CPR Pro Handbook

A M E R I C A N S A F E T Y & H E A LT H I N S T I T U T E
CPR Pro
for the Professional Rescuer
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Student Handbook
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La certificacin de American Safety and Health Institute (ASHI) slo puede ser emitida cuando un Instructor autorizado por ASHI verifica que usted ha culminado competente y exitosamente el conocimiento esencial y los objetivos en habilidades del programa.
American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 USA 800-246-5101 ashinstitute.org Copyright 2009 by American Safety & Health Institute. All Rights Reserved. Revised September 2009. No part of the material protected by this copyright notice may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the American Safety & Health Institute. Some images used under license 2006 Custom Medical Stock Photo. The procedures and protocols in this book are furnished for informational use only and are subject to change without notice. The publisher, however, makes no guarantee as to, and assumes no responsibility for, the correctness, sufficiency or completeness of such information or recommendations. Other or additional emergency, safety or health measures may be required under particular circumstances. Printed in the United States of America. PRN2007 (9/09)
Preface
Table of Contents
Section 1 Introduction
Sudden Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Circulatory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Barrier Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Proper Removal of Contaminated Gloves Skill Guide #1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3 3 4 4 6 7 7 7 8 8 9 10 10 11 12 14 15 16 17 18
This training guide is provided online for individual use only. Reprinting for classroom distribution is prohibited.
Section 2 Cardiovascular Disease

Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acute Coronary Syndromes (ACS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sudden Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chain of Survival for Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chain of Survival for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Section 3 Resuscitation Skills

Resuscitation Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Opening the Airway Skill Guide #2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Protecting the Airway Skill Guide #3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rescue Breaths Skill Guide #4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bag-Mask Skill Guide #5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . External Chest Compressions Skill Guide #6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Section 4 Defibrillation
Defibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Section 5 Emergency Action Steps

Assess, Alert, and Attend to the ABCDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . When Using Advanced Airways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary of CPR/AED Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adult Rescue Breathing Skill Guide #7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Rescue Breathing Skill Guide #8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infant Rescue Breathing Skill Guide #9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adult CPR/AED Skill Guide #10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child CPR/AED Skill Guide #11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infant CPR Skill Guide #12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 21 23 24 24 26 27 28 29 30 31 32 33 35 36 37
Section 6 Choking
Foreign Body Airway Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adult Choking: Severe Blockage Skill Guide #13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Choking: Severe Blockage Skill Guide #14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infant Choking: Severe Blockage Skill Guide #15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Section 7 Legal and Emotional Aspects

Legal Aspects of Providing Basic Life Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Emotional Aspects of Providing Basic Life Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
End Notes
End Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Preface
CPR Pro for the Professional Rescuer
Section 1 Introduction
Sudden Cardiac Arrest

Sudden cardiac arrest is one of the leading causes of death among adults in North America. It can occur randomly, to anyone, at any time. It occurs when the hearts electrical system malfunctions and the hearts natural electrical signals become disorganized. The coordinated mechanical contraction of the heart muscle is lost and a chaotic quivering condition known as ventricular fibrillation occurs.
Cardiopulmonary resuscitation (CPR).
The most effective treatment to end ventricular fibrillation and restore a normal heart rhythm is defibrillation, an electrical shock sent through the heart muscle. The sooner defibrillation can be provided, the greater a chance that patient can survive. An Automated External Defibrillator, or AED, is a small, portable computerized device that is designed to allow initial responders to defibrillate.
Sudden cardiac arrest victim.
The heart abruptly stops pumping blood and oxygen to the body. Brain tissue is especially sensitive to a lack of oxygen. When oxygen is cut off, brain death can occur quickly, within a matter of minutes. The lack of available oxygen to the brain causes the patient to quickly lose consciousness, stop breathing, and collapse. Unless immediate care is provided to restore the hearts regular rhythm, the chance to survive is lost. Cardiopulmonary resuscitation, or CPR, allows a trained bystander to immediately begin restoring some circulating oxygen to the brain through a combination of external chest compression and rescue breaths. By itself, CPR is only a stop-gap measure that can buy critical time in which to provide more specific treatments to re-establish a normal heart rhythm.
Defibrillation with an AED.
Attached with wires and adhesive pads to the chest of a sudden cardiac arrest patient, the AED checks the hearts electrical activity, decides if ventricular fibrillation is present, and allows for a defibrillation shock to be delivered.
Introduction
Respiratory System
Because the body cannot store oxygen, it must continually supply itself through the actions of the respiratory and circulatory systems.
Respiratory system.
The respiratory system brings air, containing oxygen, into the body, and removes carbon dioxide, a waste product created by the bodys use of oxygen. When you take a breath, muscles in the chest contract, and create a vacuum that draws air through the windpipe, and into the lungs. In the lungs, oxygen from the air is absorbed into the bloodstream and circulated throughout the body. Carbon dioxide is transferred from the bloodstream back into the lungs. Chest muscles relax and air is exhaled out of the lungs and back into the environment. Carbon dioxide is released in the exhaled air. Not all of the oxygen is used by the body in the breathing process. Inhaled air contains approximately 21% oxygen. Exhaled air contains about 1617% oxygen. When delivered through rescue breaths, there is still enough oxygen to support life.
Circulatory system.
Arteries carry oxygenated blood from the heart to body tissues. Veins return used blood back to the heart where carbon dioxide is released and fresh oxygen is picked up. The fresh blood is returned to the heart and the cycle repeats. If the heart stops, it is possible to return at least some of the blood flow through the circulatory system by compressing the chest cavity. Increased pressure in the chest and direct compression of the heart causes blood to move out of the chest and into the rest of the body. CPR, the combination of rescue breaths and external chest compressions, has proven to be capable of providing oxygenated blood flow to vital organs during cardiac arrest. Immediate CPR by a bystander could double or triple a patients chance of survival.
Circulatory System
The circulatory system uses the blood stream to deliver oxygen and nutrients to body tissues and remove waste products. The driving force of the circulatory system is the heart. Special tissue runs throughout the heart that is capable of creating and conducting electric current. This electric current triggers the rhythmic mechanical contractions that create the flow of blood through the body.
Introduction
Infectious Diseases
Bloodborne pathogens are viruses or bacteria that are carried in blood and can cause disease in people. There are many different bloodborne pathogens, but Hepatitis B (HBV), Hepatitis C (HCV), and the Human Immunodeficiency Virus (HIV) are the ones most commonly addressed.1,2
Disposable gloves.
Never wash or reuse disposable gloves. Throw away both gloves in an appropriate container. Use an alcohol-based hand rub, or soap and water, to clean your hands and other exposed skin.4
Blood spill.
The estimated risk for acquiring HIV, HBV, or HCV infection from performing CPR is extremely low, about one in one million. There have been no reports of infection acquired during CPR training.3 Universal precautions is a way to limit the spread of infectious diseases by preventing contact with blood and certain body fluids. To observe universal precautions means that whether or not you think the patients blood or body fluid is infected, you act as if it is.
Compared with soap and water, alcoholbased hand rubs are more effective in reducing bacteria on hands and cause less skin irritation.
Make sure gloves are always available. If you find yourself in an emergency and you dont have any gloves, improvise. Use a plastic bag, or some other barrier to help avoid direct contact.
Barrier Devices
Simple infection-control measures, including the use of barrier devices, can reduce the risk of an infectious disease during CPR. A simple but effective barrier for skin-to-skin contact is the use of disposable gloves. Quickly inspect gloves before putting them on. If a glove is damaged, dont use it. When taking contaminated gloves off, do it carefully. Dont snap them. This may cause blood to splatter.
Mask and shield.
Masks allow you to provide rescue breaths without direct skin-to-skin contact. They come with a replaceable one-way valve and possibly a filter to block con-
Introduction
taminated fluids. All emergency response kits should include at least one mask. Disposable face shields do not prevent contamination of the rescuers side of the shield. To reduce the risk of transmitting infection, professional rescuers should use a face shield only as an emergency substitute for mouth-to-mouth breathing, and should switch to a mask or bag-mask device as soon as possible.
To reduce the risk of infection, you should: Always wear barrier protection in emergency situations. Carefully remove gloves, clothing and any other contaminated material. Place them in appropriately labeled bags or containers.
Bag-mask devices.
Bag-mask devices are designed for use in clinical and emergency settings to provide oxygen and ventilation to a patient who is not breathing or is not breathing adequately. When used with supplemental oxygen, the bag-mask device can provide up to 100% oxygen. They are available in different sizes for adult, child, and infant patients.
Eye protection.
Any time there is a risk of spraying or splatter of blood or body fluids, you should use goggles or safety glasses with side protection to help protect your eyes.
Introduction
Decontaminating Surfaces Decontaminate all surfaces, equipment, and other contaminated objects as soon as possible. Clean with a detergent and rinse with water. Use a bleach solution of one quarter cup (.06 liter) of household bleach per one gallon (3.79 liters) of water to sanitize the surface. Spray on the solution and leave it in place for at least 2 minutes before wiping.
Skill Guide #1
Proper Removal of Contaminated Gloves
1 2 3 4 5
6
Without touching the bare skin, grasp either palm with the fingers of the opposite hand.
Gently pulling the glove away from the palm and toward the fingers, remove the glove inside out. Hold on to the glove removed with the fingers of the opposite hand.
Without touching the outside of the contaminated glove, carefully slide the ungloved index finger inside the wrist band of the gloved hand.
Gently pulling outwards and down toward the fingers, remove the glove inside out.
Throw away both gloves in an appropriate container. Use an alcohol-based hand rub to clean your hands and other exposed skin after providing first aid. If an alcoholbased hand rub is not available, wash with soap and water.
Introduction
Section 2 Cardiovascular Disease
Cardiovascular Disease
Cardiovascular disease directly affects the heart and the large vessels of the circulatory system. The term generally reflects a progressive deterioration of the tissues involved. The most common problems associated with cardiovascular disease are stroke and acute coronary syndromes. They are the leading causes of death for both men and women in the United States, and account for nearly 40% of all deaths.5 You can lower your risk for cardiovascular disease by making healthy lifestyle choices. Eat a healthy diet to prevent or reduce high blood pressure and high blood cholesterol. Maintain a healthy weight. Control your alcohol intake. Dont smoke. Exercise as directed by your doctor.
Signs and symptoms of a stroke may occur suddenly:8 Numbness or weakness on one side of the body Trouble speaking or understanding Trouble seeing in one or both eyes Loss of balance or coordination Severe headache If you suspect a stroke may be occurring, ask the patient to: Smile. Raise both arm. Speak a simple sentence. If the patient has any trouble with any of these tasks: Alert EMS immediately. Position the patient comfortably. Comfort, calm, and reassure the patient. Provide supplemental oxygen if it is available.
Acute Coronary Syndromes (ACS)

The term acute coronary syndromes applies to a number of serious conditions involving the heart. These include unstable chest pain, or angina, and myocardial infarction (heart attack).9 A heart attack occurs when oxygenated blood flow to part of the heart is severely diminished or cut off. If not resolved, heart tissue will die. This could result in a serious disability or sudden cardiac arrest.
Stroke
A stroke occurs when the blood supply to part of the brain is suddenly interrupted, or when a blood vessel in the brain bursts and spills blood into the surrounding tissue.6 A stroke can result in serious issues with a patients ability to feel, move, or communicate. Damage can be limited by early recognition and prompt professional medical treatment.7
Heart attack. Stroke graphic.
Signs and symptoms can vary in intensity. Suspect a heart attack if the following signs and symptoms appear: Chest pain or a dull discomfort behind the breastbone that may spread to the arms, back, neck, jaw, or upper abdomen Shortness of breath Weakness, nausea, or dizziness Heavy sweating Anxiety Uncertainty and embarrassment Denial that something serious is occurring, which can delay treatment and increase the risk of death If you suspect a heart attack is occurring, do the following: Alert EMS immediately. Have the patient sit and rest quietly. Loosen any tight clothing. Help patient take existing heart medication. Usually this is nitroglycerin, placed or sprayed under the tongue. If the patient does not have a history of aspirin allergy, advise the patient to chew and swallow a half or whole adult aspirin tablet (162325 mg). Provide supplemental oxygen if it is available.
Suspect a sudden cardiac arrest has occurred if someone: Collapses without warning, Is unresponsive to voice and touch, Appears to not be breathing or is making shallow, ineffective attempts to breath, and Looks dead. If you suspect a sudden cardiac arrest has occurred, immediately alert EMS, perform CPR, and defibrillate as soon as possible with an AED.
Family members of patients who have had a recent heart attack should take CPR training and be familiar with the use of an AED. Employers should consider the use of AEDs at their worksites to reduce the time to defibrillation, with the goal of improving survival. All professional responders should be equipped with and trained in the use of an AED.
Chain of Survival for Adults
Sudden Cardiac Arrest

Sudden cardiac arrest is an emergency that occurs abruptly and without warning.10 Without early recognition and treatment, most likely from a bystander, a patient will not survive.
The Chain of Survival is a concept that is used to communicate the key factors that must be in place to increase survival from sudden cardiac arrest.11 The links in the chain of survival include: Early recognition and activation of EMS Early CPR Early defibrillation Early advanced life support The chain of survival begins with early recognition and rapid activation of EMS or an Emergency Action Plan. Early activation may include assistance by an emergency operator, specially trained to provide CPR instructions over the phone.12
Sudden cardiac arrest (SCA).
Early CPR will buy some time for a defibrillator to arrive and improve the chance that defibrillation will work.
Early defibrillation can return the heart to a normal rhythm. Survival rates are highest when CPR is started immediately and defibrillation occurs within three to five minutes. Advanced life support involves medical procedures and medications used by paramedics, nurses, or doctors to help protect survival and recovery.13 If any one of these links is weak or missing, the patient is unlikely to survive. When all the links are strong, the greatest chance for survival occurs.
The Chain of Survival in children emphasizes: Prevention Early CPR Early activation of EMS Early pediatric advanced life support Injury is a leading killer of children aged 14 and under worldwide. Most injuries can be prevented by taking simple safety measures.14 Death rates for drowning are highest in children less than five years old. Placing infants on their backs to sleep and giving them a pacifier significantly reduces the risk of Sudden Infant Death Syndrome.15,16 When a child is found unresponsive and not breathing, performing CPR is the priority. Immediate CPR, with effective rescue breaths, has been shown to significantly increase survival for infants and children.17 When available, have another bystander alert EMS. However, if you are alone, provide about two minutes of CPR before alerting EMS yourself. As with an adult, prompt professional treatment will help protect survival and recovery.
A childs heart does not usually stop suddenly, as is most often the case in adults. Typically, a childs breathing will be lost first, by a situation such as drowning or choking. In these cases, the heart slows over an extended time and then stops from the lack of oxygen in the blood. Rapid treatment should include CPR with a particular emphasis on establishing an open air passage to the lungs and providing rescue breaths that create a visible rise of the chest. Early care could reverse the effects of a weakening heart.
Chain of Survival for Children
Section 3 Resuscitation Skills
Resuscitation Skills
Before looking at the process of resuscitation, it is helpful to focus on each of the individual skills that are involved. Because patients will vary in age, CPR guidelines use the following age ranges: Infants are less than about 1 year of age.
Children are about from 1 year of age to about the onset of puberty. Adults begin with the onset of puberty.
Airway
The airway is the passageway between the mouth and lungs. The airway must be open so air can enter and leave the lungs freely. Blockage of the airway is most commonly caused by the relaxation of the tongue when a patient becomes unresponsive. The Head-tilt, Chin-lift airway maneuver will pull the tongue away from the back of the throat and open the airway.
Jaw Thrust maneuver.
Jaw Thrust with head-tilt can be a convenient and effective method of opening the airway when using a ventilation mask, or bag-mask, during rescue breathing or multi-rescuer CPR. If a patient is unresponsive or semi-responsive and fluids are endangering his airway, immediately turn the patient on his side to allow fluids to drain. Roll the patient like a log without twisting the spine or head out of alignment. Sweep the mouth with your finger to remove any foreign material collecting there.
Opening the airway.
When the potential for a neck injury exists, Jaw Thrust without head-tilt can be used to open the airway. If the Jaw Thrust does not open the airway, use the Head-tilt, Chin-lift maneuver.
Log-roll.
Placing an unresponsive person in a recovery position uses gravity to help protect the airway from becoming blocked by the tongue, vomit, or secretions. Use the recovery position only if the patient is uninjured and breathing normally.
10
Using a barrier device such as a mask or bag-mask to give rescue breaths is recommended for professional healthcare providers. Rescuers can consider using a face shield until a mask or bag-mask is available. Face shields minimize direct contact with a patient but may not reduce the risk of infection. Do not take deep breaths when providing rescue breaths. Taking deep breaths is unnecessary. It could result in over ventilation and may cause you to hyperventilate. When working with other rescuers, rescue breaths can be done from above the patients head using Jaw Thrust. When supplemental oxygen is available, attach a connecting tube to the mask and provide a minimum flow rate of 10-12 liters per minute. A bag-mask device allows rescuers to provide positive pressure ventilations without having to blow into it. Bag-masks come in adult, child, and infant sizes. Use the size most appropriate for the size of the patient. It takes significant practice to effectively use bag-mask and that should be a consideration in its use. A bag-mask can be used by a single rescue but is ideally used by two.
Recovery position.
Once in the recovery position, check the patients breathing regularly. Make sure there is no pressure on the chest that could make it harder to breath. Also make sure the patients body position is stable so he does not roll onto his face or back. As a rule, you should not move an injured patient unless you determine you absolutely have to. When you suspect injuries are present, use a modified recovery position called the HAINES position. HAINES stands for High Arm In Endangered Spine. When using the HAINES position, there is less neck movement and less risk of spinal-cord damage.
Breathing
Rescue breaths use your exhaled air to force oxygen into the lungs of a person who has stopped breathing. Not all of the oxygen is used by the body in the breathing process. Inhaled air contains approximately 21% oxygen. Exhaled air contains about 1617% oxygen. When delivered through rescue breaths, there is still enough oxygen to support life.
Bag-mask with two rescuers.
When available, use supplemental oxygen with a bagmask. Provide a minimum flow rate of 10-12 liters per minute. Use a reservoir system to provide 100% oxygen delivery. Depending on your relationship to a patient and the availability of a barrier device, you may elect to provide mouth-to-mouth rescue breaths, using the same technique as with a face shield. Mouth-to-nose rescue breaths may be useful if a rescuer has difficulty with mouth-to-mouth. Tilt the patients head back with one hand and use the other hand to lift the chin and close the patients mouth. Seal your lips around the patients nose and blow.
Rescue breaths using a mask.
11
A stoma is a surgical opening in the front of the neck through which a person can breathe. Rescue breaths can be directly given into the stoma using a childsized face mask. Direct mouth-to-stoma rescue breaths can be considered if a mask is not available. Air can be forced into the stomach instead of the lungs when giving forceful breaths. This can reduce the effectiveness of the breaths and may cause a patient to vomit. To prevent this, give each breath in one second and give only enough air to see a visible chest rise, but no more than that. Allow the patient to exhale completely between breaths.
pipe and the muscles on the side of the neck and compress inward. Pulse checks can be difficult in emergency situations, even for experienced rescuers. If you are not certain that a pulse is present within 10 seconds, assume it is absent. For infants, use the brachial pulse in the inside of the upper arm. Lay your fingers across the arm and compress inward.
Pressure applied to the cricoid cartilage in the neck can compress the esophagus against the spine and help prevent air from being forced into the stomach with ventilation. This will lower the chance that vomiting will occur.
Child/infant pulse check.
External chest compressions are done by applying a rhythmic application of pressure over the lower half of the breastbone. Chest compressions result in forward blood flow as a result of increased pressure in the chest and direct compression of the heart.
Cricoid pressure.
Locate the patients Adams apple, or thyroid cartilage, with your finger. Sliding your finger downward, you will feel an indentation just below the thyroid cartilage and then another rigid structure. This is the cricoid cartilage. Using the tips of your thumb and index finger, firmly press the cricoid cartilage directly backwards and hold it in place. Take care to not push to one side or the other. If the patient coughs or gags at anytime, release the pressure.
Circulation
To assess for circulation of an adult or child, try to locate the carotid pulse found on either side of the windpipe in the neck. Locate the thyroid cartilage. Slide your fingers into the groove between the wind-
Adult chest compressions.
12
Compressions need to be hard and fast. Allow the chest to fully recoil at the top of each compression and minimize any interruptions to compressions. As an alternative technique, rescuers who have difficulty pushing hard can hold the wrist of the hand on the chest with the other hand and push down with both. The compression technique for children is similar to adults. Depending on the relationship of your size to the child, you can use either one or two hands to compress the chest.
For infant compressions, use two fingers in the center of the chest just below the nipple line. When using two rescuers, compressions on an infants chest can be done using both thumbs with the compressors hands encircling the infants chest.
Infant chest compressions.
Child chest compressions.
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Skill Guide #2
Opening the Airway
1 2 3 1 2 3 4
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Head-Tilt, Chin-Lift
Blockage of the airway is most commonly caused by the relaxation of the tongue when a patient becomes unresponsive.
Tilting the head and lifting the chin will pull the tongue away from the back of the throat and open the airway.
Dont press too hard on the soft area under the chin. Doing so can block the airway. Dont push the mouth completely closed.
Jaw Thrust
When the potential for neck-injury exists, Jaw Thrust without head-tilt can be used to open the airway.
Positioned above the patient, place your hands on either side of the head. Hook your fingers underneath the angles of the jaw, just below the ear.
Use counter pressure against the cheeks to displace the jaw and move it upward without tilting the head. If the Jaw Thrust does not open the airway, use the Head-tilt, Chin-lift maneuver instead.
Jaw Thrust with Head-Tilt

The Jaw Thrust maneuver with head-tilt can be a convenient and effective method of opening the airway when using a mask, or bag-mask, during rescue breathing or multi-rescuer CPR.
Skill Guide #3
Protecting the Airway
1 2 1 2 3 1 2 3
Log Roll
When a patient is unresponsive or semi-responsive and fluids are endangering the airway, immediately turn the patient on his side to allow fluids to drain. Roll the patient to avoid twisting of the spine. Keep the head in line with the body. Sweep the mouth with your finger to remove any foreign material collecting there.
Recovery Position (No Injuries)

Kneel beside patient and make sure legs are straight. Place arm nearest to you out at a right angle to the body, palm up.
Bring far arm across chest and hold back of hand against patients cheek nearest you. Grasp far leg just above knee and pull it up. Keeping patients hand pressed against the cheek, pull on far leg to roll the patient toward you.
Adjust the upper leg so both the hip and the knee are bent at right angles. Adjust upper leg so patients body is stable. Assess breathing and monitor patient.
HAINES Position (Suspected Injury)

Kneel beside patient. Place patients closest arm above head and furthest arm across chest. Lift patients nearest leg just above the knee.
Place your hand under hollow of patients neck to help lift and control head. Roll patient toward you and rest head on the extended arm.
Bend legs at knees to stabilize patients body. Assess breathing and monitor patient.
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Skill Guide #4
Rescue Breaths
Using a Face Shield
1 2 3 1 2 3
16
Place face shield over patients mouth and nose. Tilt patients head and lift chin. Pinch patients nose.
Take a normal breath, open your mouth wide, and place your mouth on the face shield around patients mouth. Press down to create an air tight seal, and blow through the opening on the shield. Make chest visibly rise, but no more than that. Remove your mouth from shield with each rescue breath and allow patient to exhale. If the patient is an infant, place your mouth over the infants mouth and nose.
Using a Ventilation Mask

Place mask over the patients mouth and nose. Tilt patients head and lift chin into mask to create an air tight seal.
Take a normal breath and place your mouth around the oneway valve on the mask. Blow through valve and make chest visibly rise, but no more.
Remove your mouth from the valve with each rescue breath and allow patient to exhale.
Skill Guide #5
Bag-Mask
2 or More Rescuers
Rescuer 2
Squeeze bag to ventilate. Give each breath in 1 second. Make chest visibly rise, but no more.
1 Rescuer
Position yourself above patients head. Place mask over mouth and nose. Use thumb and first finger of one hand around valve in a C position to press mask against patients face. Use your remaining three fingers in an E position to lift up jaw. Tilt head back to open airway. If patient is injured, use Jaw Thrust only. Squeeze bag with your free hand to ventilate. Give each breath in 1 second. Make chest visibly rise, but no more.
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1 2 3 1 2
Rescuer 1
Position yourself above patients head. Place mask over patients mouth and nose. Place your hands on either side of the head. Use your thumbs and heels of your hands to hold mask in place. Hook your fingers underneath the angles of the jaw, just below the ear. Lift and tilt head backward. If you suspect a neck injury, do not tilt head. Use counter pressure against cheeks to displace jaw and move it upward.
Skill Guide #6
External Chest Compressions
Adults
Place heel of one hand in center of chest between nipples. Put other hand on top of first. Your fingers can be straight or fastened together, but kept off chest. Position your shoulders directly over your hands. Straighten your arms and lock your elbows. Use upper body weight to help compress chest. Push straight down on chest approximately 1122 inches or 45 centimeters. Release your pressure and allow for full recoil of chest. Without interruption, compress at a rate of about 100 times per minute. Do not push over the lower part of the breastbone. Keep up the force and speed of compressions.
Children
Use heel(s) of either 1 or 2 hands to compress. Place hand(s) on the center of the chest, between the nipples. Using upper body weight, compress about 1312 the depth of the chest at a rate of about 100 compressions per minute.
Infants
Compress the center of chest with two fingertips just below the nipple line. Compress about 1312 the depth of the infants chest at a rate of about 100 per minute.
With two or more rescuers, compress the breastbone using two thumbs, with your fingers encircling the chest.
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Section 4 Defibrillation
Defibrillation
Ventricular fibrillation is the most common heart rhythm that occurs in sudden cardiac arrest. AEDs allow healthcare providers who are not trained in advanced techniques to defibrillate. Integrated voice prompts help make them simple to operate.
the pads on the chest. Pads need to be removed from their protective lining to ensure proper adherence to the chest wall.
Placing pads.
Automated External Defibrillator (AED).
When pads are properly attached, an AED will automatically begin to analyze a patients heart rhythm to decide if a shock is needed. No one should touch the patient during analysis. A voice prompt and warning sound will inform you a shock is recommended. All rescuers need to be safely cleared from the patient before delivering the shock. Immediate CPR is recommended following an initial defibrillation shock. Additional shocks may be required. Listen carefully to the AED voice prompts and provide any indicated care.
Survival rates for sudden cardiac arrest are highest when immediate CPR is performed and defibrillation is provided within 35 minutes. If you witness the collapse of a patient who is found to be in cardiac arrest, initiate CPR and defibrillate as soon as an AED is available. If you respond to an arrest that you have not witnessed, your protocols may require you to perform about 2 minutes of CPR prior to using an AED. There are many different brands of AEDs, but the same basic steps apply to all of them. Turn on the AED. Adhere the AED pads to the patients bare chest. Allow the AED to automatically analyze the heart rhythm. Deliver a shock if directed to by the AED. Turning on an AED will begin voice prompts that will help guide you through the steps of care.
Deliver shock.
Defibrillation is provided through adhesive pads attached to the patients bare chest and connected by wires to the AED. These pads typically have pictures on them that indicate the proper placement of
Defibrillation CPR Pro for the Professional Rescuer
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Ventricular fibrillation is uncommon in children, but it can occur. AEDs can be used for children older than 1 year of age.18 An AED may have special pads or a key to deliver a lower, child-sized amount of electricity.19 If a child-specific AED is not available, it is okay to use an AED set up for an adult.
Moisture on the victims chest can reduce the ability of the pads to adhere. If the victims chest is sweaty or wet, quickly dry it before attaching the pads. Move a victim out of standing water before attaching the pads. If a message indicating motion occurs, make sure CPR has been stopped and the cables are not being moved. If a message regarding the battery is displayed, the battery is probably low. If the AED will not charge to deliver a shock, change the battery.
Remove medication patches and wipe the skin clean before attaching pads. Medication patches may block the shock and can cause burns to the skin. A noticeable scar and lump on the chest may indicate an underlying implanted medical device such as a pacemaker or defibrillator. Place the edge of the pads at least 1 inch or 2.5 centimeters away from any implanted device. To prevent the accidental ignition of bedding or clothes divert emergency oxygen away from the victim when shocks are delivered with an AED. AEDs can be used safely on metal surfaces as long as the electrode pads do not come into contact with the metal.
Children defibrillation devices.
Troubleshooting
Troubleshooting prompts from the AED can help guide you through some common problems with its use. Stay calm and do what the AED tells you to do. Hair on the chest may prevent the electrode pads from making effective contact. If a voice prompt indicates a pad problem, press the pads firmly against the chest. If the prompt continues, quickly remove the pads tearing out the hair, and apply a second set of pads. If the problem continues, quickly shave the hair off of the chest underneath and attach another set of pads.
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Defibrillation
Section 5 Emergency Action Steps
Assess, Alert, and Attend to the ABCDs

The emergency action steps are intended to help you manage life-threatening problems of the airway, breathing and circulation.
oxygen. If you are alone with an unresponsive adult, immediately alert EMS yourself. Get an AED and oxygen, if they are available, and quickly return to the patient.
Always pause for a moment as you approach and assess the scene for safety. If the scene is not safe, make sure it is before you enter. Assess any patients. Form an initial impression of the severity of their problems. Signs that CPR may be needed include: Patient is not moving. Tissue color is bluish or ashen, especially around the lips. Breathing is shallow, gasping, or absent.
Alert EMS.
Attend to the ABCDs. Make sure the patient is face up on a firm, flat surface. If the patient is on his face, roll him over but minimize twisting of the head and neck. Attend to the airway. Open the airway using Head-tilt, Chin-lift. Use the Jaw Thrust if you suspect a neck injury.
Adults
Kneel next to the patient. Gently tap or squeeze the patients shoulder and ask, Are you all right? Use the patients name if you know it.
Open the airway.
Assess victim.
If the patient is unresponsive, have another person alert EMS if it has not already been done. If available, have the person return with an AED and emergency
Emergency Action Steps
Attend to breathing. Lean close to the patient and look for chest movement, listen for air leaving the mouth and nose, and feel for air blowing on your cheek. Check for at least 5, but no more than 10 seconds.
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best blood flow possible. After 30 compressions, open the patients airway and give two rescue breaths that make the chest visibly rise. Without delay, return to the chest and begin compressions again. Compressions need to be hard and fast. Allow the chest to fully recoil at the top of each compression and minimize any interruptions to compressions. Provide continuous cycles of 30 compressions to 2 rescue breaths until an AED is available, you are relieved by another rescuer, or the patient responds.
Check for breathing.
It may be difficult to determine whether an adult patient is breathing normally or not. Normal breathing is effortless, quiet, and regular. Occasional gasps are not normal and are not capable of supplying the patient with enough oxygen to sustain life. If the patient is breathing normally, place him on his side in a recovery position. If you are not positive that the patient is breathing or breathing normally, quickly give two rescue breaths. If the patients chest does not rise with the first rescue breath, re-tilt the patients head, lift the chin, and give the second breath.
Single rescuer CPR.
When another rescuer is available, perform CPR with 2 rescuers. One rescuer performs rescue breaths and the other performs chest compressions. When giving rescue breaths, pause compressions, and allow the breaths to be given. Change places every few minutes to prevent fatigue. Do this quickly, in less than 5 seconds.
Give two rescue breaths.
Attend to circulation. After the delivery of the two rescue breaths, check the patients pulse. Check the pulse for no more than 10 seconds. If a pulse is present, perform rescue breathing. Provide 1 rescue breath about every 5 to 6 seconds.
Two-rescuer CPR.
If the pulse is absent, or you are not sure after 10 seconds, perform CPR. Give 30 chest compressions at a speed of about 100 per minute. Keeping up the force, length, and speed of compressions helps create the
When an AED becomes available, use it immediately, unless your protocols indicate otherwise. Turn the AED on and listen to the voice prompts. Expose the chest by tearing or cutting the shirt.
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Remove the defibrillation pads from their packaging. Look at the pictures on the pads to see exactly how to place them. Remove the self-adhesive backing and attach the electrodes to the patients bare chest. Make sure the electrode attaches firmly to the skin. Allow the AED to analyze the patients heart rhythm. Ensure nobody touches the patient during analysis. If a shock is indicated, warn everyone out loud to stay CLEAR of the patient. Make sure no one, including you, is touching the patient. Press the shock button on the AED to deliver the shock. Immediately resume CPR and follow any instructions given by the AED. If the patient becomes responsive at any time, stop CPR.
Attend to the child. Open the airway. Check for the presence or absence of breathing. Take at least 5 seconds and no longer than 10. If the child is breathing, place her in the recovery position. If breathing is absent give 2 rescue breaths. For children, you may have to try a couple of times to give breaths that make the chest visibly rise. It is critical that rescue breaths make an infant or childs chest rise during resuscitation. Check the childs pulse for no longer than 10 seconds. If the pulse is present and is 60 beats per minute or greater, perform rescue breathing, providing 1 rescue breath every 3 to 5 seconds. If the pulse is less than 60 beats per minute, absent, or you are not sure, begin CPR. Provide continuous cycles of 30 compressions to 2 rescue breaths until an AED is available, you are relieved by another rescuer, or the child responds.
Defibrillation.
Supplemental Oxygen Even the best chest compression provides only about 25%33% of the normal blood and oxygen flow from the heart. The combination of low blood flow and low oxygen causes organs to fail and leads to death. Giving rescue breaths with supplemental oxygen permits the rescuer to provide a higher concentration of oxygen. Oxygen-rich breaths deliver critically needed oxygen to the heart and brain. For this reason, when available, healthcare providers, first responders, and professional rescuers should use supplementary oxygen when performing rescue breathing. Ideally a bag-mask device should be attached to an oxygen reservoir to allow delivery of 100% oxygen to the patient.
Child CPR.
When performing CPR on a child with 2 rescuers, provide continuous cycles of 15 compressions to 2 breaths. When giving rescue breaths, pause compressions and allow the breaths to be performed. If the collapse of the child was witnessed, use an AED as soon as one is available. If the collapse was not witnessed, perform about two minutes of CPR before using the AED. Turn the AED on and listen to the voice prompts. Expose the chest. Remove the defibrillation pads from their packaging, peel them from their backing, and apply them to the childs bare chest. With most AEDs, place one pad on the center of the chest, just below the collarbones. Place the other pad on the center of the back between the shoulder blades.
Children
The emergency action steps for children are similar to adults with a few key differences. Assess the scene for safety. Assess the child for response. Have a bystander alert EMS. When alone, stay with the child and, if indicated, provide about two minutes of CPR before leaving to call for EMS.
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Child defibrillation.
Infant two-rescuer CPR.
Allow the AED to analyze the childs heart rhythm. Ensure nobody touches the child during analysis. If a shock is indicated, warn everyone to stay CLEAR of the child. Make sure no one, including you, is in contact with the child. Press the shock button on the AED to deliver the shock. Immediately resume CPR and follow any instructions given by the AED.
When performing CPR on an infant with 2 rescuers, provide continuous cycles of 15 compressions to 2 breaths. When giving rescue breaths, pause compressions to allow the breaths to be performed.
When Using Advanced Airways

Professional rescuers may use an advanced airway device such as the laryngeal mask airway, esophogeal-tracheal-combitube, or endotracheal tube to provide rescue ventilations. When an advanced airway is in place, remove the mask from the bag-mask device and attach the bag directly to the airway to ventilate. Give ventilations at a rate of 6 to 8 times a minute, regardless of the patients age.
Infants
The emergency action steps for an infant are similar to an adult or child. Assess the scene for safety. Assess the infant for response. You may try tapping the foot. Have a bystander alert EMS. When alone, stay with the infant and, if indicated, provide about two minutes of CPR before leaving to call for EMS. Attend to the infant. Open the airway. Check for the presence or absence of breathing. Take at least 5 seconds and no longer than 10. If the infant is breathing, place him in the recovery position. If breathing is absent, provide 2 rescue breaths. Check the infants brachial pulse for no longer than 10 seconds. If the pulse is present and is 60 beats per minute or greater, perform rescue breathing, providing 1 rescue breath every 3 to 5 seconds. If the pulse is less than 60 beats per minute, absent, or you are not sure, begin CPR. Provide continuous cycles of 30 compressions to 2 rescue breaths until you are relieved by another rescuer or the infant responds.
Bag-mask to advanced airway.
When performing CPR with an advanced airway in place, it is no longer necessary to pause compressions. Ventilations and compressions can be performed independently.
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Special CPR Considerations

Pregnancy Chest compressions may not be effective when a woman who is 6 months pregnant or more is lying at on her back. This is because the baby puts pressure on a major vein that returns blood to the heart. If possible, prop up the woman slightly on her left side using a rolled blanket (or similar) when performing chest compressions. This will reduce this pressure and provides the most blood ow to mother and baby. Perform chest compressions higher on the breastbone, slightly above the center. Hypothermia Get inside or out of the wind. Prevent additional heat loss by removing wet clothes and insulating the victim from further exposure. If the body is frozen solid, the nose and mouth are blocked with ice, and chest compression is impossible, do not start CPR. When debrillating, if the victim does not respond to one shock, focus on continuing CPR and re-warming the victim to a range of 30C32C (86F89.6F) before repeating the debrillation attempt. Submersion/Near-Drowning Because the scene may be unsafe (waves, currents, cold water, bad weather), proper training in the use of personal lifesaving equipment, such as torpedo buoys and personal otation devices, is critical for a safe rescue. If available, get the victim into a boat or other vessel. If no boat is available, get the victim to shore. Start BLS/CPR when indicated, as soon as it is safe to do so. Expect vomiting. When it occurs, turn the victims mouth to the side and remove the vomit with a gloved nger sweep or cloth. If a head, neck, or back injury is suspected, use the HAINES method or roll the victim like a log. Minimize movement. Avoid twisting the head, neck, or back. Do not attempt to drain water from the lungs using abdominal thrusts. They are unnecessary and potentially dangerous. Move victim out of freestanding water and dry chest before attaching AED. Electric Shock Consider any fallen or broken wire extremely dangerous. Do not touch (or allow your clothing to touch) a wire, victim, or vehicle that could be energized. Do not approach within 8 feet of it. Notify the local utility and have trained personnel sent to the scene. Metal or cable guard-rails, steel wire fences, and telephone lines may be energized by a fallen wire and may carry the current a mile or more from the point of contact. Never attempt to handle wires yourself unless you are properly trained and equipped. Start CPR if indicated, as soon as it is safe to do so. Lightning Strike When multiple victims are struck by lightning at the same time, give the highest priority to those without signs of life. Start CPR if indicated, as soon as it is safe to do so. Because many victims are young, they have a good chance for survival if immediate CPR is given. Remove smoldering clothing, shoes, and belt to prevent burns. Cardiac Arrest and Injury Be sure to clear mouth of blood, vomit, and other secretions. It is unlikely for someone who is in cardiac arrest caused by a serious injury to survive.
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Summary of CPR/AED Procedures

Adult
Begins with onset of puberty
Child
About 1 year of age to onset of puberty
Infant
Less than 1 year of age
Assess
Assess Scene
If the scene is unsafe or at anytime becomes unsafe, GET OUT! Tap shoulder, shout name. If the scene is unsafe or at any- If the scene is unsafe or at anytime becomes unsafe, time becomes unsafe, GET GET OUT! OUT! Tap shoulder, shout name. Tap foot, shout out.
Assess Patient
Alert
Alert EMS or Emergency Plan Get an AED and/or emergency oxygen
Send a bystander. When alone, do it yourself immediately. Send a bystander. When alone, perform about 2 minutes of care before doing it yourself. Send a bystander. When alone, perform about 2 minutes of care before doing it yourself.
Attend
Open Airway
Head-tilt, Chin-lift Jaw Thrust for suspected neck injury Look, listen, and feel for at least 5 seconds, but no more than 10. Place patient in recovery position and monitor breathing. Provide 2 rescue breaths. 1 second in length Make chest visibly rise, but no more Palpate carotid pulse in neck for no more than 10 seconds. Perform Rescue Breathing; 1 breath every 56 seconds. Perform CPR 1 Rescuer 30:2 2 Rescuer 30:2 Center of chest, between nipples; 2 hands 112 to 2 inches 100 times per minute Hard, fast, complete recoil, minimize interruption Head-tilt, Chin-lift Jaw Thrust for suspected neck injury Look, listen, and feel for at least 5 seconds, but no more than 10. Place patient in recovery position and monitor breathing. Provide 2 rescue breaths. 1 second in length Make chest visibly rise, but no more Palpate carotid pulse in neck for no more than 10 seconds. Perform Rescue Breathing; 1 breath every 35 seconds. Perform CPR 1 Rescuer 30:2 2 Rescuer 15:2 Center of chest, between nipples; 1 or 2 hands 13 to 12 depth of chest 100 times per minute Hard, fast, complete recoil, minimize interruption Head-tilt, Chin-lift Jaw Thrust for suspected neck injury Look, listen, and feel for at least 5 seconds, but no more than 10. Place patient in recovery position and monitor breathing. Provide 2 rescue breaths. 1 second in length Make chest visibly rise, but no more Palpate brachial pulse in upper arm for no more than 10 seconds. Perform Rescue Breathing; 1 breath every 35 seconds. Perform CPR 1 Rescuer 30:2 2 Rescuer 15:2 Center of chest, 2 fingers just below nipple line or 2 thumbs with hands encircling chest (2 rescuers) 13 to 12 depth of chest 100 times per minute Hard, fast, complete recoil, minimize interruption No recommendation
Check Breathing
Breathing Present?
Breathing Absent? Rescue Breaths
Check Circulation
Pulse Present? Pulse Absent?
Compressions
Defibrillation with an AED
Turn on power Attach pads Analyze If indicated, deliver shock Resume CPR and follow voice prompts
Use Child system; if not available, use an AED Turn on power Attach pads Analyze If indicated, deliver shock Resume CPR and follow voice prompts
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Skill Guide #7
Adult Rescue Breathing
Perform these steps quickly in a minute or less
Emergency Action Steps Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT! Assess Patient. Tap shoulder, shout name. Not moving? No response? Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, do this yourself. Attend to the ABCs.
Airway Open Airway
A B C C
Tilt head, lift chin. If you suspect a neck injury, use Jaw Thrust.
Breathing Check Breathing

Look, listen, and feel for 5, but no more than 10 seconds. No breathing! If the patient is not breathing, or not breathing adequately, give 2 rescue breaths that make chest visibly rise.
Circulation Check Pulse

Check the carotid pulse in the neck for no more than 10 seconds. Pulse is present!
Perform Rescue Breathing

Give each breath in 1 second. Make the chest visibly rise each time. Perform 1 breath every 56 seconds (10-12 breaths per minute). Reassess the carotid pulse about every 2 minutes. Take no longer than 10 seconds to do so.
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Skill Guide #8
Child Rescue Breathing
Emergency Action Steps Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT! Assess Child. Tap shoulder, shout name. Not moving? No response? Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, stay with the child and provide 2 minutes of care before doing this yourself. Attend to the ABCs.
Airway Open Airway
A B C C
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Look, listen, and feel for 5, but no more than 10 seconds. No breathing! If the child is not breathing, or not breathing adequately, give 2 rescue breaths that make chest visibly rise.

Check the carotid pulse in the neck for no more than 10 seconds. Pulse is present and 60 bpm!

Give each breath in 1 second. Make the chest visibly rise each time. Perform 1 breath every 35 seconds (1220 breaths per minute). Reassess the carotid pulse about every 2 minutes. Take no longer than 10 seconds to do so.
Skill Guide #9
Infant Rescue Breathing
Emergency Action Steps Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT! Assess Infant. Tap shoulder, shout name. Not moving? No response? Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, stay with the infant and provide 2 minutes of care before doing this yourself. Attend to the ABCs.
Airway Open Airway
A B C C

Look, listen, and feel for 5, but no more than 10 seconds. No breathing! If the infant is not breathing, or not breathing adequately, give 2 rescue breaths that make chest visibly rise.

Check the brachial pulse on the inside of the upper arm for no more than 10 seconds. Pulse is present and 60 bpm!

Give each breath in 1 second. Make the chest visibly rise each time. Perform 1 breath every 3-5 seconds (12-20 breaths per minute). Reassess the brachial pulse about every 2 minutes. Take no longer than 10 seconds to do so.
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Skill Guide #10

Adult CPR/AED
Emergency Action Steps Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT! Assess Patient. Tap shoulder, shout name. Not moving? No response? Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, do this yourself. Attend to the ABCDs.
A B C D D
Airway Open Airway

Tilt the head, lift the chin. If you suspect a neck injury, use Jaw Thrust.

Look, listen, and feel for 5, but no more than 10 seconds. No breathing! If the patient is not breathing, or not breathing adequately, give 2 rescue breaths that make chest visibly rise.

Check the carotid pulse in the neck for no more than 10 seconds. No pulse!
Perform CPR
1 Rescuer (30:2)
Push hard and fast (100x per min.) 1122 inches deep. Allow chest to recoil completely. Minimize interruptions. Provide continuous cycles of 30 compressions and 2 rescue breaths until AED arrives, EMS arrives, or patient responds.
2 or More Rescuers (30:2)

One rescuer performs compressions; the other rescue breaths. Pause compressions when breaths are given. Quickly change positions at least every two minutes.
Defibrillation Use an AED if Available

Turn on AED and follow voice prompts. Attach pads to bare chest; allow AED to analyze heart. If shock advised, CLEAR patient and deliver shock. Immediately resume CPR. Follow AED voice prompts.
Skill Guide #11

Child CPR/AED
Emergency Action Steps Assess Scene. If scene is not safe or at any time becomes unsafe, GET OUT! Assess Child. Tap shoulder, shout name. Not moving? No response? Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, provide two minutes of care before doing this yourself. Attend to the ABCDs.
A B C D D
Airway Open Airway


Look, listen, and feel for 5, but no more than 10 seconds. No breathing! If the child is not breathing, or not breathing adequately, give 2 rescue breaths that make chest visibly rise.

Check the carotid pulse in the neck for no more than 10 seconds. No pulse!
Perform CPR
1 Rescuer (30:2)
Push hard and fast (100x per min.) 13 to 12 the depth of chest. Allow chest to recoil completely. Minimize interruptions. Provide continuous cycles of 30 compressions and 2 rescue breaths until an AED arrives, EMS arrives, or child shows signs of life.

One rescuer performs compressions; the other rescue breaths. The compressor pauses while breaths are given. Quickly change positions at least every two minutes.
Defibrillation Use an AED if Available

Turn on AED and follow voice prompts. Attach pads to bare chest; allow AED to analyze heart. If shock advised, CLEAR child and deliver shock. Immediately resume CPR. Follow AED voice prompts.
Skill Guide #12

Infant CPR
Emergency Action Steps Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT! Assess Infant. Tap foot, shout. Not moving? No response? Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, stay with the infant and provide 2 minutes of care before doing this yourself. Attend to the ABCDs.
Airway Open Airway
A B C D
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Look, listen, and feel for 5, but no more than 10 seconds. No breathing! If the infant is not breathing, or not breathing adequately, give 2 rescue breaths that make chest visibly rise.

Check the brachial pulse on the inside of the upper arm for no more than 10 seconds. No pulse!
Perform CPR
1 Rescuer (30:2)
Push hard and fast (100x per min.) 13 to 12 the depth of the chest. Allow chest to recoil completely. Minimize interruptions. Provide continuous cycles of 30 compressions and 2 rescue breaths until EMS arrives or infant shows signs of life.

One rescuer performs compressions; the other rescue breaths. Pause compressions when breaths are given. Compress with thumbs and fingers encircling chest. Quickly change positions at least every two minutes.
Section 6 Choking
Foreign Body Airway Obstruction

Choking occurs when an object blocks the passage that allows air in and out of the lungs.
For adults and children, repeated abdominal thrusts are recommended to relieve the blockage until the object is expelled or the patient becomes unresponsive.
Abdominal thrusts for adults. Choking victim.
Food, especially large pieces, is the most common cause of choking. Young children are particularly at risk because of the small size of their air passages, inexperience with chewing, and a natural tendency to put objects in their mouths.20,21 Rescuers must be able to recognize the difference between a mild blockage and a severe blockage of the airway. A mild blockage can typically be cleared by the patient through a natural coughing reaction. If a patient can speak, or has strong coughing or gagging, stay with them and encourage them to try and cough the foreign object out. Be ready to take actions if symptoms worsen. If the blockage is not easily relieved and the patient is struggling, alert EMS. When a severe blockage occurs, it is impossible to clear the airway through natural means. Help from a bystander is required to save the patients life. Signs of a severe blockage include: Hands clutching throat Patient cannot speak, cough, or make any sound Blue lips, nails, skin To assess a patient you think may be choking simply ask, Are you choking? If patient nods yes or is unable to speak, cough, or cry act quickly!
For infants, repeat a combination of back blows and chest thrusts.
Back blows and chest thrusts for infants.
If the choking patient is in the late stages of pregnancy or is obese, and you cannot get your arms around the abdomen, you can perform chest thrusts to remove the blockage.
Choking
33
Abdominal thrusts have been associated with severe and fatal complications. Complications may occur even when abdominal thrusts are performed correctly. DO NOT perform abdominal thrusts on an adult or child unless it is necessary. A patient who has had an airway obstruction that was removed by abdominal or chest thrusts should be evaluated by EMS and seen by a physician to assure no internal injuries resulted from the event. Abdominal thrusts are not recommended for infants because you may damage internal organs.
Pregnant choking victim.
If you are alone, it is possible to relieve the blockage yourself. Attempt to give yourself abdominal thrusts until the object is expelled. If that does not work, press your abdomen quickly over any firm surface (back of a chair, side of a table, etc.). If a choking patient becomes unresponsive during treatment, change your approach to care. Carefully get the patient to the ground and alert EMS. If alone with a child, give about 2 minutes of CPR, then alert EMS.
Adult CPR.
Begin CPR. Each time the airway is opened for rescue breaths, look for an object in the patients throat. If you see it, remove it. Continue CPR until the AED or EMS arrives or the patient shows signs of life.
34
Choking
Skill Guide #13

Adult Choking: Severe Blockage
Assess Patient. Suspect severe blockage if patient reacts suddenly and is clutching throat.
Responsive
1 2 3 1 2 3
Choking
Stand behind patient. Make a fist. Place thumb side against patients abdomen, just above the navel and below ribs. Grasp fist with other hand.
Quickly thrust inward and upward into abdomen. Repeat thrusts until object is expelled or patient becomes unresponsive.
Becomes Unresponsive
Carefully get patient to ground. Alert EMS.
Begin CPR. Each time airway is opened for rescue breaths, look for an object in patients throat. If seen, remove it.
Continue CPR until an AED arrives, EMS arrives, or patient shows signs of life.
35
Quickly ask, Are you choking? If patient nods yes or is unable to speak or cough act quickly.
Skill Guide #14

Child Choking: Severe Blockage
Assess Child. Suspect severe blockage if child reacts suddenly and is clutching throat.
Responsive
1 2 3 1 2 3
36
Quickly ask, Are you choking? If child nods yes or is unable to speak or cough act quickly.
Stand or kneel behind child. Make a fist. Place thumb side against childs abdomen, just above the navel and below ribs. Grasp fist with other hand.
Quickly thrust inward and upward into abdomen. Repeat thrusts until object is expelled or child becomes unresponsive.
Carefully get child to ground. Alert EMS.
Begin CPR. Each time airway is opened for rescue breaths, look for an object in childs throat. If seen, remove it.
Continue CPR until an AED arrives, EMS arrives, or child shows signs of life.
Choking
Skill Guide #15

Infant Choking: Severe Blockage
Assess Infant. Suspect severe blockage if infant suddenly becomes very quiet.
Responsive
1 2 3 1 2 3
Choking
Lay infant face down on your forearm. Support head and tilt it downward. Give 5 firm back blows between shoulder blades. Sandwich infant between your arms and roll over onto other forearm.
Using two fingertips just below nipple line, give five chest thrusts. Repeat 5 back blows and 5 chest thrusts until object is expelled or infant becomes unresponsive.
Place infant on a firm flat surface. Alert EMS.
Begin CPR. Each time airway is opened for rescue breaths, look for an object in infants throat. If seen, remove it.
Continue CPR until EMS arrives or infant shows signs of life.
37
Quickly look at infants face. If the infant is silent and unable to cry, and has blue lips, nails, and skin act quickly.
Section 7 Legal and Emotional Aspects
Legal Aspects of Providing Basic Life Support

Good Samaritan Laws These are laws to prevent someone who has voluntarily helped another in need from being sued for wrongdoing. You are generally protected from liability as long as you act reasonably and in good faith without payment or reward, and you do not provide care beyond your skill level. Abandonment If you decide to help in an emergency, you must not leave the patient until someone with equal or more training takes over. Consent Consent is permission. A responsive adult must agree to receive emergency medical care. Expressed consent means the patient gives his or her permission to receive care. To get consent, first identify yourself. Then tell the patient your level of training and ask if its okay to help. Implied consent means that permission to provide care to an unresponsive patient is assumed. This is based on the idea that a reasonable person would give permission to receive lifesaving care if able. Consent for children must be gained from a parent or legal guardian. When life-threatening situations exist and the parent or guardian is not available, care should be given based on implied consent. When suffering from a disturbance in normal mental functioning, like Alzheimers disease, a patient may not understand your request for consent. Consent must be gained from a family member or legal guardian. Duty to Act This is a requirement to act toward others and the public with the watchfulness, attention, caution and prudence that a reasonable person in the same circumstances would use. If a persons actions do not meet this standard, then the acts may be considered negligent, and any damages resulting may be claimed in a lawsuit for negligence. If you are a state-licensed healthcare provider, first responder, or other professional rescuer expected to give emergency medical care, including CPR, you almost certainly have a duty to act. However, BLS performed voluntarily on a stranger in need while off-duty is generally considered a Good Samaritan Act. Starting CPR Start CPR for all patients in cardiac arrest unless signs of irreversible death are present, including rigor mortis (limbs of corpse stiff and impossible to move), dependent lividity (settling of blood in
lower portions of body, causing a purplish red discoloration), or conditions are present that are incompatible with life (decomposition, decapitation, massive head injury, etc.). Do not start CPR if it puts you in danger of injury, or the patient has a valid DNR order. In a mass casualty incident with limited resources, patients requiring rescue breathing or CPR are considered dead and attempts to resuscitate them should not be started. Stopping CPR Do not stop CPR until a healthcare provider or other professional rescuer with equal or more training takes over, you are exhausted, the scene becomes too dangerous to continue, or the patient shows signs of life. You can also stop if the physician in charge of the patient decides to order the resuscitation effort stopped (follow local protocol, standard operating procedures, and/or medical direction). Except when death is obvious, irreversible brain damage or brain death cannot be reliably assessed or predicted. Rescuers should never make an impulsive decision about the present or future quality of life of a cardiac arrest patient, because such decisions may be incorrect. Advanced Directives and Living Wills These are documents authorized by state law that allow a person to appoint someone as his or her representative to make decisions on resuscitation and continued lifesupport in a situation where a person has lost decision-making capacity (for example, if in a coma). These documents may also be referred to as a durable power of attorney. Advanced directives are statements about what the patient wants done or not done when the patient cant speak on his or her own behalf. Laws about advanced directives are different in each state. You should be aware of the laws in your state. Do Not Resuscitate (DNR) or Do Not Attempt Resuscitation (DNAR) Orders The DNR/DNAR order is a kind of advanced directive. This is a specific request not to have CPR performed. In the United States, a doctors order is required to withhold CPR. Therefore, unless the patient has a DNR order, EMS providers and hospital staff should attempt resuscitation. Patients who are not likely to benefit from CPR and may have a DNR order include those with terminal conditions from which they are unlikely to recover. Outside the hospital, healthcare providers, first responders, and other professional rescuers should
38
Legal and Emotional Aspects
begin CPR if there is a reasonable doubt about the validity of a DNAR order or advanced directive, if the patient may have changed his or her mind, or the patients best interests are in question.
During Incident Anxiety/worry Trembling/shaking Sweating Fast breathing Pounding heartbeat, shock, anger Excitement, intense fear Nausea Following Incident Thinking about event repeatedly Worry about self or loved ones Guilt for not having done more Tense muscles, diarrhea/constipation, nausea/vomiting, headaches, fatigue Easily startled Lack of interest in usual activities Sadness, feeling detached Sleep problems/nightmares Problems concentrating Hyperactive/depressed During the incident, remain calm and act sensibly. Accept your own limitations as a rescuer. Following the incident, remind yourself that stress reactions are normal and will pass. Get back into a normal routine as soon as possible. Be kind to yourself. Allow yourself time to deal with memories of the incident. Accept every persons right to his or her own feelings. Keep what happened in a realistic perspective. Be sure to exercise, eat, drink, and rest. Have a connection to professional resources for continued care if necessary.
Emotional Aspects of Providing Basic Life Support

Rescuers trained in CPR are often unwilling to perform it both in and outside the hospital setting. There are a variety of reasons given, including fear of disease, fear of hurting the patient, fear of performing the skills incorrectly, and fear of liability. It is important to remember that the risk of getting disease while giving CPR is extremely low and observing universal precautions for patients of all ages will make it lower. Fears associated with CPR skill performance can be reduced through regular participation in quality training that focuses on simple, practical skills and confidence building.22 Still, when resuscitation is attempted, doctors, nurses, EMS providers and bystanders can experience a wide range of negative reactions and emotional stress. Failed resuscitation attempts often leave rescuers especially those who perform resuscitation infrequently feeling guilt when CPR was not done right. This distress is normal and usually temporary. Although CPR should be done right and at a high quality, it is helpful to remember that a person in cardiac arrest is already dead (without breathing or a pulse). It is not possible to make the patient worse. You can only help.23 Traumatic stress reactions are a normal, human response to a traumatic event and are usually temporary. Symptoms begin within minutes of the traumatic event and should disappear within hours or a couple of days.
Legal and Emotional Aspects
39
End Notes
End Notes
1
13
Heart and Stroke Foundation of Canada; Available: http://ww2.heartandstroke.ca/ [24Oct05]. Safety Tips; Safe Kids Worldwide: www.safekids.org/. [8Dec05]. SIDS: Back to Sleep Campaign; The National Institute of Child Health and Human Development (NICHD); Available: http://www.nichd.nih.gov/sids/ [19Apr05]. Hauck FR, Omojokun OO, Siadaty MS; Do pacifiers reduce the risk of sudden infant death syndrome?; A metaanalysis; Pediatrics; 2005 Nov;116(5):71623. LopezHerce J, et al.; Longterm outcome of paediatric cardiorespiratory arrest in Spain; Resuscitation; 2005 Jan;64(1):7985. Samson RA, et al.; Use of automated external defibrillators for children: an update: an advisory statement from the pediatric advanced life support task force; International Liaison Committee on Resuscitation; Circulation; 2003 Jul 1;107(25):32505. Atkins DL, Jorgenson DB; Attenuated pediatric electrode pads for automated external defibrillator use in children; Resuscitation; 2005 Jul;66(1):317. CDC; Nonfatal chokingrelated episodes for children 0 to 14 years of age; United States; 2001; Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5142a 1.htm [26Aug08]. Chiu CY, Wong KS, Lai SH, Hsia SH, Wu CT; Factors predicting early diagnosis of foreign body aspiration in children; Pediatr Emerg Care; 2005 Mar;21(3):1614. Attitude toward Performing CPR; 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations; hosted by the American Heart Association in Dallas, Texas; January 2330, 2005; Circulation; 2005;112:III100III108 and Resuscitation; Volume 67; Supplement 1; Pages S1S190; (December 2005); 2005; International Liaison Committee on Resuscitation, American Heart Association, Inc. and European Resuscitation Council. Shenefelt, R; Emotional Aspects of Basic Life Support; Presentation; Scientific Program of the New Zealand Resuscitation Council Conference; Wellington, NZ; November, 1999.
U.S. Department of Labor; Occupational Safety & Health Administration Regulations (Standards 29 CFR) Bloodborne pathogens 1910.1030; Available: http://www.osha.gov/ [23Mar05]. Division of Healthcare Quality Promotion, National Center for Infectious Diseases Centers for Disease Control and Prevention; Standard Precautions; January 1996; Available: http://www.cdc.gov/ncidod/dhqp/ gl_isolation_standard.html [26Aug08]. Mejicano GC, Maki DG; Infections acquired during cardiopulmonary resuscitation: estimating the risk and defining strategies for prevention; Ann Intern Med; 1998 Nov 15;129(10):81328. Hand Hygiene in Healthcare Settings; Division of Healthcare Quality Promotion, National Center for Infectious Diseases Centers for Disease Control and Prevention; Available: http://www.cdc.gov/handhygiene/ [26Aug08].
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19 5
Preventing Heart Disease and Stroke Addressing the Nations Leading Killers; National Center for Chronic Disease Prevention and Health Promotion; Available: http://www.cdc.gov/dhdsp/library/toolkit/index.htm [26Aug08]. National Institute of Neurological Disorders and Stroke; National Institutes of Health; Available: http://www.ninds.nih.gov/disorders/stroke/stroke.htm [26Oct05]. Liferidge AT, Brice JH, Overby BA, Evenson KR; Ability of laypersons to use the Cincinnati Prehospital Stroke Scale; Prehosp Emerg Care; 2004 OctDec;8(4):3847. Learn To Recognize A Stroke; 2005 American Heart Association, Inc; Available: http://www.strokeassociation.org/ [13Jun05]. The Merck Manual; Section 16; Cardiovascular Disorders; Ch. 202; Coronary Artery Disease; Available: http://www.merck.com/mmpe/sec07/ch073/ch073a.html [26Aug08].
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22
23 10
Diseases and Conditions Index; National Heart Lung and Blood Institute; National Institutes of Health; U.S. Department of Health and Human Services; Available: http://www.nhlbi.nih.gov/health/dci/Diseases/scda/scda_ whatis.html [09-16-09] Newman MM; The Chain of Survival takes hold; JEMS; 1989;14 (8):1113. Hau SR, et al.; Factors impeding dispatcherassisted telephone cardiopulmonary resuscitation; Ann Emerg Med; 2003 Dec;42(6):7317.
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End Notes
American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 USA 541-344-7099 ashinstitute.org
Copyright 2009 by the American Safety & Health Institute. Revised September 2009. All rights reserved. No part of this publication may be reproduced, stored in retrieval system, or transmitted by any means, electronic, photocopying, or otherwise, without prior written permission from the American Safety & Health Institute. Printed in the United States of America PRN2007 (9/09)

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A M E R I C A N S A F E T Y & H E A LT H I N S T I T U T E

Section 2 Cardiovascular Disease

Section 3 Resuscitation Skills

Section 5 Emergency Action Steps

Section 7 Legal and Emotional Aspects

CPR Pro for the Professional Rescuer

Sudden Cardiac Arrest

Cardiopulmonary resuscitation (CPR).

Defibrillation with an AED.

CPR Pro for the Professional Rescuer

CPR Pro for the Professional Rescuer

Mask and shield.

CPR Pro for the Professional Rescuer

CPR Pro for the Professional Rescuer

CPR Pro for the Professional Rescuer

Section 2 Cardiovascular Disease

Acute Coronary Syndromes (ACS)

Heart attack. Stroke graphic.

CPR Pro for the Professional Rescuer

Chain of Survival for Adults

Sudden Cardiac Arrest

Sudden cardiac arrest (SCA).

CPR Pro for the Professional Rescuer

CPR Pro for the Professional Rescuer

Chain of Survival for Children

Section 3 Resuscitation Skills

Jaw Thrust maneuver.

Opening the airway.

CPR Pro for the Professional Rescuer

Bag-mask with two rescuers.

Rescue breaths using a mask.

CPR Pro for the Professional Rescuer

Child/infant pulse check.

Adult chest compressions.

CPR Pro for the Professional Rescuer

Infant chest compressions.

Child chest compressions.

CPR Pro for the Professional Rescuer

Jaw Thrust with Head-Tilt

CPR Pro for the Professional Rescuer

Recovery Position (No Injuries)

HAINES Position (Suspected Injury)

CPR Pro for the Professional Rescuer

Using a Ventilation Mask

CPR Pro for the Professional Rescuer

CPR Pro for the Professional Rescuer

CPR Pro for the Professional Rescuer

Automated External Defibrillator (AED).

Children defibrillation devices.

CPR Pro for the Professional Rescuer

Section 5 Emergency Action Steps

Assess, Alert, and Attend to the ABCDs

Open the airway.

CPR Pro for the Professional Rescuer

Check for breathing.

Single rescuer CPR.

Give two rescue breaths.

CPR Pro for the Professional Rescuer

CPR Pro for the Professional Rescuer

Infant two-rescuer CPR.

When Using Advanced Airways

Bag-mask to advanced airway.

CPR Pro for the Professional Rescuer

Emergency Action Steps