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BLS Positioning: Best Practices

When performing BLS in the field, it is important to have the patient and the caregivers in the best position possible.  Sometimes, the manner of the victim’s incapacitation leads to attempting CPR in awkward positions.  However, compressions are very much about the physics of the action, and if you don’t have the patient in the right position, the chances of those compressions being effective dwindle.  In EMS situations, the problem with patient positioning takes on a whole new meaning as it is difficult to position someone who has undergone trauma.

Even in the hospital, though, you have to have the correct positioning for compressions to be the most effective.  For instance, attempting to perform CPR on a patient who is lying in a soft bed will not result in the best perfusion.  Similarly, it may be difficult to array around the patient all of the personnel who respond to the situation.  Once ACLS starts, this problem compounds, but even in BLS, it is a tightly choreographed dance to get rescue breaths and compressions to the patient in a timely manner.  It does take more than two people to perform BLS effectively, but only two at a time can actually work on the victim.

Patient Orientation

For the best results, the patient should be flat on their back, on a hard surface, with their head accessible.  As most EMS workers know, this is not always possible.  It is difficult to decide to move a patient into the correct position for CPR when you are not sure of the other injuries they may have sustained.  Cardiac arrest is a life threatening condition, though, and that usually means that you can move patients even if they are not spinal cleared.  However, you may find an arresting patient in a car and they are unable to be moved at all.

It is very difficult to move a patient in the field into the position of best practice.  Even in public places, there just may not be enough room to stretch the patient out for chest compressions.  In this case, it is important to get the patient out as quickly as possible to a stretcher and hopefully, to the ambulance.  With the use of a backboard, you can perform effective CPR in the rig, but the time it takes to get them there is critical.  As an EMS worker, you have to use your best judgment on how and why you choose to move a patient for CPR.

Use of Backboard

Backboards are vital in the positioning of BLS patients.  For compressions to work, the heart has to be squeezed between the pistoning of the hands and a hard surface.  Beds, dirt, and other soft surfaces do not provide this squeezing, and it can impact how well the compressions move blood through the victim’s body.  For this reason, backboards are used to ensure that the compressions are effective and help with the overall survival of the patient.

It is easy to run into a room or a scene and start compressions, but you need to think about the mechanics involved.  Especially if the patient is on a bed, you need to roll them to the side, slide a hard board under their shoulders, and then resume compressions.  If you forget, you can severely impact your patient’s ability to overcome the cardiac arrest.  Most crash carts have short backboards for this usage, and ambulances have an abundance of boards that can be used.  The problem is that it is sometimes easy to forget to have them in place while the rush of BLS is on you.  Remember that you need to press against something, and a soft surface will not provide the amount of resistance you need.

Placement of BLS Care Team

It takes a group of people to perform effective BLS, but you may not have the luxury of a group.  If you are approaching the victim on your own, then you will want to focus only on compressions.  However, compressions are exhausting, and they can very quickly lead you to poor performance or unable to continue.  This is why it is helpful to have more than one person working compressions.  If the first person is unable to continue, the second can step in.

The other important part of this team is the person giving the rescue breaths.  If there is more than one person, then rescue breaths can be attempted, and the two can switch between jobs to take some of the strain off the compressor.  With a whole team, though, usually one person can work the bag-valve-mask while several rescuers switch off with compressions.  It is through this teamwork and switching out that BLS is performed effectively by rescuers.  One person should be at the head for breaths.  One should be on the chest doing compressions, and one or more people should standby to take over the compressions when the other becomes exhausted.