Introduction to CPR
CPR is an emergency procedure performed to save the life of someone in cardiopulmonary arrest. It involves a sequence of activities replicating the heart's pumping and breathing of the lungs to carry oxygen throughout the body.
- Cardiac arrest is when the heart stops beating and can not pump blood to the brain and other vital organs. When this happens, CPR is performed to restart the heart.
- Anyone can perform CPR, but it is recommended that only trained medical professionals perform CPR on someone who is in cardiac arrest.
- Although CPR is unlikely to restart a stopped heart, it will maintain blood flow to the victim's brain until advanced lifesaving techniques are available.
Standard CPR involves performing chest compressions and providing rescue breaths.
Chest compressions replicate the heart's pumping action by administering high-quality chest compressions. With this technique, the blood moves to the body's vital parts.
How to perform chest compressions?
- Place the victim on their back on a firm, flat surface.
- Place the heel of your hand at the center of the victim's chest and the other on top of the first hand. Interlock your fingers.
- Use your body weight to help you administer the compressions.
- Use quick, forceful pumps to compress the chest at a rate of 100-120 compressions per minute.
The rescuer will manually breathe air into the victim's lungs, which will simulate the act of inhalation. The air will help oxygenate the blood flowing through the lungs. The air consists mostly of carbon dioxide. But, it also contains all the oxygen that the rescuer's body did not use, constituting almost 17% of the exhaled air. This is enough to sustain the victim's life until the emergency response team arrives.
How to give rescue breaths?
- Before giving rescue breath, open the victim's airway using a head tilt, chin lift, or jaw thrust maneuver if there is a suspected spine and neck injury.
- Pinch the person's nose shut and place your mouth over their mouth.
- Blow into the person's mouth for about one second to make their chest rise.
- Allow the person to exhale and repeat the steps.
- Avoid excessive ventilation, and chest rise should appear natural.
- If the chest doesn't rise during the 1st rescue breath, open the airway again using head tilt and chin lift, then give the 2nd rescue breath.
Trained Rescuers: Those trained in CPR/AED can assess the situation, contact emergency services and provide conventional CPR with chest compressions and rescue breathing.
Untrained Rescuers: Those without formal training can perform Hands-only CPR, which involves pushing hard and fast on the chest with a rhythm of 100-120 beats per minute. Guidance can be provided by the 911 operator while they are on the line.
Chain of Survival
The American Heart Association and Emergency Cardiovascular Care's Chain of Survival are crucial when performing CPR. The chain of survival is a sequence of interventions which, when effectively implemented, can mitigate the mortality that arises from sudden cardiac arrest. There are five links in the chain of survival:
1. Immediate recognition of cardiac emergencies, call 911.
2. CPR with emphasis on chest compressions. Decreasing the delay in beginning compressions increases survival rates.
3. Provide rapid defibrillation with an AED within minutes of the onset of symptoms.
4. Trained medics administer advanced life support.
5. Post-cardiac arrest care is administered in a hospital setting.
The American Heart Association (AHA) Chain of Survival is integral in restoring cardiac arrest victims to good health. Bystanders can make an invaluable contribution by addressing the first three links: Early recognition and activation of the Emergency Medical System (EMS), Early Cardiopulmonary Resuscitation (CPR), and Early Defibrillation. Doing so can help save a life and significantly improve the patient's long-term prognosis.
Recovery as part of the chain of survival: The American Heart Association has found that further progress is needed despite improved sudden cardiac arrest survival rates since 2012. To address this, they have recently included recovery in the Chain of Survival - encompassing both adult and pediatric in-hospital and out-of-hospital care.
Good Samaritan Law
Good Samaritan laws are legal statutes that provide some level of legal protection for those who voluntarily provide first aid, emergency medical care, or assistance to individuals who are injured or otherwise in peril. Generally, they protect rescuers from liability for unintentional injury or wrongful death that results from their efforts.
Under Good Samaritan Laws, a person assisting an injured person is free from civil liability under the following conditions:
- The person helping must be acting voluntarily
- Without the expectation of reimbursement or compensation in any form
- Aid must be given at the scene of the emergency.
Good Samaritan Laws do not apply to persons providing advice and aid through their regular employment, such as paramedics, doctors, nurses, and other healthcare professionals.
The CAB Sequence
CAB stands for Compressions, Airway, and Breathing. These are the three key components of cardiopulmonary resuscitation (CPR).
- Compressions refer to the pressing and releasing of the chest to simulate the pumping of the heart. Chest compressions should be performed at a minimum of 100-120 beats per minute, with 30 compressions followed by two breaths in a cycle of 30:2.
- Airway refers to opening and maintaining the airway to allow oxygen flow. The victim’s head should be tilted slightly back to open the airway.
- Breathing refers to the provision of artificial respiration to the patient. The nose should be pinched for adults, and the victim should receive 10-12 breaths per minute. For infants and smaller children, the mouth and nose should be covered with the mouth and receive 12-20 breaths per minute, each lasting at least one second.
Utilizing the C-A-B approach, one can quickly provide life-saving care to a victim by administering compressions at a faster rate and ensuring vital blood flow to major organs.
Administering CPR to Adult
Scene safety: Before administering CPR, it's important to check the scene for factors that could harm you, such as traffic or fire. Make sure the scene is safe before responding to an emergency.
Check for consciousness: Tap on the adult victim's shoulder firmly and ask, "Are you OK?" loudly.
Call 911: If the victim is unconscious, call 911 or ask someone else to call before performing CPR. Even if you perform high-quality CPR on the spot, getting paramedics to the scene as quickly as possible is crucial. If possible, ask a bystander to look for an AED.
Check Pulse and Breathing: Check the pulse and breathing for about 10 seconds.
- If the victim has normal breathing, put him in the recovery position and wait for the responders to arrive.
- If the victim has a pulse but not breathing, give rescue breaths only
- If the victim doesn't have a pulse and you do not hear breathing or only hear a few gasps, begin CPR immediately.
1 person CPR ratio is 30:2 (30 chest compressions followed by 2 rescue breaths)
Provide 30 chest compressions
- Place the victim on their back on a firm, flat surface.
- Perform chest compressions on the lower half of the breastbone (sternum).
- Push hard and fast with a chest compression depth of 2-2.4 inches deep.
- The chest compression rate is 100-120 compressions per minute.
- Chest compression fraction: You must target at least a 60 percent chest compression fraction goal.
- Allow chest recoil after each compression.
Give 2 Rescue Breaths
- Open the airway using head tilt, chin lift technique
- One breath every 6 seconds or 8-10 breaths per minute.
- Avoid excessive ventilation.
Repeat: Continue giving 30 chest compressions and 2 rescue breaths until the adult victim shows any signs of life, AED becomes available, or the EMS arrives on site.
Administering CPR to Children
Performing CPR on children between 1 and 8 years old is typically the same as for adults, but with a few differences:
Activating EMS: If the child is unresponsive, call 911 immediately or ask a bystander to call and search for an AED machine.
If you are alone and did not witness the collapse, perform 2 minutes of CPR before leaving the child to call 911. Return to the child immediately and continue CPR if there's still no pulse or breathing.
CPR Hand placement: Place two hands (or one hand if the child is tiny) on the child's sternum.
CPR Compression depth: 2 inches deep
Administering Infant CPR
Check for Consciousness: Flick the bottom of the infant's foot to elicit a response. This takes the place of tapping the shoulder of an older person.
Call 911: If there is no response from the infant, call 911 immediately or ask a bystander to call. If you are alone, perform 2 minutes of CPR first before calling 911.
Give 30 Chest Compressions: Place two fingers of your hand in the center of the chest. Gently use your fingers to compress 1/3 of the chest circumference or about 1.5 inches deep. Apply steady, vigorous compressions at a rate of 100-120 per minute. Allow chest recoil after each compression.
Step 4: Rescue Breathing
If you are comfortable giving rescue breaths, give two of them between each series of 30 chest compressions. Give one breath every 3-5 seconds and avoid excessive ventilation.
Repeat: Continue performing cycles of 30:2 compression to ventilation ratio until the infant regains consciousness or Emergency Medical Services arrive.
Note: The Infant CPR ratio is 30:2. But if there are 2 rescuers present, the compression to ventilation ratio on infants will be 15 chest compressions and 2 rescue breaths.
CPR with 2 Rescuers
If you find an unconscious victim and someone else is available to help, have them call 911 and locate an automated external defibrillator (AED) while you assess the situation and determine if CPR is needed. If CPR is necessary, start compressions immediately. With two rescuers present, follow these steps:
1. Rescuer 1 will perform chest compressions and rescue breaths until Rescuer 2 returns with an AED.
2. When rescuer 2 arrives with an AED, place it on the side opposite Rescuer 1, who is performing chest compressions.
3. Rescuer 2 will turn on the AED and attaches the pads to the victim's chest. Rescuer 1 will continue CPR while the pads are being placed until it is time to analyze the heart rhythm.
4. Rescuer 2 clears the victim, ensuring neither rescuer touches the victim and waits for the AED to analyze.
5. Rescuer 2 will push the SHOCK button if a shock is indicated.
6. If no shock is needed, rescuer 2 will resume chest compressions.
7. During analysis, Rescuer 2 and Rescuer 1 should switch positions to prevent rescuer fatigue and ensure that rescuers provide high-quality chest compressions at the proper chest compression depths and rate.
When the second rescuer returns without an AED: Continue providing chest compressions and audibly count each compression. Rescuer 2 should maintain the person's airway using the head tilt chin lift technique and provide two rescue breaths after every 30 compressions. To avoid fatigue, switch positions between Rescuer 1 and 2 every two minutes.
Hands-only CPR, also known as compression-only CPR, is an emergency technique that provides continuous chest compression to an individual who has undergone cardiopulmonary arrest. It is a type of CPR that does not involve rescue breaths. Instead, it only involves chest compressions to circulate oxygenated blood throughout the body until medical help arrives.
Hands-Only CPR aims to keep oxygenated blood moving through the body, thereby reducing the time the brain is deprived of oxygen. Without oxygen, brain cells can die quickly, and death can occur within minutes. By performing Hands-Only CPR, bystanders can help ensure that oxygenated blood is circulating and help prevent brain cell death. Anyone can perform it, including untrained bystanders.
How to perform Hands-only CPR?
1. If the person is not breathing or not breathing normally, call 911 and then begin chest compressions.
2. Place the heel of your hand on the breastbone at the center of the person's chest. Place your other hand on top of your first hand and interlace your fingers.
3. Use your body weight to help you perform the compressions. You should compress the chest at least 2 inches but no more than 2.4 inches.
4. Perform 30 compressions at a rate of at least 100-120 compressions per minute.
5. If the person starts breathing independently, stop performing chest compressions and monitor their breathing. If the person does not start breathing independently, continue chest compressions until emergency medical help arrives.
Automated External Defibrillator
An Automated External Defibrillator (AED) is a life-saving device used to treat sudden cardiac arrest victims. It is designed to detect abnormal heart rhythms and deliver an electrical shock to the heart to restore a normal heartbeat. AEDs are often seen in workplaces, airports, schools, and public places, where they can provide a critical link in the chain of survival for anyone at risk for sudden cardiac arrest.
AEDs are easy to use and require minimal training. Most are equipped with a built-in audio system that instructs the user to analyze the patient’s heart rhythm and deliver the shock if needed. Many AEDs are also equipped with visual instructions and, often, notification systems that can be customized to alert non-rescuer bystanders when help is needed.
AEDs have been proven to be life-saving for anyone at risk for sudden cardiac arrest. They are an essential tool for ensuring the best chance of survival for any individual who experiences a sudden episode of cardiac arrest.
How to use an AED?
1. Perform CPR while the AED is being prepared.
2. Turn on the AED and follow the prompts.
3. Place the pads onto the patient’s chest. Make sure they’re in the right spot.
4. If the AED requires it, make sure the patient is dry and clear of clothing and jewelry on the chest.
5. Stand clear and ensure nobody touches the patient or AED while it's analyzing.
6. Push the “shock” button when the AED asks that you do so.
7. After giving the shock, let the AED analyze the patient’s heart rhythm again.
8. If the patient is still not breathing or showing any signs of life, continue CPR until the AED recommends another shock or the patient returns to life.
Choking is the airway blockage due to an object lodged in the throat or windpipe. Most commonly, it occurs when the food we eat goes down the wrong pipe and lodges in the throat before reaching the stomach. The universal sign for choking is making a fist with one hand and tapping it against the palm of the other hand. Not only can choking be a dangerous medical emergency, but it can also be fatal if not treated immediately.
When choking is suspected, it is important to stay alert and take action immediately. Delays can be deadly as the person choking can quickly become unconscious or even die. It is also important to remember that someone choking may be unable to speak due to the obstruction, so it is essential to be attentive and act quickly.
How to relieve choking if the adult/child victim is conscious?
The first step when someone is choking is encouraging the victim to cough to try and dislodge the object. If that does not work, you may perform the Heimlich maneuver or abdominal thrusts to dislodge the object.
How to perform the Heimlich maneuver:
1. Stand behind the person and wrap your arms around the person's waist.
2. Make a fist with your one hand and place it slightly above the person's navel and below the ribcage.
3. Grasp your fist with your other hand and press your fist into the person's abdomen with a quick, upward thrust.
4. Perform this thrust a second time if needed.
5. Check the person's mouth to see if the object has been dislodged.
6. If not, continue performing the Heimlich Maneuver in sets of five until the object is dislodged.
How to relieve choking if the adult/child victim is unconscious?
If the adult/child victim becomes unconscious, you should call 911 immediately and begin administering chest compressions and rescue breaths while waiting for emergency help to arrive. If the victim responds and starts breathing, turn them into the recovery position and monitor their breathing until help arrives.
Infant choking is a serious health hazard that can be caused when a baby swallows a small object or food that gets lodged in its throat. This can block the airway, making breathing hard and potentially causing death. It is important to be aware of the signs of infant choking and to know what to do if it occurs.
The most common sign of infant choking is coughing or gagging. Other signs may include difficulty breathing, wheezing, or a bluish tint to the skin. If you suspect an infant is choking, it is important to act quickly.
If an infant is choking, follow these steps:
1. Lay the infant face down on your forearm. Support their head with your hand.
2. Give five back blows: Using the heel of your hand, give 5 back blows between the infant's shoulder blades.
3. Give five chest thrusts: Turn the infant over so they are facing up and give 5 chest thrusts. Place two fingers in the middle of the chest just below the nipples and push inwards and upwards.
4. Check their mouth. If the object is still visible, carefully remove it.
5. If the infant is still choking, call 911 and resume back blows and chest thrusts.
The recovery position is a basic first aid technique that keeps a cardiac arrest patient that is unresponsive but has normal breathing in the most anatomically safe position until help arrives. It enables the patient to remain comfortable and can be used for all ages. Aside from cardiac arrest patients, it is also commonly used when a patient has suffered a drug or alcohol overdose or any other situation where they are unresponsive but still breathing.
How to put a victim in the recovery position?
1. Place the patient on their side. Kneel or crouch behind the person and roll them slowly onto their side. Support the head, so the uppermost ear is pointed towards the ground.
2. Position the arm nearest the ground at a right angle. Bend the patient’s elbow and rest the hand against the cheek, in line with the ear. If the arm is lower than the elbow, you can use a pillow or folded clothing to support it.
3. Bring the top leg up and across the body. Bend the knee and the hip, so the foot of the top leg rests flat against the ground.
4. Tilt the head. This helps keep the airway open. Gently tilt the head back, and to the side, so the chin can secure against the chest.
5. Check the airway. Gently lift the chin with one hand and check the airway is clear. Do not remove the chin from the chest.
6. Make sure the position is stable. Ensure the patient is not in pain; support the head and position the torso comfortably but securely.
7. Lastly, note when the patient was placed in the recovery position. Make sure to check the patient’s breathing and vital signs regularly.