UNIT52 Response to Basic Emergencies PROCEDURE ADULT CPR, ONE RESCUER Standard precautions should be followed if at all possible. This means gloves should be worn and a barrier device used. If the victim is bleeding, a gown and mask may also be necessary. These items should be readily available in a health care facility. Careful evaluation is required before CPR is administered. 1. Gently shake the person and ask, Are you okay? Call the victim s name if you know it (Figure A). 2. Call out for help. If someone responds to your call, send her to call the EMS system. If no one P responds to your call, call the EMS system yourself and return to the victim as soon as possible. 3. Turn the victim on his back as a unit, supporting the head and back (Figure B). For CPR to be effective, the victim must be lying on his back on a hard surface. 4. Open the airway, using a head-tilt, chin-lift technique. 5. Maintain the open airway with the head-tilt, chinlift technique or jaw-thrust maneuver. Place your ear near the victim s mouth. At the same time, Are you okay? FIGURE A Gently shake the patient and ask, Are you okay? FIGURE B Support the head and back while turning the patient as a unit.
2 UNIT 52 Response to Basic Emergencies observe the victim s chest. You are looking, listening, and feeling for any signs that the victim may be breathing (Figure C). If the victim is breathing, maintain an open airway, monitor his breathing, and call EMS if that was not done earlier. 6. If there are no signs of breathing, seal the victim s nose with your thumb and forefinger and seal the victim s mouth, using your mouth or a barrier device. 7. Ventilate 2 times, taking 1 second for each ventilation (Figure D). Allow the chest to deflate between ventilations. Watch the chest rise to determine if enough air is getting through. 8. After the ventilations, check for the presence of a heartbeat. Maintain the open airway, using the head-tilt technique, with one hand. With the other hand, feel for the victim s carotid pulse on the near side of the victim (Figure E). If there is a pulse, but no respirations, continue with ventilations at the rate of 1 every 6 to 8 seconds. Continue to check periodically for a pulse. 9. If there is no pulse, begin chest compressions at the ratio of 30 compressions to 2 ventilations. Kneel by the victim s shoulders and determine proper hand placement. Your shoulders should be over the victim s sternum. Using correct hand placement and technique, compress the victim s FIGURE D Give 2 full ventilations. Make sure the chest rises and falls with each ventilation. chest 1 1 /2 to 2 inches. While doing compressions, you must: Locate the landmark hand position (Figure F). Use an imaginary line between the nipples as your landmark in the male. In the female with developed breasts, move up slightly higher to approximately the center of the chest. Place the heel of one hand on the landmark. Proper hand placement is very important to prevent injury. FIGURE C Hold the airway open and look, listen, and feel for respirations on your cheek and ear. FIGURE E Check the carotid pulse in the notch on either side of the neck.
UNIT 52 Response to Basic Emergencies 3 FIGURE F Proper hand placement is very important to prevent further injury. Position the heel of one hand in the center of the chest on the landmark. Use an imaginary line between the nipples as your landmark in the male. FIGURE G Now position the heel of the other hand on top of the landmark hand. Only the heel of the hands should touch the chest. Avoid applying pressure on the ribs with your fingers. Place the heel of your other hand on top of the landmark hand (Figure G), interlacing the fingers (Figure H). Lock your elbows. Keep your elbows straight, with your shoulders directly over the victim s sternum (Figure I). Compress the sternum straight down 1 1 /2 to 2 inches at a rate of 100 compressions a minute. (This is not 100 actual compressions a minute, but rather a rate of 100 per minute, meaning more than one compression per second.) Downward pressure should be on the sternum only. Avoid pressing on the ribs with your fingers. Keep the fingers interlaced and slightly elevated from the chest. Compressions should be smooth and rhythmic. Your goal should be to push hard and push fast with each compression. FIGURE H Interlock your fingers. The fingers of the lower hand should be elevated slightly so they do not apply pressure to the ribs.
4 UNIT 52 Response to Basic Emergencies Effort Arm (back) 11/2 "- 2" Upstroke Downstroke Completely release pressure, but maintain hand contact with the chest between each compression. The release in pressure allows the heart to refill with blood. Count out loud during compressions: one and, two and, three and, Fulcrum (hip joints) Piston (arms) 10. Do 30 compressions to 2 ventilations per cycle. 11. Repeat the 30:2 cycle until help arrives or you are exhausted and unable to continue. If a second rescuer joins you while CPR is in progress, change to two-person CPR. Resistance (lower half of sternum) FIGURE I Lock your elbows. Position your shoulders directly over the sternum. PROCEDURE P ADULT CPR, TWO-PERSON The techniques for two-person CPR are exactly the same as for one person. The compression to ventilation rate is 30 compressions to every 2 ventilations. Chest compressions are done at the rate of 100 per minute. The two rescuers should be on opposite sides of the victim if possible. 1. If CPR is in progress: a. The second rescuer comes in after the first rescuer has completed a cycle of 30 compressions and 2 breaths. b. One rescuer moves to the victim s head, opens the airway, and checks for spontaneous return of the pulse when no compressions are performed. c. The other rescuer finds the correct hand position. d. If the pulse is absent, say, No pulse. The ventilator gives 2 breaths and the compressor begins chest compressions. At the end of the 30th compression, the compressor pauses very briefly to allow the other rescuer to give 2 ventilations (Figure A). e. The ventilator is responsible for reevaluating the patient. Palpate the carotid pulse during the second rescuer s chest compressions. You will feel a pulse if the compressions are effective. 2. If no CPR is in progress and both rescuers arrive on the scene at the same time: a. Both rescuers must decide what needs to be done, and they must start immediately. b. One rescuer calls the EMS system while the other person begins one-rescuer CPR. c. One rescuer goes to the head of the victim and determines unresponsiveness positions the victim opens the airway checks for victim s breathing if breathing is absent, says no breathing and gives 2 ventilations
UNIT 52 Response to Basic Emergencies 5 To Switch Sides 3. When the rescuers are on opposite sides of the victim: a. The change of positions takes place without interrupting the 30:2 sequence (Figures B to C). b. The rescuer performing compressions directs when the switch takes place, at the end of every fifth 30:2 sequence. FIGURE A Slip in 2 breaths after every 30 compressions. checks for pulse; if no pulse, says no pulse d. Second rescuer (at the same time as first rescuer does above procedure) finds location for chest compressions places hands in proper position initiates external chest compressions after first rescuer says no pulse e. During the cycle, the ventilator should monitor the pulse during compressions and breathing to determine the effectiveness of these procedures. f. The compressor gives 30 compressions at the rate of 100 a minute, then pauses briefly, keeping the hands in place on the chest. The ventilator gives 2 ventilations. The cycle resumes with 30 compressions to 2 ventilations and repeats indefinitely until further help arrives, the victim regains consciousness, or the rescuers are exhausted and unable to continue. g. When more than 1 rescuer is present, rescuers should change compressor roles about every 2 minutes or 5 cycles of CPR (1 cycle of CPR = 30 compressions and 2 rescue breaths). Rescuers should try to complete the switch in 5 seconds or less. FIGURE B-1 Rescuers can change positions without interrupting the sequence. FIGURE B-2 The rescuers should change positions about every 2 minutes or 5 cycles of CPR (1 cycle of CPR = 30 compressions and 2 rescue breaths).
6 UNIT 52 Response to Basic Emergencies The ventilator gives 2 breaths, assumes the position for compressions, and locates the proper hand position. The compressor, after the 30th compression, moves to the victim s head. The rescuer at the victim s head gives 2 breaths and the rescuer at the chest with CPR. FIGURE C After moving to the chest, the rescuer finds the landmark and places hands in position. The person at the head checks for return of pulse and respiration. If there is a pulse but no breathing, continue with ventilations and monitor the pulse. 4. When the rescuers are on the same side of the victim: a. The compressor initiates the switch by saying so while continuing chest compressions. b. The ventilator gives 2 ventilations after the 30th compression. c. After the ventilations, the ventilator moves quickly behind and around the compressor and assumes the compressor position. d. The compressor moves to the victim s head to check the pulse and to become the new ventilator. e. The new compressor gets in position beside the victim s chest, assumes the correct hand position, and waits to begin compressions. f. The new ventilator quickly moves to the victim s head, and resumes with the correct procedure. 5. Remember, if the victim resumes breathing and the pulse returns, place the victim in the recovery position and continue to monitor the pulse and respirations. PROCEDURE P CPR FOR INFANTS Note the similarities and differences between CPR on infants and adults: The ratio of compressions to ventilations is 30:2. Note that the compression-to-ventilation ratio is the same for all patients, regardless of age. The rate is 100 compressions a minute. Remember, this is the speed of the compressions, and not the actual number of compressions delivered. Breaths are given with the rescuer s mouth covering the infant s nose and mouth. Breaths must be gentle. Circulation is assessed by taking the brachial or femoral pulse rather than the carotid pulse. To find the landmark in an infant, draw an imaginary line through the nipples. The landmark is approximately one finger s width below this line, in the lower half of the chest. Do not press on the xiphoid process. If there are 2 rescuers, the preferred hand placement for chest compressions in an infant is to encircle the chest and back with the hands, then compress downward with the thumbs. If you are alone, use the tips of your second and third fingers (index and middle fingers) to apply compressions. The depth of compressions is approximately one-third of the depth of the child s body.
UNIT 52 Response to Basic Emergencies 7 Compressions should be deep enough to produce a palpable pulse during compression. Compressions should be smooth and rhythmic. Reevaluate periodically for the return of a pulse. Continue compressions until the infant can sustain a heart rate of more than 60 beats per minute. 1. Determine unresponsiveness by tapping the shoulder (Figure A). 2. Call out for help. If a second rescuer is present, have him activate the EMS system. 3. Support the infant s head and shoulders and place the infant on his back on a firm surface. 4. Use the head-tilt, chin-lift technique to open the airway. Be careful not to tilt the head back too far (Figure B). FIGURE A Determine unresponsiveness by tapping the shoulder. 5. Maintain an open airway and place your head in position over the infant s chest to look, listen, and feel for breathing (Figure C). If the infant is breathing and there are no signs of trauma, place the infant in recovery position. 6. If the infant is not breathing, maintain an open airway and give 2 breaths with your mouth completely covering the infant s nose and mouth. The breaths must be gentle because of an infant s small size. If the breaths do not cause the chest to rise, reposition the head and attempt to ventilate again. 7. Assess for signs of circulation, such as coughing, movement, and color. Determine lack of pulse by feeling for the brachial or femoral pulse with two fingers, while maintaining an open airway (Figure D). 8. If the pulse is absent, or less than 60 per minute, begin chest compressions: Draw an imaginary line between the nipples. If there are two rescuers, encircle the chest with your hands. Use your fingertips to support the back. Position your thumbs one finger-width below the imaginary line in the middle of the sternum. If this is not possible, or if you are alone, place your index finger below the imaginary line in the middle of the chest. Place your middle and ring fingers next to the index finger. Use these fingers to compress the sternum at that point (Figure E). Do not compress over the xiphoid process. FIGURE B Open the airway with the head-tilt, chin-lift maneuver. Avoid tipping the head back too far. The infant s airway is similar to a drinking straw. If you bend it too far back, you will cause an obstruction. FIGURE C Look, listen, and feel for breathing.
8 UNIT 52 Response to Basic Emergencies FIGURE E Compress the sternum with 2 or 3 fingers. FIGURE D Check the brachial pulse. Compress the sternum about one-third to onehalf the depth of the chest at a rate of 100 per minute. One rescuer who is alone should use a 30:2 compression-to-ventilation ratio. If two rescuers are available, they should use a 15:2 compression-to-ventilation ratio. 9. Do 5 cycles (2 minutes) of compressions and rescue breaths. 10. Check the brachial or femoral pulse. 11. If you are alone, activate the EMS system now. 12. If the pulse is absent, or less than 60 per minute, continue rescue breaths and compressions. 13. Continue CPR until further help arrives or you are exhausted and unable to continue. PROCEDURE P CPR FOR CHILDREN, ONE RESCUER 1. Establish unresponsiveness by tapping the shoulder and calling the child s name. 2. If another person is available, have that person activate the EMS system. If another person is not present, give 5 cycles of rescue support and then activate the EMS system. 3. Use the head-tilt, chin-lift method to open the airway. Check for breathing by looking, listening, and feeling. If the child is breathing or begins breathing, place the child in the recovery position. 4. If there is no breathing, give 2 breaths, taking 1 second per breath. Observe the child s chest for rising. Allow the chest to deflate between breaths. 5. Assess for signs of circulation, such as coughing, movement, and color. Assess for heartbeat by taking the carotid pulse. If pulse is present but there is no breathing, do rescue breathing of 1 breath every 3 to 5 seconds (20 breaths per minute).
UNIT 52 Response to Basic Emergencies 9 6. If there is no pulse, locate the landmark by using the imaginary line between the nipples. Put the heel of one hand on this line. Give 30 chest compressions (at a rate of 100 compressions per minute). The compression depth is approximately one-half the depth of the child s chest, or 1 to 1 1 /2 inches. Keep the heel of your hand in contact with the chest and avoid bounding. Make sure you are directly on the sternum, not on the ribs or xiphoid process. Open the airway and provide 2 slow breaths. Repeat the cycle. 7. After about 5 cycles of rescue support, activate EMS, if this was not done previously. 8. Continue CPR until further help arrives, you are exhausted and unable to continue, or the child s pulse and respirations are restored. EXPLORING THE WEB Description 1st-Aid for Choking AAP NRP Neonatal Resuscitation Program ACLS.net ACLS/BCLS Certification Online American Association of Critical Care Nurses American College of Emergency Physicians American Heart Association American Red Cross Child First Aid and Safety CPR Review Emergencies and First Aid Emergency & First Aid Emergency Medical Services, National Highway Traffic Safety Administration (NHTSA), U.S. Department of Transportation Emergency Nurses Organization EMS Village EMSresource.net First Aid First Aid First Aid familydoctor.org First Aid Tips Location http://www.ou.edu/oupd/choke.htm http://www.aap.org/nrp/nrpmain.html http://www.acls.net http://www.aclscertification.com http://www.aacn.org http://www.acep.org/webportal http://www.americanheart.org http://www.redcross.org http://www.kidshealth.org/parent/firstaid_safe http://davidge2.umaryland.edu/~emig/cpr03.html http://www.health.harvard.edu/fhg/firstaid/firstaid.shtml http://library.thinkquest.org/10624/1staid.html http://www.nhtsa.dot.gov http://www.ena.org http://www.emsvillage.com http://www.emsresource.net http://firstaid.about.com http://library.thinkquest.org/10624/1staid.html http://familydoctor.org/x5870.xml http://www.alfambulance.net/firstaid.htm
10 UNIT 52 Response to Basic Emergencies First Aid Web Heart and Stroke Foundation HeartCenterOnline Initial Life Support Foundation Learn CPR Mayo Clinic First-Aid Guide MediSmart online emergency tutorials MERGINET National Association of Emergency Medical Technicians Yale Heart Book http://www.firstaidweb.com http://ww2.heartandstroke.ca http://heart.healthcentersonline.com http://www.ilsf.info http://depts.washington.edu/learncpr http://www.mayoclinic.com/health/firstaidindex/firstaidindex http://medi-smart.com/tutorials.htm http://www.merginet.com http://www.naemt.org http://www.med.yale.edu/library/heartbk