Overview of the International Guidelines:  The American Heart Association (AHA) has presented a long-term goal to create valid and widely accepted international resuscitation guidelines based on international science produced by international resuscitation experts.  The AHA Guidelines 2000 Conference was more than an update of previous AHA recommendations for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC).  The conference included similar recommendations published by the European Resuscitation Council for the first time.  At the 2005 Consensus Conference researchers debated all aspects of detection and treatment of cardiac arrest.  The constant question: how to get more bystanders and healthcare providers to learn quality CPR.

Overview: Cardiovascular disease accounts for nearly one million deaths per year in the United States.  Half of these deaths are due to coronary heart disease, and most occur suddenly within two hours of the onset of symptoms.  Other causes of sudden death may include drowning, suffocation, electrocution, drug overdose, and trauma.  Many of these deaths can be prevented by providing immediate basic life support (BLS) and advanced life support (ALS) care.  Implementing the chain of survival is essential for successful resuscitation.  Adult chain of survival is rapid access to the emergency medical services (EMS), early CPR (BLS), early defibrillation, and early ALS.  Pediatric chain of survival is  prevention, early CPR (BLS), early access to emergency services, and early ALS.

Adult Chain of Survival

Basic Life Support (BLS):  BLS helps prevent circulatory and/or respiratory arrest by two main steps.  First, through prompt recognition, intervention, and early entry into emergency medical services (EMS).  Secondly, BLS also externally supports the circulation and respirations of a victim in cardiac or respiratory arrest through rescue breathing and/or cardiopulmonary resuscitation (CPR).

When sudden death occurs vital organs (heart, brain, liver, lungs, and kidneys) do not receive oxygen.  If artificial circulation and breathing are given to a victim via CPR, within the first few minutes of arrest, chances of survival are best. If CPR is not provided within 4 to 6 minutes of arrest brain damage begins to occur.  To avoid irreversible brain damage or organ failure it is necessary to know the signs of sudden death and start CPR without delay. 

Myocardial Infarction (Heart Attack):  A myocardial infarction (MI) occurs when an area of the heart muscle is deprived of blood (oxygen) for a prolonged period.  It usually results from severe narrowing or complete blockage of a diseased coronary blood vessel and results in death to the heart muscle cells.  Typically the larger the affected vessel the greater the area of damage.  Blood vessel spasms whether spontaneous or secondary to drugs such as cocaine can also result in an MI.  The MI in turn may lead to lethal heart rhythms like ventricular fibrillation (V-Fib) which resembles a quivering heart that is unable to produce a pulse (perfusion).

Signs and Symptoms of an MI (Heart Attack):  Chest pain, pressure, or tightness that persists in the chest for greater than 15 minutes and not relieved by rest or nitroglycerin.  Chest pain of some degree is experienced in 75% of patients who experience an MI.  Other possible symptoms may include: Feeling of indigestion, victim in denial, nausea, sweating, weakness, shortness of breath, nitroglycerin meds, and pain in arm, neck, jaw

Signs and symptoms of an MI may be mild, severe or even absent and can happen without warning.  People having an MI may ignore or deny their symptoms.  If someone complains of the above symptoms you should activate EMS and keep the person calm.  A thrombolytic (clot buster) medication if indicated should be administered to the patient within the first hour of the MI. The greatest danger of an MI is cardiac arrest.  If the adult person is in cardiac arrest activate EMS and begin CPR.  The best chance of survival is when CPR is started within minutes of cardiac arrest and a defibrillator is readily available.

Stroke (Brain Attack) CVA:  Strokes (CVA) are the third leading cause of death in the United States, and the leading cause of disability nationwide.  A stroke typically is an illness of sudden onset.  It is caused by occlusion (blockage) or rupture of a blood vessel that supplies the brain.  A stroke may be either ischemic (blockage) or hemorrhagic (bleeding) in most cases. 

Ischemic stroke – Most commonly a blood vessel is blocked by a blood clot or plaque that either developed within the vessel or arose from another source from within the body and migrates to the brain.  Approximately 75% of strokes are ischemic.  If the patient arrives to the hospital with minimal delay a thrombolytic (clot buster) medication could possibly limit and/or reverse symptoms if given within 3 hours of onset. 

Hemorrhagic stroke – is the result of a ruptured blood vessel in the brain. The bleeding can occur adjacent to the brain or into the substance of the brain tissue.  A neurosurgeon consultation is required.

Risk Factors for a Stroke – Controllable: High blood pressure, cigarette smoking, high red blood cell count, and heart disease

Risk Factor for a Stroke – Uncontrollable: Age, gender, race, diabetes (to a degree), prior stroke, heredity,and cardiac bruits

Transient Ischemic Attack (TIA) (Mini-Strokes): A TIA may be a precursor for a future stroke. A brief and typically self correcting episode of focal neurological dysfunction. A TIA may be a sign of atherosclerosis and a risk for stroke.

High platelet and/or red blood cell (RBC) count: An increase in RBC’s thickens the blood and makes clots more likely.

Carotid Bruits: An abnormal sound heard when a stethoscope is placed over an artery.  Indicates plaque deposits in vessels and suggests partial obstruction.

Signs and Symptoms of a Stroke:

*Cincinnati Stroke Scale uses arm drift, facial droop, and speech to indicate a possible stroke

*Weakness, clumsiness, or numbness of arm, leg or face

*Trouble talking or understanding speech

*Dimness or loss of vision in one or both eyes

*Severe headache

*Loss of consciousness

*Asymmetry (one side different than the other)

*Nausea and/or vomiting

Prevention is very important.  The most important prevention of stroke is early recognition and control of risk factors. 

Risk Factors and Healthy Heart Living: Risk factors that increase the risk of having a heart attack or stoke can be divided into two categories being those you can control and those you cannot control.

Controllable Risk Factors: Cigarette smoke, high blood pressure, cholesterol Level, exercise, dDiabetes (to a degree), weight, and stress.

Uncontrollable Risk Factors: Heredity, gender, age, and race

Persons who have more than one risk factor are at a higher risk of developing vascular disease than persons who have none.  Parents can lower a child’s risk factors of heart disease by setting good examples for healthy heart living.

Cigarette Smoking / Tobacco Products: Elimination of tobacco consumption and second hand smoke is the number one most modifiable risk factor that a person can take to reduce the likelihood of heart disease and stroke. Cigarette smoking is a major cause of coronary heart disease (CHD) in men.  It also predisposes women who take oral contraceptives containing estrogen to cardiovascular disease. Smokers have a 70% higher risk of dying from heart attacks, strokes, and other diseases than non-smokers. Smoking accelerates atherosclerosis (vessel damage) and transient elevations in blood pressure which contribute to strokes. Smoking also increases the formation of aneurysms (weakening of a blood vessel).

High Blood Pressure: High blood pressure (hypertension) affects one in four American adults. Increases the risk of heart attack and stroke. High blood pressure is the number one risk factor for stroke.  The risk of a hemorrhagic (bleeding) stroke rises with an increase in blood pressure.

High Blood Cholesterol: Cholesterol is a substance found in animal food products, and is very high in egg yolks and organ meats. Excess cholesterol is deposited in the blood vessels which may lead to atherosclerosis.

Obesity: Obese people are at greater risk of hypertension and diabetes. Avoid extreme diets because they usually leave out foods necessary for good health. Regular exercise helps tone muscles, helps the heart work better, helps avoid gaining weight, and gives you a sense of well-being. In this country the number one reason for obesity is over eating although hypothyroid medications are among the most prescribed medications in the United States.

Pediatric Basic Life Support:

Injury is the leading cause of death in children and young adults.  Motor vehicle collisions account for nearly half of all pediatric injuries and death.  Contributing factors include failure to use proper passenger restraints, inexperienced adolescent drivers, and alcohol use.  Proper use of child seat restraints and lap-shoulder harnesses can prevent an estimated 65% to 75% of serious injuries and fatalities to passengers under 4 years of age.  Proper positioning of children in cars where airbags are used would further decrease the number of deaths.

Pediatric injuries are a leading cause of death among children aged 5 to 9 years.  Every year 200,000 children are injured and more than 600 die from bicycle-related trauma.  This is the leading cause of pediatric closed head injuries.

Drowning (in general any cause of asphyxial arrest) is a significant cause of death and disability in children younger than 4 years of age.  Burns are also a large cause of injury and death to this age group.

Firearms are responsible for an increasing number of unintentional pediatric homicides and suicides.  More than 4,500 children under 20 years of age die from firearm injuries, and thousands are injured every year.

The most common cause of cardiac arrest in infants and children is respiratory arrest.  Most emergency situations involving infants and children are due to preventable accidents.  Many of these accidents could be prevented by using car seats, seat belts, and by having a safe home environment.

 Other safety precautions to help prevent deaths or injuries to infants and children are to have 2 ways out of a building in case of an emergency. Have working fire detectors and fire extinguishers. Cook on the back burners of the stove when possible.  Turn pan handles inward on the stove.  Turn home water heater temperature to 120 degrees or less.  Store poisonous substances in a locked cabinet and located out of reach of children.

If an infant or child swallows a poison only give syrup of ipecac if a doctor or poison control center advises to do so.  It may cause more harm to the victim depending on the type of poison taken.

Automated External Defibrillator (AED’s):

It has been proven that early defibrillation (electrical shock) has improved survival of victims in cardiac arrest. This is especially true of adult cardiac arrest.  Over 90% of adult cardiac arrest victims experience ventricular fibrillation (V-Fib) which is a useless quivering of the heart.  The most effective treatment for V-Fib is electrical defibrillation. The probability of successful defibrillation diminishes rapidly over time.  Many adult patients in V-Fib can survive even if defibrillation is performed as late as 6 to 10 minutes after arrest.  Basic CPR however cannot convert hearts in V-Fib to a normal rhythm – defibrillation does.  The goal is to place a defibrillator, if needed, on a cardiac arrest victim within 5 minutes of the arrest.  If the patient is defibrillated 5 minutes after the onset of arrest the odds of cardiac conversion is still 50%. 

   Automated Defibrillators refer to defibrillators that incorporate a rhythm analysis system.  Fully automated will analyze the heart rhythm and deliver a shock.  Semi-automated will analyze the heart rhythm and a rescuer must press the shock button when advised by the AED.  Some AEDs on the market today offer both adult and pediatric shocking options.

2005 Guidelines: When attempting defibrillation, all rescuers should deliver 1 shock followed by immediate CPR for 5 cycles (about 2 minutes).  Once AEDs are programmed by the manufactures, they should prompt rescuers to allow a rhythm check every 2 minutes.  AEDs programmed under 2000 guidelines deliver 3 consecutive shocks if needed followed by 1 minute of CPR if indicated.

Guidelines to Use an AED

• Patient must be unresponsive
• Not breathing and no pulse
• Not lying in water
• Not in direct contact with metal
• Remove any medication patches
• Place pads 2 inches way from medical implants
• Shave hair on chest if excessive

AED Use on Pediatric Patients

• Pads/Electrodes – If adult and pediatric pads are both available place the adult pads on a person 8 years of age or older.  Place the pediatric pads on patients 1 to 8 years of age.  There is no recommendation for or against the use of AEDs for infants at this time. As a general rule AEDs are not recommended for infants.
• If the AED available only has adult pads and the victim is a child then use the adult pads in the absence of pediatric pads.  Even though this is not an ideal situation the risks outweigh the benefits.
• When treating a child found in cardiac arrest in the out-of-hospital setting provide 5 cycles (about 2 minutes) of CPR before attaching the AED. 
• If a healthcare provider witnesses a sudden collapse of a pediatric victim, the healthcare provider should use an AED as soon as it is available.
• For in-hospital resuscitation an AED or manual defibrillator should be used as soon as possible.  If a manual defibrillator is used the defibrillation dose is 2 J/kg first shock then 4 J/kg thereafter.  If using an AED the dose is automatically adjusted.

When to do Respiratory or Cardiac Resuscitation:  Respiratory arrest – is when breathing stops.  Respiratory arrest may be caused by choking, stroke, smoke inhalation, trauma, drug overdoses, or causes of sudden death.  Children are more likely to experience respiratory arrest first which leads to cardiac arrest. 

Cardiac arrest – is when the heart does not produce a pulse.  Cardiac arrest may be caused by respiratory arrest, heart attack, stroke, smoke inhalation, trauma, drug overdose, or other causes of sudden death. The most common cause of cardiac arrest in children or infants is respiratory arrest.  The most common cause of adult cardiac arrest is abnormal cardiac (heart) rhythms.

When to Activate EMS or Hospital Personnel: Whenever two or more rescuers and/or bystanders are available one should be assigned to activate EMS immediately and retrieve an AED, if readily available.  The caller should know at a minimum the phone number they are calling from and the address and/or location where help is needed.  Single rescuer alone with a victim of all ages – CALL FIRST vs. CALL FAST. The rescuer should alter the sequence of notification for additional help based on the most likely etiology of the victim’s problem.  For sudden collapse of any aged victim the rescuer should call for additional help (EMS) and retrieve an AED (when readily available) and return to victim. The AHA has five exceptions when a rescuer should perform rescue efforts for about two minute (5 cycles) then leave the victim of any age and call EMS:

1) Submersion/near-drowning

2) Poisoning/overdose

3) Trauma

4) Respiratory arrest

5) Unwitnessed collapse

All other situation the rescuer should call EMS then provide rescue efforts.

CPR Skills

There are three basic rescue skills to interview the victim:

A=Airway (open airway)

B=Breathing

C=Circulation

D=Defibrillation (if needed)

Each assessment starts with the ABC’s to see if other actions are needed.  First, check to see if the victim is unresponsive before opening the airway.  Second, check to see if the person is breathing before giving any breaths.  Third, check to see if the person has a pulse (or other signs of circulation) before giving chest compressions.  At anytime a rescuer forgets what to do contact EMS for instructions.

Assessing Responsiveness and Positioning

The first thing to assess is if the victim is unresponsive.  Gently tap the victim and ask are you OK.  Position the victim on their back on a hard, firm, and flat surface.  If the rescuer needs to turn the victim over, if possible, roll them so their head, neck, and back turn without twisting.

  
If the victim is breathing and has a pulse place the victim in the recovery position (lateral recumbent) to protect the airway.

Opening Airway with Head-Tilt Chin-Lift Maneuver (Non-trauma Victim):

Kneel near the victim’s shoulders.  Place one hand on victim’s forehead and apply firm downward pressure to tilt their head back.  Place 2 fingers of your other hand under the victim’s chin and lift to bring the chin forward (up).  These steps will move the victim’s tongue from the back of the throat and open the airway.

Opening the Airway with a Jaw Thrust Maneuver (Trauma Victim)

Jaw thrust maneuver is an alternate method of opening the airway of the victim with suspected neck injuries.  Place yourself above the victims head.  Grasp with both hands the angles of the victim’s lower jaw.  With both hands lift the jaw (mandible) forward (up).

Breathing

Once the victim’s airway is open, look for their chest to rise and fall, listen for any breaths and feel for any breathing on your cheek.  If the victim is breathing keep the airway open until help arrives.  If the victim is not breathing administer rescue breathing also referred to as ventilations.

To provide artificial mouth to mouth ventilations to a non-breathing adult or child keep their airway open and pinch the nose with your thumb and index fingers.  Take a deep breath and place your mouth tightly over the victim’s mouth and give a full breath until the victim’s chest rises.  Repeat this step a total of 2 times. 

To provide artificial mouth to mouth/nose ventilations to an infant or newborn cover the victim’s nose and mouth with your mouth.  Give enough air to make the infant’s chest rise.

Each ventilation, for all ages, should be delivered over a 1 second time period.  The victim should appear to be taking nice easy breaths when ventilations are given.

Complications of Rescue Breathing: The three most common causes for air entering the stomach instead of the lungs are giving the victim too large of a breath (over inflation), breathing to fast and forcefully, and not opening the airway properly. These common mistakes may cause the victim’s stomach to bloat.  If this happens ensure the airway is open and deliver slow smooth breaths until the chest rises.

If the victim’s airway is open and their chest does not rise after each ventilation reposition the head and reattempt to ventilate.  If chest rise is still not present the airway may be blocked or obstructed.  Obstructed airway procedures are explained later in this packet. 

Bag-Valve-Mask Ventilations and Mouth-to-Mask Ventilations: Healthcare professionals providing BLS care should be trained to deliver effective oxygenation and ventilations using bag-valve and mouth-to-mask techniques as the primary method of ventilation support.  

The BLS course will focus on the use of bag-valve because this device is traditionally more readily available for healthcare providers versus mouth-to-mask device (pictured to immediate left). 

There are many ways to use a bag-valve-mask device properly.  It is preferred that a minimum of two trained rescuers are available.  One rescuer secures the mask to the victim’s face and the other squeezes the bag to ventilate.  If a lone rescuer is using the bag-valve-mask one hand forms a “C” clamp over the mask to create an airtight seal to the victim’s face.  The other hand squeezes the bag.  It is very difficult for a lone rescuer with minimum experience to ensure an adequate seal around the mask without assistance from other trained rescuers.

Circulation: If you have given 2 breaths and the victim’s chest has risen, next check if the victim has a pulse.  To find a carotid pulse in an adult or child victim place 2 fingers over the Adam ’s apple and move the fingers towards yourself into the “groove” along the windpipe.  Feel gently for a heart beat for 10 seconds. If you have given 2 breaths and the victim’s chest has risen, next check if the victim has a pulse.  Feel gently for a heart beat for 10 seconds.

To find a brachial pulse in an infant or newborn place 2 fingers on the inside of the victim’s upper arm that is closest to you.  Feel gently for a heart beat for 10 seconds. 

 If a pulse is present the rescuer should only provide rescue breathing/ventilations and withhold chest compressions.  For an adult victim that is not breathing but has a pulse give one breath every five to six seconds (about 10 to 12/minute).  For children and infants rescue breathing rates are one breath every three to five seconds (about 12 to 20/minute). 

During rescue breathing with a pulse remember to periodically reassess the circulation status for changes.  If the pulse becomes absent provide chest compressions.

Note:  Under current guidelines the term for circulation is “signs of circulation.”  Examples would include; pulse, movement, breathing, moaning, and coughing.

Chest Compression

Even when CPR chest compressions are performed correctly problems or complications such as punctured lungs, lacerated liver, cardiac contusion, broken ribs and/or sternum (breast bone) may occur.  In many studies doing chest compressions on victims with a pulse only caused significant damage to approximately 3% of victims when using proper hand placement.  Correct hand placement is vital to limit chest damage. 

Hand Placement for Chest Compression

Adult Victims – Place the palm of one hand on the sternum (breastbone) between the victims nipple line. Your palm should be over the lower/bottom 1/2 of the victim’s sternum.  Place your other hand on top of the first and interlock your fingers. Position your fingers so they do not touch the victim’s chest. You should compress in a downward motion 1 ½ to 2 inches.  Allow the chest to recoil before providing the next compression.

Child Victims - Follow all the steps as with adult but only use heel of one hand to compress the chest.  Using current guidelines it is not wrong to use two hands on a child to reach a compression depth of 1/3 to 1/2 of the chest thickness.

Infant or Victims - Keep the airway open with your hand that is closest to the victim’s head.  Place two fingers from your other hand between the infants nipple line.  These fingers should be on the lower 1/2 of the sternum. Compression depth is 1/3 to 1/2 of the chest thickness. 

Adult One-Rescuer CPR

1)      Check if unresponsive.

2)      Call EMS (refer to “when to call EMS”).

3)      Place victim on hard / firm surface.

4)      Open airway.

5)      Check for breathing for 3-5 seconds.

6)      If not breathing give 2 slow breaths.

7)      Check for pulse.

8)      If no pulse begin chest compressions at a rate of 100/min with 30 compressions followed by 2 ventilations for two minute then reassess for circulation.

9)      If still no pulse continue CPR and reassess every few minutes thereafter.

Adult Two-Rescuer CPR

1)      Check if unresponsive.

2)      Call EMS (refer to “when to call EMS”).

3)      Rescuer 1: The person at the head is in charge.

4)      Place victim on hard / firm surface.

5)      Open airway.

6)      Check for breathing for 3-5 seconds.

7)      If not breathing give 2 slow breaths.

8)      Check for pulse.

9)      Rescuer 2: If no pulse find hand placement for chest compressions.  Give chest compressions at a rate of 100/min with 30 compressions followed by 2 ventilations by rescuer 1.

10)   Rescuer 1: reassess circulation after two minutes of CPR.  Switch positions every two minutes.

Switching Positions: During two person CPR it is suggested that rescuers change positions every 2 minutes.  Also CPR should not be interrupted for more than 10 seconds as a general guideline. You can switch at that time or complete one more cycle then switch. 

• The breaths are always given during the pause after the 30^th compression to allow adequate time for the ventilations.
• To verify good compressions the ventilator periodically feels for a pulse during the 15 compressions.
• If an advanced airway is being used on the victim compressions and ventilations are performed as separate functions. The ventilator provides 8 to 10 breaths per minute and the compressor performs 100 compressions per minute uninterrupted.

Child One Rescuer CPR

1)      Check if unresponsive.

2)      Place victim on hard / firm surface.

3)      Open airway.

4)      Check for breathing for 3-5 seconds.

5)      If not breathing give 2 slow breaths.

6)      Check for pulse.

7)      If no pulse begin chest compressions at a rate of 100/min with 30 compressions followed by 2 ventilations for two minutes then reassess for circulation.

8)      Call EMS (refer to “when to call EMS”).

9)      After notification of EMS and if still no pulse continue CPR and reassess every few minutes thereafter.

Note: If the heart rate is less than 60 begin CPR

Child Two-Rescuer CPR

1)      Check if unresponsive.

2)      One Rescuer call EMS (refer to “when to call EMS”).

3)      Rescuer 1: The person at the head is in charge.

4)      Place victim on hard / firm surface.

5)      Open airway.

6)      Check for breathing for 3-5 seconds.

7)      If not breathing give 2 slow breaths.

8)      Check for pulse.

9)      Rescuer 2: If no pulse find hand placement for chest compressions.  Give chest compressions at a rate of 100/min with 15 compressions followed by 2 ventilations by rescuer 1.

10)   Rescuer 1: reassess circulation after two minutes of CPR.   Switch positions every two minutes.

Switching Positions

During two person CPR it is suggested that the rescuers change positions every two minutes.  Also CPR should not be interrupted for more than 10 seconds as a general guideline. You can switch at that time or complete one more cycle then switch. 

• The breaths are always given during the pause after the 15^th compression to allow adequate time for the ventilation.
• To verify good compressions the ventilator periodically feels for a pulse during the 15 compressions.
• If the heart rate is less than 60 begin CPR
• If an advanced airway is being used on the victim compressions and ventilations are performed as separate functions. The ventilator provides 8 to 10 breaths per minute and the compressor performs 100 compressions per minute uninterrupted.

Infant One Rescuer CPR

1)      Check if unresponsive.

2)      Place victim on hard / firm surface.

3)      Open airway.

4)      Check for breathing for 3-5 seconds.

5)      If not breathing give 2 slow breaths into victim’s mouth and nose.

6)      Check for pulse in upper arm.

7)      If no pulse begin chest compressions at a rate of approximately 100/min with 30 compressions followed by 2 ventilations for two minute then reassess for circulation.

8)      Call EMS (refer to “when to call EMS”).

9)      After notification of EMS and if still no pulse continue CPR and reassess every few minutes thereafter.

Note: If the heart rate is less than 60 begin CPR

Infant Two-Rescuer CPR

1)      Check if unresponsive.

2)      One Rescuer call EMS (refer to “when to call EMS”).

3)      Rescuer 1: The person at the head is in charge.

4)      Place victim on hard / firm surface.

5)      Open airway by positioning yourself above the victims head (jaw thrust).

6)      Check for breathing for 3-5 seconds.

7)      If not breathing give 2 slow breaths into mouth and nose of victim.

8)      Check for pulse in upper arm or groin.

9)      Rescuer 2: If no pulse find hand placement for chest compressions. Stand toward feet of infant and use the 2 thumb-encircling technique to deliver compressions.  Give chest compressions at a rate of 100/min with 15 compressions followed by 2 ventilations by rescuer 1.

10)   Rescuer 1: reassess circulation after two minutes of CPR.  If still no pulse continue CPR and reassess every few minutes thereafter.

• The breaths are always given during the pause after the 15^th compression to allow adequate time for the 2 ventilations.
• To verify good compressions the ventilator periodically feels for a pulse during the 15 compressions.
•  If the heart rate is less than 60 begin CPR.
• If an advanced airway is being used on the victim compressions and ventilations are performed as separate functions. The ventilator provides 8 to 10 breaths per minute and the compressor performs 100 compressions per minute uninterrupted.

CPR Chart

Introduction to Obstructed Airway (Choking Skills)

Causes in Adults: Foreign body (meat most common), large poorly chewed food, alcohol

consumption, dentures, and unconsciousness (tongue most common).

Causes in child/infants: Foreign body (marbles, beads, coins, grapes, and hotdogs), infections, and unconsciousness.

How to Know When Someone is Choking

Foreign bodies may cause partial or complete airway obstructions. The victim may be conscious or unconscious.   The blockage can be placed in three categories.

1)      Partial obstruction with good air exchange: If good air exchange is present the victim has a strong cough and can breathe and talk.  If good air exchange call for help and do not interfere!

2)      Partial obstruction with poor air exchange: The victim has a weak cough, high pitched noises while inhaling, and increasing respiratory difficulty.  Victim’s skin may appear blue. 

3)      Complete airway obstruction: The victim cannot cough, breathe or talk.  The victim may hold their throat. 

 You should help the victim remove the foreign body if poor air exchange or complete blockage is witnessed.

Note: If the victim is unconscious with a complete airway obstruction you will not be able to breathe air into the victim’s lungs during ventilations.

Conscious Obstructed Airway Skills for Adult and Child

1)      Look for universal sign if choking (grasping throat).  Ask the victim if they can talk or cough.  Ask are you choking.

2)      If others are available activate EMS.  If alone activate EMS when victim goes unresponsive.

3)      Stand behind the victim and place one of your legs between the victim’s legs for stability.

4)      Wrap your arms around the victim’s waist.  Make a fist and place the thumb just above the victim’s navel and below the sternum.  Place the other hand over the first fist.

5)      Press your fists into the victim’s stomach (abdomen) with a rhythmic inward and upward movement.  Like a banana shape.

6)      Repeat these steps until the obstruction comes out, goes unresponsive, or starts coughing forcefully.

Note: This skill is the same for a child and adult.  The main difference is that the rescuer should go to their knees and get lower to the ground for a child victim.

Conscious Obstructed Airway Skills for Pregnant, Obese, or Recent Abdominal Surgery Victims

1)      Look for universal sign of choking.  Ask the victim if they can talk or cough.  Ask are you choking.

2)      If others are available activate EMS.  If alone activate EMS when victim goes unresponsive.

3)      Stand behind the victim and place one of your legs between the victim’s legs for stability.

4)      Wrap your arms around the victim’s chest just under the armpits. 

5)      Make a fist and place a thumb side on the lower ½ of the victim’s sternum (same location as if you are performing a chest compression for CPR). Place the other hand over the first fist.

6)      Press your fists into the victim’s chest with a rhythmic inward movement.  Like you are trying to knock the wind out of the victim.

7)      Repeat these steps until the obstruction comes out, goes unresponsive, or start coughing forcefully.

Conscious Obstructed Airway for Infant

1)      Look for signs of poor air exchange.

2)      If others are available activate EMS.  If alone activate EMS when victim goes unresponsive.

3)      Pick up infant supporting the head and neck.

4)      Turn the victim over (face down) on your arm with the infant’s head lower than the body.

5)      Put the heel of the other hand between the infant’s shoulder blades.  Deliver 5 sharp, rhythmic, and forceful back blows.

6)      Support the infant’s head and turn them over (facing up) resting on your forearm with head lower than body.

7)      Position 2 fingers from your other hand on the infant’s chest just like delivering a CPR compression.  Deliver 5 sharp, rhythmic, and forceful chest thrusts.

8)      Repeat these steps until the obstruction comes out, goes unresponsive, or coughs forcefully (cries).

Conscious to Unconscious Obstructed Airway for Adult

1)      Help the victim to the ground. Place victim on hard / flat surface.

2)      Call EMS (refer to “when to call EMS”).

3)      With one hand perform a tongue-jaw lift and look for the object.

4)      With your other hand perform a finger sweep for the object only if you see the object.

5)      If you cannot get the object then open the airway and give a breath.  If the victim’s chest does not rise reposition the airway and try another breath.

6)      If chest still does not rise perform 30 chest compressions just like CPR.

7)      After delivering 30 compressions go back to victim’s head and open airway and look into the mouth for the object followed by a finger sweep if you see the object then give two ventilations.

8)      If air still does not enter the chest repeat the compressions, look/sweep and ventilate steps until air enters.

9)      Once air enters the chest move on and check letter “C” in the ABC’s.

Conscious to Unconscious Obstructed Airway for Child

1)      Help victim to ground.

2)      Call EMS (refer to “when to call EMS”).

3)      Place victim on hard / flat surface.

4)      With one hand perform a tongue-jaw lift and look for the object.

5)      With your other hand do a finger sweep only if you see the object.  If you cannot get the object then open the airway and give a breath.  If the victim’s chest does not rise reposition the airway and try another breath.

6)      If chest still does not rise perform 30 chest compressions just like CPR. 

7)      After delivering 30 compressions go back to victim’s head and open airway and look into the mouth for the object followed by a finger sweep only if you see the object then attempt two ventilations.

8)      If air still does not enter the chest repeat the thrust, look/sweep and ventilate steps until air enters.

9)      Once air enters the chest move on and check letter “C” in the ABC’s.

Note: If two rescuers performing the skill can change to 15 compressions versus 30.

Conscious to Unconscious Obstructed Airway Skills for Infant

1)      Help victim to hard /firm surface and place victim face up.

2)      Call EMS (refer to “when to call EMS”).

3)      With one hand perform a tongue-jaw lift and look for the object.

4)      With your other hand do a finger sweep only if you see the object.  If you cannot get the object then open the airway and give a breath.  If the victim’s chest does not rise reposition the airway and try another breath.

5)      If chest still does not rise perform 30 chest compressions just like CPR.

6)      After delivering 30 compressions go back to victim’s head and open airway and look into the mouth for the object followed by a finger sweep only if you see the object then two ventilations.

7)      If air still does not enter the chest repeat the compressions, look/sweep if visible, and ventilate until air enters.

8)      Once air enters the chest move on and check letter “C” in the ABC’s.

Note: If two rescuers performing the skill can change to 15 compressions versus 30.

Safety in CPR

The vast majority of CPR performed is done by healthcare workers.  The layperson that performs CPR is most likely to so do in the home where the victim is known by the rescuer.  To prevent possible transmission of pathogens several devices have been developed to minimize such risks to the rescuer.  Some examples are face shields, face mask (mouth-to-mask), and bag-valve-masks.

Miscellaneous Points to Remember

• In rescuing drowning or hypothermic victims remember that survival is possible even after long periods of time.
• If an unconscious victim vomits simply turn the victims head to the side and clear the vomit and then resume BLS.
• Good Samaritan law is to decrease the fear of legal consequences when helping someone in an emergency. 
• Whenever leaving a victim place them in the recovery position (on their side).
• Advanced airway is defined as; LMA, combitube, and endotracheal tube. When performing CPR with an advance airway device in place deliver 8 to 10 ventilations per minute for adult, child and infant ages.
• AHA defines a newborn as hours old until leaving the hospital. Newborn CPR is a specialty skill related to neonatal settings.  If you do not specialize in this age group it is acceptable to treat newborns as infants as learned in this program.

Neonatal/Newborn versus Infant BLS

1)      Newborn is hours old to discharge from hospital.  Infant is a general term from birth to 1 year.  If you have not completed a neonatal CPR class it is acceptable to apply infant BLS procedures to newborns until specially trained responders arrive.

2)      Newborn rescue breathing is at a ventilation rate of 40 to 60 per minute.

3)      Newborn CPR ventilation to compression is 120 tasks per minute (30 ventilation and 90 compressions in a minute). 

4)      Newborn CPR ratio is 3 compressions and 1 ventilation.

5)      Newborn compression depth is 1/3 the depth of chest.  About 1/2 to 1/3 of an inch.

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