CARDIOPULMONARY RESUSCITATIONCardiopulmonary Resuscitation or CPR is an emergency medical procedure indicated in victims of cardiac arrest and sometimes in victims of severe symptomatic cardiovascular and circulatory compromise. A victim of cardiac arrest is defined as a person who is unresponsive, pulseless, and apneic (or exhibiting agonal respirations). Agonal respirations are ineffective breaths produced with poor respiratory effort, volume, quality, or rate that are unsustainable of life. CPR technique typically includes external delivery of chest compressions and ventilations/breaths. CPR produces circulation in the absence of spontaneous cardiac output and allows for delivery of oxygen rich blood throughout the body. Effectively delivered CPR prolongs cellular death and may allow time for more definitive care to be deliveredEmergency Situation Considerations> Personal SafetyYour number 1 priority in any situation should be your own personal safety. You should never put yourself in extreme danger to help someone else. You cannot do any good for anyone if you become injured or hurt. If you are uncomfortable or in fear for yourself - retreat to safety and await professional help.>Nature of Emergencies & Staying CalmEmergencies by nature are stressful and take a toll on everyone involved. To be able to help someone else you must remember to remain calm. You must make rational decisions based upon processing rapid information related to the situation you are in without influence of emotion. Failure to remain calm and/or separate emotion may cause you to make poor decisions. These poor decisions may cost you or someone else their life. Calm rescuers also equate to calm victims / bystanders.>Emergency PreparednessBefore an emergency happens is the proper time to start preparing for it. Once the situation occurs there is little opportunity for planning and organization. In your daily life, look around and think about common situations that may occur and how you should respond to them.>Calling For Help/911 (US)Remember Who, What, Where, and How! Who? This includes who you are and who needs help. What is going on? This determines if a fire truck, police officer, or ambulance is needed. Where? Give the complete address if known. If not, describe the location by looking around and giving any information you can see. How to reconnect? Always give the telephone number in which you are calling from or can be reached at should you become disconnectedHow to perform CPR for Adults:Scene Assessment/Personal Safety:You must make your personal safety the top priority in any emergency situation. If you become injured or killed you will not be able to do any good for anyone else. You becoming injured will take resources away from the original victim possibly worsening their outcome. Things may not be as they appear. Evaluate the scene to make sure there is no risk to yourself. Never put yourself in a situation you are not comfortable with. Think BEFORE Acting/Responding. After insuring your safety, evaluate the scene for clues, resources, and additional victims as your approach. Having good situational awareness helps you better help others. Remember whose emergency it is.THERE IS NO WAY OF CHANGING THE PAST OR RESERVING WHAT HAS HAPPENED TO ANY VICTIM. YOU WANT TO MAKE THINGS BETTER - NOT WORSE. TRY TO REMAIN CALM.

Assess the Victim:Upon finding a suspected victim of cardiac arrest and insuring your own safety - you should assess the victim for responsiveness and determine the appropriate actions for that person. You must remember that things may not be as they appear. Is every person found laying on a sidewalk or in a public place in need of CPR? They may be simply asleep; under the influence of drugs, alcohol; perhaps be homeless; or even mentally ill. You must determine what situation you are faced with before taking any other actions. To assess the victim you should tap and shake the victim physically and yell at the victim "ARE YOUR OKAY?". You want to use enough stimulus that would awaken an average person. The victim may be deaf or hard of earring - by physically shaking and tapping the victim - we know with certainty their status.Assess Breathing:After Tapping/Shouting you should assess the victim for breathing. Remember Look, Listen, & Feel. Lower your head down and LOOK at the victims chest; LISTEN for coming out the victims mouth and nose; and FEEL for movement on the victims chest. You should Look, Listen, and Feel for 5 to 10 seconds unless it obvious the victim is not breathing (Blue, etc.). If the victim is NOT breathing or breathing normally - you should continue with the steps of CPR.Call 911 / Getting Additional Resources:If your assessment of the victim determines that they are unconscious & unresponsive or not acting appropriately you must call 911 and/or obtain additional resources. If you fail to call 911 or obtain additional resources you will be responsible for providing care indefinitely. An ambulance does not magically appear when someone is injured, hurt, or in cardiac arrest. You must remember to activate Emergency Medical Services (or other appropriate resources) as soon as possible.ABC is now CAB: CPR Compressions now are performed prior to opening the airway and giving breaths.Circulation: Checking For A Pulse:Layperson rescuers should not check for a pulse while performing CPR. The average person has little practice in obtaining a pulse therefore it is unrealistic to expect accuracy during an emergency situation. You should assume that unless the victim wakes up during your assessment or shows signs of life during CPR that the person is pulseless and needs CPR to be continued. Healthcare Providers or persons trained in checking for a pulse may do so if they feel comfortable. If you check for a pulse and do not feel a pulse or are not sure if a pulse is present - begin CPR immediately.If a person is unresponsive, has a pulse, and CPR is performed: no ill effect (other than rib fracture) or cardiovascular damage will occur. Therefore, always err on the side that the victim is pulseless and begin CPR as soon as possible.Circulation: Chest CompressionsThe fundamental principle of CPR is that we want blood and oxygen circulating throughout the body at all times. Circulation equates to potentially prolonging and mitigating cellular injury and death. The primary intervention to be performed for circulation is Chest Compressions. Chest Compressions circulate blood and oxygen. When performing CPR with rescue breathing, give 30 compressions followed by 2 breaths (30:2 Compressions to Breaths Ratio). Transition from compressions to breaths and back to compressions as quickly as possible. Your goal should be to begin chest compressions within 10 seconds of discovery of the victim and to not interrupt compressions for more than 10 seconds for any reason unless absolutely necessary.How to Perform Chest CompressionsMake sure the victim is laying flat on their back, face up, on a HARD FIRM SURFACE. The floor is typically the best option in most situations. The transition of the victim from their location to the floor does not have to be a graceful one. You must get them on the floor (or other firm surface) as quickly as possible. Recognize that if the victim is not on a firm surface compressions will likely move the body up and down and not compress the chest (Visualize doing compressions on a water bed).Next, quickly remove any clothing covering the chest. This allows us to find the correct location to perform compressions and use an AED when it arrives.Locate the center of the chest, between the breasts and place the palm of one hand on top of the lower half of the sternum. Place the second hand on top of the first hand in a manner that is comfortable for you. You may overlay or interlock your fingers. Position yourself over the victim and use your entire body to push up and down on the persons chest. Keep you elbows locked and think of moving at the waist. This ensures you use your entire body to perform compressions. If you use your arms and not your body - your arms will become fatigued quickly and you will not be pushing at the right rate and depth.Compress the chest at the rate of at least 100 compressions per minute. Think of the beat of the song "Staying Alive" by the Bee Gees. The beat of "Staying Alive" is 100 beats per minute. If you match compressions with this song - you will be performing compressions at the right speed. Remember to pace yourself so not to get fatigued. After each compression, allow the chest to return to its normal position before compressing again. This chest recoil allows the heart to refill with blood and provide the most effective CPR possible.If performing rescue breathing, perform 30 compressions, perform a head-tilt/chin-lift, give two rescue breaths (looking for chest rise and fall) and resume compressions as quickly as possible. If performing "Compression Only CPR" simply compress the chest at the rate of 100 compressions per minute without interruption or delay.Remember that when CPR is not being performed, blood and oxygen are not circulating, and cellular injury and death may occur.2 Rescuers Present:If another rescuer arrives or is present during the rescue effort perform CPR as described above expect you may alternate and switch roles as needed. One rescuer should perform 30 compressions and the second rescuer provide 2 rescue breaths. You should change roles every 2 minutes (or 5 sets of 30:2) or as needed to prevent fatigue. When working with another rescuer counting out loud when doing compressions will allow them to know when to give breaths. Teamwork is very important and each rescuer should evaluate the rescue effort and provide feedback as needed.Rib Fracture:While performing CPR rib fracture is common. You may feel ribs break, feel or hear bone rubbing on bone, or see free floating ribs on the victims chest. Chest compressions should continue without delay or modification. If the person survives the cardiac arrest their ribs will heal. Saving their life out weighs the risk of rib fracture.To perform chest compressions effectively:1.) Push Hard and Push Fast. Pushing hard and pushing fast helps keep circulation moving.2.) Continue CPR continuously without delay or pause unless absolutely required.Reasons to stop or pause CPR include: The person wakes up/shows signs of life, someone else takes over, to use an AED, irreversible signs of death or you can no longer continue.3.) Aim for the rate of at least 100 compressions per minute. Think "Staying Alive".Airway: Opening the AirwayWhen a person becomes unconscious, they loose all muscle tone. The tongue being a muscle relaxes and may block the airway (trachea/windpipe) of the victim. The tongue is the most common cause of airway obstruction in an unconscious adult. To mitigate this and reopen the victims airway, we must perform a physical intervention to lift and move the tongue out of the way. The maneuver used to open a victims airway is called ahead tilt/chin lift.With the victim laying face up on a hard firm surface place one hand on the forehead of the victim while grasping the bony portion of the chin with the other. Tilt the head and lift the chin at the same time. This lifts the tongue and creates a pocket for oxygen to travel.When you open the victims airway you may hear sounds of oxygen or gasses escaping and/or may see fluid, vomit, or froth escape from the victims mouth. Anything blocked from the tongue in the trachea will potentially escape when the airway is opened. Do not confuse this with breathing or stop CPR if this occurs.Breathing: Rescue BreathsRescue breaths are the process of giving artificial breathing to someone who isn't breathing on their own. When giving rescue breathing, give just enough air (volume) to see the chest rise. Giving too much volume may cause harm to the victim. Simply think of lungs as nothing more than balloons. If you over inflate/hyperventilate a balloon it pops; the same is potentially true with a human lung. In addition to causing injury to the lung from over inflation and hyperventilation - may cause air to enter the stomach which may induce or cause vomiting. Vomiting is dangerous as it may lead to aspiration and development of pneumonia if the victim survives.

Breathing: Mouth to MouthMouth to Mouth breathing is considered the easiest and most readily available option as it does not require any special equipment to perform. Mouth to Mouth breathing is performed by opening the victims airway (head-tilt/chin-lift), covering the victims mouth completely with your mouth, pinching the victims nose (to keep the oxygen from escaping back out the nose), and giving a regular breath for about 1 second into the victim. When giving the breath you should see the chest rise. Let the victim exhale and give the second breath just as you did with the first breath. If you do not see the chest rise and fall with each breath, readjust the head, making sure you have the airway open and attempt the breaths again. If the breaths do not make the chest rise and fall for a second time - move on to circulation and compressions.Breathing: Mouth to MaskMouth to Mask Breathing is the delivery of rescue breaths through a barrier mask to protect the rescuer from becoming exposed to the victims bodily fluids. Barriers devices such as a pocket mask should be used to provide rescue breathing when available and delivering rescue breaths.Pocket Masks are usually made of plastic and contain a one way value designed to limit exposure to the rescuer to exhaled air, bodily fluids, and disease process.To use the mask, place it on the victims face with the pointy end over the bridge of the nose. Place one hand over the top of the mask holding it firmly on the face, Place the second hand on the bottom portion of the mask while grasping the chin; perform a head tilt/chin lift. Deliver breaths as in mouth to mouth breathing except place your mouth on the one way valve. Deliver each breath for about 1 second; looking for the chest to rise.Breathing: Rescue Breathing without Compressions:During a major medical event and sometimes prior to cardiac arrest, you may be faced with a victim who is not breathing or not breathing effectively but still is maintaining adequate circulation and perfusion. When faced with these types of situations if in your opinion the victim does not yet need CPR with compressions but exhibits any signs or symptoms of poor oxygen exchange, Rescue Breathing should be considered.To provide rescue breathing: (after contacting 911 or obtaining additional resources): 1.) Open the victims airway with a head-tilt chin-lift as in CPR; 2.) Give 1 Rescue Breath Every 5 to 6 Seconds for Adults OR Every 3 to 5 Seconds for Pediatric Victims.Be sure with each breath to witness the chest rise and fall. Count each second slowly (One-One Thousand, Two-Mississippi) between rescue breaths to avoid hyperventilation or gastric inflation (air getting into the stomach) which may induce vomiting.If while facing an emergency, you can not remember how often to deliver a Rescue Breath to a victim of any age: 1.)Remain Calm 2.)Focus on Your Own Breathing 3:)Provide a Rescue Breath to the victim each time you breath (You Breath - They Breath) until other trained help arrives.Hands Only Cardiopulmonary Resuscitation (CPR)Compression Only Cardiopulmonary Resuscitation (CPR)Hands Only CPR / Compression OnlyCPRis a research tested alternative method of delivering CPR without rescue breaths. Rescuers during Hands Only CPR / Compression Only CPR should focus on continued non-stop effective compressions.How It Works:Hands Only CPR / Compression Only CPR works by primarily circulating the oxygen inspired by the victim prior to collapse. This preexisting oxygen is circulated during compressions to attempt to delay desaturation and cellular death. The amount of oxygen available and the time of efficiently with Hands Only CPR / Compression Only CPR is variable upon the victim and circumstances related to the cardiac arrest. Regardless, Hands Only CPR / Compression Only CPR is a viable alternative option for providing cardiac arrest care over doing nothing; and is perfect for situations in which you discover or witness a sudden cardiac arrest, have no barrier device, and you do not feel comfortable giving unprotected mouth to mouth ventilations.

Cardiopulmonary Resuscitation (CPR) for Children Cardiopulmonary Resuscitation (CPR) for InfantsDefining a child:A child is a victim who is over the age of 1 and up to the age of puberty. Puberty for this context is defined as breast development in females and underarm or facial hair in males. Puberty is used as the establishment of adulthood as developmental changes may effect aspects of CPR. In addition to puberty the overall size of the victim should be considered due to the current epidemic of obese children in the United States. If the victim is the size of an adult - treat them as an adult and not a child - regardless of age or puberty status.Reason for Cardiac Arrest in Children/Infants:Children and Infants suffer from cardiac arrest typically as a result of a respiratory event such as choking or respiratory arrest. Not from a cardiac condition - It is uncommon to hear of a child or infant having a heart attack. Children and Infants typically do not have a history of high blood pressure, smoking, or other conditions that are applicable to adults. Due to children and infants likely going into cardiac arrest due to respiratory event, we must recognize that oxygenation and circulation need to be initiated as quickly as possible for these age groups.Hypoxia (or lack of oxygen inside the body) is a reversible cause of cardiac arrest. If oxygenation and circulation are performed quickly and effectively the cardiac arrest may improve or allow the person to recover.When to Call or Get Help for Children and Infants in Cardiac Arrest:Due to children and infants going into cardiac arrest most likely to respiratory cause; one must consider the value of outside resources in the life saving effort. You should recognize that time is the enemy, especially in pediatric victims, and delay in treatment or care may result in a poor outcome. The sooner care is initiated for a child or infant - the higher the chance of survivability. Therefore there are special guidelines for when to obtain or call 911 when faced with a pediatric cardiac arrest.If you are ALONE and FIND an infant or child in cardiac arrest:Perform the steps of CPR immediately without delay for 2 minutes or 5 sets of 30:2 before leaving the pediatric victim to get help or call 911. Due to finding the child and the unknown time involved since collapse, delaying starting CPR may result in cellular injury or death. By performing the steps of CPR for 2 minutes or 5 cycles of 30:2, we circulate blood and oxygen potentially restarting the clock on a poor outcome. This allows us to build the pediatric victim back up with oxygenation before leaving to call 911 or obtain help without fear of causing more harm (at least for a few minutes).If you witness the pediatric victim collapse or have someone else around:Treat the victim as an adult. Get additional resources and Call 911 (or have someone else do it) immediately then return to the victim and begin CPR.Cell Phones: If you are alone and have a cell phone it may be possible to call 911 & begin the steps of CPR at the same time regardless if you witness the arrest or not. Remember that time is the enemy.ABC's of Life for Children (1 to Puberty): CAB - Compressions, Airway, BreathingCirculation:Same as an Adult. Remember to Push Hard and Push Fast. Do not hesitate or restrict compressions due to the smaller size of the child. Recognize that performing poor compression equates to poor circulation and cellular injury and death. Attempt to push 1/2 to 1/3 the chest depth of the child (approximately 2 inches). If the child is small in size, you may use one hand instead of two when performing compressions. You may use the second hand to maintain an open airway to allow for potential CPR induced ventilation; and stabilize the child from moving during compressions, if you prefer.Airway:Same as an Adult except look in the airway for a potential choking object that potentially could be removed.Breathing:Same as an Adult. If giving rescue breaths, give a lower volume of air when giving breaths. Give just enough breath to see the chest rise.ABC's of Life for Infants (Birth to Age 1): CAB - Compressions, Airway, BreathingCirculation:Compressions have to performed differently for infants than they would be for larger children and adults due to their smaller size. To perform compressions on an infant, place the infant on a flat hard surface, face up, and locate the middle of the chest between the breasts. Place two fingers of one hand on top of the sternum about a fingers tips length below the nipple line. Place the second hand on the infants head to maintain an open airway and to stabilize the victim. Push on the chest using the two fingers at the rate of at least 100 compressions per minute at a depth of 1/3 the chest depth. If giving CPR with rescue breathing perform 30 compressions to 2 breaths (30:2 ratio).Airway & Breathing:Same as a Child.Recommendations

COMPONENTADULTSCHILDRENINFANTS

RecognitionUnresponsive

No breathing or no normal breathing(gasping)No breathing or only gasping

No pulse palpated within 10 seconds

CPR sequenceC-A-B

Compression rateAt least 100/min

Compression depthAt least 2 inches (5cm)At least AP diameterAbout 2 inches (5cm)At least AP diameterAbout 1 inches (4 cm)

Chest wall recoilAllow complete recoil between compressionsHCPs rotate compressions every 2 minutes

Compression interruptionsMinimize interruptions in chest compressionsAttempt to limit interruptions to