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CARDIOPULMONARY RESUSCITATION
Adult CPR, Two Rescuer


IMPORTANT!: Cardiopulmonary resuscitation (CPR) is a procedure used to maintain blood circulation throughout the body until the Emergency Medical Services (EMS) can respond to the emergency. You must never perform CPR unless you have completed an approved course, taught by an approved instructor. The American Heart Association and the American Red Cross both offer such courses in communities across the country. The information on this page is not intended to take the place of an approved course. Everybody should take a course in CPR and become proficient in first responder care. This is especially important if you have or take care of children, the elderly, or someone with cardiac or breathing problems. Contact your local AHA, ARC, or local hospital about classes in CPR and become certified today!"



COMPONENTS OF CPR

The skill of cardiopulmonary resuscitation consists of three parts:
  • A (airway) skills.

  • B (breathing) skills.

  • C (circulation) skills.

Before beginning CPR, you need to know how to determine if the airway is open and to correct a blocked airway by using the head-tilt/chin-lift or jaw-thrust technique. You need to know how to determine if the patient is breathing by using the look, listen, and feel technique. You need to know how to correct the absence of breathing by performing rescue breathing.

To perform CPR, you must combine the airway and breathing skills with the circulation skills. You do this by checking for a pulse. If there is no pulse, you must correct the patient's circulation by performing external chest compressions. The airway and breathing components push oxygen into the patient's lungs. The external chest compressions move the oxygenated blood through the body. External chest compressions are done by depressing the patient's sternum (breastbone). This causes a change in the pressure of the patient's chest and causes enough blood to flow to sustain life for a short period of time.

CPR by itself cannot sustain life indefinitely. It should be started as soon as possible to give the patient the best chance of survival. It is only by performing all three parts of the CPR sequence that you can keep the patient alive until more advanced medical care can be administered. In many cases, the patient will need defibrillation and medication in order to recover from cardiac arrest.





SIGNS OF EFFECTIVE CPR

It is important to know the signs of effective CPR so you can assess your efforts to resuscitate the patient. The signs of effective CPR are:
    1. A second rescuer feels a carotid pulse while you are compressing the chest.
    2. The patient's pupils constrict when they are exposed to light.
    3. Independent breathing begins or the patient gasps. 4. An independent heartbeat, which is the goal of CPR, begins. This does not occur often without advanced life support procedures.

If some of these signs are not present, evaluate your technique to see if it can be improved.





WHEN TO START & STOP CPR

CPR should be started on all non-breathing, pulseless patients, unless they are obviously dead. Few reliable criteria exist by which death can be determined immediately. The following criteria are reliable and indicate that CPR should not be started.
    1. Decapitation: Decapitation occurs when the head is separated from the rest of the body. When this occurs, there is obviously no chance of saving the patient.

    2. Rigor mortis: This is the temporary stiffening of muscles that occurs several hours after death. The presence of this stiffening indicates the patient is dead and cannot be resuscitated.

    3. Evidence of tissue decomposition: Tissue decomposition or actual flesh decay occurs only after a patient has been dead for more than a day.

    4. Dependent lividity: Dependent lividity is the red or purple color that occurs on the parts of the patient's body that are closest to the ground. It is caused by the person's blood seeping into the tissues on the dependent, or lower, part of the person's body. Dependent lividity occurs after a person has been dead for several hours.

If any of the preceding signs is present in a pulseless, non-breathing person, you should not begin CPR. If none of these signs is present, you should begin CPR. It is far better to start CPR on a person who is later declared dead by a health care provider than to withhold CPR from a patient whose life might have been saved.

Remember: Unless you are sure that a person is obviously dead, activate the EMS system and then begin CPR.





WHEN TO STOP CPR

You should discontinue CPR only when:
    1. Effective spontaneous circulation and ventilation have been restored.
    2. Resuscitation efforts have been transferred to another trained person who continues CPR.
    3. A physician assumes responsibility for the patient.
    4. The patient is transferred to properly trained EMS personnel.
    5. Reliable criteria for death (as previously listed) are recognized.
    6. You are too exhausted to continue resuscitation, environmental hazards endanger your safety, or continued resuscitation should place the lives of others at risk.





ADULT CPR, TWO RESCUER


In many cases, a second trained person will be on the scene to help you perform CPR. Two-person CPR is more effective than one-person CPR. One rescuer can deliver chest compressions while the other performs rescue breathing. Chest compressions and ventilations can be given more regularly and without interruption. Two-person CPR is also less tiring for the rescuers. You and a partner can continue to perform effective CPR for a longer period of time than you could alone.

Standard precautions should be followed if all possible. This means gloves should be worn and a barrier device should be used. If the victim is bleeding, a gown and mask may also be necessary. These items should be readily available in a health care facility. In the field, or at home, these items may or may not be available. However, CPR should be initiated and maintained regardless of standard precautions if it means that a life could be saved.

Careful assessment is required before CPR is administered.



In two-person CPR, one rescuer delivers ventilations (mouth-to-mouth or mouth-to-mask breathing) and the other gives chest compressions. Position yourselves on either side of the patient. The sequence of steps is the same as for one-person CPR, but the tasks are divided as follows:

1. Rescuer One determines the patient's state of consciousness by gently shaking the person's shoulder and asking him, "Are you okay?" Call the victim's name if you know it.

2. Call 9-1-1 to activate the EMS system if the patient is unconscious. If other people are present, as them to call for EMS. If only two rescuers are present, one will have to leave to call and return to the victim as soon as possible.

3. Turn the victim on his back as a unit, supporting the head, neck, and back. For CPR to be effective, the victim must be lying on his back on a hard surface.



4. Rescuer One opens the airway using the head-tilt, chin-lift technique or jaw-thrust technique.

5. Rescuer One maintains the open airway with the head-tilt, chin-lift technique and places his or her ear near the victim's mouth and nose. At the same time, s/he is observing the victim's chest. Rescuer One is looking, listening, and feeling for any signs that the victim may be breathing. Watch for chest movement and look, listen, and feel for 3 to 5 seconds. If victim is breathing, maintain open airway, monitor breathing, call EMS if not done earlier.



6. If there are no signs of breathing, Rescuer One seals the victim's nose with his/her thumb and forefinger and seals the victim's mouth using your mouth or a barrier device.

7. Rescuer On ventilates 2 times, taking in 1-1/2 to 2 seconds for each ventilation. Allow the chest to deflate between ventilations. Watch the chest rise to determine if enough air is getting through.



8. After the ventilation, Rescuer One assesses for the presence of a heartbeat. Maintain the open airway, using the head-tilt technique or jaw-thrust technique, with one hand. With the other hand, feel the victim's carotid pulse on the near side of the victim. Take 5 to 10 seconds to determine whether there is a pulse. If there is a pulse, but no respirations, continue with ventilations at a rate of 1 every 5 seconds (12 per minute). Continue to check periodically for a pulse.





9. If there is no pulse, Rescuer Two begins chest compressions at the ratio of 5 compressions to 1 ventilation. Kneel by the victim's shoulders and determine proper hand placement. Your shoulders should be over the victim's sternum. Using correct hand placement and technique, compress the victim's chest 1-1/2 to 2 inches. While doing compressions, as Rescuer Two, you must:

  • Place your bottom hand over the victim's sternal notch.

  • Place your other hand on top of your bottom hand - only the heel of your bottom hand should be touching the victim's chest.

  • Keep your elbows straight, with your shoulders directly over the victim's sternum.

Compress 1-1/2 to 2 inches each time.
  • Maintain hand contact with the victim's chest.

  • Allow the chest to relax during the upstroke.

  • Use a compression rate of 80 to 100 compressions per minute.

  • Count out loud during compressions: one and, two and, three and,...

  • After the 5th compression, Rescuer Two tells Rescuer One to ventilate the victim. ("Breathe") Rescuer Two should pause compressions just long enough for Rescuer One to ventilate once.



10. Do 5 compressions to 1 ventilation per cycle.

11. Rescuer One places his or her fingers on the carotid pulse of the victim periodically, while Rescuer Two continues with compressions. If the compressions are done correctly, Rescuer One should feel a beat for each compression. This confirms adequate CPR is being accomplished.
  • 5 compressions and 1 ventilation for each cycle.

  • Take 1-1/2 to 2 seconds for each ventilation.

  • Observe chest rise to check for effectiveness of ventilations.

  • Use a compression rate of 80 to 100 compressions per minute.

12. Every few minutes, Rescuer One should feel for the carotid pulse and then ask Rescuer One to stop compressions. If the victim/patient's heart is beating on its own, Rescuer One can feel a pulse. In this case, compressions can be stopped. Rescue breathing should be continued until spontaneous breathing resumes. If there is no pulse, CPR should be resumed.

Compressions and ventilations should remain rhythmic and uninterrupted. By counting out loud, Rescuer Two can maintain delivery of compressions at the rate of 80 to 100 per minute and also let Rescuer One know when to ventilate the patient's lungs. Once you and your partner establish a smooth pattern of CPR, do not stop, except for 5 seconds to check for a return of the victim/patient's pulse or to move the victim/patient.

Note: Two-person CPR is not performed on infants because they are too small to be worked on by two people. See Infant CPR for more information.





SWITCHING RESCUERS

If two-person CPR must be continued for a long period of time, you or your partner may become exhausted. If this occurs, it helps to switch positions. A switch allows the person giving compressions (Rescuer Two) to rest his or her arms. Switch only when necessary, and do it as smoothly as possible so the break in rate and regularity of compressions and ventilations is minimal. There are many orderly ways to switch positions. You should learn the method practiced in your EMS system. One method is as follows:
    1. As Rescuer Two becomes tired, he or she says the following out loud (instead of counting): "we---will---switch---next---time." One word is spoken as each compression is done. These words replace the counting sequence for these five compressions.

    2. After this sentence is spoken, Rescuer One completes one ventilation after the fifth compression and then moves to the chest to do the compressions.

    3. Rescuer Two completes the fifth compression and moves to the head of the victim/patient to maintain the airway and ventilation.

    4. Rescuer Two then checks the carotid pulse for 5 seconds. If the carotid pulse is absent, Rescuer Two says "No Pulse" and ventilates the victim/patient once.

    5. Rescuer One then begins compressions.



You should practice switching until you can do it smoothly and quickly. Switching is much easier if the rescuers work on opposite sides of the victim/patient.




RELATED CPR LINKS

  • ADULT CPR, ONE PERSON RESCUER

  • ADULT CPR, TWO PERSON

  • CHILD CPR, ONE PERSON (Patient Age: 1 year to 8 years old)

  • INFANT CPR, ONE PERSON (Patient Age: Less than 1 year old)

  • CPR COMPLICATIONS & LEGALITIES


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