Foreword Dr Teh Peng Hooi, O.St.J. FAMS (Orthopaedic) MBBS (S PORE), FRCS (EDIN) Vice Chairman, National St. John Council, Singapore Director, St John Ambulance Association, Singapore In Singapore, heart disease is the second commonest cause of death, accounting for 22.8% of all deaths in 2006. About 2400 new heart attacks and 980 out of hospital sudden cardiac arrests occur yearly. The overall survival rate for pre-hospital cardiac collapses, despite the excellent healthcare services in Singapore, is only 2.6%. There are 2 main reasons for the poor overall survival rate in pre-hospital cardiac collapse cases namely the small number of people trained in cardio pulmonary resuscitation or CPR and the limited effectiveness of performing CPR only. While the performance of CPR in cardiac arrest may save life it must be remembered that this procedure is useful if the heart stops beating (asystole) which occur in about 20% of cases. In the majority of cases during cardiac arrest the heart is in ventricular fibrillation and CPR done here alone is not very effective. Defibrillation of the heart using a machine can reverse this abnormal rhythm and correct this problem. Currently small portable machines for use outside the hospitals are available to correct the abnormal rhythm during the cardiac arrest. Such a machine is called Automated External Defibrillator or AED. St John Ambulance Singapore is now launching a course to teach not only CPR but the correct use and handling of the AED machines to members of the public. It is hoped that such machines will be easily and readily available in offices, shopping centres, community centres and homes in years to come. It is also the hope of St John Ambulance Singapore that many in Singapore will be trained in CPR and the use of AED. In this way the survival rate for those with cardiac arrest occurring outside the hospital can improve considerably. The CPR committee of St John Ambulance Association, Singapore is to be congratulated for developing this course material and booklet as well as spearheading the teaching of this programme to members of the public in Singapore. Page 1
Table of Contents General instructions to participants... 3 Introduction of the Cardio-Pulmonary System... 4 The heart in relation to the chest... 4 Circulatory System... 5 Heart Attack... 7 The Chain of Survival... 9 One Rescuer Cardio-Pulmonary Resuscitation for Adults... 10 Automated External Defibrillator... 10 Generally the sequences in the use of AED... 18 Stop defibrillation when:... 19 Documentation:... 20 House keeping of the AED:... 20 Adult one-man CPR-AED (DR ABCD)... 21 CPR till AED ready... 23 Page 2
General instructions to participants 1. Participants are to arrive at least 15 minutes before the course is scheduled to begin. 2. Participants who are late for more than half an hour from the stated starting time will not be allowed to join the course and deemed as absent. Course fees will not be refunded. 3. Participants are advised to be suitably attired so as to allow unhindered movement during manikin practice. Female participants are advised to wear pants or slacks. 4. Participants are to inform the Chief Instructor before the commencement of any course if they are having any type of infectious disease including any upper respiratory tract infection. This is because each training session will involve close physical contact with their fellow participants especially during rescue breathing (mouth-to-mouth). 5. Participants are to inform the Chief Instructors if they have orthopaedic or heart problems, bronchial asthma, or a female participant is pregnant. 6. Participants are advised to read thoroughly the given notes before they come for the course. 7. No jewellery should be worn and female participants will be required to remove any lipstick before manikin practice. 8. Do not attempt to perform CPR unless you have gone through training, as improper techniques could lead to injuries. 9. Participants must disinfect the manikins thoroughly using the spirit swabs immediately after each attempted mouth-to-mouth breathing practice. 10. Participants will be required to pass a written and practical test before being awarded a course certificate in CPR+AED. Page 3
Introduction of the Cardio-Pulmonary System The heart in relation to the chest Sternum (Breastbone) Heart (Located between sternum and spine) Xiphoid process Lower tip of the sternum The heart is a muscular organ, about the size of a clenched fist. It is located in the center of the chest behind the breastbone (Sternum) and in front of the spine. The coronary arteries (not shown) are special arteries that supply blood to the heart muscle itself. Page 4
Circulatory System Head & Arms Right Lung Right Heart Deoxygenated blood returning from the body is pumped through the pulmonary artery to the lungs where it picks up fresh oxygen. Veins Trunk & Legs Left Lung Left Heart Receives oxygenated blood from the lungs and is pumped through the aorta to the rest of the body. Arteries Capillaries The function of the heart is to pump blood to the lungs, where it picks up oxygen, and then to the rest of the body, where it delivers the oxygen. The adult heart pumps approximately 5 liters of blood per minute. All cells of the body require oxygen to carry out their normal functions. When the heart stops pumping (cardiac arrest), oxygen is not circulated, and the oxygen stored in the brain and other vital organs is used up quickly. The heartbeat is triggered by natural electrical impulses sent through the heart 60 100 times per minute in the healthy, resting adult. During exercise the heart of the average person can pump up to 25 liters each minute (about 5 times at resting state). A properly performed chest compression can produce ⅓ of the normal cardiac output. This amount of cardiac output, though not optimal, is enough to maintain basic life support in a collapsed casualty. Page 5
The lungs consist of many tiny air sacs (alveoli) surrounded by small blood vessels (capillaries). Nerve impulses from the brain to the chest muscles and the diaphragm cause a person to breathe. With each breath, air is carried through the airway (nose, mouth, throat, larynx, trachea and bronchi) and into the air sacs of the lungs At sea level, approximately 21% of air is oxygen. When the air sacs fill with this air, oxygen enters the blood in the vessels surrounding the air sacs. The oxygenated blood returns to the heart, which pumps it throughout the body. As oxygen is taken up from the blood by body cells, carbon dioxide is given off as a waste product. Carbon dioxide is carried by the blood to the air sacs and is exhaled out of the body. When air is inhaled, only one fourth of the oxygen is taken up by the blood; the rest is exhaled. This is why mouth-to-mouth rescue breathing can provide the casualty with enough oxygen. When breathing stops (respiratory arrest), the heart continues to pump blood for several minutes, carrying existing stores of oxygen to the brain and the rest of the body. Early, prompt rescue efforts for the casualty of respiratory arrest or choking (foreign body airway obstruction) can often prevent the heart from stopping (cardiac arrest). Page 6
Heart Attack Heart attack occurs when the blood vessel (called coronary artery) that supplied the heart muscle is completely blocked. It is the end result of a gradual accumulation and built-up of fatty deposits (cholesterol plaques) on the inner lining of the coronary artery (a process called atherosclerosis). Initially the lumen of the blood vessel is narrowed, resulting in the reduction of blood flow that carried oxygen and nutrient to heart muscle. When the lumen of the blood vessel is completely blocked, usually due to formation of clot that formed on the crack or split surface of the cholesterol plaque, the affected heart muscle is deprived of blood supply and die. This is called heart attack (or myocardial infraction). A person suffering from a heart attack may die suddenly (sudden death) due to a very fast but irregular heart rhythm (ventricular fibrillation), a non-functioning heart (asystole) or severe heart failure (pump failure). Narrowing of blood vessel due to atherosclerosis Blockade of coronary artery causing heart attack Page 7
The symptoms of heart attack are many and varied. These include: Severe chest discomfort or pain, usually lasting 20 minutes or longer, may be associated with: sweating weakness, or near fainting shortness of breath or breathlessness a sense of impending doom or death nausea (feeling of wanting to vomit) or vomiting Common causes of sudden death in adults include: o heart attack o stroke o trauma o drowning o suffocation o electrocution o drug overdose o severe asthma o severe allergic reaction o hereditary heart illnesses o foreign body airway obstruction o viral infection affecting the heart While heart attack is a common cause of collapse in an adult, respiratory arrest is a more common cause of collapse in an infant. Risk Factors: Narrowing of the blood vessels usually occurs slowly over the years. However, this may occur prematurely in the presence of certain risk factors. Important risk factors that can cause heart attack include: A. Risk factors that cannot be altered (i) Age. Risk increases with advancing age. (ii) Male gender. Males are more likely to suffer from heart attack than females (iii) Family history of heart attack, especially if it occurs early in members of the immediate family B. There are other risk factors that are equally important as the above ones, but they can be altered by treatment or healthy lifestyle habits. These are (i) Smoking (ii) High blood pressure (hypertension) (iii) High blood sugar level (diabetes mellitus) (iv) High blood cholesterol level (dyslipidemia) (v) Chronic stress (vi) Overweight/obesity (vii) Lack of exercise/sedentary lifestyle In order to reduce the chances of suffering from coronary heart disease or heart attack, it is important to have healthy lifestyle habits: i.e. (a) No smoking (b) Regular exercises (c) Stress management (d) Eat more vegetables and fresh fruits, but less fatty or salty food (e) Maintain ideal body weight (through regular exercises and eating healthy food) Page 8
The Chain of Survival St. John Ambulance Association, Singapore Early Access First Link: Recognition of early warning signs, such as chest pain and shortness of breath, that prompts a person to call 995 before collapse, are the key components of this link. Early CPR Second Link: CPR is a temporary intervention that attempts to restore breathing and circulation. It loses its value if the third and fourth links are not rapidly carried out. Early Defibrillation Third Link: Studies done have shown that early defibrillation is most likely to improve survival rates for out-of-hospital cardiac arrest patients. This is because defibrillation is the most effective way to convert ventricular fibrillation back into normal heart rhythm. Early Advanced Cardiac Life Support (ACLS) ACLS brings equipment to support ventilation, establish intravenous access, administer drugs, control arrhythmias and prepare the patient for transport. Fourth Link: Any delay could be fatal or results in poor chance of survival and should be avoided! Page 9
One Rescuer Cardio-Pulmonary Resuscitation for Adults Danger Lookout for unsafe environment e.g. exposed electrical wires, fire, possible explosion, construction works or poisonous gas. Remove the casualty to a safe environment, if necessary. Responsiveness The rescuer, upon arriving at the scene of the collapsed casualty, quickly assesses any injury and determines whether the casualty is conscious. The rescuer firmly taps casualty s shoulders and ask loudly (Figure 1): Hello! Hello! Are you Okay? Figure 1: Determine unresponsiveness Shout If the casualty is unresponsive, immediately call out loudly for help (Figure 2): Help! Call for ambulance, 995. Get an AED Even if no one is in sight, call out for help, as very often someone within earshot will come to assist the rescuer. If a phone is immediately available, call the emergency number to report the incident. Figure 2: Activate the Emergency Medical Services (EMS) Position the casualty For CPR to be effective, the casualty must be lying on a firm and flat surface. If the casualty is suspected to have sustained head injury or spinal injury, the rescuer should move the casualty only if absolutely necessary. If the casualty is lying face down, the rescuer must roll the casualty as a unit (log roll) so that the head, shoulder and torso move simultaneously without twisting (Figure 3). The casualty should be flat on his back with face up, in the position ready for CPR. Figure 3: Turn the casualty into supine position Page 10
Airway St. John Ambulance Association, Singapore One of the most important actions for successful resuscitation is immediate opening of the airway. Head tilt-chin lift manoeuvre is effective in opening the airway (figure 4 & 5). Steps: 1. Place one hand on the casualty s forehead and apply firm, backward pressure (using rescuer s palm) to tilt the head back. 2. Place 2 fingers of the other hand at the angle of the jaw bone. Figure 4: Blocked airway 3. Lift the chin forward and support the angle of the jaw, helping to tilt the head back (Head Tilt-Chin Lift). Precautions: (a) The finger must not press deeply into the soft tissue under the chin, which might obstruct the airway. (b) The thumb should not be used for lifting the chin. (c) The mouth should not be completely closed. Figure 5: Open airway Breathing While maintaining an open airway, the rescuer will check the casualty s breathing (up to 10 seconds) by placing rescuer s ear over the casualty s mouth and nose, and observe casualty s chest (Figure 6). LOOK - for the chest to rise & fall LISTEN - for air inhalation and exhalation FEEL - for the flow of air on your cheek Figure 6: Determine respiration Page 11
The casualty must be lying on a firm and flat surface when performing chest compression. There may be inadequate blood flow to the brain if the head is elevated above the heart even though chest compression is properly performed. Chest Compression If there is no breathing, starts Chest Compression immediately. Steps: 1. Kneel close to the casualty s chest. CPR can be performed from either side of the Casualty. 2. With the middle finger of the rescuer s hand, he locates one of the lowermost ribs on the side next to him (Figure 7). 3. The fingers are then slid along the rib to the notch where the lowermost ribs meet at the sternum (breastbone) in the centre of the lower part of the chest. Figure 7: Locating the lowermost rib 4. With the middle finger on the notch, the index finger is placed next to the middle finger. (Figure 8). 5. The heel of the other hand (which has been used on the forehead to maintain head position) is then placed on the lower half of the sternum, just next to the index finger (figure 9). Figure 8: Slide fingers along the rib until the middle finger feels the notch 6. The first hand is then removed from the notch, placed on top of the hand, which is on the sternum. Figure 9: Place heel of other hand next to the index finger Page 12
7. The fingers may be either extended (figure 10) or interlaced (interlocked) (figure 11) but should be kept off the chest. 8. Rescuer s elbows should be locked into position with arms straightened (figure 12). 9. To achieve adequate pressure with the least effort, rescuer should lean forward until his shoulders are directly over his outstretched hands. The shoulders of the rescuer should be directly over the sternum of the casualty so that the thrust for each chest compression is straight down on the sternum. If the thrust is not straight down, casualty s torso has a tendency to roll. Thus, part of the downward force is lost and the chest compression is less effective (Figure 12). Figure 10: Fingers extended position Figure 11: Fingers interlaced position 10. Compress with enough force to depress the sternum at least 5 cm for normal-sized adult. This will improve blood circulation to the lungs and thus increase oxygen supply to maintain life (figure 12). 11. During compression, when the rescuer uses the weight of his upper body, he will not depend on the strength of his arms and shoulders. Instead of having to push from his shoulders, he lets the natural weight of his body fall forward providing the force necessary to depress the casualty s sternum. Keep the arms straight during each chest compression (figure 13). Figure 12: Proper position of the rescuer 12. Then, the rescuer is to release this pressure to allow blood to flow into the heart and lungs. If the heart and lungs cannot be refilled, there will be insufficient blood to carry oxygen throughout the body on the next compression. Therefore, releasing the pressure completely and allow the chest to return to its normal position is important. i.e allow complete recoil of the chest wall after each compression. The time allowed for release should be equal to the time required for compression. Do not pause between compressions (figure 14). Figure 13: Depress the sternum using the natural weight of the rescuer s body Figure 14: Release of compression pressure fully without lifting the hands off the casualty s chest Page 13
13. Compression rate is at least 100 times per minute, say mnemonic: 1&2&3&4&5& 1&2&3&4&10& 1&2&3&4&15 1&2&3&4&20 1&2&3&4&25 1&2&3&4&30 14. After the 30 chest compressions, move up to the casualty s head quickly to open the airway again. Take a breath, pinch and close the casualty s nostrils, seal the casualty s mouth, then deliver 2 rescue breaths. 15. Move back to the chest, locate correct landmarks and maintain proper hand position. Begin 30 chest compressions at least 100 times per minute. 16. Repeat the above cycle (30:2) until help or AED arrives and takes over, or casualty starts moving. Precautions: 1. Do not lift your hands off the chest completely or change their position in any way during compression otherwise you may miss the exact location. 2. Bouncing compressions, jerky movements, improper hand position and leaning on the chest must be avoided as they are less effective and also likely to cause injury to the casualty. Perform 2 ventilations After each 30 chest compressions, rescuer has to perform 2 ventilations to provide the casualty s lungs with oxygen. Steps: 1. With rescuer s hand resting on the casualty s forehead, the rescuer gently pinches the casualty s nostrils and closes it with his thumb and index finger, thereby preventing air from escaping. 2. Rescuer takes a breath and places the lips around the casualty s mouth, creating an airtight seal. 3. Give 2 ventilations (1 second per breath). 4. On delivering each breath, the rescuer should observe the rise of casualty s chest wall. While the rescuer takes a breath of fresh air, he should observe the fall of the casualty s chest wall. If the casualty s chest rises and falls, the rescuer knows that the lungs are receiving adequate ventilation (Figure 15). Figure 15: Mouth-to-Mouth ventilation. Page 14
Ventilation volume is between 400 ml to 600 ml. Just enough to see the chest rises but not too great a volume of air which is likely to cause air to enter the stomach and result in gastric distention. Precautions: If the first attempt to ventilate the casualty is unsuccessful, re-position the casualty s head and re-attempt the ventilation. Improper chin and head position is the most common cause of difficulty with ventilation. Guidelines for effective ventilation 1. Open your mouth wide enough to create a good seal. 2. Don t apply too much pressure with your mouth, or your lips may be bruised. 3. Light mouth contact is less likely to break the teeth or loosen the casualty s dentures. Remove the dentures only if they are loose or blocking the airway. 4. The casualty s nostrils can be closed easily if pinched right at the nasal opening 5. Ventilate with enough pressure to cause the chest to rise. 6. Lift your mouth away just long enough to take another quick breath. 7. Mouth-to-nose ventilation may be more effective when it is impossible to ventilate through the casualty s mouth, e.g. injury to the mouth. 8. If the chest does not rise, check that: a. the head is tilted back sufficiently; b. the nostrils are completely closed; c. you have a firm seal around the casualty s mouth; d. the airway is not obstructed by vomitus, blood or a foreign body. Page 15
Basic Cardiac Life Support Training Handbook Proper One Rescuer CPR Sequence 400 600 ml 2 secs St. John Ambulance Association Assessment Guide Chart Copyright Property of St. John Ambulance Association Compression depth at least 5cm 18 secs 6 secs 120 secs 130 secs Page 16
Automated External Defibrillator Introduction Most of the casualties who die from heart attacks suffered from chaotic, irregular heart rhythms call ventricular fibrillations (VF). During ventricular fibrillation there is no effective cardiac output and hence vital organs such as the brain and kidneys receive no oxygen and nutrients. After 4 minutes of cardiac arrest, the brain cells start to die. The longer these organs are deprived of oxygen, the less likely that these casualties will survive. Currently, the only effective way to revert ventricular fibrillation to the normal, perfusing heart rhythm is by electric shock (defibrillation) Automated External Defibrillator (AED) AED is a sophisticated, computerized device that uses a microprocessor to analyze the heart rhythm when activated. It uses voices to guide and prompt the lay rescuer to safely attempt defibrillation when indicated. AED has been extensively tested and has been shown to be fairly accurate in the heart rhythm analysis. On the other hand, any lay person without sophisticated medical training can safely and effectively operate AED to save life after some basic CPR-AED training. Normal heart rhythm Ventricular fibrillation (VF) Page 17
Generally the sequences in the use of AED Chest preparation- Power on AED Electrode pads placement Cardiac rhythm analysis Electric shock 1. Once the Automated External Defibrillator (AED) is available, the AED operator has to check for any potential danger like: WET surface; METAL surface; Flammable gases. 2. The AED operator will place the AED beside the patient at a site that does not interfere / obstruct CPR. 3. AED operator will prepare the chest by the following steps: Remove or cut away the clothing from the casualty s chest if necessary; Place the jewellery away from the defibrillation pads (electrodes pads); Remove any medication patches from the casualty s chest; May need to shave those hair away where you are going to place the defibrillation pads; Wipe the sweat away where you are going to place the defibrillation pads; Place the defibrillation pads at least 8 cm or 4 fingers breath away from the pacemaker, if there is one. 4. Once the chest preparation has been completed, switch on the AED and follow the instruction from the machine. When machine sound: Apply pads to patient s bare chest, plug in pads connector next to flashing light. (Notes: the exact words will depend on the model of AED). 5. Place one pad to the right below the collar bone and the other pad below the left nipple. With a female victim, do not place it over the breast. Note: Ensure the defibrillation pads are firmly attached by pressing gently over center of the pad to ensure good contact and around the edges for good adhesion. Figure 18: Placement of the defibrillation pads 6. While the AED operator is preparing the AED, the other rescuer, if available, can still continue the CPR. When the rescuers heard: Analyzing heart rhythm, do not touch the patient., then the rescuer has to stop CPR. 7. The AED operator has to ensure that no one is touching the casualty when the AED is analyzing heart rhythm. 8. Once the AED has detected a shockable rhythm, it will sound: Shock advised, charging..., stay clear of patient. 9. The AED operator shouts: Stand clear. 10. Once the AED sound: Deliver shock now, press the orange button now, the AED operator will say: STAND CLEAR then press the SHOCK button. Page 18
11. The AED will sound: Shock delivered, pause..., start CPR. 12. The rescuers will restart 30 chest compressions and 2 ventilations immediately for 1-2 minutes after the first electric shock. 13. The AED will re-analyze heart rhythm, it will sound: Analyzing heart rhythm, do not touch the patient, analyzing heart rhythm (AED operator has to ensure no one is touching the casualty or performing chest compression when the defibrillator is analyzing heart rhythm). 14. When the AED detects non shockable rhythm,, it will sound: No shock advised, pause, It is safe to touch the patient, check for signs of circulation. Checking for return of spontaneous breathing after AED detected non shockable rhythm 15. Check for spontaneous breathing using the LOOK-LISTEN-FEEL technique. If breathing is present, turn victim to recovery position, maintain an open airway and monitor closely for relapse. If breathing is absent, continue CPR. 16. Hand over the casualty to the ambulance officer when they arrive, detach the pads connector from the AED machine but keep the defibrillation pads on the casualty s chest. Stop defibrillation when: The casualty is breathing spontaneously. The emergency medical team takes over the resuscitation. The AED indicates that no shock is advised. Page 19
Documentation: St. John Ambulance Association, Singapore AED operator has to document the incidents and information related to the use of the AED machine. The following information should be documented: Name of the casualty, AED operator and the CPR operator; The estimated timing of casualty s collapse, how long the CPR operator has performed CPR; Mark the time the AED was put on; Record the number of shocks and the times of each shock; Record the arrival of the ambulance and the name of the Paramedic; Record which hospital that the ambulance will be conveying the casualty to. House keeping of the AED: AED operator has to Check the status / life of the battery. Replenish those disposal items in the AED kit after use. AED kit: Shaver (disposal) Gloves (disposal) A small towel (disposable) Defibrillation pads (disposal) A pair of scissors (can be reused after cleaning) Page 20
Adult one-man CPR-AED (DR ABCD) Danger : e.g. electric current, poisonous gas, explosion, heavy traffic Ensure that the scene is safe Response : Call, tap and said loudly. Hello! Hello! Are you OK? Shout : If no response >> Call ambulance 995. Get an AED. Airway : Head tilt-chin lift Breathing : Look, listen & feel (< 10 seconds) If no breathing >> start CPR Chest Compression : Correct compression landmark Proper body and hand position Vertical compression: at least 5cm in depth; rate is at least 100/min Allow complete relaxation of pressure after each compression 1&2&3&4&5& 1&2&3&4&10& 1&2&3&4&15 1&2&3&4&20 1&2&3&4&25 1&2&3&4&30 perform 30 chest compressions : 2 ventilations Give 2 ventilations (1sec/breath; volume 400-600ml/breath) allow lung deflation between each breath If fail during 1 st attempt ventilation, to reposition the head with head tilt-chin lift, then attempt 2 nd ventilation. Defibrillation : Use AED as soon as available and indicated Exclude specific AED contraindications (metal, flammable gas, water immersion), correct position of pads, all cleared, deliver one shock, immediately followed by 1-2 minutes of CPR Repeat the above cycle (30:2) until healthcare professional takes over or casualty starts moving. (Conscious) Page 21
Summary of one-rescuer Cardiopulmonary Resuscitation Sequence CPR Sequence Adult and Older Child Establish unresponsiveness, activate EMS (995) Immediately Open Airway Check for breathing: If casualty is breathing: place in recovery position. If casualty is not breathing: Compression Landmarks Head Tilt-Chin Lift Look-Listen-Feel Lower half of sternum Compression Method Heel of 1 hand, other hand on top Compression Depth At least 5 cm Compression Rate At least 100 per minute Compression / Ventilation Ratio 30 : 2 IMPORTANT If the rescuer is previously trained in CPR but is not confident or unwilling to do mouth to mouth ventilation, then the rescuer should give hands-only CPR. The rescuer should continue hands-only CPR until an automated external defibrillator arrives and is ready for use or ambulance/medical personnel take over the care of the casualty. Tips for a good and effective chest compression a) It must be done at the rate of at least 100 compressions per minute b) The depth of each compression should be at least 5cm c) The rescuer should release the pressure completely from the chest wall at the end of each compression to allow complete recoil but without losing the correct position for compression d) The rescuer must be positioned directly above the casualty's chest (i.e. 90 degrees above the victim's chest) and must compress vertically using his/her body weight e) The rescuer must ensure that his hands are correctly positioned on the center of the chest wall (lower half of the breast bone or sternum) f) There must be minimal interruption or delay during chest compression Page 22
CPR till AED ready SHOCK ADVICE? No Check Breathing Yes (all Clear) Press to shock Absent CPR (30 : 2) Present Check other injury After every 1 shock Immediately followed by 1-2 min CPR (30 : 2) No Injury Recovery position AED remains connected Monitor breathing every 5 minutes Page 23