Basic Life Support

Contents
• Introduction to BLS
• Adult BLS
• BLS with AED
• Team dynamics
• BLS in children
• Infant BLS
• Choking in adults, children and infants
 Learning Objectives
The BLS Course focuses on what rescuers need to know to perform high-quality CPR
in a wide variety of settings. You will also learn how to respond to choking
emergencies. After successfully completing the BLS Course, you should be able to
• Apply the BLS concepts of the Chain of Survival
• Recognize the signs of someone needing CPR
• Perform high-quality CPR for an adult, child or infant
• Demonstrate the appropriate use of an AED
• Provide effective ventilations by using a barrier device
• Describe the importance of teams in multirescuer resuscitation
• Describe the technique for relief of foreign-body airway obstruction for an
adult, child or infant
 Introduction
• Sudden cardiac arrest: a leading cause of death
• 70% of cardiac arrest occurs out of hospital and have poor outcome

• BLS is the foundation for saving lives after cardiac arrest

• Quick assessment, early identification of the condition
• Respond quickly and properly
• Application of High-quality CPR for victims of all ages
• Single rescuer and multi-rescuer team
4
 High Quality CPR
• Start compressions within 10 seconds of recognition of cardiac arrest.
• Push hard, push fast: Compress at a rate of 100 to 120/min with a depth of
– At least 2 inches (5 cm) for adults
– At least one third the depth of the chest, about 2 inches (5 cm), for children
– At least one third the depth of the chest, about 1½ inches (4 cm), for infants
• Allow complete chest recoil after each compression.
• Minimize interruptions in compressions (try to limit interruptions to less
than 10 seconds).
• Give effective breaths that make the chest rise.
• Avoid excessive ventilation.
5
 Chain of Survival
• Chain of survival includes elements of
emergency cardiovascular care
adopted by AHA in conditions of
cardiac arrest

• Depends on location of the victim

– IHCA: In Hospital Cardiac Arrest

– OHCA: Out-of-Hospital Cardiac Arrest 6

 Chain of Survival: IHCA
The links in IHCA include;
• Surveillance, prevention, and treatment of prearrest
conditions
• Immediate recognition of cardiac arrest and activation of
the emergency response system
• Early CPR with an emphasis on chest compressions
• Rapid defibrillation
• Multidisciplinary post–cardiac arrest care
• Additional treatment, observation, rehabilitation and
psychological support
7
 Chain of Survival: OHCA
The links in OHCA includes
• Immediate recognition of cardiac arrest and activation of
the emergency response system
• Early CPR with an emphasis on chest compressions
• Rapid defibrillation with an AED
• Effective advanced life support (including rapid
stabilization and transport to post–cardiac arrest care)
• Multidisciplinary post–cardiac arrest care
• Recovery: Additional treatment, observation,
rehabilitation and psychological support
8
 IHCA Vs OHCA
Element IHCA OHCA
Initial support Depends on Hospital system, Depends on community and EMS
surveillance, monitoring and providers
provider teams

Resuscitation Trained personnel available, Lay rescuers initiate resuscitation,

teams with multi-disciplinary team replaced by EMS for CPR and
of professionals transport to ED/cardiac center

Resources Immediately access to AED +/-, trained personnel +/-,

additional personnel, backup resources may be lacking
defibrillators, cardiac care
Constraints Both situations may have Crowd control (family), space
constraints, device failures, transportation
9
 Pediatric Chain of Survival
• Unlike adults where cardiac arrest is often sudden, in children, cardiac arrest is usually secondary to
respiratory failure or shock

Therefore, pediatric chain of survival includes;

• Prevention of arrest
• Rapid activation of the emergency response system
• Early high-quality bystander CPR
• Effective advanced life support (including rapid stabilization and transport to post–cardiac arrest care)
• Integrated post–cardiac arrest care
• Additional treatment, observation, rehabilitation

10
 Moving Forward with BLS
• Adult BLS
• AED
• Team dynamics
• Child BLS
• Infant BLS
• Choking
11
Adult BLS
 Basic Framework of CPR
Type of CPR depends on level of training,
experience, victim, equipment etc.
• Hands only CPR:
– Single rescuer with limited
training/equipment
– Chest compression only until help
arrives
• 30:2 CPR
– E.g. Drowning
• High performance team
– Trained team with equipment (bag
mask device etc.)
Adult Cardiac Arrest Algorithm
 1-rescuer Adult BLS Sequence
1. Verify scene safety
– For the rescuer and the victim
2. Check for responsiveness
– Tap the victim’s shoulder and shout “Are you OK?”
– If the victim is not responsive, shout for nearby help
3. Activate ERS
– Call ambulance (102) (OHCA)
– Mobilize code team or ALS team (IHCA)
– If alone: get AED yourself, or send other person to get AED
 1-rescuer Adult BLS Sequence (continued…)

4. Assess for victim’s breathing and pulse simultaneously

– Should not take > 10s

– Breathing: look at victim’s chest for respiratory movement

of chest
• If breathing: monitor until help arrives
• If not breathing or is gasping: is a sign of cardiac arrest

– Checking pulse: carotid pulse

• If not felt within 10s begin CPR starting with chest compressions
• ERS must already have been activated, and send someone to get
AED
1-rescuer Adult BLS Sequence (continued…)
1-rescuer Adult BLS Sequence (continued…)

• 5. Begin High-Quality CPR

– Remove/move clothing covering victim’s chest for appropriate hand
placement and proper placement of AED pads
– Beginning with chest compressions

– High Quality CPR

– Use AED as soon as available

– Resume CPR
 Adult Chest compressions
• Importance
– Several chest compressions are necessary to increase blood flow to the heart and
brain
– Interruption of chest compression reduces the flow significantly
• High quality chest compression
– Single rescuers should have compression to ventilation ratio of 30:2 for any age
– Compress at the rate of 100-120/min
– Compress the chest 2 inches (5 cm)
– Allow chest to recoil after each compression
– Minimize interruption in between compressions
• Note: for compressions to be effective, the victim should be in a firm surface
Chest compression technique
 Adult Breaths: Opening the Airway
• Two methods for opening the airway
– Head tilt-chin lift
• Do not use if head/neck injury is suspected
• Do not press deeply under the chin: blocks
the airway

– Jaw thrust:
• Used if head or neck injury is suspected or if
the other method fails
Airway: Head tilt-chin lift
Airway opening: Jaw thrust
 Adult Breaths: Barrier Devices
• Use of barrier devices, such as pocket masks is recommended as
standard precaution.
• Face shields should be replaced by pocket masks.

• Pocket masks
– Have 1-way valve to divert exhaled air, fluids etc. away from rescuer
– Some also have inlet for oxygen tube
– Available in different sizes for adults, children and infants
Use of Pocket Masks
 Bag-Mask Device
• Used to provide positive pressure
ventilation to a victim not
breathing normally

• Can be used with/without oxygen

• Available in various sizes of bag

and mask for adults, children and
infants
Using Bag-Mask Device (1 Rescuer)
 Using Bag-Mask Device (2-Rescuers+)
• First rescuer help to open the airway by
head tilt-chin lift or jaw thrust and also
keeps the mask sealed covering the
nose and mouth
– Thumb and the index fingers of both
hands forms “C” to hold the mask
against the face
– Remaining 3 fingers forms “E” to lift both
sides of the jaw against the mask
• Other rescuer squeezes the bag
 2 Rescuer Adult BLS Sequence
1. Verify scene safety, check responsiveness and get help
– Second rescuer activates the emergency system and retrieves the AED

2. Assess for breathing and pulse

3. Determine next actions depending on findings
– If palpable pulse and breathing normally: monitor
– If pulse present, breathing absent: rescue breaths
– If no pulse, abnormal/absent breaths: high quality CPR
 2 Rescuer Adult BLS Sequence
4. High quality CPR
– One rescuer begins effective chest compressions
– Second rescuer provides effective breaths
– The role is reversed every 2 minutes or 5 cycles to make sure
quality of CPR is maintained
– Waste minimal time in switching the roles (<5 seconds)

5. Use AED as soon as available and continue CPR

 High Performance Teams
• Rescuers should switch compressions after every 5 cycles
(2 minutes) of CPR
• Additional rescuer can help with bag-mask device
• Each rescuer has a role
2-Rescuer Adult BLS: compression
2-Rescuer Adult BLS: Breaths
 When to stop CPR?
• ROSC
• Trained help arrives (ambulance, ALS team)
• Too exhausted to continue
• Physician directed (DNR)
• Unsafe scene
Automated External Defibrillator
AED
 Introduction
• Automated External Defibrillator (AED) is a light-weight portable
computerized device
• That can identify abnormal heart rhythm that needs a shock
• Can deliver a shock intended to stop abnormal (shockable)
rhythm
– Ventricular fibrillation
– Pulseless ventricular tachycardia
• This stuns and resets the electrical activity of the heart
• Simple to operate – even for non-medical persons
37
 Why early defibrillation?
• Time between collapse and defibrillation is an important factor
for survival from sudden cardiac arrest

• Time delay between the last compression and application of

shock has to be minimized

• Shock is much more likely to be effective for Return of

Spontaneous Circulation (ROSC) in cases of shockable rhythm as
compared to CPR only.
38
 Public Access Defibrillation (PAD)
• To make early defibrillation possible, trained rescuers and AEDs are
made available in public places
• Specially in crowded places
• Airports, offices, shopping malls, etc.
• Ambulances are also equipped with AEDs.

• PAD is registered to local Emergency Medical Services (EMS)

• Ensure availability of trained rescuers for high quality CPR and AED use
• AED has to maintained to be in a usable condition

39
 Maintaining AED
• Ensure the following
– Charged /replacement battery
– AED pad replacement (including pediatric pads)

• Ensure availability of following accessory items

– Scissors, razor
– Wipes
– Gloves
40
 Call for AED and AED Arrival
• AED is called for when activating the EMS

• Once AED arrives, operate it staying at a side of the victim

– Opposite the rescuer providing CPR

• This allows
– Easy access to place the pads on chest
– Without interfering the rescuer providing the high-quality CPR
41
 Using the AED
(May vary as per model of AED)

1. Open the carrying case and power on the AED

– Follow the voice prompts from AED

2. Attach the AED pads to victim’s bare chest

– Adult/children pads
– Site of attachment of pads are indicated in the
pads
– Connect the cable to the device

42
 AED Placement Options
• AED pads should be placed by following the
diagram on the pads.

It can be
• Anterolateral
• One below right clavicle, other over lower left side of
the chest
• Anteroposterior
• One over left side of chest between lower sternum
and left nipple
• Other over left side of victim’s back beside the spine
43
 Using the AED (Continued…)
3. “Clear” the victim to allow AED to analyze the rhythm
• Make sure victim is not touched while AED analyses the rhythm
(High quality CPR should continue till the onset of analysis of rhythm)
• After analysis AED prompts if shock is advisable or not.

4. Deliver shock if AED advises shock

• Clear the victim: no one touches the victim
• Loudly state “clear”
• Press the “Shock” button
• AED will deliver a shock which will cause contraction of the
victim’s muscle

44
 Using the AED (Continued…)
5. Resume high quality CPR
– If shock is not advised, or immediately
after shock delivery, resume CPR
– Starting with chest compressions

6. After 5 cycles of CPR/2 minutes, AED

will prompt again for steps 3 (rhythm
analysis for ROSC) and 4 (shock delivery)
– Continue until ALS providers take over,
or if victim starts to breathe or move
45
 Special circumstances
• Hairy chest
• May cause difficulty for pads to come in contact with the skin
• Will cause difficulty to check rhythm or delivery of shock
• AED will prompt to check pads
• Shave the area before applying the pads

• Wet chest
• DO NOT use AED in water
• Pull the victim out of water
• Wipe dry the chest before applying pads and delivering shock
• AED can be used in snow
46
 Special circumstances
• Implanted pacemakers
– Implanted devices may block the delivery of the shock if pads are attached
directly over them
– So, attach pads avoiding the site of placement of pacemakers

• Transdermal medication patches

– Do not place pads directly over the medication patches.
– It may cause burns and blocks the transmission of energy of shock
– Remove the medication patch and wipe the area before attaching the AED
pad
47
Team Dynamics
 Introduction
• Multi-rescuer resuscitation attempt
• Increases chance of success
• Gives best chance of survival
• Shorter duration of interruption in chest
compression
• Chest compression fraction of 60% is recommended
• 80% is achievable with good team work
 Elements of team dynamics
• Roles during resuscitation attempt
• What to communicate
• How to communicate
Roles during resuscitation
 Contd….
• Constructive intervention
• Knowing your limits
• Ask for assistance and advice
 What to communicate

• Knowledge sharing
• Team leader should ask for observation and
feedback
• Prevents possible oversight
• Summarizing
• Helps respond to Victim’s changing condition
 How to communicate
• Closed loop communication – call by name
- eye contact
- team members confirm verbally
- respond after task
• Clear message
• Mutual respect
 Debriefing
• During or at end
• Perform better
• Aid in identification of strength and weakness
BLS in Children
 BLS for children
• Above 1yr of age to puberty
• Breath important due to respiratory failure or
shock
1 rescuer BLS
• 30: 2
• Pulse – femoral, carotid artery
• One hand or two hand
• Mouth to mouth cover the nose
• After 2 min or 5 cycles get AED
• Rescue breath – 12-20/min
 2 rescuer
• 15: 2
• Use AED when available
 Chest compression depth
• Adult and adolescent – at least 5 cm
• Children – 1/3rd of AP diameter of chest- 5 cm
• Infant – 4cm
 AED
• Child pad for less than 8 yrs
• Child attenuated AED
• Adult pad – two shouldn’t
touch
• adult shock dose better than
no shock.
Infant BLS
Key differences between infant BLS and child or adult BLS

1. Location of pulse check

2. Techniques of delivering chest compressions
3. Compression depth
4. Compression-ventilation rate and ratio for 2-
rescuers
5. When to activate emergency response system
 Location of pulse check
• Brachial artery in infants
1. To find brachial pulse in an infant, place 2 or 3 fingers on the
inside of upper arm, between the infant’s elbow and
shoulder
2. Press gently for at least 5 sec, but not more than 10 seconds
while trying to feel for the pulse

• If no pulse or heart rate <60 bpm with signs of poor

perfusion Start chest compressions
• If you are not sure of pulse and infant is unresponsive and
not breathing or gasping immediately start chest
compressions
Techniques of delivering chest compressions
a. 2 thumb-encircling hands in the center of
the chest, just below the nipple line for two
rescuers
b. 2 fingers in the centre of the chest, just
below the nipple line for single rescuer
Techniques of delivering chest compressions
 Compression depth
• At least 1/3 the chest depth, approx. 1 ½
inches (4 cm)
Compression-ventilation rate and ratio for 2-rescuers
• Same as for child- at the rate of 100-120/min, 15:2
ratio for 2 rescuers
Chest compressions in infants-One rescuer
1. Place the infant on a firm flat surface
2. Place 2 fingers in the centre of chest just below the nipple line [do not
press on bottom of the breastbone]
3. Push hard and fast. Press at least 1/3 the depth of chest (approx. 4cm)
and rate 100-120/min
4. At the end of each chest compression, allow the chest to recoil
5. Minimize interruptions in chest compressions
6. Keep compression and breaths in a ratio of 30:2 until further helps
arrives or ROSC
Chest compressions in infants- Two rescuers
1. Place the infant on a firm flat surface
2. Place both thumbs side by side in the center of the chest, just below
the nipple line and support the infant’s back with the fingers of both
hands
3. With hands encircling the chest, use both thumbs to depress the
lower half of breastbone at least 1/3 the depth of infant’s chest
(approx. 4cm) and rate 100-120/min
4. At the end of each chest compression, allow the chest to recoil
5. Minimize interruptions in chest compressions
6. Keep compression and breaths in a ratio of 15:2
7. Switch roles every 2 min (10 cycles of 15:2)
When to activate emergency response system
• Witnessed leave the infant briefly to call for
further help, then return to the infant

• Not witnessed provide 2 min of CPR before

leaving the infant to get further help
 Breathing

• In infant  mouth to mouth-and-nose breaths (if can’t

cover then mouth-mouth with nose pinched)
• Open the airway with head tilt-chin lift (be careful- not to
extend the head beyond the neutral position; external ear canal
should be level with top of infant’s shoulder)
• While giving breaths, create airtight seal and look for
chest rise
 Rescue breathing
• Give 1 breath every 2-3 seconds (about 20-30 breaths per
minute)
• Each breath should result in visible chest rise
• Reassess every 2 min
 Infant ventilation with bag and mask
• Select a bag and mask of appropriate size

• Perform head tilt-chin lift, then press the mask onto

infant’s face, making a seal
[do not cover eyes or overlapping the chin]

• Connect supplementary oxygen to mask when

available
CHOKING
 CHOKING
• Foreign body airway obstruction

• Suspect choking if someone is suddenly

unable to speak or talk, particularly if eating

• Encourage the person to cough

 Choking In Adults And Children
• Mild Obstruction
– Breathing but may also be wheezing
– Coughing and making noise
• Severe Obstruction
– Clutching the neck (universal sign of choking)
– Weak or no cough
– Unable to make noise or talk; may make high-pitched noise
– Little or no breathing
– Appears cyanotic (blue around lips and fingertips)
 Universal sign of choking
• Hands clutched in throat
 Abdominal thrusts/Heimlich maneuver
• Only be used when a person is responsive and older than one year
of age.
• AHA recommendation
• Steps
1. Stand behind the responsive person. Wrap your arms around their waist
under their ribcage.
2. Put the side of your fist above the person’s navel in the middle of their belly.
Do not press on the lower part of the sternum .
3. With your other hand, hold the first fist and press forcefully into the person’s
abdomen and up toward their chest .
4. Continue performing these thrusts until the obstruction is relieved or the
person becomes unresponsive.
Abdominal thrusts
Heimlich on Lying Down Position
Heimlich on Lying Down Position
Heimlich on Lying Down Position
Place one hand on top of the other. Place the heel of the
bottom hand on the person's abdomen. This is the area just
below the ribcage but above the umbilicus.
Heimlich on Lying Down Position
Using your bodyweight, press your hands into the
person's abdomen with a slight upward motion
CHOKING: 5 back blows with 5 abdominal thrusts

• If the cough becomes ineffective, give up to 5 back blows:

– Lean the person forward. Apply blows between the shoulder
blades using the heel of one hand.
• If back blows are ineffective, give up to 5 abdominal thrusts
• If choking has not been relieved after 5 abdominal thrusts
continue alternating 5 back blows with 5 abdominal thrusts
until it is relieved, or the person becomes unresponsive.
• If the person becomes unresponsive, start CPR.
 If you're alone and choking
• Call for help
• Perform abdominal thrusts to dislodge the item.
– Place a fist slightly above your navel.
– Grasp your fist with the other hand and bend over a hard
surface — a countertop or chair will do.
– Shove your fist inward and upward.
If you're alone and choking
 If the person is obese or pregnant, do high
abdominal thrusts
• Stand behind the person, wrap your
arms them, and position your hands
at the base of the sternum
• Quickly pull inward and upward

93
 Infants: Back blows/chest thrusts
1. Hold the infant in your lap.

2. Put the infant with their face down and their head lower than their chest; they
should be resting on your forearm. Put your forearm on your thigh .

3. Support the infant’s head and neck with your hand and be sure to avoid putting
pressure on their throat.

4. Using the heel of your free hand, deliver five back blows between the infant’s
shoulder blades.

5. Using both hands and arms, turn the infant face up so they are now resting on
your other arm; this arm should now be resting on your thigh.
 Infants: Back blows/chest thrusts
6. Make sure the infant’s head is lower than their chest.

7. Using the fingers of your free hand, provide up to five quick

downward chest thrusts over the lower half of the breastbone. Perform
one thrust every second.

8. If the obstruction is not relieved, turn the infant face down on your
other forearm and repeat the process.

9. Continue doing these steps until the infant begins to breathe or

becomes unresponsive.
Back blows/chest thrusts
Performing the Heimlich on an Infant

“Sandwiched” between two forearms

Performing the Heimlich on an Infant
Performing the Heimlich on an Infant
Performing the Heimlich on an Infant
Algorithm: Paediatric foreign Body Obstruction
 Keep in Mind
• Continue cycles of 5 back blows and 5 abdominal
thrusts until the object is coughed up or the person
starts to breathe or cough

• Take the object out of mouth only if you see it.

• Never do a finger sweep unless you can see the object

in the person's mouth 102