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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.
INFANT CPR, ONE RESCUER
An infant is defined as anyone under one year of age. The principles of CPR are the same for adults and infants. In actual practice, however, you must use slightly different techniques for an infant. The steps for one-person CPR for infants are listed below.
NOTE DIFFERENCES BETWEEN CPR ON INFANTS AND ADULTS:
CPR on infants is always performed by one person only.
The ratio is always 1 rescue breath (ventilation) to 5 compressions.
Breaths are given with rescuer's mouth covering infant's nose and mouth.
Breaths must be gentle.
Circulation is assessed by taking the brachial pulse rather than the carotid pulse.
Chest compressions are administered by placing your index finger below an imaginary line between the nipples, with middle and ring fingers placed next to index finger. Compress sternum only 1/2 to 1 inch at least 100 times per minute.
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.
INFANT CPR OVERVIEW
Careful assessment is required before CPR is administered.
Infants who have suffered cardiac arrest will be unconscious and not breathing. They will nave no pulse. to check for cardiac arrest, you first need to check and correct the airway. Do not tilt the head back too far as this may occlude the infant's airway. Next check for breathing by using the look, listen and feel technique. Correct the absence of breathing by giving mouth-to-mouth-and-nose breathing. (See Obstructed Airway instructions at the bottom of this page.)
To check for the presence of circulation, feel for the brachial pulse on the inside of the upper arm. Use two fingers on one hand, while maintaining the head tilt with the other hand. If there is no pulse, you must begin chest compressions.
Draw an imaginary line between the two nipples, and place your index finger below the imaginary line in the middle of the chest. Place your middle and ring fingers next to your index finger. Use your middle and ring fingers to compress the sternum. Make sure you do not compress above the xiphoid process. Compress the sternum about 1/2 to 1 inch (approximately 1/3 to 1/2 the depth of the chest). Compress the sternum at least 100 times per minute. You will give one rescue breath after every 5 chest compressions.
When doing chest compressions on an infant, you can place the infant on a solid surface such as a table or you can cradle the infant in your arm, as shown below.
You will not need to use much force to achieve adequate compressions on infants because they are so small and their chests are so pliable (which is why taking a training course is so important to learn and do proper technique and practice on CPR "dummies").
STEPS IN ONE-PERSON CPR FOR INFANTS
1. Support infant's head and shoulders and place infant on his or her back on a firm surface. Position the infant with his or her face up on a firm surface, such as a table top or cradle in the rescuer's arm (as seen above).
2. Establish the infant's level of responsiveness. An unresponsive infant is limp. Gently shake or tap the infant on his or her shoulder to determine whether he or she is unconscious. Call for additional help if the patient is unconscious. Activate the EMS system by calling 911. If there is more than one rescuer present on the scene, have the second person make the phone call to activate the EMS system while the other starts the assessment and CPR on the patient. If the rescuer is alone, start rescue support and after one minute of rescue support, check pulse and then activate the EMS system. The single rescuer should then continue with rescue support until the emergency help arrives on the scene.
3. Open the airway. This is best done by the head-tilt / Chin-lift method. It is possible to obstruct the airway of an infant by tilting the head back too far. Therefore, to open the airway of an infant, tilt the head back to a sniffing position, but do not tilt it back as far as it will go. Continue holding the head with one hand.
4. Check for breathing. Place the side of your face close to the mouth and nose of the infant as you would for an adult. Look, listen, and feel for breathing 3 to 5 seconds. If the infant is breathing and there are no signs of trauma, place the infant in recovery position (patient is turned onto their left side).
5. If the infant is not breathing, maintain open airway and give 2 slow, 1- to 1-1/2 second breaths. To breathe for an infant, place your mouth over the infant's mouth and nose, completely covering them with your mouth. Because the lungs of an infant are very small, it is important to give very small, gentle puffs of air. Use enough air to make the chest rise. Do not use large or forceful breaths.
6. Check for circulation. Check the bracial pulse rather than the carotid pulse. The brachial pulse is on the inside of the arm. While maintaining an open airway, you can feel the pulse by placing your index finger and middle fingers on the inside of the infant's arm halfway between the shoulder and the elbow. Check for 5 to 10 seconds.
7. If there is no pulse, begin chest compressions while maintaining open airway. An infant's heart is located relately higher in the chest than an adult's heart. Therefore, you must deliver chest compressions by pressing on the middle (rather than the lower) portion of the sternum. Imagine a horizontal line drawn between the nipples. Place your index finger below the line in the middle of the chest. Place your middle and ring fingers next to your index finger.
Use the middle and ring fingers to compress the sternum. Do not compress over the xiphoid process. Because the chest of an infant is smaller and more pliable than the chest of an adult, use only two fingers to compress the chest. Compress the sternum 1/2 to 1 inch. To achieve good results, the infant must be lying on a firm surface. Since the heart rate of an infant is faster than an adult's, you must deliver compressions at the rate of at least 100 times per minute. The ratio of cardiac compressions to ventilations is 5 compressions to 1 ventilation instead of the 15 to 2 ratio in the adult. The size of the infant makes two-person CPR impractical.
8. Continue compressions and ventilations. Give one slow ventilation after each set of 5 compressions during a 1- to 1-1/2 second pause.
9. Reassess the patient after 20 repetitions (about 1 minute) and very few minutes thereafter until the patient begins to breathe on their own or until emergency help arrives on the scene. Transport to a medical facility for further medical assessment and treatment.
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. If a second rescuer feels a brachial pulse (infant) or carotid pulse (child and adult) 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 or a baby begins to make crying sounds.
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 DISCRIPTION & 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 severly 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.
OBSTRUCTED AIRWAY - CONSCIOUS INFANT
Perform this procedure only if the airway of the conscious infant is completely obstructed and someone has witnessed or strongly suspects tht there is a foreign body obstruction. If the infant cannot breathe because of infection, the infant should be rushed to the nearest life support facility. Procedures to clear the airway should not be performed. Allow the infant with respiratory distress to find and maintain the most comfortable position.
1. Determine whether there is airway obstruction by observing breathing difficulties, weak or absent cry, or ineffective cough. Immediately begin obstructed airway procedure if signs of obstruction are present.
2. Supporting infant's head and neck with one hand, position the infant face down with head lower than trunk, over one arm (support you arm with your thigh) and deliver up to 5 back blows. This is done with the heel of your free hand, delivering back blows forcefully between the infants shoulder blades.
Note direction of hands.
3. Supporting infant on your arm, turn infant face up on his or her back, keeping the head lower than the trunk and deliver up to 5 chest thrusts in midsternal region over the lower half of the sternum (also known as the breastbone), using landmarks for positioning as for chest compressions. Do chest thrusts more slowly than chest compressions. Depress the sternum 1/2 to 1 inch for each thrust. Avoid the tip of the sternum (xiphoid process). Abdominal thrusts (such as those performed with the Heimlich maneuver) are not recommended in infants.
Note chest thrust finger positioning.
4. Repeat steps 2 and 3 until the foreign body is expelled or infant becomes unconscious.
IF THE INFANT BECOMES UNCONSCIOUS
5. Call out for help. If someone responds, have that person call and activate the EMS system. Place infant on his or her back.
6. Perform tongue-jaw lift. Do not perform a blind finger-sweep, but remove the foreign body if you can see it. Blind finger sweeps should not be performed on infants or small children.
7. Open airway with head tilt-chin lift and try to give rescue breaths.
8. Reposition head and try again to give rescue breaths.
9. Deliver up to 5 back blows.
10. Deliver up to 5 chest thrusts.
11. Perform tongue-jaw lift and remove foreign body if you can see it.
12. Maintain open airway with head tilt-chin lift and try again to give rescue breaths.
13. Repeat steps 8 through 12 until successful.
14. If you are alone and your efforts are unsuccessful, activate the EMS system after trying to clear the airway for about one minute.
15. When obstruction is removed, check for breathing. If there is no breathing, give rescue breaths. If there is no pulse, give 2 breaths and start cycles of compressions and rescue breaths. If pulse is present, open airway with chin lift-head tilt and check for breathing. If there is breathing, place in recovery position. Monitor breathing and pulse while maintaining open airway. If no breathing, give 1 rescue breath every 3 seconds (20 breaths per minute). Monitor pulse.
OBSTRUCTED AIRWAY: UNCONSCIOUS INFANT
1. Determine unresponsiveness as instructed above.
2. Call out for help.
3. Support head and neck and turn infant on back with a firm, hard surface.
4. Use head tilt-chin lift method to open airway. Do not tilt head too far back.
5. Determine lack of breathing by maintaining open airway and looking, listening, and feeling for breathing.
6. Try to give rescue breaths by placing your mouth over infant's nose and mouth.
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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