technique in her patient care.
– Specimen for culture and sensitivity is collected.
Symptomatic measures are employed for fever,
inflammation and pain. IVF and medications are
administered as ordered.
 Neurogenic Shock
This shock results from loss of sympathetic tone
resulting to widespread vasodilatation.
• The patient who suffers from neurogenic shock may
have warm, dry skin and BRADYCARDIA!
 Neurogenic Shock
• MEDICAL MANAGEMENT:
– This involves restoring sympathetic tone, either through
the stabilization of a spinal cord injury or in anesthesia,
proper positioning.
 Neurogenic Shock
• NURSING MANAGEMENT:
– The nurse elevates and maintains the head of the bed at
least 30 degrees to prevent neurogenic shock when the
patient is receiving spinal or epidural anesthesia.
 Anaphylactic Shock
• This shock is caused by a severe allergic
reaction when a patient who has already
produced antibodies to a foreign substance
develops a systemic antigen-antibody reaction
 Anaphylactic Shock
• MEDICAL MANAGEMENT:
– Treatment of anaphylactic shock requires removing the
causative antigen, administering medications that restore
vascular tone, and providing emergency support of basic
life functions.
– EPINEPHRINE is the drug of choice given to reverse the
vasodilatation
 Anaphylactic Shock
• NURSING MANAGEMENT:
– It is very important for nurses to assess history of
allergies to foods and medications!
– Drugs are administered as ordered and the responses to
the drugs are evaluated.
Triage
• “trier”- to sort

• To sort patients in groups based on the

severity of their health problem and the
immediacy with which these problems
must be addressed
Triage in the E.R.
• Berner’s
1. Emergent

2. Urgent

3. Non-urgent
Triage in DISASTER!
• NATO
1. Immediate

2. Delayed

3. Minimal

4. Expectant
 Triage
1. Emergent
– Patients have the highest priority
– With life-threatening condition
2. Urgent
– Patients with serious health problems
– Not life-threatening, MUST be seen in 1 hour
3. Non-urgent
– Episodic illness that can be addressed within 24 hours
 Triage category Priority Color Conditions

Immediate
Triage
1
in Disaster
RED Chest wounds, shock,
open fractures, 2-3
burns

Delayed 2 YELLOW Stable abdominal

wound, eye and CNS
injuries

Minimal 3 GREEN Minor burns, minor

fractures, minor
bleeding

Expectant 4 BLACK Unresponsive, high

spinal cord injury
Preparing for terrorism
1. Recognition and Awareness
2. Use of personal protective equipments
3. Decontamination of contaminants
Biological Weapons
ANTHRAX
• Drug of choice is Ciprofloxacin or
Doxycycline

SMALLPOX
• Supportive
Chemical Weapons
Organophosphates
– Supportive care
– Soap and water
– Atropine
– Pralidoxine
Cyanide
– Sodium nitrite, Amyl Nitrite, Methylene Blue
– Sodium thiosulfate
– Hydrocobalamin
CYANIDE POISONING
 Radiation
Alpha Particles Cannot penetrate skin
Causes local damage

Beta Particles Moderately penetrate the skin

Can cause skin damage and internal
injury if prolonged

Gamma Particles Penetrate skin

Can cause serious damage
X-ray is an example