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David OlleyAED and BLSA practical guide to automated external debrillationand basic life support4thEdition
4thEditionThis handbook is ideal for use insupport of a properly structured rstaid course. It will also prove invaluableas ongoing reference for someonewho has completed the course.AED and BLSSudden Cardiac Arrest 2How the heart works 2Arhythmias 2Ventricular Fibrillation 2Debrillation 2Chain of survival 3Basic Life Support 4Airway 4Chest Compressions 5Rescue Breathing 6Hygiene and PPE 7The AED 9Using the AED 9Placement of pads 10AED Flowchart 11AED Safety 12AED and Children 12AED Storage 13AEDRespiration 14Hypoxia 14Oxygen Therapy 16Equipment 16The Pulse Oximeter 16Oxygen Cylinders 19Cylinder Safety 19Oxygen Regulators 19Bag/Valve Mask (BVM) 21Non Rebreather Mask 22Nasal Cannula 23Simple Oxygen Mask 23Venturi Mask 23Delivery Guidelines 24Oxygen and Poisoning 27Oxygen Safety 28Glossary 29The Recovery Position 30Oxygen
AED & BLS FIRST AIDIntroductionSudden cardiac arrest (SCA) occurs when the heart suddenly and unexpectedly stopsbeating. This results in a lack of blood supply and therefore oxygen, to the brain and otherorgans. Left untreated, it will lead to death in a very few minutes.The heart works as a pump by regularly contracting and relaxing at a rate of around 60 to80 times aminute. The speed and rhythm of the contractions are controlled by a group ofpacemaker cells in the heart wall. These cells send out an electrical signal along nervepathways in the heart walls and stimulate the heart muscle to contract. The rate willdepend upon several factors such as fear and excitement or exercise and will respond todemand. The heart’s electrical system regulates the mechanical system and in a healthyheart the result is a rhythmic and co-ordinated beating.Problems with the heart’s electrical system can result in abnormal heart rhythms orarrhythmias. There are many dierent types of arrhythmias. Some may cause the heartto beat too fast, some too slow and some may cause the heart to stop beating altogether.SCA occurs when the heart stops beating.In VF, the signal to the ventricles or pumpingchambers of the heart becomes disorganised,resulting in the pumping chambers starting toquiver very rapidly and irregularly. When thishappens there is very little output from theheart to the other organs of the body anddeath will follow within a few minutes. VFcauses more sudden cardiac arrests than anyother arrhythmia, and without the correct treatment 95% of suerers will die.The only treatment proven to restore a normal heart rhythm is to administer an electricshock to the casualty’s heart. This is called debrillation and can be life-saving in suddencardiac arrest. The machine used to deliverthe shock is a debrillator and the type ofmachine most commonly used outside of aspecialist hospital unit would be anautomated external debrillator or AED.Debrillators have been around for manyyears but their use in the past has beenrestricted to individuals with specialistknowledge.How the heart worksVentricular FibrillationDebrillation
The problem has never been in knowing how to shock but in knowing when to shock andthe danger was in giving a shock to someone who didn’t need one. The AED has solved thisproblem by using a computer to recognise whether or not a casualty needs a shock and bynot charging up or delivering a shock to someone who does not need one. This means thatAEDs can be used safely by non-medical people to save lives in sudden cardiac arrest.The eect of debrillation decreases as time passes so the earlier into the event that thecasualty can be shocked the more likely it is that it will be successful. Chances of survivaldecrease at around 10% a minute so early debrillation can be lifesaving.Chain of SurvivalThe chain of survival demonstrates the steps that are necessary to increase the casualty’schance of surviving sudden cardiac arrest. Their chances will be greatly improved whenall of the links are in place.3AED & BLS FIRST AIDDebrillationEarly Access Early CPR Early Deb Advanced Care Post Arrest CareEarly AccessEarly recognition and an immediate 999 call are critical. If there is an AED close by,send somebody to fetch it if possible.Early CPRThe emphasis is on immediate and good quality chest compressions. If you are trained,provide 30 chest compressions and two rescue breaths and repeat the cycle until theAED is ready or emergency medical responders arrive and take over. If you are nottrained then concentrate on chest compression only*.Early DebAs soon as an AED (Automated External Debrillator) becomes available it should beattached to the patient’s chest and you should follow the visual and voice prompts.AEDs are simple and safe to use, even if you have not received specic training. Thereis no reason to delay debrillation.Early ACLSEective advanced life support will be provided by the emergency medical respondersand may include high-quality CPR, debrillation, oxygen and use of medicines orappropriate devices.Good Post Arrest CareComprehensive, multidisciplinary system of care which will include close monitoring,specic medication and an action plan for eective ongoing care.
Basic Life Support (Adult)AED & BLS FIRST AIDApproach with CARE- Make sure there is no danger to yourself, the casualty or bystanders.- Deal with danger if appropriate but do not take any chances with your own safety.Check RESPONSE- Check initially in the position you nd them.- Speak loudly to them.- Use their name or ask them to open their eyes.- If no response, shake them gently by the shoulder.If they respond:- Leave them in the position that you found them- Check to nd out what might be wrong.- Observe and reassess regularly.If they do not respond:Open the AIRWAY- Undo anything tight around the neck and remove theirglasses if worn.- Place one hand on the forehead and two ngers of theother hand under the bony part of the jaw.- Gently rotate the head backwards and lift the jaw.- This lifts the tongue and straightens the airway.Check for NORMAL BREATHING- Place your ear over the casualty's nose and mouth,looking downwards towards their feet.- Check for no more than 10 seconds.LOOK - for movementLISTEN - for breathingFEEL - for breath on the cheekSeizure and Sudden Cardiac ArrestBe suspicious of Cardiac Arrest in any patient presenting with seizure and carefullyassess their breathing following the seizure. Be prepared to oer life support asappropriate.
AED & BLS FIRST AID3Basic Life Support (Adult)If they ARE breathing normally- Examine them carefully for any immediately life threatening injury, such as severebleeding and treat of possible.- Turn them carefully into the Recovery Position as soon as it is practical to do so.If they ARE NOT breathing normally- Ask someone to fetch an AED if one is available- Ensure that an ambulance is called. Try to call yourself without leaving the casualty.- If you have a speaker phone, switch it on.- Calling ambulance control means that they can locate the nearest AED and arrangefor it to be sent if necessary. They can also oer advice on diagnosis and treatment andif necessary, talk you through the procedure.- Start CPR with 30 chest compressionsDeliver CHEST COMPRESSIONSChest Compressions should be performed with the casualty laying at on their back ona rm surface. It should not be necessary to undress them or expose the chest unlessthey are wearing very heavy outer clothing.Place the heel of one hand inthe centre of the chest, ontop of the breastbone.Place the heel of the otherhand on top of the rst. Keepyour ngers from pressing onthe chest wall.Position yourself with yourshoulders directly above theirchest, with your arms straightand your elbows locked.- Push straight down on their chest to a depth of 5 -6 cm.- Release the pressure completely between compressions, keeping your hand in contactwith the chest.- Keep movements smooth and not jerky. Erratic or violent movements may injure thecasualty and will not pump blood eciently.- Compress the chest at a rate of 100 - 120 compressions a minute.- It is important to maintain the quality, rate and depth of compressions.Your performance is liable to deteriorate as you get tired. For this reason it isrecommended that if another rescuer is available and can perform chestcompressions, you should change over every two minutes.
Basic Life Support (Adult)AED & BLS FIRST AIDDeliver RESCUE BREATHSAir in the atmosphere contains about 21% oxygen. When we breathe we only use whatwe need, about 4%, so the air that we breathe out still contains around 17% oxygen.This is more than enough to maintain life in our casualty.Take no more than 10 seconds to deliver two rescue breaths.Use the ngers of the handperforming the head tilt to pinchthe nose closed. Take a normalbreath.Seal your lips around their mouthand blow steadily until the chestrises. Each breath should besucient to cause the chest torise, as in normal breathing.Release the nose and keeping theairway open, let them breatheout. Re-seal your lips and giveanother rescue breath.Give two breaths in total.- Each breath should take about one second to deliver.- Watch the chest as the breath is delivered to ensure that it rises.- Do not interrupt compressions by more than 10 seconds to deliver the two breaths.- Following the second breath, immediately replace your hands on the chest andcontinue CPR with a further 30 chest compressions.- Continue CPR with a ratio of 30 compressions to 2 breaths until the arrival of the AEDor ambulance, or until the patient recovers.
AED & BLS FIRST AID7Basic Life Support (Adult)Regurgitation / VomitingRegurgitation is common during resuscitationattempts. If it occurs:- Turn the casualty on to their side, facing away fromyou.- Support their weight on your legs to prevent themfrom rolling back.- Ensure that their head faces down and that theiropen mouth is at the lowest point to ensure drainage.- If necessary, remove debris from their mouth withyour ngers.- Place the casualty on their back, open the airwayand check for normal breathing.- Resume CPR immediately if required.Hygiene and Personal ProtectionAdministering Basic Life Support oers little threat to the rescuer. There is a perceivedthreat from blood borne viruses such as HIV or Hepatitis, but realistically this is a bloodproblem. They will not be transmitted giving or receiving rescue breathing.However, many people are reluctant to oer rescue breathing because of this perceivedrisk or because of contamination of the casualty’s face with vomit or blood. If this is thecase they may be more comfortable using some sort of barrier between themselves andthe casualty.To be eective these barriers should contain a one-way valve.Pocket MaskPocket Masks are large and substantial,often coming in a case. Most masks willhave a one-way valve. Some may havean attachment for oxygen tubing. Theyrequire some practice and training to beused eectively, but give a greaterfeeling of security to the rescuer.They t over the nose and mouth of thecasualty and the rescuer blows throughthe valve until the chest rises.
Unresponsive and notbreathing normallyCall 999 and ask for anambulanceDeliver 30 chestcompressionsGive 2 rescue breathsContinue CPR 30:2When AED arrives switchit on and follow promptsOne of the most useful pieces of equipment that a First Aider may have access to is amobile telephone. Almost everyone carries one and you will have a connection in mostparts of the country.Most mobiles come with a hands fee orspeaker option so it will allow you totelephone for an ambulance and thenspeak to ambulance control and getadvice whilst performing First Aid.In most cases the ambulance controllerwill advise on the steps to take and talkyou through any procedures necessary.It also allows you to update the controllerabout any changes in the casualty’s condition so that priorities may be re-assessed.Getting AdviceSummaryAED & BLS FIRST AID
Some AEDs will automatically switch on when you open the lid. With others you mayhave to press the ON button.Attach leads to the AED if necessary- Remove the pads from any outer packing.- Look carefully at the instructions on the pads.- Peel o any backing paper and stick the padsonto the casualty’s chest as shown.- One pad should be placed below the rightcollar bone, next to the breastbone.- The other pad should be placed below the leftarmpit, on the side of the chest wall, over thelower ribcage. It is not important which wayround the pads are placed.- Do not stop to remove them if you haveplaced them the opposite way to the diagram.Keep clear during analysisEnsure that nobody touches the casualty whilst theAED is analysing the heart rhythm as this may lead toinaccurate results.Follow voice promptsActivate the AEDAttach the padsAnalyseAED & BLS FIRST AID7The AEDAn AED can be used safely by almost anyone, so its use is not restricted to trainedrescuers. However training is useful to improve performance, leading to a betteroutcome.When using an AED keep interruptions to chest compressions to a minimum. Do notstop to check the casualty or discontinue CPR unless they show obvious signs ofrecovery, such as opening their eyes, speaking or starting to breathe.The AEDThe appearance of individual AEDs may vary from maker to maker but they will all havesimilar layouts and properties.The essence of AED design and use is simplicity and so you should be able to use anyAED in exactly the same sequence.One type of AED may be used for illustration but the instructions apply equally to all.
- If the voice prompts direct you to start CPR, startchest compression and rescue breathing immediately.- Maintain CPR for two minutes or until prompted tostop.- Continue to follow voice prompts.- Ensure that everybody is clear of the casualty.- Press the shock button as directed.- After the shock is delivered continue CPR for two min-utes, or until directed to stop.- Allow the AED to analyse.- Continue to follow voice promptsThe casualty’s chest should be exposed to enable correct pad placement.If the chest is wet it may prevent the pads from stick-ing and making a good contact. Towel dry is usuallysucient.Excessive chest hair may also prevent eectivecontact. The area where the pads are to be placedshould be quickly shaved if possible.Do not delay debrillation if a razor is notimmediately available.It is important that the left side pad is placed wellback to the side of the rib cage.If it is too close to the front, current travelling frompad to pad will travel across the front of the chest,missing the heart.With the pad placed well to the side the current willtravel from pad to pad through the heart muscle.No Shock IndicatedShock IndicatedPlacement of Chest PadsThe AEDAED & BLS FIRST AID
Shout “HELP”Call 999Send for an AEDAEDAnalysesrhythmNO shock advisedResume CPRFor 2 minutesResume CPRFor 2 minutesContinue until they startto breathe normallyAED & BLS FIRST AID3Life Support & DebrillationUnresponsive?Open airwayCheck breathingNot breathingnormally?Start CPR at 30:2until AED attachedShock advisedGive one shock
An AED is like any other electrical appliance in that certain safety precautions should beobserved to minimise the risk of injury to the operator, assistants or even the casualty.Keep the electrodes (pads) separate: do not allow them to touch when the machine isswitched on. This could complete the circuit and could be dangerous.Never connect the pads to anyone except a casualty in suspected cardiac arrest: Alive AED should never be connected to anyone for demonstration or training purposes.Be aware of patches on the skin: some medications, particularly GTN may beadministered via skin patches. Avoid placing the elec-trodes directly over the patch.Be aware of implants: Devices such as pacemakers orcardioverters may be implanted under the skin. Theirpresence is often marked by a scar or bump. They aremost commonly found high on the left side of the chestand so are not often a problem for pad placement. Tryto keep pads 10cm away if possible.Be aware of inammable environments: Because ofthe risk of sparks the casualty may have to be removedfrom an area containing inammable vapours, before a shock is given.Risk of shock to others: if the pads are making good contact then there is very little riskof shock to others, even in a wet or conductive environment, as long as they are not in di-rect contact with the casualty. Current will travel from one pad to the other and not intothe surrounding area. Thankfully it is rare to have to use an AED on achild. Their use however can be life saving insome circumstances.There may be a potential problem with someAEDs as they are calibrated to recognise adultabnormalities and deliver a shock which isappropriate for an adult. The strength of thisshock through a child’s heart may be sucient to cause damage to the heart muscle, tothe point of making resuscitation impossible. Therefore, if you are in a situation wherethere is a likelihood of having to treat a child, it would be a good idea to have a set ofchild pads stored with the AED. These pads and leads are designed to reduce the powerof the shock delivered to the child, to limit any possible damage to the heart.For infants the pads are designed to be placed centrally on the chest and upperback,directly opposite one another, although on older children they may be placed inthe conventional “adult” position.AED SafetyAEDs and ChildrenAEDAED & BLS FIRST AID
Children over the age of 8 years can be treated with adult pads and protocol whilstchildren between 1 and 8 years should be treated with paediatric pads if available. If nopaediatric pads are available use adult pads front and back. Although there may be somerisk it is better than doing nothing.All children should receive at least one minute of eective CPR before attempts are madeto debrillate as per paediatric life support guidelines.AEDs and Children (Continued)The AED should be stored in a secure but easily accessible location.Storage should be clean and dry.If located in a public area security may be maintained byhaving the unit enclosed in a cabinet with a breakable sealarrangement. Cabinets should have a clear door so thatthe AED is clearly visible. They should also allow easychecking of the unit’s ashing “ready” light.Many cabinets will also have an alarm that is activatedwhen the unit is removed or the door opened. This may beaudible or visual, for example a ashing strobe light.The location of the AED should be clearly signed using the accepted international sign.Depending on other circumstances it may be useful to store other items with the AED sothat they are easily available.These may include:- Spare battery- Spare pads, including paediatric pads if appropriate- Razor for shaving the chest- TuCuts for opening clothing- Towel for wiping the chest- GlovesStorageAED & BLS FIRST AID3AED
Oxygen is a gas that forms around 21% of the air that we breathe. It is essential to life,being used by every cell in the body to help convert fuel into energy (metabolism)Our bodies store very little oxygen, just a few minutes worth, so as we need a constantsupply we need to continuously replace it by respiration.EnvironmentalCould be due to a lack of oxygen in the ambientair, due to altitude or other causes.Impaired VentilationNormal ventilation depends upon themechanical eect of the contracting diaphragmand inter-costal muscles to alter the volume ofthe chest cavity, thus creating a dierence inpressure and drawing air in, to be trapped in thelungs.Factors that could interfere with this mightinclude damage to the chest wall or anobstruction to the airway preventing air fromreaching the air sacs.Causes of HypoxiaOxygen and RespirationAED & BLS FIRST AIDThere are four stages in the respiration process:Ventilation: from the surrounding air into the air sacs of the lungsPulmonary Gas Exchange: transfer of Oxygen from the air sacs into the blood streamand Carbon Dioxide from the blood into the lungs to be breathed out.Gas Transport: from the pulmonary capillaries, through the circulation to the peripheralcapillaries.Peripheral Gas Exchange: from the tissue capillaries into the cells.The ventilation and gas transport stages depend on mechanical pumps to work, whilstthe gas exchange steps rely on passive diusion.When the air that we breathe contains adequate levels of oxygen and all of the elementsof respiration are working properly our bodies will be supplied with all of the oxygen weneed, but should one part of the process fail our bodies become short of oxygen, a con-dition known as HypoxiaHypoxia literally means a shortage of oxygen in the body.Hypoxaemia means a shortage of oxygen in the blood.InhalationLungDiaphragmDiaphragm contractsand moves down
Impaired Gas ExchangeFor ecient gas exchange in the lungs there needsto be a balance between air containingadequate amounts of oxygen entering the lungs(ventilation) and the ow of blood through thepulmonary capillaries (perfusion).Factors which may interfere with gas exchangeinclude altered blood ow from poor cardiacoutput (heart disease, shock or pulmonaryembolism) or a lack of oxygen carrying abilityfrom reduced haemoglobin (anaemia) orcarbon monoxide poisoning.There may be collapse of the air sacs(pneumonia, pulmonary oedema or othermedical conditions) or chronic conditions (COPD).Causes of Hypoxia (Continued)BronchioleAlveoliPulmonaryveinPulmonaryarteryCapillariesCO2outO2inHypoxia may be dicult to see in the earlystages, as signs and symptoms may be absent ormay vary from individual to individual.Signs and Symptoms- Rapid breathing- Cyanosis- Lethargy- Poor judgement- Dizziness- Headache- Breathlessness- Fatigue- Nausea- Visual impairment- EuphoriaRecognition of Hypoxia3HypoxiaAED & BLS FIRST AIDA more accurate way of recognising and conrming hypoxia, or at least hypoxaemia,is through the use of a device called a Pulse Oximeter.