Respiratory therapists serve as vital members of the healthcare team. This means that they play an important role in emergency cardiovascular life support.
When providing emergency care, first and foremost, RT’s are responsible for establishing and maintaining the patient’s airway in order to facilitate ventilation and oxygenation. They also assist with pharmacological therapy, circulatory support, and patient monitoring, among other important duties.
With that said, it’s important to develop an understanding of the different types of cardiovascular life support, which is what this guide is all about. So, if you’re ready, let’s get into it.
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What is Cardiovascular Life Support?
Cardiovascular life support is a set of medical procedures designed to maintain blood circulation and breathing in a person who has suffered cardiac arrest. There are three primary types:
- Basic Life Support (BLS)
- Advanced Cardiovascular Life Support (ACLS)
- Pediatric Advanced Life Support (PALS)
All respiratory therapists are required to maintain a BLS certification, which includes the deliverance of cardiopulmonary resuscitation (CPR). They must also maintain an ACLS certification as well because they often work with patients in critical care units.
A PALS certification is generally only required for medical personnel who work with neonatal or pediatric patients, although it may be required for every RT in some facilities.
Cardiopulmonary Resuscitation
Cardiopulmonary Resuscitation (CPR) is an emergency medical procedure for life support that involves repeated chest compressions and artificial ventilation in an effort to restore spontaneous breathing and blood circulation in a patient who is in cardiac or respiratory arrest.
Basic Life Support
Basic Life Support (BLS) is a type of cardiopulmonary resuscitation that is performed without equipment or medications to assist with the immediate survival of a patient who is in cardiac or pulmonary arrest.
It involves delivering high-quality chest compressions and ventilations and the use of an AED if necessary. BLS courses and certifications are required for healthcare professionals and others who need to know how to perform cardiovascular life support skills.
BLS Procedure
To give a brief summary, the process of BLS goes like this:
First, make sure that the scene is safe and then check the patient for a response. If there is no response, you should open the airway by using a head-tilt, chin-lift maneuver.
Look, listen, and feel for breathing. If there is no breathing, call for emergency services and send for an AED. Then you immediately need to begin chest compressions and rescue breaths at a ratio of 30:2. Give 30 chest compressions followed by 2 rescue breaths and then repeat this cycle.
When the AED arrives, attach the electrode pads and follow the spoken and visual commands of the device. It will determine if the patient has a life-threatening heart rhythm and deliver an electrical shock if necessary.
If no shock is advised, you can continue CPR until the emergency services arrive.
Advanced Cardiovascular Life Support
Advanced Cardiovascular Life Support (ACLS) is an advanced form of emergency life support for the treatment of cardiac arrest, stroke, myocardial infarction, and other life-threatening cardiovascular emergencies.
It’s a more advanced type of emergency care that extends BLS capabilities beyond immediate ventilatory and circulatory assistance.
Examples of ACLS Therapeutic Measures:
Here are some of the types of therapy performed during ACLS:
- Intubation and airway stabilization
- Mechanical ventilation
- Cardiopulmonary resuscitation (CPR)
- Cardioversion
- Defibrillation
- Chest tube insertion
- Needle decompression
- Central venous catheter placement
- Breathing treatments
- Oxygen therapy
Keep in mind that other therapeutic methods may be performed during ACLS. These are just some of the most common examples.
ACLS is typically a group effort that is performed by a team of doctors, nurses, and respiratory therapists. Each provider is specially trained and should have their ACLS certification while working in a setting that may require emergency life support.
What is Pediatric Advanced Life Support (PALS)?
Pediatric Advanced Life Support (PALS) is an advanced form of emergency life support for the treatment of cardiovascular emergencies in pediatric patients.
The PALS program was created by the American Heart Association and American Academy of Pediatrics with a goal of achieving the best possible outcome for a pediatric patient in emergency circumstances.
PALS is similar to ACLS except it is designed specifically for the treatment of critically ill infants and children instead of adults.
Cardiovascular Life Support Practice Questions:
1. Do respiratory therapists play a vital role in emergency cardiovascular life support?
Yes, yes they do.
2. What is the goal of basic life support?
The goal of basic life support (BLS) is to restore ventilation and circulation to victims of airway obstruction and respiratory or cardiac arrest.
3. What is CPR?
Cardiopulmonary resuscitation (CPR) basic emergency procedure for life support, consisting of artificial respiration and manual external cardiac massage.
4. What is the most common cause of sudden death in adults?
Coronary artery disease; accidents are the most common cause of death in young people.
5. What are the fundamental steps of basic CPR of health care providers for a witnessed cardiac arrest?
(1) Confirm unresponsiveness. (2) Call for help and activate the EMS system. (3) Check for a pulse (less than 10 seconds). (4) Perform 30 cardiac compressions. (5) Give two 1-second breaths to produce visible chest rise. (6) Initiate automated external defibrillation immediately
(perform defibrillation as soon as possible).
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6. During CPR, how many compressions and breaths should you give?
Five cycles of 30 compressions to 2 ventilations CPR for adults should be given between attempts at defibrillation using only one shock followed immediately by chest compressions.
7. Evaluating the effectiveness of CPR is important and requires rescuers to watch for what?
Visible chest rise and fall with ventilation and to push hard and fast when delivering chest compressions.
8. What are the complications of CPR?
Worsening of potential neck injuries, gastric inflation and vomiting, and internal trauma during chest compressions. Correct technique minimizes the risk for such complications.
9. The Respiratory Therapist is most often called on to do what during CPR?
Establish an airway and ventilation with elevated FiO2 during ACLS of hospitalized patients. Most often, knowledge and skill with bag-valve devices and oropharyngeal airways are required. Special care should be taken not to hyperventilate the patient during or after cardiac arrest.
10. Common pharmacologic agents used during ACLS include?
Atropine for bradycardia, epinephrine and amiodarone or lidocaine for ventricular arrhythmias, and epinephrine or vasopressin for cardiac arrest and hypotension.
11. In the post-resuscitative phase, the Respiratory Therapist may need to do what?
Help maintain normal ventilation and oxygenation and assist the physician and nurses in monitoring the patient’s condition.
12. The Respiratory Therapist is often involved in care after cardiac arrest of a victim who does what?
Responds favorably to CPR.
13. What is an abdominal thrust?
External pressure forcefully exerted on the abdomen, under the diaphragm, to expel obstructing objects from the upper airway
14. What is ACLS?
It stands for Advanced Cardiac Life Support and includes emergency medical procedures beyond basic life support; includes intravenous fluid life establishment, possible defibrillation, drug administration, control of cardiac arrhythmia, and use of ventilation equipment. This procedure usually needs direct or indirect supervision of a physician.
15. Why are chest compressions performed?
To provide adequate circulation.
16. How to perform chest compressions?
Compress the sternum 2 inches at a rate of 100 compressions per minute. If there is an interruption, resume quickly.
17. What is an AED?
A portable automatic device to perform defibrillation on patients outside the hospital.
18. AN AED is used for what rhythms?
VF and VT.
19. What is BLS?
Cardiopulmonary resuscitation designed to re-institute either circulatory or respiratory function without equipment or drugs.
20. What is CABD’s of resuscitation?
Circulation, airway, breathing, and defibrillation.
21. How does cardiac output from compressions compare to normal cardiac output?
It is about one-fourth of the normal output during compressions.
22. When is cardioversion used?
It is used in atrial fibrillation, defibrillation is done on the R-wave.
23. What is CPR?
It is the basic emergency procedure for life support, consisting of artificial respiration and manual external cardiac massage.
24. What is defibrillation used for?
It is used for the termination of ventricular fibrillation by delivering a direct counter-shock to the patient’s precordium. It is not timed with a wave.
25. During the resuscitation of a victim in cardiac arrest, how many breaths should be given over what period of time?
2 breaths should be given over 1 second.
26. Electrical shock can cause what?
Cardiac or respiratory arrest. Remove the patient from the electrical source, turn off electricity, and maintain rescuer safety.
27. Exhaled air provides what percentage of oxygen?
16 percent.
28. What is gastric inflation?
It is the introduction of air into the stomach and intestine and is caused by prolonged mouth to mouth. It occurs 17% of cases. For prevention, use a mask.
29. Health care providers should use what ratio for adult and children during CPR?
30:2, compressions to ventilations.
30. Health care providers should use a ratio of what for infants?
3:1, compressions to ventilations (2 rescuers).
31. What are the CPR considerations for patients with implanted pacemakers and defibrillators?
Compressions should be done, generally, do not interfere with compressions, pads should be placed at least 1 inch from the location of pacemaker or defibrillator.
32. What are some considerations for performing infant compressions?
Use the lower half of sternum, place index finger at the nipple line, then tall and ring finger are used for the compressions, use the other hand to maintain head position, compress 1.5 in. at 100/minute.
33. In general, how should you give compressions on an adult?
Hard and fast.
34. What are the most effective instructions for giving CPR?
Give 100 compressions per minute, depth of 2 inches, allow the chest to recoil and minimize interruptions.
35. What is mouth to mouth ventilation?
The rescuer uses deeper breath than normal 700-1000 mL, delivers breath over 1 second. There should be a visible chest rise.
36. What should you do if the patient has a pulse but is not breathing?
Start ventilation immediately and 8-10 breaths/minute.
37. Providing artificial ventilation must take place how quickly to prevent biologic death?
Within 4-6 minutes.
38. When should pulse and rhythm checks after the shock be performed?
After 5 cycles of CPR have been completed.
39. Pulseless ventricular rhythms are what?
They are the first manifestation of cardiac arrest in 25% of cases.
40. How to restore the airway?
Inspect for a neck/facial injury, move the victim to the supine position, movement of lower jaw and extension of neck pulls the tongue out of the way, head-tilt chin-lift, jaw thrusts.
41. How to restore ventilation?
Asses for breathing, check for chest movement; it takes no longer than 3-5 minutes.
42. What is the leading cause of death in the United States?
Sudden Cardiac Arrest.
43. What are the steps for administering BLS as a single practitioner?
(1) Check for lack of movement, response, and not normal breathing or only gasping. (2) No response, check for pulse within 10 seconds. (3) Activates emergency response system. (4) If no AED, start compressions and rescue breathing at a ratio of 30:2 for adult cardiac arrest. (5) Open the airway and check breathing. (6) If the patient is not breathing, give 2 breaths that can produce a rise of the chest and resume compressions. (7) When AED arrives with the response team, perform shock.
44. What is synchronized cardioversion?
A counter-shock synchronized with the heart’s electrical activity.
45. When do you stop ALS?
When there is a spontaneous pulse and breathing, pronounced death by the doctor, or if the patient has a DNR status.
46. When is mouth to nose ventilation used?
Trismus (involuntary contraction of the jaw muscles-lock jaw), traumatic jaw, mouth injury, or if the mouth seal is difficult to maintain.
47. When should you start to use chest compressions on a neonate?
If the heart rate decreases to less than 60 beats per minute despite adequate ventilation with 100% oxygen.
48. With two rescuers, how often should you switch positions?
Every 5 cycles, or about every 2 minutes.
49. An advanced airway will allow the rescuer to achieve one or more of the following goals:
Deliver ventilations that are nonsynchronous with chest compressions, restore airway patency, maintain adequate ventilation, isolate and protect the airway from aspiration, provide access for clearance of secretions, and provide an alternate route for administration of selected drugs.
50. As long as air exchange is present, the patient should be reassured and allowed to clear his or her own airway by doing what?
By coughing.
51. Assuming mouth-to-mouth ventilation is successful and the patient remains apneic, continue the effort at what?
At a rate of one breath every 5–6 seconds to maintain a minimal adult rate of 10 to 12 breaths/minute.
52. Cardioversion is similar to defibrillation with what two exceptions?
Countershock is synchronized with the heart’s electrical activity (the R wave). The energy used during cardioversion usually is less than that applied during defibrillation.
53. Chest compressions on a neonate are indicated when?
If the heart rate falls below 60 beats/min, or remains between 60 and 80 beats/min despite adequate ventilation with 100 % oxygen for 30 seconds.
54. What is defibrillation?
An unsynchronized shock used to simultaneously depolarize the myocardial fibers.
55. During CPR, drugs should be given how?
By rapid bolus injection.
56. During respiratory arrest, the victim must be provided with oxygen within?
4 to 6 min or biological death will follow.
57. Exhaled air provides what?
It provided approximately 16% oxygen, which is sufficient to achieve an arterial oxygen tension of 50 to 60 mmHg.
58. What is the goal of BLS?
It is to restore ventilation and circulation.
59. If the adult victim with FABO becomes unresponsive, the rescuer should do what?
Move the patient to the ground, activate the EMS system, and begin CPR.
60. In adults, you should compress the sternum how much?
1.5 to 2 inches (3.8 to 5 cm).
61. In an adult, chest compressions should be done how?
They should be done on the lower half of the sternum at a rate of 100 compressions/minute.
62. In infants and children, two rescuers should use a compression/ventilation ratio of what?
15:2
63. What is the most common cause of airway obstruction?
Loss of muscle tone, which causes the tongue to fall back into the pharynx.
64. Neonatal chest compressions are given to a depth of?
Approximately one-third of the anteroposterior diameter of the chest.
65. Pharyngeal airways restore airway patency by?
By separating the tongue from the posterior pharyngeal wall.
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66. What is the ratio between downstroke/upstroke?
1:1
67. Rescue attempts continue until when?
Advanced life support is available, the rescuers note spontaneous pulse and breathing, or a physician pronounces the victim dead.
68. What are the three steps for administering BLS?
(1) Check for movement or response, (2) Activate emergency medical services, and (3) if no response, check pulse within 10 seconds.
69. What 4 drugs may be given through the ET tube?
Epinephrine, Lidocaine, Atropine, Narcan.
70. What artery should be used to evaluate pulselessness?
In Adults, you should use the carotid, and in infants, you should use the brachial.
71. What is a complication associated with abdominal thrusts?
Vomiting
72. What is the most common and one of the most useful types of monitoring used during ACLS?
Electrocardiography
73. What is the primary procedure recommended when spinal trauma is not suspected?
The head-tilt/chin-lift technique.
74. What is the universal distress signal for foreign body obstruction?
Clutching the throat.
75. What should be used when neck injuries are suspected and only done by trained clinicians?
The jaw thrust.
Final Thoughts
Cardiovascular life support is a critical topic and skill for all respiratory therapists and students. This includes CPR, BLS, ACLS, and PALS.
Hopefully, the information in this guide can help make the learning process easier for you.
We have a similar guide on hemodynamic monitoring that I think you’ll find helpful. Thanks for reading and, as always, breathe easy, my friend.
Written by:
John Landry, BS, RRT
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
References
- Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
- Faarc, Heuer Al PhD Mba Rrt Rpft. Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017.
- Jardins, Des Terry. Cardiopulmonary Anatomy & Physiology: Essentials of Respiratory Care. 7th ed., Cengage Learning, 2019.
- Awar, Mark. “Advanced Cardiac Life Support. Reviewing Recommendations from the AHA Guidelines.” PubMed, Nov. 2003, pubmed.ncbi.nlm.nih.gov/14628394.
- “Impact of Advanced Cardiac Life Support‐skilled Paramedics on Survival from Out‐of‐hospital Cardiac Arrest in a Statewide Emergency Medical Service.” National Center for Biotechnology Information, U.S. National Library of Medicine, Feb. 2007, www.ncbi.nlm.nih.gov/pmc/articles/PMC2658195.