5.3 Emergency Response: CPR, Heimlich Maneuver, and Acute Events
Key Takeaways
- For a conscious adult exhibiting a partial airway obstruction with a forceful, productive cough, the nurse aide must not deliver abdominal thrusts or back blows, but must stay with the resident and encourage continuous coughing.
- If a conscious resident exhibits complete airway obstruction, the CNA must deliver rapid inward and upward abdominal thrusts (Heimlich maneuver) midway between the navel and xiphoid process until the object is expelled or the resident becomes unresponsive.
- High-quality Basic Life Support (BLS) follows the CAB sequence (Compressions, Airway, Breathing) with chest compressions delivered at a rate of 100 to 120 per minute at a depth of 2 to 2.4 inches, after first confirming the resident does not have an active DNR order.
- When a resident experiences a grand mal seizure, the nurse aide must ease the resident to the floor, protect the head, clear surrounding furniture, turn the resident onto their side to prevent aspiration, time the seizure, and never force any object into the mouth.
5.3 Emergency Response: CPR, Heimlich Maneuver, and Acute Events
In long-term care facilities, life-threatening clinical crises occur suddenly and without warning. Whether confronting acute foreign body airway obstruction during mealtime, sudden cardiac arrest, an evolving ischemic stroke, a violent tonic-clonic seizure, or profuse arterial hemorrhage, the Certified Nurse Aide's prompt recognition and precise manual execution of emergency protocols represent the critical dividing line between recovery, permanent neurological impairment, and death.
Foreign Body Airway Obstruction: Clinical Recognition & Management
Choking is a leading cause of accidental mortality among institutionalized older adults. Geriatric residents are highly vulnerable to airway obstruction due to physiological dysphagia (impaired swallowing reflex), neurological deficits from Parkinson's disease or stroke, ill-fitting dentures, dry oral mucosa (xerostomia), altered mental status, and sedating medications. The universal visual sign of choking is the resident clutching their hands tightly around their throat.
Clinical Distinction: Partial vs. Complete Airway Obstruction
When a resident begins to choke, the CNA must instantly determine whether the obstruction is partial or complete before intervening:
RESIDENT CLUTCHES THROAT / COUGHS AT MEALTIME
│
Assess Airway & Vocal Ability
│
┌────────────┴────────────┐
▼ ▼
PARTIAL OBSTRUCTION COMPLETE OBSTRUCTION
• Forceful coughing • Inability to speak, cry, cough
• Speaks short words • High-pitched stridor or silence
• Audible air exchange • Cyanosis around lips/nails
│ │
▼ ▼
DO NOT INTERFERE! EXECUTE IMMEDIATE HEIMLICH!
Encourage forceful Deliver rapid upward & inward
coughing; stay at bedside abdominal thrusts above navel
- Partial Airway Obstruction with Good Air Exchange: The resident is coughing forcefully, can speak in short words, and exhibits audible air exchange. CLINICAL MANDATE: DO NOT INTERFERE. Never deliver back blows or abdominal thrusts to a resident who is coughing forcefully. An individual's voluntary forceful cough creates significantly higher peak expiratory pressures than manual thrusts. Intervening prematurely can dislodge a partially seated food bolus, wedging it firmly into the subglottic space and converting a manageable partial obstruction into a lethal complete obstruction. The CNA must remain at the resident's side, provide calm reassurance, and continuously encourage forceful coughing until the obstruction clears.
- Complete Airway Obstruction (Poor or No Air Exchange): The resident is completely unable to speak, breathe, or cough; makes silent gasping efforts or produces high-pitched inspiratory stridor; exhibits facial congestion progressing rapidly to peripheral cyanosis (bluish tint around lips, mucous membranes, and nail beds); and displays extreme panic. This is an immediate life threat requiring instant emergency intervention.
Abdominal Thrusts (The Heimlich Maneuver) for the Conscious Adult
To relieve a complete airway obstruction in a conscious adult or older child, the CNA executes rapid abdominal thrusts:
- Assess and Announce: Rapidly ask the resident: "Are you choking? Can you speak?" If the resident nods and is unable to verbalize sound, announce clearly: "I am trained in first aid, I am going to help you."
- Stance and Positioning: Stand directly behind the resident. Place one of your feet slightly forward between the resident's legs to establish a broad, stable base of support. This stance prevents you from being pulled over if the resident suddenly collapses.
- Encircle the Abdomen: Wrap your arms around the resident's waist, beneath their armpits.
- Hand Placement: Make a tight fist with your dominant hand. Position the thumb side of your fist flat against the resident's abdomen in the midline, slightly above the navel (umbilicus) and well below the xiphoid process (the inferior tip of the breastbone). Never place your fist directly over the xiphoid process or ribs; doing so can fracture the sternal cartilage, lacerating the liver, spleen, or stomach.
- Grasp and Deliver Thrusts: Grasp your fist firmly with your other hand. Deliver a series of quick, forceful, distinct upward and inward thrusts (a sharp "J"-shaped vector). Each thrust must be a distinct, deliberate attempt to compress the diaphragm upward, forcing air from the lungs to pop the foreign obstruction out of the trachea like a cork from a bottle.
- Continue Until Cleared or Unconscious: Continue delivering rapid abdominal thrusts until the foreign object is forcefully expelled from the mouth, or the resident loses consciousness.
Clinical Modification: Chest Thrusts
When a choking resident is visibly pregnant (second or third trimester) or morbidly obese such that your arms cannot encircle their abdomen, abdominal thrusts are contraindicated. Instead, perform chest thrusts: stand behind the resident, wrap your arms directly under their axillae, place the thumb side of your fist against the center of the resident's sternum (mid-breastbone), grasp your fist with your other hand, and deliver rapid, backward thrusts straight into the chest cavity.
Protocol for the Unresponsive Choking Victim
If a choking resident loses consciousness during the delivery of thrusts, the nurse aide must immediately pivot to the unconscious choking protocol:
- Controlled Descent to the Floor: Support the resident's weight, carefully ease them backward down your forward thigh to the floor, and support their head and neck to prevent impact trauma. Ensure the resident is positioned flat on their back on a firm surface.
- Summon Immediate Emergency Assistance: Call out loudly for help: activate the emergency code pendant, summon the charge nurse, call 911, and request the facility's Automated External Defibrillator (AED) and emergency crash cart.
- Initiate Chest Compressions (BLS): Immediately begin cardiopulmonary resuscitation (CPR), starting with 30 chest compressions. Do not check for a pulse. Chest compressions create significant intrathoracic pressure that may dislodge the foreign body from beneath the vocal cords.
- Airway Inspection & The Strict Finger Sweep Rule: Open the airway using the head-tilt/chin-lift maneuver. Look inside the resident's mouth and pharynx. Perform a finger sweep ONLY IF the foreign object is clearly visible and within easy reach. Insert your hooked index finger along the inside of the cheek and sweep the object out. NEVER PERFORM A BLIND FINGER SWEEP. Sweeping blindly through an unvisualized airway can push a foreign food mass deeper into the larynx, completely impaction the airway, or induce severe pharyngeal lacerations and laryngospasm.
- Ventilation Attempts: Deliver 2 rescue breaths using a pocket mask or bag-valve-mask. If the chest does not rise, reposition the head (re-tilt the chin) and attempt 1 more breath. If the airway remains blocked, immediately resume 30 chest compressions. Continue the cycle of 30 compressions, airway visualization, and ventilation attempts until emergency medical responders arrive or the obstruction is relieved.
Basic Life Support (BLS) Foundations & Code Status
Resuscitation in long-term care must always align with the resident's legal advance directives and institutional code status:
- Code Status Verification: Before initiating resuscitation, staff must verify whether the resident has an active Do Not Resuscitate (DNR) order or Physician Orders for Life-Sustaining Treatment (POLST) indicating "No Code." If an active DNR order is documented in the medical record, CPR must be ethically and legally withheld, and the charge nurse summoned immediately to provide comfort care. If code status is Full Code or unknown, resuscitation must be initiated immediately without delay.
- The AHA CAB Sequence: High-quality resuscitation adheres strictly to the CAB sequence: Compressions - Airway - Breathing. High-quality chest compressions must take priority over ventilation to maintain critical coronary artery and cerebral blood perfusion.
Standards for High-Quality Adult CPR:
- Compression Rate: Deliver chest compressions at a rate of 100 to 120 compressions per minute (matching the tempo of the classic song "Stayin' Alive").
- Compression Depth: Compress the adult sternum to a depth of at least 2.0 inches (5 cm), but no greater than 2.4 inches (6 cm).
- Full Chest Recoil: Allow complete, unmitigated chest recoil at the end of each compression. Never lean on the resident's chest between compressions; incomplete recoil prevents the ventricles from refilling with venous blood, drastically reducing cardiac output.
- Hand Placement: Position the heel of one hand on the lower half of the sternum (center of the chest between the nipples); place your second hand directly over the first, interlocking your fingers. Keep your elbows locked straight with your shoulders positioned directly over your hands, using your upper body weight to compress.
- Minimize Interruptions: Limit all pauses in chest compressions (for rescue breaths, AED analysis, or pulse checks) to less than 10 seconds.
- Compression-to-Ventilation Ratio: Deliver 30 compressions followed by 2 rescue breaths for a single-rescuer adult resuscitation. Each breath is delivered over 1 second, observing for visible chest rise.
Acute Cardiovascular & Neurological Emergencies
Myocardial Infarction (Heart Attack)
Myocardial infarction occurs when coronary artery blood flow is acutely occluded, causing ischemic heart muscle necrosis. While classic symptoms include crushing substernal chest pressure, radiating pain down the left arm or into the jaw, diaphoresis (cold sweats), and acute shortness of breath, geriatric residents frequently experience "silent" or atypical heart attacks. In elderly females and individuals with diabetic neuropathy, heart attacks frequently present without chest pain, manifesting solely as sudden profound exhaustion, acute dizziness, epigastric nausea resembling indigestion, or sudden delirium.
CNA Actions: Keep the resident completely resting in a seated or Semi-Fowler's position to reduce cardiac oxygen demand; summon the charge nurse immediately; loosen restrictive neckwear; provide calm reassurance; and obtain baseline vital signs.
Acute Ischemic Stroke & The FAST Protocol
Stroke occurs when cerebral arterial blood flow is interrupted by an embolus or hemorrhage. Intravenous thrombolytic therapy ("clot-busting" tPA) must be administered within a narrow clinical window of 3 to 4.5 hours from symptom onset to dissolve clots and salvage brain tissue. CNAs utilize the validated FAST screening protocol:
| Letter | Assessment Dimension | Clinical Evaluation Method |
|---|---|---|
| F | Face Drooping | Ask the resident to smile or show their teeth. Observe for asymmetry, flattened nasolabial folds, or one side of the mouth drooping downward. |
| A | Arm Weakness | Ask the resident to raise both arms straight forward with palms up for 10 seconds. Observe if one arm drifts downward or cannot be lifted. |
| S | Speech Difficulty | Ask the resident to repeat a simple sentence ("The sky is clear today"). Note slurred speech, inappropriate words, or complete inability to speak (aphasia). |
| T | Time to Alert Nurse / 911 | Note the exact time symptoms began (or when the resident was last seen normal). Report this timestamp immediately to the nurse and 911 dispatch. |
Acute Seizure Management Protocols
Seizures in older adults stem from cerebrovascular accidents, metabolic imbalances, brain tumors, fever, or traumatic brain injuries. A generalized tonic-clonic (grand mal) seizure involves sudden loss of consciousness, violent muscle contractions, and jaw clenching. The CNA must execute strict protective protocols:
- Remain with the Resident: Never leave a seizing resident alone. Call out loudly to summon the charge nurse immediately.
- Safe Lowering to the Floor: If the resident is seated in a wheelchair or standing, ease them gently down to the floor to prevent high-impact fall injuries.
- Cushion the Head: Place a folded blanket, pillow, or jacket beneath the resident's head to protect the cranium from blunt trauma against the floor.
- Clear Surrounding Hazards: Move away bedside tables, chairs, trash cans, and electrical cords to prevent injury during motor spasms.
- Loosen Restrictive Clothing: Loosen tight collars, ties, or clothing around the neck to promote unrestricted ventilation.
- Turn to the Lateral Recovery Position: Gently turn the resident onto their side. The side-lying position allows saliva, blood, and vomitus to drain freely from the mouth by gravity, preventing fatal aspiration.
- ABSOLUTE PROHIBITION: Never Place Anything in the Mouth: Never force tongue depressors, spoons, bite blocks, or fingers into a seizing resident's clenched jaws. Forcing objects into the mouth fractures teeth, dislocates the jaw, causes severe bleeding, obstructs the airway, and risks severe bite amputations to the caregiver's fingers.
- Do Not Restrain Convulsive Movements: Never attempt to pin down or restrain the resident's shaking limbs. Fighting convulsive spasms causes bone fractures and muscle tears.
- Time the Seizure: Note the exact start time and duration of the convulsive activity.
- Post-Ictal Supportive Care: After convulsions cease, the resident enters a post-ictal phase characterized by deep sleep, confusion, and headache. Keep the resident on their side, maintain privacy, provide quiet reassurance, measure vital signs, and report all details to the charge nurse.
Emergency External Hemorrhage Control
Severe external bleeding from arterial lacerations or ruptured varicose veins can induce hypovolemic shock within minutes. The CNA must execute rapid hemorrhage control:
- Direct Continuous Manual Pressure: Don clean disposable gloves immediately. Place a sterile gauze pad, clean washcloth, or towel directly over the bleeding wound and apply firm, continuous manual pressure. Direct pressure compresses bleeding vessels against underlying anatomical structures, initiating the physiological clotting cascade.
- Maintain and Reinforce Dressings: If blood saturates and seeps through the initial gauze dressing, DO NOT REMOVE THE SOAKED DRESSING. Peeling away saturated gauze tears away fragile, newly formed blood clots and fibrin strands, triggering heavier bleeding. Instead, place fresh sterile gauze pads directly on top of the saturated layer and maintain firm, uninterrupted pressure.
- Elevation Above Heart Level: If an extremity (arm or leg) is bleeding and there are no signs of bone fracture, elevate the limb above the level of the resident's heart while maintaining direct pressure. Elevation reduces hydrostatic arterial pressure at the wound site, slowing blood loss.
- Monitor for Hypovolemic Shock: Alert the charge nurse immediately and monitor for signs of decompensating shock: cool, pale, clammy skin; rapid, thready pulse; rapid, shallow respirations; progressive confusion; and hypotension. Keep the resident lying flat and warm with blankets.
While dining in the facility dining room, a resident begins to cough forcefully and gasps while eating solid food. The resident's face is slightly flushed, but they are able to speak in short phrases and make loud coughing sounds. What is the CNA's proper response?
A nurse aide enters a room and finds a resident lying on the floor experiencing an active, violent grand mal seizure with clenched jaws. Which action represents safe clinical care?
While performing morning care, a certified nurse aide notices that a resident has sudden right-sided facial sagging and slurred speech. When asked to raise both arms, the resident's right arm drifts downward. In the FAST stroke recognition protocol, what does the letter "T" represent?