BLS includes several components
- assessment of the scene
- assessment of the subject’s state of consciousness
- calling for help by telephone;
- ABC (assessment of airway patency, presence of breathing and cardiac activity);
- cardiopulmonary resuscitation (CPR): consisting of cardiac massage and mouth-to-mouth respiration;
- other basic life support actions.
In emergency situations, the first thing to do – after assessing that the area presents no further risk to the operator or casualty – is to assess the person’s state of consciousness:
- place yourself close to the body;
- the person should be shaken by the shoulders very gently (to avoid further injury);
- the person should be called out loud (remember that the person, if unknown, may be deaf);
- if the person does not react, then he/she is defined as unconscious: in this case no time should be wasted and an immediate request should be made to those close to you to call the medical emergency telephone number 118 and/or 112;
in the meantime start the ABCs, i.e:
- check if the airway is free from objects obstructing breathing;
- check if breathing is present;
- check if cardiac activity is present via carotid (neck) or radial (pulse) pulse;
- in the absence of breathing and cardiac activity, initiate cardiopulmonary resuscitation (CPR).
Cardiopulmonary resuscitation (CPR)
The CPR procedure should be performed with the patient placed on a hard surface (a soft or yielding surface makes compressions completely unnecessary).
If available, use an automatic/semiautomatic defibrillator, which is capable of assessing cardiac change and the ability to deliver the electrical impulse to perform cardioversion (return to a normal sinus rhythm).
On the other hand, do not use a manual defibrillator unless you are a doctor: this could make the situation worse.
Cardiac massage: when to do it and how to do it
Cardiac massage, by non-medical staff, should be performed in the absence of electrical activity of the heart, when help is not available and in the absence of an automatic/semiautomatic defibrillator.
Cardiac massage consists of the following steps:
- The rescuer kneels by the side of the chest, with his or her leg at the level of the casualty’s shoulder.
- He removes, opening or cutting if necessary, the victim’s clothing. The manoeuvre requires contact with the chest, to be sure of the correct position of the hands.
- Place your hands directly in the centre of the chest, above the sternum, one on top of the other
- To avoid breaking ribs in case of a patient potentially suffering from brittle bones (advanced age, osteogenesis imperfecta….), only the palm of the hands should touch the chest. More specifically, the point of contact should be the palmar eminence, i.e. the lowest part of the palm close to the wrist, which is harder and on axis with the limb. To facilitate this contact, it may be helpful to interlock your fingers and lift them slightly.
- Shift your weight forward, staying on your knees, until your shoulders are directly above your hands.
- Keeping the arms straight, without bending the elbows (see photo at the beginning of the article), the rescuer moves up and down with determination, pivoting on the pelvis. The thrust should not come from the bending of the arms, but from the forward movement of the whole torso, which affects the victim’s chest thanks to the rigidity of the arms: keeping the arms bent is a Mistake.
- To be effective, the pressure on the chest must cause a movement of about 5-6 cm for each compression. It is essential, for the success of the operation, that the rescuer releases the chest completely after each compression, absolutely avoiding that the palm of the hands detaches from the chest causing a harmful rebound effect.
- The correct rate of compression should be at least 100 compressions per minute but no more than 120 compressions per minute, i.e. 3 compressions every 2 seconds.
In case of simultaneous lack of breathing, after every 30 compressions of cardiac massage, the operator – if alone – will stop the massage to give 2 insufflations with artificial respiration (mouth to mouth or with mask or mouthpiece), which will last about 3 seconds each.
At the end of the second insufflation, immediately resume with cardiac massage. The ratio of cardiac compressions to insufflations – in the case of a single caregiver – is therefore 30:2. If there are two caregivers, artificial respiration can be performed at the same time as cardiac massage.
For every 30 compressions of cardiac massage, 2 insufflations with artificial respiration must be given (ratio 30:2).
Mouth-to-mouth respiration consists of the following steps:
- Lay the casualty in a supine position (stomach up).
- The victim’s head is turned backwards.
- Check the airway and remove any foreign bodies from the mouth.
If trauma is NOT suspected, lift the jaw and bend the head backwards to prevent the tongue from blocking the airway.
If spinal trauma is suspected, do not make any rash movements, as this may make the situation worse.
Close the victim’s nostrils with your thumb and forefinger. Caution: forgetting to close the nose will render the whole operation ineffective!
Inhale normally and blow air through the mouth (or if this is not possible, through the nose) of the victim, checking that the ribcage is raised.
Repeat at a rate of 15-20 breaths per minute (one breath every 3 to 4 seconds).
It is essential that the head remains hyperextended during insufflations, as an incorrect airway position exposes the victim to the risk of air entering the stomach, which can easily cause regurgitation. Regurgitation is also caused by the power of blowing: blowing too hard sends air into the stomach.
Mouth-to-mouth respiration involves forcing air into the victim’s respiratory system with the aid of a mask or mouthpiece.
If a mask or mouthpiece is not likely to be used, a light cotton handkerchief can be used to protect the rescuer from direct contact with the victim’s mouth, especially if the victim has bleeding wounds.
The new 2010 guidelines warn the rescuer of the risks of hyperventilation: excessive increase in intrathoracic pressure, risk of insufflation of air into the stomach, reduced venous return to the heart; for this reason, insufflations should not be too vigorous, but should emit an amount of air no greater than 500-600 cm³ (half a litre, in no more than one second).
The air inhaled by the rescuer before blowing must be as “pure” as possible, i.e. it must contain as high a percentage of oxygen as possible: for this reason, between one blow and the next, the rescuer must raise his head to inhale at a sufficient distance so that he does not inhale the air emitted by the victim, which has a lower density of oxygen, or his own air (which is rich in carbon dioxide).
Repeat the cycle of 30:2 for a total of 5 times, checking at the end for signs of “MO.TO.RE.” (Movements of any kind, Breathing and Breathing), repeating the procedure without ever stopping, except for physical exhaustion (in this case if possible ask for a change) or for the arrival of help.
If, however, the signs of MO.TO.RE. return (the victim moves an arm, coughs, moves his eyes, speaks, etc.), it is necessary to go back to point B: if breathing is present, the victim can be placed in the PLS (Lateral Safety Position), otherwise only ventilations should be performed (10-12 per minute), checking the signs of MO.TO.RE. every minute until normal breathing is resumed completely (which is about 10-20 acts per minute).
Resuscitation must always begin with compressions, except in the case of trauma or if the victim is a child: in these cases, 5 insufflations are used, and then the compressions-inflations alternate normally.
This is because, in the case of trauma, it is assumed that there is not enough oxygen in the victim’s lungs to ensure efficient blood circulation; even more so, as a precautionary measure, if the victim is a child, start with the insufflations, since it is presumable that a child, enjoying good health, is in a state of cardiac arrest, most likely due to trauma or a foreign body that has entered the airways.
When to stop CPR
The rescuer will only stop CPR if:
- Conditions in the location change and it becomes unsafe. In the event of serious danger, the rescuer has a duty to save himself.
- the ambulance arrives with a doctor on board or the medical car sent by Emergency Number.
- qualified help arrives with more effective equipment.
- the person is exhausted and has no more strength (although in this case we usually ask for changes, which should take place in the middle of the 30 compressions, so as not to interrupt the compression-inflation cycle).
- the subject regains vital functions.
Therefore, if there is a cardiopulmonary arrest, mouth-to-mouth resuscitation must be used.
When not to resuscitate?
Non-medical rescuers (those who are usually on 118 ambulances) can only ascertain death, and therefore not initiate manoeuvres:
- in case of externally visible brain matter, decerebrate (in case of trauma for example);
- in case of decapitation ;
- in case of injuries totally incompatible with life ;
- in the case of a charred subject;
- in the case of a subject in rigor mortis .
The most recent changes (as can be seen from the A.H.A. manuals) relate more to order than procedure. Firstly, there has been an increased emphasis on early cardiac massage, which is considered more important than early oxygenation.
The sequence has therefore changed from ABC (open airway, breathing and circulation) to CAB (circulation, open airway and breathing):
- start with 30 chest compressions (which must begin within 10 seconds of recognition of heart block);
- proceed to airway opening manoeuvres and then ventilation.
This only delays the first ventilation by about 20 seconds, which does not adversely affect the success of CPR.
In addition, the GAS phase has been eliminated (in the assessment of the victim) because agonal gasping may be present, which is perceived by the rescuer both as a sensation of breath on the skin (Sento) and audibly (Ascolto), but which does not cause effective lung ventilation because it is spasmodic, shallow, and very low frequency.
Minor changes concern the frequency of chest compressions (from about 100/min to at least 100/min) and the use of cricoid pressure to prevent gastric insufflation: cricoid pressure should be avoided as it is not effective and may prove harmful by making it more difficult to insert advanced respiratory devices such as endotracheal tubes etc.
Lateral safety position
If breathing returns, but the patient is still unconscious and no trauma is suspected, the patient should be placed in a lateral safety position.
This involves bending one knee and bringing the foot of the same leg under the knee of the opposite leg.
The arm opposite the bent leg should be slid across the ground until it is perpendicular to the torso. The other arm should be placed on the chest so that the hand is on the side of the neck.
Next, the rescuer should stand on the side that does not have the arm extended outwards, place his/her arm between the arc formed by the patient’s legs and use the other arm to grasp the head.
Using the knees, gently roll the patient onto the side of the outer arm, accompanying the movement of the head.
The head is then hyperextended and held in this position by placing the hand of the arm that is not touching the ground under the cheek.
The purpose of this position is to keep the airway clear and to prevent sudden spurts of vomit from occluding the airway and entering the lungs, thus damaging their integrity.
In the lateral safety position, any fluid emitted is expelled from the body.
First aid and BLS in children and infants
The method for BLS in children from 12 months to 8 years is similar to that used for adults.
However, there are differences, which take into account the lower lung capacity of children and their faster breathing rate.
In addition, it should be remembered that the compressions must be less deep than in adults.
We start with 5 insufflations, before proceeding to cardiac massage, which has a ratio of compressions to insufflations of 15:2. Depending on the corpulence of the child, compressions can be performed with both limbs (in adults), one limb only (in children), or even just two fingers (index and middle fingers at the level of the xiphoid process in infants).
Finally, it should be remembered that since the normal heart rate in children is higher than in adults, if a child has circulatory activity with a heart rate of less than 60 beats/min, action should be taken as in the case of cardiac arrest.