Part 4: Adult Basic Life Support 1V-21 system,prompt dispatch of EMS personnel, rapid delivery to leave the victim to phone 911. Then return as quag.ce detection of the signs of stroke, prompt activation of the EMs victim responds but is injured or needs medical assistar a hospital capable of providing acute stroke care, prearrival possible and recheck the victim's condition frequently notification, immediate and organized hospital care, appro- priate evaluation and testing, and rapid delivery of fibrino- Activate the EMS System(Box 2) lytic agents to eligible patients. If a lone rescuer finds an unresponsive adult (ie, no move- Patients at high risk for a stroke and their family members ment or response to stimulation), the rescuer should activate must learn to recognize the signs and symptoms of stroke and the EMS system(phone 911), get an AED (if available), and to call EMS as soon as they detect any of them. The signs and return to the victim to provide CPR and defibrillation if symptoms of stroke are sudden numbness or weakness of the needed. When 2 or more rescuers are present, one rescuer face,arm,or leg, especially on one side of the body; sudden should begin the steps of CPr while a second rescuer confusion, trouble speaking or understanding; sudden troul activates the EMS system and gets the AED. If the emergency seeing in one or both eyes; sudden trouble walking, dizziness, occurs in a facility with an established medical respe loss of balance or coordination; and sudden severe headache system, notify that system instead of the EMS system. with no known cause. 81, 82 Healthcare providers may tailor the sequence of rescue EMS dispatchers should be trained to suspect stroke and ctions to the most likely cause of arrest. 92 If a lone healthcare rapidly dispatch responders 83 who should be able to perform provider sees an adult or child suddenly collapse, the collapse an out-of-hospital stroke assessment(Loe 3 to 5: Class is likely to be cardiac in origin, and the provider should phor Ila), 4-87 establish the time the patient was last known to be 911, get an AED, and return to the victim to provide CPr and "normal, "support the ABCs, notify the receiving hospital use the AED. If a lone healthcare provider aids a drowning that a patient with possible stroke is being transported there, victim or other victim of likely asphyxial(primary respira and consider triaging the patient to a facility with a stroke unit tory) arrest of any age, the healthcare provider should give 5 (OE 5 to 8: Class IIb).88-91 It may be helpful for a family cycles(about 2 minutes)of CPR before leaving the victim to member to accompany the patient during transport to verify activate the EMs system. the time of symptom onset. If authorized by medical control When phoning 911 for help, the rescuer should be prepare EMS providers should check the patient's glucose level to answer the dispatcher's questions about location, what during transport to rule out hypoglycemia as the of happened, number and condition of victims, and type of aid altered neurologic function and to give glucose if blood sugar provided. The caller should hang up only when instructed to is low do so by the dispatcher and should then return to the victim When the stroke victim arrives at the emergency depart- to provide CPR and defibrillation if needed. ment(ED), the goal of care is to streamline evaluation so that initial assessment is performed with Open the Airway and Check Breathing(Box 3) puted tomography(CT) scan is performed and interpreted To prepare for CPR, place the victim on a hard surface in within 25 minutes, and fibrinolytics are administered to face up(supine)position. If an unresponsive victim is face selected patients within 60 minutes of arrival at the ED and down(prone), roll the victim to a supine(face up)position.If vithin 3 hours of the onset of symptoms. Additional infor- a hospitalized patient with an advanced airway (eg, endotra- mation about the assessment of stroke using stroke scales and cheal tube, laryngeal mask airway [LMAl, or esophageal the management of stroke is included in Part 9: " Adult tracheal combitube [Combitube]) cannot be placed in the Stroke upine position (eg, during spinal surgery), the healthcare CPR with the patient in a prone Adult BLs Sequence position( Class IIb). See below The steps of BLS consist of a series of sequential assessments and actions. which are illustrated in the bls algorithm Open the Airway: Lay Rescuer The lay rescuer should open the airway using a head tilt-chin (Figure 2). The intent of the algorithm is to present the steps lift maneuver for both injured and noninjured victims(Class in a logical and concise manner that will be easy to learn, Ila). The jaw thrust is no longer recommended for lay remember, and perform. The box numbers in the following section refer to the corresponding boxes in the Adult BLS escuers because it is difficult for lay rescuers to learn and perform, is often not an effective way to open the airway, and Healthcare Provider Algorithm may cause spinal movement( Class IIb) Safety during CPR training and performance, including the use of barrier devices, is discussed in Part 3. Before approach Open the Airway: Healthcare Provider ing the victim the rescuer must ensure that the scene is safe. a healthcare provider should use the head tilt-chin lift Lay rescuers should move trauma victims only if absolutely maneuver to open the airway of a victim without evidence of necessary(eg, the victim is in a dangerous location, such as head or neck trauma. Although the head tilt-chin lift tech- nique was developed using unconscious, paralyzed adult olunteers and has not been studied in victims with cardiac Check for Response(Box 1) arrest, clinical93 and radiographic (LOE 3)evidence94, 95 and a Once the rescuer has ensured that the scene is safe, the case series (loe 5)96 have shown it to be effective rescuer should check for response. To check for response, tap Approximately 2% of victims with blunt trauma have a the victim on the shoulder and ask, "Are you all right? " If the spinal injury, and this risk is tripled if the victim has adetection of the signs of stroke, prompt activation of the EMS system, prompt dispatch of EMS personnel, rapid delivery to a hospital capable of providing acute stroke care, prearrival notification, immediate and organized hospital care, appro￾priate evaluation and testing, and rapid delivery of fibrino￾lytic agents to eligible patients.79,80 Patients at high risk for a stroke and their family members must learn to recognize the signs and symptoms of stroke and to call EMS as soon as they detect any of them. The signs and symptoms of stroke are sudden numbness or weakness of the face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; and sudden severe headache with no known cause.81,82 EMS dispatchers should be trained to suspect stroke and rapidly dispatch responders83 who should be able to perform an out-of-hospital stroke assessment (LOE 3 to 5; Class IIa),84–87 establish the time the patient was last known to be “normal,” support the ABCs, notify the receiving hospital that a patient with possible stroke is being transported there, and consider triaging the patient to a facility with a stroke unit (LOE 5 to 8; Class IIb).88–91 It may be helpful for a family member to accompany the patient during transport to verify the time of symptom onset. If authorized by medical control, EMS providers should check the patient’s glucose level during transport to rule out hypoglycemia as the cause of altered neurologic function and to give glucose if blood sugar is low. When the stroke victim arrives at the emergency depart￾ment (ED), the goal of care is to streamline evaluation so that initial assessment is performed within 10 minutes, a com￾puted tomography (CT) scan is performed and interpreted within 25 minutes, and fibrinolytics are administered to selected patients within 60 minutes of arrival at the ED and within 3 hours of the onset of symptoms. Additional infor￾mation about the assessment of stroke using stroke scales and the management of stroke is included in Part 9: “Adult Stroke.” Adult BLS Sequence The steps of BLS consist of a series of sequential assessments and actions, which are illustrated in the BLS algorithm (Figure 2). The intent of the algorithm is to present the steps in a logical and concise manner that will be easy to learn, remember, and perform. The box numbers in the following section refer to the corresponding boxes in the Adult BLS Healthcare Provider Algorithm. Safety during CPR training and performance, including the use of barrier devices, is discussed in Part 3. Before approach￾ing the victim, the rescuer must ensure that the scene is safe. Lay rescuers should move trauma victims only if absolutely necessary (eg, the victim is in a dangerous location, such as a burning building). Check for Response (Box 1) Once the rescuer has ensured that the scene is safe, the rescuer should check for response. To check for response, tap the victim on the shoulder and ask, “Are you all right?” If the victim responds but is injured or needs medical assistance, leave the victim to phone 911. Then return as quickly as possible and recheck the victim’s condition frequently. Activate the EMS System (Box 2) If a lone rescuer finds an unresponsive adult (ie, no move￾ment or response to stimulation), the rescuer should activate the EMS system (phone 911), get an AED (if available), and return to the victim to provide CPR and defibrillation if needed. When 2 or more rescuers are present, one rescuer should begin the steps of CPR while a second rescuer activates the EMS system and gets the AED. If the emergency occurs in a facility with an established medical response system, notify that system instead of the EMS system. Healthcare providers may tailor the sequence of rescue actions to the most likely cause of arrest.92 If a lone healthcare provider sees an adult or child suddenly collapse, the collapse is likely to be cardiac in origin, and the provider should phone 911, get an AED, and return to the victim to provide CPR and use the AED. If a lone healthcare provider aids a drowning victim or other victim of likely asphyxial (primary respira￾tory) arrest of any age, the healthcare provider should give 5 cycles (about 2 minutes) of CPR before leaving the victim to activate the EMS system. When phoning 911 for help, the rescuer should be prepared to answer the dispatcher’s questions about location, what happened, number and condition of victims, and type of aid provided. The caller should hang up only when instructed to do so by the dispatcher and should then return to the victim to provide CPR and defibrillation if needed. Open the Airway and Check Breathing (Box 3) To prepare for CPR, place the victim on a hard surface in a face up (supine) position. If an unresponsive victim is face down (prone), roll the victim to a supine (face up) position. If a hospitalized patient with an advanced airway (eg, endotra￾cheal tube, laryngeal mask airway [LMA], or esophageal￾tracheal combitube [Combitube]) cannot be placed in the supine position (eg, during spinal surgery), the healthcare provider may attempt CPR with the patient in a prone position (Class IIb). See below. Open the Airway: Lay Rescuer The lay rescuer should open the airway using a head tilt–chin lift maneuver for both injured and noninjured victims (Class IIa). The jaw thrust is no longer recommended for lay rescuers because it is difficult for lay rescuers to learn and perform, is often not an effective way to open the airway, and may cause spinal movement (Class IIb). Open the Airway: Healthcare Provider A healthcare provider should use the head tilt–chin lift maneuver to open the airway of a victim without evidence of head or neck trauma. Although the head tilt–chin lift tech￾nique was developed using unconscious, paralyzed adult volunteers and has not been studied in victims with cardiac arrest, clinical93 and radiographic (LOE 3) evidence94,95 and a case series (LOE 5)96 have shown it to be effective. Approximately 2% of victims with blunt trauma have a spinal injury, and this risk is tripled if the victim has a Part 4: Adult Basic Life Support IV-21