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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 received appropriate training, taught by an approved instructor. You must successfully complete an approved course before you perform these procedures. 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.
THE CARDIAC CHAIN OF SURVIVAL
In most cases of cardiac arrest, CPR by itself will not be enough to save lives. It is the first link in the American Heart Association's "chain of survival", which includes the following links:1. Early access to the emergency medical services (EMS) system.
2. Early CPR.
3. Early defibrillation.
4. Early advanced care by paramedics and hospital personnel.
As a first responder, you have the ability to help the patient by providing early CPR and by making sure that the EMS system has been activated. Some first responders may also be trained in the use of automated defibrillators. By keeping these links of the chain strong, you will help to keep the patient alive and early advanced care can be administered by paramedics and hospital personnel.
Just as an actual chain is only as strong as its weakest link, so too this CPR chain of survival is only as good as its weakest link. Your actions in performing early CPR are vital to giving cardiac arrest patients their best chance for survival.
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 non 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.
IF YOU WORK IN A HEALTH CARE FACILITY:
In a health care facility, you must know whether CPR is to be initiated. A patient who is very elderly or who has a terminal illness may not wish to be resuscitated if cardiac arrest occurs. In these cases the physician must write an order "do not resuscitate" (DNR) or "no code". This order is placed within the patient's file and should be reviewed by patient care employees prior to a cardiac arrest incident. If there is no DNR order, full life support measures are given for cardiac arrest.
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.
CHILD CPR, ONE RESCUER
A child is defined as anyone between the age of 1 and 8 years of age. If the child is older than 8 years, CPR and management of obstructed airway is done the same as for adults. The principles of CPR are the same for adults and children. In actual practice, however, you must use slightly different techniques for a child between the ages of 1 and 8 years old. The steps for one-person CPR for a child are listed below.
NOTE DIFFERENCES BETWEEN CPR ON A CHILD AND ADULTS:
CPR on a child is usually performed by one person only.
Use less force to compress the child's chest as compared to an adult.
Use only one hand to depress the sternum 1- to 1-1/2 inches.
Use less force to ventilate a child. Ventilate only until the child's chest rises.
The rate of compressions is 100 per minute, instead of 80 to 100 compressions for an adult.
Breaths should be given at a rate of one breath every 3 seconds instead of one breath every 5 seconds for an adult.
STANDARD PRECAUTIONS
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.
STEPS IN ONE-PERSON CPR FOR A CHILD
Careful assessment is required before CPR is administered.
1. Establish the child's level of responsiveness. Tap and gently shake the child's shoulder and shout "Are you okay?" Call the patient's name if you know it.
2. Call out for help. If someone responds to your call, send that person to call 911 to activate the EMS system. If no one responds to your call, give one minute of rescue support and then call the EMS system yourself and return to the patient as soon as possible.
3. Turn the child on his or her back while supporting the head and neck. For CPR to be effective, the child must be lying on his or her back on a hard surface, such as the floor or on a table top.
4. Open the airway, using a head tilt-chin lift technique. If the child has experienced injuries that may include spine and/or neck trauma, use the jaw-thrust technique instead of the head-tilt, chin-lift technique to prevent further trauma to the neck and/or spine. Maintain an open airway.
5. Check for breathing. Place the side of your face and your ear close to the nose and mouth of the child. At the same time, observe the child's chest. You are looking, listening, and feeling for any signs that the child may be breathing. You should look, listen, and feel for air movement of the chest, listen for sounds of air movement along side of your face and check for breathing for 3 to 5 seconds. If signs of breathing are absent, place your mouth over the child's mouth, seal the child's nose with your thumb and index finger, and begin mouth-to-mouth rescue breathing. A mouth-to-mask ventilation device may be used. If the child is breathing, maintain open airway, monitor breathing, call EMS if not done earlier. Place a breathing child in recovery position (on the left side).
6. Give 2 slow breaths. Blow and ventilate slowly for 1- to 1-1/2 seconds for each ventilation using just enough force to make the chest rise. Allow enough time for the lungs to deflate between breaths. Watch the chest rise to determine if enough air is getting through.
8. Check for circulation. Locate the child's larynx with your index and middle finger. Slide your fingers into the groove between the larynx and the muscles at the side of the neck to feel for the carotid pulse. Check for 5 to 10 seconds to determine whether there is a pulse. If there is a pulse, but no respirations, continue with rescue breathing at a rate of 1 every 3 seconds (20 per minute). If the pulse is absent, proceed to step 9.
9. If there is no pulse, begin chest compressions. Place the heel of one hand on the lower third of the sternum, two fingers widths above the xiphoid process. Place the other hand on top and apply 5 compressions. Each compression should be about 1 to 1-1/2 inches and at the rate of 100 compressions per minute. Count the compressions out loud: "One and two and three and...."
10. After 5 chest compressions, ventilate the patient's lungs. Deliver 1 slow breath. Repeat the cycle.
11. Check for pulse. After 1 minute and every few minutes thereafter, check for a carotid pulse. If there is no pulse, continue the cycle of 5 compressions to 1 breath.
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 contract when they are exposed to light.
3. The patient's skin color improves (from blue to pink).
4. Independent breathing begins or the patient gasps.
5. 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.
AIRWAY OBSTRUCTION DESCRIPTION & PREVENTION
DESCRIPTION
Choking can result in unconsciousness and cardiopulmonary arrest. It is often caused by food or other foreign body lodged in the throat (airway). Indeed, choking caused by foreign-body airway obstruction accounts for about 3,000 deaths each year. Recognition and proper management of choking is of key importance to safety at home and in restaurants and other public places. (Other conditions that may cause unconsciousness or airway obstruction but are managed differently include stroke, epilepsy, swelling due to infection, head injury, intoxication, overdose, coma of any cause, and heart arrest.)
PREVENTION
Adults:
- Cut food into small pieces, bite sized pieces.
- Chew food slowly and thoroughly before swallowing, especially if you are wearing dentures.
- Avoid laughing and talking while chewing and swallowing. Intensive breathing or a sudden intake of air (such as when laughing or talking) can cause food to be inhaled with the breath and lodged in the throat. There is a reason we are told not to speak with our mouths full of food, other than it being socially unattractive.
- Avoid excessive intake of alcohol before and during meals. Never give food or drink to an unconscious person or someone with severely altered mental states who are unable to effectively chew and swallow their food or drink.
Infants & Children:
- Keep marbles, small toys, deflated balloons, beads, thumbtacks, plastic bags and other small and pliable objects out of their reach and prevent them from walking, running, or playing when they have food or toys in their mouth. Childproof your home for small babies and children. Keep your floors clean of debris and watch your baby outdoors for objects they can stick in their mouths (such as bugs, rocks, twigs). Babies are well known for sticking anything and everything in their mouths.
- Inspect clothing and toys frequently for loose objects (such as buttons) or broken pieces that can be be placed in the mouth.
- Do not allow babies and small children to wear jewelry they can get loose and put in their mouth (such as earrings, bracelets, necklaces, barrettes).
- Keep pills (as well as other medications - not only can they be a choke hazard but can be poisonous for a small child), small candies, chewing gum, and other small food objects out of reach of small children and babies.
Supervision is important in the prevention of choking problems in children.
CHILD WITH FOREIGN BODY AIRWAY OBSTRUCTION
CONSCIOUS CHILD
1. Ask "Are you choking?" If the child is breathing and continues to be able to speak or cough, do not interfere but take the child to an advanced life support facility (usually an emergency room at a nearby hospital). If the child has a fever and a history of illness, the air passages may be swollen. Transport immediately to an emergency care facility. Determine there is an airway obstruction by observing breathing difficulties such as the child is unable to speak or has a weak or absent cry, has ineffective coughing and high-pitched. Immediately begin the obstructed airway sequence as described below.
2. Give abdominal thrusts. Abdominal thrusts are not recommended in infants. Abdominal thrusts can be performed while standing or if the child is small, it can be done with the rescuer on his or her knees. If the patient is lying on the floor, the rescuer can straddle the patient's knees or feet to perform the procedure.
3. Repeat thrusts until foreign body is removed or the child becomes unconscious.
IF THE CHILD BECOMES UNCONSCIOUS
4. Call out for help. If someone responds, have that person call and activate the EMS system.
5. Perform tongue-jaw lift. Do not perform a blind finger-sweep, but remove the foreign body if you can see it using a finger sweep to remove it. Blind finger sweeps should not be performed on infants or small children.
6. Open airway and try to do rescue breathing. If still obstructed, reposition head and try to do rescue breathing again.
7. Give up to 5 abdominal thrusts.
8. Repeat steps 5 through 7 until effective. If the child is breathing or begins breathing, place in recovery position.
9. If airway obstruction is not relieved after about one minute, activate the EMS system if it has not been done already.
OBSTRUCTED AIRWAY: UNCONSCIOUS CHILD
1. Establish unresponsiveness. If another person is present, have that person activate the EMS system.
2. Open airway and try to ventilate. If unsuccessful, reposition head and try ventilations again.
3. Give up to 5 abdominal thrusts.
4. Perform tongue-jaw lift, remove foreign body only if you can see it.
5. Repeat steps 2 to 4 until effective. If child is breathing or resumes breathing, place in recovery position.
6. If airway obstruction is not relieved after about one minute, activate the EMS system, if it has not been done already.
7. Reposition head, check mouth seal, and try again to give rescue breaths.
8. Activate the EMS system. If someone else is available, have that person make the call.
9. Deliver up to 5 back blows.
10. Deliver up to 5 chest thrusts.
11. Do tongue-jaw lift and remove foreign body if you can see it.
12. Try to do rescue breaths again.
13. Repeat steps 9 through 12 until successful.
14. If you are alone and your efforts are unsuccessful, activate the EMS system after about one minute of effort.
15. Check for pulse and respirations when obstruction is removed.
16. If infant is breathing, place in recovery position. Maintain open airway and monitor pulse and breathing. If there is no breathing, give 20 rescue breaths per minute and monitor the pulse.
17. If there is no pulse, give 2 rescue breaths and start cycles of compressions and breaths. If there is a pulse, open airway and check for breathing.
EMERGENCY MEDICAL SERVICES (EMS) SYSTEM
When you begin first aid for choking or cardiopulmonary resuscitation, you must consider the victim to need advanced life support. He or she will have the best chance of surviving if your community has an Emergency Medical Services system. This system includes an efficient communications-alert system, such as telephone #911, of which the public is well aware with well-trained rescue personnel (EMTs & Paramedics) who can respond rapidly with properly equipped vehicles and an emergency facility that is open 24 hours a day to provide advanced life support as well as an intensive care section in the hospital. You should work with all interested agencies to achieve such a system if your community does not have one in place.
Keep important phone numbers readily available by posting them near your phone and/or other easily accessible place (such on the refrigerator door or posted on your computer monitor) and/or having them stored in your wireless phone memory to use when needed.
Emergency Telephone Numbers
From home: ______________________________________
From work: ______________________________________
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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