Basic Life Support

About a month ago I took the Basic Life Support (BLS) course with the Canadian Heart and Stroke Association. Due to restrictions related to COVID and my level of French (practicing language during CPR class might not be advisable, I thought), the spots where I could take such class in English in Montreal were limited. Thus, on the early morning of a gloriously frosty Saturday I left my cozy abode and headed towards the metro, which took me of the island of Montreal to Laval (it was the last station on the orange metro line). On ascending from the underground I’ve discovered that Laval area had it’s own transport system and my OPUS card won’t function there, but luckily the station was not completely deserted and a fellow early passenger vouchsafed to me that one can pay in the bus or buy a ticket at the station. The bus was soon around and carried me further into the unknown, five or six stops into it, to be precise.

The course itself is a must for healthcare workers and public safety personnel, as well as students and trainees in these areas. I’ve taken a similar class before sometime during six years in the university and what I remember most was the intensity of physical exertion of performing proper chest compressions. One can take it with two other institutions in Canada, apart from Canadian Heart and Stroke Association:

• Canadian Red Cross
• St. John Ambulance Canada

It’s length is around 4 hours and the certificate one gains with a successful completion is valid for one year. The course is available in both English and French. The fee varies from 0 to 120 CAD in Québec, as far as I could find. Note that the fee does not include the price of required manuals that are available both in paper and in digital version. Here I must warn you that electronic version made me to register with two other online services to gain access to the PDF, that I was unable to download and read offline, without further registrations and downloading of a specific app. So, don’t be like me and register long enough beforehand so that you’ll have enough time to get a paper version in your mailbox.

Apart from me there were two workers from centers that care for elderly, two pharmacists and a nurse, who had to drive to Montreal from Ontario, as this was the closest option available to them. We began with a short intro and proceeded to first watch the video instructions, then discussed several topics, finally descending to the mannequins who’d silently accompanied us from the beginning and finished with a test to assure adequate level of information being retained.

A bit of background physiology here: the heart is a muscular pump that should normally contract at a regular rate of 60–100 beats/minute for it to be able to provide stable and sufficient blood circulation. When for some reason or other the heart’s contractions become uncoordinated instead of strong concerted effort we get inefficient twitching that lacks the propulsive power, we get in fact a cardiac arrest. The return of the normal rhythm is essential because without it the cells and tissues will not get blood and oxygen they need and will begin to die (within as little as 3 minutes), thus the shorter waiting time from the start of cardiac arrest to the administration of an electric shock the better chances the person will have to survive and retain their normal functioning. While there might be no AED on the spot, immediately starting CPR will force the blood to move and breaths will enrich the said blood with oxygen, hopefully until either the heart will regain it’s normal rhythm and person revives, AED will be found or EMS team arrives with more sophisticated interventions and possibility of transportation.

Most cardiac arrest happen due to arrhythmia, but there are variety of other causes such as coronary heart disease, myocardial infarction (MI or heart attack), congenital heart diseases, electrocution, drowning, recreational drug use, etc. Of note here is that although a heart attack might lead to cardiac arrest, not all of MIs will be causing cardiac arrest, thus not all people suffering from MI need to get CPR and receive electric shock.

Let’s look into differences between MI and cardiac arrest:

— MI is essentially a death of muscle cells of the heart as a result of compromised blood flow in one or more of its blood vessels, commonly due to an atherosclerotic plaque. People suffering MI:

• most commonly stay conscious
• will have discomfort or pain in upper chest, that might travel to their arm, neck and jaw on the left side, although women might only feel extreme fatigue, discomfort or pain in the upper abdomen or their back
• might be short of breath, nauseated, lightheaded, sweating

— cardiac arrest will manifest itself as:

• sudden loss of consciousness
• lack of response to sound or touch
• lack of breathing or only gasping (which is not normal)

Now both are emergencies and calling 911 for both is a good start, but after that the algorithms of management differ.

Let’s look at some of the things that I have learned or been reminded off, that might come useful.

1. Safety first — if you’ve found an unresponsive person, before doing anything else verify that the setting is safe to be in, as again what first responders dislike more than having to deal one casualty is having to deal with two. If it is not safe, save yourself first, then inform proper services. If it is safe enough, proceed to step 2.
2. Check the person — ask them if they are OK in a loud, clear voice, and tap them on the shoulder, if they are unresponsive, shout for nearby help and call 911. Get AED (automated external defibrillator) and emergency equipment or send someone to find it (there are multiply mobile apps with the locations of AEDs marked on the map).
3. Assess person’s breathing and pulse simultaneously for no more than 10 seconds — check carotid pulse and observe their chest for breathing movements:

• if they have full, regular pulse and normal breathing, then stay with them until emergency responders arrive,
• if they have normal pulse, but do not breath or gasp only, then do rescue breathing at 1 breath each 5–6 seconds or about 10–12 breaths per minute, check their pulse every 2 minutes and be ready to proceed to CPR if pulse is no longer felt,
• if they have neither pulse, nor breathing or gasp only, then proceed to CPR.

4. CPR:

• do not to move the victim around if possible, but it is important to have them on a firm surface to deliver effective chest compressions and remove the clothes from their chest to attach AED pads, when they arrive
• for a single rescuer position yourself by the side of the victim to facilitate the maneuvers and minimize the pauses when switching from breathing to compressions and vice versa, the rate of compressions to breaths is 30 to 2, regardless of victim’s age
• one has to compress at rate of 100–120/min, with depth reaching at least 5 cm and allow for full chest recoil (it gets quite intense very fast)
• keep interruptions to a minimum as even short break will mean it will take a few seconds to re-establish blood flow to the brain
• proper positioning of hands is important — slide your hand from the victim’s armpit parallel to ribs towards the sternum, it should end up on lower half of sternum, then put the heel of another hand on top of the first, and make sure you push straight down
• there is such a thing as a CPR feedback device which will beep at you when you do not press deep enough
• airway must be opened either by head tilt-chin lift (put one palm on their forehead and push down to tilt the head, and another hand under their chin to move the jaw by pushing up on the bony part under the chin to lift the chin), or jaw thrust maneuver (stand behind their head, place your hands on either side of their head, under the angles of the lower jaw and move the jaw forward); use the latter if neck trauma is suspected
• perform breaths only if it is safe for you, i.e. you have face shield or a pocket mask, the person is well known and close to you, etc., otherwise keep to compressions, although on the whole the risk of infection transmission is judged as low
• mask should cover both nose and mouth and should be kept firmly in place to provide seal
• if doing breathing, deliver each breath for more than 1 second (we’re trying to emulate normal breathing here, and not adding gastric inflation to the victim’s problems), watch for chest rising and get back to compressions in less than 10 seconds
• if using bag-mask device — use thumb and forefinger to press the mask to the face and use remaining fingers to grab the angle of the jaw, lift it and press it to the mask, you’ll be squeezing the bag with the other hand (it’s tricky and requires repetition to be performed satisfactory, that’s why practice session with the mannequins is so important); when/if more people are available another person might be squeezing the bag, which is more efficient
• in 2 rescuer situation one will be doing compressions, counting them out loud and the other breaths, with switching roles every 2 minutes, or 5 cycles of compression/breaths taking less than 5 seconds to do so, or when prompted by AED; keep an eye on each other to spot insufficient performance and correct that in time

5. AED is a portable device, capable of delivering sufficient shock to stop abnormal heart rhythm and let the heart re-establish its normal one. It comes in packs or boxes equipped with everything needed for its use. Some of them turn on automatically when their container is opened. Powered on device will provide you with instructions, step by step, but in general it goes like this:

• attach the pads to person’s bare chest, their position will be pictured on the pads, then attach connecting cables to AED
• on prompting from AED, clear the victim (no one should be touching them) for the it to analyze their heart rhythm
• the device will inform you whether the shock is needed
• if it is, clear the victim, loudly state “Everybody clear” and be sure to look to make sure that no one is in contact, then push the shock button
• if it is not, then continue CPR beginning with compressions
• in about 2 minutes or 5 cycles of CPR, the AED will prompt you to clear to examine the rhythm and check for shockability again, then follow either of the two above mentioned options until the EMS team arrives or the victim begins to breath, move or display other signs of life
• if the victim was found in water, it is important to take them out before applying and using AED, if they are only wet, then removal of clothing from the chest and wiping it are all that is needed for the safe use of AED
• if the victim had a scalping injury, then place the pads on the remaining skin of the chest, with minimum of 13 cm between the pads
• if the victim has an implanted defibrillator on their chest, place the pad at least 2.5 cm away from it
• if the victim has hairy chest, one has to remove them at least partially for better conductivity, for that purpose in some boxes there might be a razor, but one can also use a spare adult pad (make sure though that it is indeed a spare one) to remove the hair quickly
• use adult AED pads for everyone older than 8 years, and if no adult pads are available, focus on CPR, as shock delivered through child pads is insufficient for the adult

Some nuance in pediatric victims

• one supposed to tap on a child’s shoulder or on the heel of an infant (less than 1 year old child)
• check infant’s brachial pulse ( in the middle on the inner side of their arm), child’s carotid pulse or femoral pulse (on the side of their groin, in the crease between the lower belly and the thigh), check it for at least 5 seconds but not more than 10
• if the victim is not breathing, but has pulse, then provide rescue breathing at 1 breath every 3–5 sec or 12–20 breaths per minute (just enough so their chest rises); however, if pulse remains 60 beats per minute or less with signs of poor circulation (cool extremities, pale, bluish or mottled skin, weak pulse, declining responsiveness), begin chest compressions
• if you are alone and have witnessed sudden collapse, leave the victim to get help and AED when no phones and suchlike are available, or if possible and safe take the child with you
• if the you’ve found them in unresponsive state or collapse was not sudden, proceed to CPR beginning with compressions (single rescuer is advised to use 2 finger technique with infant and 1 or 2 hands compressions, depending on the child’s size and required effort to provide sufficient depth), after about 2 minutes of which if you are still alone and were not able to call 911 leave the victim to find help and AED
• if two rescuers are available use compression-to-breath ratio of 15:2, with depth of 5 cm for children and of 4 cm for infants
• if victim is an infant and there are two rescuers, the one who does compressions advised to use 2 thumbs-encircling hands technique as it is more efficient
• when opening airway with infants do not overextend their necks, as it will increase the risk of blocking it, keep their head in neutral position — ear at level with top of the shoulder
• younger victims of cardiac arrest tend to have it due to respiratory conditions or shock, which means that they often lack oxygen before the onset of arrest, which in turn means that compressions alone won’t be as effective as with adults, hens it is very important to do both compressions and breaths
• AED usage: 1. if pediatric pads unavailable, use adult ones and make sure they do not overlap, 2. if AED has a child shock dose button, use that, 3. in infants manual defibrillator is preferred, though it’s use is more complicated, if manual one is unavailable, then use with pediatric dose attenuator, if neither of the two is at hand, use AED without attenuation and place the pads thusly — one on the front, in the middle of the chest and another on their back, between shoulder blades; adult shock dose is better than no dose

Lastly, chocking relief:

• do not slap upright, coughing person on the back
• as long as victim is coughing and breathing, encourage coughing and stay with them
• if chocking continues or worsens, call 911
• if person is clutching their throat, unable to speak, make high-pitched noise with inhaling or no noise at all, cannot cough or do so weakly, perform abdominal thrusts (Heimlich maneuver) immediately
• if obstruction continues and they loose consciousness, proceed to CPR for 2 minutes during which before breaths check their mouth for the obstructing object (however, refrain from finger sweeps as it may worsen the obstruction), and if you are alone and have no phone with you, go to find help after that
• when the person looses consciousness, larynx muscles might relax enough to allow for some air intake, so doing breaths is not pointless, plus chest compressions might help to dislodge the obstruction
• with infants it is a bit more tricky:

— with responsive infant you should 1. sit down and place it face down with head lower than their body on your lap, resting your forearm on the said lap and supporting and stabilizing infant’s head and jaw from below, 2. deliver 5 forceful back slaps between infant’s shoulder blades with the heel of the other hand, 3. then place the free hand on infant’s back to support their head and neck, fixing them between your forearms, 4. turn the infant as a unit supporting their neck and head face upwards on your lap, with your forearm on the thigh for support, 5. provide 5 downward chest thrusts with two fingers, similar to infant chest compressions, 6. repeat until the object if removed or infant becomes unresponsive

— with unresponsive infant call for help and proceed to CPR, each time when you open airway check their mouth for the object, and if it is easily extracted, remove it

• and finally, if you are all alone and begin to choke, use a sturdy chair with a back, and try and to fall, as it were, with your upper belly on the said back forcefully, or I think any horizontal bar would do