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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 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!"
CPR TRAINING
As a first responder and/or a health care provider, you should successfully complete a CPR course through a recognized agency such as the American Heart Association (AHA), the National Safety Council (NSC), or the American Red Cross (ARC). These courses may be available through your local regional offices or your local hospitals and the fees usually range from about $25 to $65, depending on the facility and program. You should update your skills by successfully completing a recognized re-certification course. I highly recommend taking the course designed for health care providers since this course includes not only adult CPR, but also infant CPR.
Proficiency in CPR cannot be achieved without adequate practice on adult and infant manikins. You or your workplace should schedule periodic reviews of CPR theory and practice for all people who are trained as first responders.
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.
LEGAL IMPLICATIONS OF CPR
Living wills and advance directives are legal documents in which patients request that specified medical procedures not be started on them. 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.
First responders sometimes wonder if they should start CPR on a person who has a living will or advance directive. Because you are not in a position to determine if the living will or advance directive is valid, CPR should be started on all patients unless they are obviously dead. If a patient has a living will or advance directive, the physician at the hospital will determine whether or not to stop CPR. You should check your local policies and protocols on this matter.
Do not hesitate to begin CPR on a pulseless, non-breathing patient. Without your help, the patient will certainly die. You may have legal problems if you begin CPR on a patient who does not need it if this action harms the patient. However, the chances of this happening are minimal if you assess the patient carefully before beginning CPR.
Another potential legal pitfall is abandonment - the discontinuing of CPR without the order of a licensed physician or without turning the patient over to someone who is at least as qualified as you are.
To avoid these pitfalls, you need not be overly concerned about legal implications of performing CPR. Your most important protection against possible legal suit is to become thoroughly proficient in the theory and practice of CPR.
CREATING SUFFICIENT SPACE FOR CPR
As a first responder, you will frequently find yourself alone with a patient experiencing cardiac arrest. One of the first things you must do is to create or find a space in which to perform CPR. Ask yourself, "Is there enough room in this location to perform CPR?" To perform CPR effectively, you need 3 to 4 feet of space on all sides of the patient. This allows for the change of rescuers, the institution of advanced life support (ALS) procedures, and the entry of the ambulance stretcher.
If there is not enough space around the patient, you have two options:1. Quickly rearrange the furniture in the room to make space.
2. Quickly drag the patient into an area that has more room, for instance, out of the bathroom and into the living room - not the hallway.
Space is essential to a smooth rescue operation following cardiac arrest. It only takes 15 to 30 seconds either to clear a space around the patient or to move the patient into a larger area.
COMPLICATIONS OF CPR
A discussion of CPR would not be complete without mention of its complications. They can be minimized by using proper technique.
BROKEN BONES
If your hands slip to the side of the sternum during chest compressions, or if your fingers rest on the ribs, you may break ribs while delivering a compression. To prevent this, use proper hand position and do not let your fingers come in contact with the ribs. If you hear a cracking sound while performing CPR, check and correct your hand position but continue CPR. Sometimes you may break bones or cartilage even with proper CPR technique.
GASTRIC DISTENSION
Bloating of the stomach is called gastric distension and is caused by too much air blown too fast and too forcefully into the stomach. It may also be caused by a partially obstructed airway, which allows some of the air you breathe into the patient's airway to go into the stomach rather than into the lungs.
Gastric distension causes the abdomen to increase in size. A distended abdomen pushes up on the diaphragm, preventing adequate lung inflation. Gastric distension also often causes vomiting. If vomiting occurs, quickly turn the patient to the side, wipe out the mouth with your gloved fingers, and then return the patient to a supine position.
Gastric distension is mentioned here so you will work hard to prevent it. Make sure you have completely opened the airway and you are not blowing excessive amounts of air into the patient. Be especially careful if you are a large person with large lung capacity and the patient is smaller than you are. When ventilation becomes very difficult because of gastric distension, you can relieve the gastric distension by turning the patient's entire body to one side and pressing on the upper abdomen. Although this technique usually relieves the distension, it is also likely to make the patient vomit.
VOMITING
Vomiting is common during CPR, so you must be prepared to deal with it. There is not much you can do to prevent vomiting, except to keep air out of the patient's stomach. Vomiting is likely to occur if the patient has suffered cardiac arrest. The patient may have just consumed a large meal. When cardiac arrest occurs, the muscle that keeps food in the stomach relaxes, causing the patient to vomit.
If the patient vomits while you are administering CPR, immediately turn the patient onto his or her side to allow the vomitus to spill out of the mouth. Then clear the patient's mouth of remaining vomitus, first with your fingers and then with a clean cloth (if one is handy).
The patient may experience several rounds of vomiting, so you must be prepared to take these actions repeatedly. EMS units carry a suction machine with which to clear the patient's mouth. You cannot wait for one's arrival, however, because you must not wait to begin or resume CPR.
You must be sure that the patient's airway is clear for three primary reasons:1. The patient may breathe in (aspirate) the vomitus.
2. You may force vomited material into the lungs with the next artificial ventilation.
3. It takes a strong stomach and the realization that you are saving the patient's life to continue with resuscitation. But you must continue. Remove the vomitus with a towel, the patient's shirt, your fingers, or any other available object. As soon as you have cleared away the vomitus, take a deep breath and continue rescue breathing.
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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