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CPRandFirstAidStudyGuide

TheFiveFears

ManybystandersarereluctanttoperformCPR.Therearemanyreasonswhybystandersarereluctanttogetinvolved.Let’stakealookatsomeofthesereasonssothatyoucanunderstandwhytheyhavenorealbasisofsupport. FearofDisease:Useuniversalprecautionswhenthepossibilityexistsofcomingintocontactwithbodilyfluids.Usegloves,mask,and/oragownwhenyouhavethemavailable.Thebenefitofinitiatinglifesavingresuscitationinachildincardiopulmonaryarrestgreatlyoutweighstheriskforsecondaryinfectionintherescuerorthechild.Nevertheless,useofsimpleinfection-controlmeasuresduringCPRandCPRtrainingcanreduceaverylowlevelofriskevenfurther(Mejicano&Maki,1998).Thisfearisnotasprevalentwhendealingwithinfantsandchildren,whoarelesslikelytobeharboringseriousbloodbornepathogens. FearofLawsuits:Theselawsstatethatapersonactingingoodfaithwhoisrenderingreasonablefirstaidwillnotbeheldaccountablefordamagestothepersontowhomtheaidisrendered,unlessgrossandwillfulmisconductareinvolved.GoodSamaritanlawsmaydifferforfromstatetostate.Impliedconsentmeansthatthereisanassumptionthatifanunconsciouspersonwereabletorequestcare,theywoulddoso(ortheirparent/guardianwoulddosoontheirbehalf.FearofUncertainty:Peoplesometimesfearthattheywon’trememberwhattodo.Rememberingthecorrectnumberofcompressionsorthenumberofcompressionstoventilationsisnotasimportantasthewillingnesstorespondandtopushhardandfast.Hands-onlyCPRisdesignedtoprovidesimplelifesupport.Remember,anythingyoudoisbetterthandoingnothingatall! FearofHarmingtheVictim:Avictiminneedorclinicallydeadcanonlybehelpedbyyourinterventionefforts.Youcan’thurtsomeonewhoisdead,andanyinjuriesyoumayunknowinglycause(suchasinjuredribs)canbedealtwithinasurvivingvictimofrespiratoryorcardiacarrest.Childrenand infantsaresurprisinglyresilient!

FearofInjurytoSelf:Asyouwilllearn,scenesafetyisofutmostimportance,andcheckingthesceneforsafetyshouldbeyourfirstactionwhenyoucomeacrossanunconsciousvictim,evenifthevictimisachild.Ifthesceneisnotsafeforyoutoenter,youmustnotenter.Thiswillonlyresultinmorevictims.Undernocircumstancesshouldyouriskbecomingavictim.Instead,youshouldcallforhelp(activateEMS). Asarescuer,youmustalwayschecktoensurethesceneissafebeforerenderingassistancetoanyvictim!

BASICANATOMYANDPHYSIOLOGY BeforeyoulearnhowtoperformCPR,it’simportanttounderstandhowtheheart,lungs,brainandcellsperform.Hereisabriefreviewofthesesystems.

THEHEART Theheartconsistsoffourchambers,therightandleftatria(singular:atrium)andtherightandleftventricles.Theatriaarelocatedabovetheventricles,ascanbeseenintheabovediagram.Theheartisamuscularorgansuppliedbythecoronaryarteries.Itislocatedbelowyourbreastbone(sternum).Inchildrenandinfants,theirheartsareaboutthesizeoftheirfists. Theheartpumpsbloodthathasbeendeoxygenatedbysupplyingthebody’stissuesintothelungs,andwhenthatbloodhasbeenoxygenatedagaininthelungs,itexitsthelungstotheleftsideoftheheart,whereitispumpedoutintothetissuesonceagaintoprovidelive-givingoxygen. Yourbodyhasabout5litersofblood,whichcirculatethroughthissystemapproximately3timesperminute.Achildwillhavelesscirculatingbloodvolume,dependingontheirage-achildof80poundswillhaveapproximatelyhalfthecirculatingbloodvolumeofanaverage-sizedadult.Infantswillhavefarless.Thisiswhybloodlosscanbedevastatingtoachild.Whatisknownasthecardiovascularsystemiscomposedoftheheart,arteries,capillaries,andveins.

THELUNGS Yourlungsarespongy,air-filledsacs,withonelunglocatedoneithersideofthechest.Thetrachea,whichissometimescalledthewindpipe,conductsairdownintothelungsthroughthebronchi,whicharesmallertubularbranches.Thebronchithendivideintosmallerandsmallertubulescalledbronchioles.Airisexchangedinthealveoli,whicharetinysacsthatallowoxygenandcarbondioxidetomovebetweenthelungsandthebloodstreamviatinycapillaries. Yourlungstakeinoxygentosupplyyourbody’sorgansandtissues.Theyreleasecarbondioxide,awasteproduct,intotheatmospherewhenyouexhale.Roomairatregularatmosphericpressurecontains21%oxygen.Ourbodiesutilizeapproximately4-6%ofthatoxygenandreleaseabout17%backintotheatmosphere,alongwithcarbondioxide,whenweexhale. Childrenhavehigherrespiratoryratesthanadults.Higherrespiratorratesleadtoproportionatelyhigherminutevolumes.Asaresult,childrenmaybemoresusceptibletoagentsabsorbedthroughthepulmonaryroutethanadultswiththesameexposure.Childrenmayalsorespondmorerapidlytosuchagents.Becausechildren’sairwaysaremuchsmaller,andtheyhaveashortertracheaandarelativelylargertonguesizethanadults,theyaremoresusceptibletobreathingandairwayproblems.Respiratoryarrestisacommoncauseofcardiacarrestinchildren.

THEBRAIN Yourbrainneedsaconstantsupplyofoxygen.Withoutoxygen,braincellsbegintodiein4to6minutes. Onaverage,theadultbrainweighsthreepounds,anduses20%ofthebody’soxygen.Inchildren,thebrainreaches95%ofadultsizebytheageofseven. Themedullaislocatedinthebrainstemandcontrolsautomaticbodilyfunctions,includingconsciousnessandrespiratoryandcardiovascularfunction.

ThePediatricChainofSurvival Thepediatricchainofsurvivalcanbethoughtofasasequenceofeventsthatmustoccurinordertorestorehealthinachildorinfantvictimofsuddencardiacarrest.Becausechildrenaremorepronetorespiratoryarrestandshock,itisessentialtorecognizeandpreventairwayandbreathingproblemsbeforetheyoccurtopreventcardiacarrestandtoensuresurvivalandfullrecovery.Forthisreason,themostimportantlinkinthepediatricchainofsurvivalisprevention.Unintentionalinjuriesarethenumberonecauseofdeathinchildren.Children’slivescanbesavedbyfocusingonpreventionofemergencies.KnowingCPRisimportant,butevenmoreimportantisensuringthatCPRisneverneededinthefirstplace! Therefore,thePediatricChainofSurvivalincludes:

� Preventionofrespiratory/cardiacarrest � Earlyhigh-qualityCPR � ActivationoftheEmergencyResponseSystem � Earlyadvancedlifesupport � Comprehensivepost-cardiacarrestcare

THETEAMAPPROACH Inmanysituations,theremaybeonlyonerescuerwhowillcarryoutthenormalsequenceofassessmentsandactions.However,inmanysituations,thereisoftenmorethanonerescuertrainedandwillingtohelp. Thisiswhenateamapproachcanbeused.Thefirstrescuershouldtaketheroleofteamleaderanddelegatetasks.Onerescuercanprovidecompressions,onecanpreparetogivebreathswithafacemaskormouth-to-mouth,andonecanpreparetheAED.Byworkingtogether,themostefficientcarecanbegiventothepatient.Ofcourse,ifyouaretheonlyrescuerpresent,youwillhavetodoallofthesethings.Forthisreason,thestepstoperformingCPRarepresentedinalinersequence.

ChestCompressions ChestcompressionsarethemostimportantcomponentofCPR.Chestcompressionsareanattempttomimicthenormalactivityoftheheart.Whenarescuerpressesdownonavictim’schest,bloodisforcedoutoftheheartandintothearteries.Whenpressureonthechestisreleased,bloodisallowedtoreturntotheheart.Asmallamountofoxygenwillbepresentinthebloodstreamforseveralminutesaftertheheartceasestobeat,justenoughtokeepthebrainalive.Compressionscankeepvitalorgansfunctioninguntilhigherlevelcareisavailable.

Toperformcompressionsonachildvictim(aged1topuberty*): Toperformcompressionsonachild,placetheheelofyournon-dominanthandonthevictim’schestbetweenthenipples.Thenplaceyourotherhandontopofthefirstandinterlaceyourfingers.Theheelofyourhandshouldbepressingonthebottomtwo-thirdsofthesternum,avoidingthexiphoidprocess(thesmallbonyprominenceattheverybottomofthesternum(breastbone).Youshouldbeasclosetothevictim’ssideaspossible,withyourkneesagainstthevictim’sside(thiswillhelppreventbackinjuryandfatigue).Lockyourelbowsandpressdownhard,depressingthesternumatleast1/3thedepthofthechest,orapproximately2inches(5cm).Ifyoufindthatyouarepressingtoodeeplywithtwohands,useonlyonehand.Yourshouldersshouldbepositioneddirectlyoveryourhandsinastraightline.Pushhardandfast100to120timesperminute,countingoutloudasyoudoso.It’simportantthatyouallowthechesttorecoil(returntoit’snormal,relaxedposition)inbetweencompressions.Ifyoudonotallowthechesttorecoil,theheartwillnotfillcompletely,whichmeansthatlessblood(andthereforeoxygen)willbepumpedoutofthehearttovitalorganswiththenextcompression. Performingcompressionsisexhausting.Mostpeoplefindthattheybecomeveryfatiguedafterprovidingcompressionsforjustafewminutes.Whenapersonperformingcompressionsbecomesfatigued,thereisatendencytocompresslessfirmlyandmoreslowly;forthisreason,itisrecommendedthatrescuerstradeoffdoingcompressionsevery2minutestopreventfatigueandoptimizethequalityofcompressions.Ifyouarealone,youwillhavetodothebestyoucan-keepperformingcompressionsuntilhelparrivesoryouarephysicallyunabletodoso.

*Notethatpuberty,forthepurposesofCPR,isdefinedasthepresenceofunderarmhairinmalesoranybreastdevelopmentinafemale. OneRescuerChildCPR Ifyouarealoneandcomeacrossachildwhoisdown,followthestepsbelow.Ifsomeoneelseisimmediatelyavailabletoassist,usethe‘TwoRescuer’sequence. StaySafe:IfyoucomeuponachildwhomayneedCPR,lookaroundandmakesureyouandthechildareinasafeplace.Ifthechildisinwateroronaroad,trytomovethechildtoasaferarea.Ifyouareinasafearea,donottrytomovethechildashe/shemayhaveotherinjuriesthatyoucannotsee.Simplyrollhim/heroverontohisback.Makesurethechildisonafirmsurface,incasecompressionsareneeded. AssesstheVictim:Toquicklyassessthevictim,shakehisshoulderandyellathim.Checkforbreathing. Ifhe/sheisnotbreathing,orisnotbreathingnormally(i.e.,onlygasping),shoutforhelp. ActivatetheEmergencyResponseSystemandFindanAED:Yellforhelp.Ifsomeoneresponds,tellhim/hertocallforhelpbydialing9-1-1.IfyouareinanareawhereanAEDmaybeavailable,tellhim/hertogofindtheAED.Makesureyoutellthepersontoreturntoassistyouassoonaspossible.Ifyouarealoneandwitnessedthechildcollapse,callforhelpbydialing9-1-1andruntogettheAEDifyouknowwhereoneisnearby.IfyoudonotknowwhereanAEDis,beginCPRimmediatelyafterdialing9-1-1. BeginCPR

1. Checkforapulseonthesideoftheneck.Feelforapulseforatleast5secondsbutNOMORETHAN10seconds.Tocheckforacarotidpulse,slide2or3fingersintothegroovebetweenthetraches(windpipe)andtheneckmusclesatthesideoftheneck.Alternately,youcancheckforapulseinthefemoralarterylocatedinthegroin.Todothis,placetwofingersintheinnerthigh,partwaybetweenthepubicboneandthehipbone,justbelowthecreasewherethelegjoinstheabdomen.Remember,donotfeelforapulseformorethan10seconds.

2. Ifthereisnopulseorthepulseislessthan60/minutewithsignsofpoorperfusion*(orifyouareunsureifthereisapulse),beginCPRstartingwithchestcompressions.Provide30chestcompressions,followedbytwobreaths.NOTE:Ifyouarenotcomfortablegivingrescuebreathingand/oryoudonothaveamaskavailable,do‘CompressionOnly’CPR.

a. Usetheheelofonehandonthelowerhalfofthebreastboneinthemiddleofthechest.

b. Placetheotherhandontopofthefirsthand.

c. Straightenyourarmsandlockyourelbowssothatyourbodyweightisover

yourhands.d. ThemostimportantpartofCPRistoremembertopushHARDandFAST.Each

compressionshouldbeone-thirdthedepthofthechestorapproximatelytwoinchesdeepandtherateshouldbe100-120compressionsperminute.

e. Besuretoletuponthepressureonthesternumaftereachcompression(chestrecoil)sothechestcanre-expandandbloodcanflowbackintotheheart.ThepurposeofCPRistohelpthebloodflowthroughtheheartandintotherestofthevitalorgans;ifyouallowthechesttofullyre-expand,morebloodwillflowintotheheartandwillbeavailabletodelivertotherestofthebody.

f. Countoutloudasyoudocompressions.Whenyouhavedone30compressions,

trytoopenthevictim’sairwaybydoingaheadtilt/chinlift.Notethatifyouaredoing‘CompressionsOnly’CPR,youcanskipthisstep.

i. Withyournon-dominanthand,pushonthevictim’sforeheadtotilttheheadback.

ii. Withyourdominanthand,placeyourfingersunderthebonypartofthelowerjawandgentlyliftthejawtobringthechinforward.Besureyouliftuponthebonypartofthejawandnotthesofttissueunderthejawsoyoudon’tblockthevictim’sairway.Donotuseyourthumbtoliftthejaw.Allowthevictim’smouthtoremainslightlyopen.

iii. Ifyouthinktheperson’sneckmaybeinjured,avoidtheheadtilt/chinliftandusethejawthrustmaneuverifyouhavebeentrainedtodoso.Instructionsforperformingajawthrustareprovidedlaterintheunit.

g. Ifyouhaveabarrierdevicetousebetweenyourmouthandthechild’sface,useit.AlthoughtheriskofinfectionfromperformingCPRisvery,verylow,itisrecommendedtouseabarrierdevicewhenprovidingCPR.Thisincludestheuseoffacemasks.Giveeachbreathslowly–eachbreathshouldlastonesecond.Makesurethechestriseswitheachbreath.Repeat,givingasecondbreath.

h. Startanothercycleofchestcompressions.Remember,pushHARDandFAST.Alternatechestcompressions(30)andbreaths(2)untilhelparrives.

*Signsofpoorperfusion:thisreferstoalackofbloodflowthatresultsincertainvisiblesigns,includingpaleskincolororbluishdiscolorationoftheskin.Fingers,earlobes,lipsandnailbedsmaylookbluishorlightgray.Sometimestheremaybemottling,whichisamixtureofapurplishorblotchyred-bluecoloringontheextremities(armsorlegs).

Airway/Breathing Facemasksprovideabarrierbetweentherescuerandthevictim.Somemasksareequippedwithaone-wayvalvethatallowstherescuer’sbreathstoenterthevictim’sairway,butpreventsthevictim’sexpiredairfromcomingincontactwiththerescuer’sairway.Thesemasksalsopreventcontactwithvomitusandblood,whichcouldposeaninfectionrisktotherescuer.Thesemaskscanbepurchasedonlineforminimalcost,andcanbekeptvirtuallyanywhere-inapurse,carorathome.Ittakespracticetolearnhowtousethesemaskseffectivelytoprovideventilations. UsingaFaceMask:

a) Positionyourselfatthevictim’sside.Ifyouarealone(single)rescuer,positioningyourselfatthevictim’ssidewillallowyoutoprovidebothventilationsandcompressionswithouthavingtomove.

b) Positionthemaskonthevictim’sface.Masksareusuallytriangularinshape,andyouwillnoticethatthemaskhasa“pointy”end-thisendgoesoverthebridgeofthevictim’snose.

c) Sealthemaskagainstthevictim’sface.Todothis,takethehandthatisclosesttothetopofthevictim’sheadandplaceitalongtheedgeofthemask.Somepeoplefinditeasiertoforma‘C’withtheirindexfingerandthumbandusethesedigitstograspthemaskaroundthebaseofthemouthpiece.Withthethumbofyourotherhand,applypressurealongthebottomedgeofthemask.Thenplacetheremainingfingersofyoursecondhandalongthebonyedgeofthejawandliftthejawupwards.Opentheairwaybyperformingahead-tiltchin-liftprocedure.Whileyouliftthejaw,ensurethatyouaresealingthemaskallthewayaroundtheoutsideedgeofthemasktoobtainagoodsealagainstthevictim’sface.

d) Deliverairover1second,ensuringthatthevictim’schestrises.e) Ifthevictim’schestdoesnotrise,repositionthemaskandtrytogetabetterseal.

Remember,youshouldbeliftingthevictim’sjawintothemask,ratherthansimplypushingthemaskdownontothevictim’sface.

f) Provide2ventilationsover1secondeachwiththemaskafterevery30compressions.g) Ifthevictimhasapulsebutisnotbreathing,providerescuebreathingbyproviding1

breathevery3to5seconds(12-20breathsperminute).Checkforapulseevery2minutes-ifatanytimethevictimlosestheirpulse,startchestcompressionsalongwithventilationsatarateof30:2.

Mouth-to-MouthBreaths Althoughitisrecommendedtouseafacemasktodeliverbreaths,therearetimeswhenthesedevicesmaynotbenecessary.Shouldacardiacarrestoccurathome,youwouldlikelynothesitatetoperformmouth-to-mouthbreathingforyourownchild;youmightchoosetogivemouth-to-mouthtoachildinyourcareaswell.Incasessuchasthese,youwilllikelydecidethebenefitoutweighstherisktoyourownhealth,whichisvery,verysmalltobeginwith.

Toprovidemouth-to-mouthbreathstoachild:

1. Usetheheadtilt-chinlifttoholdthevictim’sairwayopen.2. Usingthehandonthevictim’sforeheadthatismaintainingtheheadtilt-chinlift,

pinchthevictim’snoseclosedusingthethumbandindexfinger.3. Inhalearegularbreath,thencoverthevictim’smouthwithyourown,creatinga

tightseal.4. Giveonebreathover1second,watchingtoseeifthechestrises.5. Ifthechestdoesn’triseasyougivethebreath,repeattheheadtilt-chinlift.6. Giveasecondbreathover1secondandwatchforchestrise.7. Ifthesecondbreathfailstogoin,goimmediatelytochestcompressions.

TheJawThrustManeuver Ifyoususpectthatachildmayhaveaneckorspinalcordinjury(i.e.,thechildhasfallen,beeninamotorvehicleaccidentorsufferedanothermechanismofinjurythatcouldresultininjurytotheneckorspinalcord),youshouldnotusetheheadtilt-chinliftmaneuvertoopenthevictim’sairway.Thiscouldfurtherdamagetheneckorspinalcord.Instead,youshouldusethejawthrustmaneuvertoopenandmaintainthevictim’sairway.

Toperformthismaneuver:

a) Placeyourhandsoneithersideofthevictim’shead.Restyourelbowsonthesurfacethatthevictimislayingon.

b) Putthefingersofbothyourhandsundertheangleofthevictim’slowerjawandliftsothatthejawslidesforward.

c) Useyourthumbtopushthelowerlipawayfromyouifthevictim’slipsclose.

UsinganAED AnAED,orautomatedexternaldefibrillator,isadevicethathastheabilitytodetectandtreat,throughelectricalenergy,thelethalarrhythmiasknownasventricularfibrillationandventriculartachycardia. Ventricularfibrillationisaconditioninwhichthelowerchambersoftheheart,theventricles,quiverinanunorganizedfashion,whichrendersthemincapableofpumpingbloodtotherestofthebody.Untreated,ventricularfibrillationrapidlycausescardiacarrest.Ventriculartachycardiaisarapidrhythmoriginatingintheventricles.Inventriculartachycardia,theventriclescontractsoquickly,albeitinasomewhatorganizedfashion,thatinadequatebloodflowisproduced.Ventriculartachycardiaoftenprecedesventricularfibrillation.Bothrhythmsarelethalifnottreated. AnAEDsendselectricalenergy(a‘shock’)throughtheheart,whichstunstheheartandallowsthenormalpacemakeroftheheart,usuallylocatedintherightatrium,totakeoverandrestoreanormalheartrhythm.

Earlydefibrillationiskeytosurvivalincardiacarrest.Foreachminutethatdefibrillationisdelayed,thechanceofsurvivalisreducedby10%.(after10minutes,fewpeoplearesuccessfullyresuscitated.) Earlydefibrillationcanincreasesurvivalratestogreaterthan50%.Rescuersshouldimmediatelybeginchestcompressions,andusetheAEDassoonasitisavailableandreadytouse.

AEDscanbefoundwherevercrowdsofpeoplegather-swimmingpools,airports,malls,sportingarenas,schools,hotels…moreandmorebusinessesarealsoinvestingintheselife-savingmachines.Insomecommunities,privateAEDownersareregisteringtheirAEDswithambulancedispatch,sothattheycanbeeasilylocatedbybystanderswhenneeded.MakeitapointtolearnwheretheAEDsinyourneighborhoodortownarelocated-youneverknowwhenyoumightneedone!IfyouworkinaplacethathasanAED,makesureyouarefamiliarwiththeAEDshouldyoueverneedtouseit. AEDshavebeendesignedtobeextremely“userfriendly”.Allyouneedtodoasarescueristurnonthemachine(themostimportantstep)andlistenasthemachineguidesyouthroughthestepstousetheAEDsafelyandeffectively.AlthoughtherearemanybrandsofAEDsonthemarket,theyallworkinasimilarfashionandaredesignedtobeusedbylayrescuers. WhenanAEDbecomesavailable(i.e.,whenyouoranotherrescuerhaveretrievedit),placeitatthechild’sside,closesttotherescuerwhowilloperateit.Inthisway,theotherrescuercancontinueperformingCPRuntiltheAEDisreadytoanalyzeanddeliverashock(ifneeded). TherearefouruniversalstepstousinganyAED.Thesewillbehighlightedinthefollowinglistofstepssotheyareeasilyrecognizable. ThestepstousinganAEDareasfollows:

Turnonthemachine.Thisisthemostimportantstep-turningonthemachinewillenabletheAEDunittoguideyouthroughthenextsteps.ToturnontheAED,openthetopofthecarryingcaseandpushtheONbutton.Note:somemodelswillturnonautomaticallywhenyouliftthelidofthecarryingcase.

2. ATTACHAEDpadstothechild’sbarechest.Exposethechild’schest.Dryitoffifwet.Chooseadultpadsforvictimswhoare8yearsofageorolder,andchoosepediatricpadsforchildrenaged1yeartopuberty.Peelofftheadhesivebacking.Placeonepadontheupperrightchestjustbelowthecollarbone.Placetheotherpadonthepatient’slowerleftribcage,acoupleofcentimetersbeneaththearmpit.Somepadsaremarked-therewillbearedheartonthepadthatistobeplacedonthevictim’sleftside(theheartside).Fordefibrillatorsequippedwithchild-sizedpads,therewillbeapictureonthefrontofthepackagetoindicatewhetherthepadsareforanadultorchild.Presspadsfirmlyontothepatient’schest.ThenattachtheconnectingcablestotheAEDunit.Note:somecableswillcomepreconnected.

3. Analyzetherhythm.IftheAEDunitinstructsyouto,CLEARthevictimwhilethe

machineisanalyzingthechild’sheartrhythm.Thismeansyoushouldensurethatnooneistouchingthechild,includingyourself.Therescuerperformingchestcompressionsorgivingbreathswillneedtostopatthispoint.Note:someAEDswillbegintoanalyzethevictim’srhythmindependently;forothers,youwillneedtopushtheANALYZEbutton.Analyzingthevictim’srhythmwilltakeupto10-15seconds,sodon’tbealarmedbythis.

4. Pushtoshock.Ifashockisadvised,themachinewillclearlystate“SHOCKADVISED,STANDCLEAR”.Youshouldensurethatnooneistouchingthevictim,includingyourself.Youneedtolookaroundtomakesurenooneistouchingthevictim’sbodywhilestating“CLEAR”orsomesimilarmessagethatwarnsothersashockistobedelivered.Onceyouarecertainthatnooneistouchingthevictim,pushtheSHOCKbutton.Youwillnoticethatthevictim’smusclescontractstrongly.

� Ifashockisnotnecessary(therhythmisnotonethatcanbehelpedbydeliveryofashock),theAEDwillstateNOSHOCKADVISEDandtellyoutoresumeCPR.

� Afterapproximately5cyclesofcompressionsandventilations,or2minutesofCPR,theAEDwillinstructyoutorepeatsteps3and4-analyzetherhythmandpushtoshockiftherhythmrequiresashockandtheAEDinstructsyoutodoso.Iftworescuersarepresent,therescuersshouldswitchpositionseachtimetheAEDisanalyzingtherhythmtopreventfatiguerelatedtodeliveryofcompressions.

� ContinueCPRalternatingwithanalysisoftherhythmuntilhelparrives(i.e.EMS) Forvictimsyoungerthan8yearsofage,someAEDsaremodifiedtodeliveralowerdoseofelectricalenergyandwillcomewithchildpads,aspreviouslymentioned.Sometimesthereisaspecialswitchorkeythatmustbeusedwiththechildpads.Butwhatshouldyoudoifonlyadultpadsareavailable?Ifadultpadsaretheonlyoption,usethem. Intermsofpadplacement,padsshouldnottouchoroverlap.Ifthepadsaretoolargeforasmallerchild’schest,placeonepadonthefrontofthechild’schestandtheotheronthechild’sback.Theideaisto

“sandwich”thechild’sheartbetweenthepads.Interestinglyenough,researchhasshownthatusingadultpadsonsmallchildren,andeveninfants,doesnotleadtopermanentheartdamageinmostcases. Forvictimsyoungerthan8yearsofage,someAEDsaremodifiedtodeliveralowerdoseofelectricalenergyandwillcomewithchildpads,aspreviouslymentioned.Sometimesthereisaspecialswitchorkeythatmustbeusedwiththechildpads.Butwhatshouldyoudoifonlyadultpadsareavailable?Ifadultpadsaretheonlyoption,usethem. Intermsofpadplacement,padsshouldnottouchoroverlap.Ifthepadsaretoolargeforasmallerchild’schest,placeonepadonthefrontofthechild’schestandtheotheronthechild’sback.Theideaisto“sandwich”thechild’sheartbetweenthepads.Interestinglyenough,researchhasshownthatusingadultpadsonsmallchildren,andeveninfants,doesnotleadtopermanentheartdamageinmostcases. ThereareafewspecialcircumstancestokeepinmindwhenusinganAED:

� Thevictimisinwater-ifthechildisinwater,pullthevictimtoadryarea.Youarenotindangerofgettingashockifthevictimisinwater.Waterisagreatconductorofelectricity,soifthevictimisinwater,theshockwillbedispersedacrosstheskinofthevictim,andthevictimwillnotreceivethefulldoseofelectricalenergyrequiredtoconvertthemtoanormalrhythm.Ifthechild’schestiswet,quicklydrythechestwithatoweloryoursleeve;however,thechestdoesNOTneedtobecompletelydry.Ifthevictimislyinginasmallpuddleorinsnow,youcansafelyusetheAEDwithoutmovingthevictim.

� Thevictimhasanimplantedpacemakerordefibrillator-obviously,ifachildhasoneofthesedevices,itwillhavefailed.Somechildrenwithseverecongenitalheartdiseasemayhaveoneofthesedevices.Youwillrecognizethesedevicesasasmalllumpundertheskinonthechest,usuallytheupperchestoneitherside.Theyaregenerallyaboutthesizeofadeckofcardsorsmaller.Youwillalsobeabletoseeascaroverthearea.Ifthevictimhasoneofthesedevices,avoidplacingtheAEDpaddirectlyoverit;doingsomayblockdeliveryoftheshock.

TwoRescuerCPRforChildren(aged1yeartopuberty) Whentworescuersarepresent,performingCPRonachildisthesameasperformingCPRonanadult,exceptthatthecompressionventilationratiowhen2rescuersarepresentdropsto15:2.Oneortwohandsmaybeusedtocompressthechesttoadepthof1/3thediameterofthechest.Rememberthatcompressionsshouldbedonewhenthereisnopulsepresentorwhenthechild’sheartrateislessthan60beatsaminuteandtherearesignsofpoorperfusion.Rescuersshouldtradeoffperformingcompressionseverytwominutestoavoidfatigue.

CPRforInfants(upto12monthsofage)

CPRforinfantsissimilartoCPRforadultsandchildren.Thereareafewdifferencesasfollows:

� Checkingforresponsiveness:nevershakeaninfantasthismaycausebraindamage.Tocheckforresponsivenessinaninfant,tapthesolesofthefeetwhilecallingtotheinfantinaloudvoice.

� Pulsechecklocation-foraninfant,itiseasiesttocheckforapulseusingthebrachial

artery.Tolocatethebrachialartery,place2or3fingersontheinsideoftheupperarmbetweentheshoulderandelbow.Pressthefingersgentlyfor5to10secondstofeelforapulse.Pushingtoofirmlymayoccludetheinfant’spulse.

� Depthofcompressions-compresstheinfant’schesttoone-thirdthedepthofthe

chest,orapproximately1½inches.

� Compressiondeliverytechnique-2fingertechnique:whenonerescuerispresent,thechestiscompressedusingtwofingersonthelowerhalfofthesternum,avoidingthexiphoidprocess(theveryendofthesternumwhereitnarrowsandcomestoapoint).Tolandmark,place2fingersinthecenteroftheinfant’schest,justbelowthenippleline.Pushdownontheinfant’schestone-thirdthedepthofthechest,orapproximately1½inches.Allowthechesttofullyrecoil(returntoitsneutralposition)inbetweencompressions.Compressionsshouldbedeliveredatarateof100-120compressions/minute.

� 2thumb-encirclinghandtechnique:Whentworescuersarepresent,thecompression:

ventilationratiodropsto15:2,thesameasforchildren.Toperformthistechnique,positionyourselfattheinfant’sfeet.Placeyourthumbssidebysideonthecenteroftheinfant’schestjustbelowthenippleline.Encircletheinfant’schestsothatthefingersofbothhandssupporttheinfant’sback.Useyourthumbstodelivercompressionsattheappropriatedepthandrate(100-120compressions/minute;1/3ofthedepthofthechestorapproximately1½inches).Thispositionallowsanotherrescuertosupportairwayandbreathingwithoutgettinginthewayoftherescuer

performingchestcompressions,andisthereforethepreferredtechniquewhentworescuersarepresent.Thistechniquealsoallowsformoreconsistentchestcompressionsandsuperiorbloodflowandbloodpressurecomparedtothe2-fingertechnique.

� Compression:ventilationratio-Thecompression:ventilationratiofor1rescuerCPRininfantsis30:2,thesameasfortworescuerCPRchildren.

WhentocallEMS-itisfarmorecommonforinfantstoexperiencearespiratoryarrestpriortogoingintocardiacarrest,unlesstheinfanthasacongenitalheartproblem;in adultstheoppositeistrue-cardiacarrestsaremorecommonduetocardiovasculardisease.Therefore,thegoalistointervenebeforetheinfantgoesintocardiacarrest.Forthisreason,whentocallEMSisdependentuponwhetheryouwitnessedtheinfant’sarrest.IfyoudidNOTwitnesstheinfant’sarrest(unwitnessedarrest)andyouarealone,youshouldprovideCPRfor2minutespriortocallingEMSandfindinganAED.Ifyouwitnessthearrest(i.e.,theinfantsuddenlybecomesunresponsive),youshouldcallEMSandgetanAEDbeforereturningtothechildtostartCPR.

OneRescuerCPRforInfants(upto12monthsofage) Ifyouarethelonerescuerofaninfant:

1. Assessthechildforresponsivenessbytappingthesolesoftheinfant’sfeetwhilecallinghis/hernameloudly.Checkforbreathing-ifthereisnobreathingortheinfantisbreathingabnormallyoronlygasping,callforhelp.

2. Ifsomeonerespondstoyourcallforhelp,askthemtocall9-1-1(activateEMS)andfindanAED.Ifyouarealoneandwitnesstheinfantgointoarrest,performCPRfor2minutesbeforecallingforhelp;ifyoucomeacrossandinfantwhohasbeen“down”foranunknownperiodoftime,call9-1-1firstbeforebeginningCPR.

3. Checktheinfant’sbrachialpulseforatleast5,butnomorethan10,seconds.Place2or3fingersontheinsideoftheupperarmbetweentheshoulderandelbow.Pressthefingersdowngentlyfor5to10secondstofeelforapulse.Remember:pushingtoofirmlymayoccludetheinfant’spulse.

4. Ifyouarenotsureyoucanfeelthepulse,thepulseisabsentortheinfant’sheartrateisbelow60beatsperminutewithsignsofpoorperfusion(paleorbluishdiscolorationintheface,extremitiesornailbeds),startCPR,beginningwith30compressionsfollowedbytwobreaths.

a. Placetheinfantonhisbackonthegroundoronafirmsurface.b. Place2fingersinthecenterofhischestjustbelowthenippleline;donotpress

ontheendofthebreastbone.c. Provide100-120chestcompressionsperminutetoadepthof1/3thedepthof

thechestorapproximately1½inches.d. Theprinciplesofprovidingbreathsforinfantsarethesameasforchildrenand

adults.Usethecorrectsizedfacemaskfortheinfant(themaskshouldcoverthemouthandnosewithoutextendingpastthechinorcoveringtheeyes).Eachbreathshouldgoinover1secondandshouldcausevisiblechestrise.Abreathshouldrequireonlyasmallpuffofairintothemouthpieceofthedevicetocausechestrise-avoidexcessiveventilations.Lastly,performaheadtilt-chinliftmaneuvertoopentheinfant’sairway;theinfant’sheadshouldbeplacedin“sniffingposition”withtheinfant’sheadtiltedjustenoughthatthenoseappearstobesniffingtheair.Inthisposition,theexternalearcanalshouldbelevelwiththetopoftheinfant’sshoulder.Avoidhyperextendingtheneck-youalsowanttoavoidallowingthechintofalldowntowardstheneck.Youcandothisbyplacingonehandontheinfant’sforeheadwhileyouperformchestcompressions.Inthisway,theinfant’sairwaywillremainopenandwillnotcloseoff.Placingasmalltowelundertheinfant’sshoulderscanhelptomaintainproperpositioning.

5. Afterabouttwominutesofcompressions(fivecyclesof30compressionsand2breaths),leavethechildtocall911andgetanAEDifyouknowwhereoneis(andyouorsomeonehasnotalreadydoneso).ThenreturntotheinfanttocontinueCPR.

6. UseanAEDassoonasitisavailable.

TwoRescuerCPRforInfants(upto12monthsofage)

1. Rescuer1-Assessthechildforresponsivenessbytappingthesolesofthefeetand

callingtohim/herloudly.Checkforbreathing-iftheinfantisnotbreathingorisbreathingabnormallyoronlygasping,sendRescuer2toactivateEMSandbringtheAED(ifoneisavailable).

2. Rescuer1-Checktheinfant’sbrachialpulseforatleast5,butnotmorethan10,seconds.Place2or3fingersontheinsideoftheupperarmbetweentheshoulderandelbow.Pressthefingersdowngentlyfor5to10secondstofeelforapulse.Remember:pushingtoofirmlymayoccludetheinfant’spulse.

3. Rescuer1-Ifyouarenotsureyoucanfeelthepulse,thepulseisabsentortheinfant’sheartrateisbelow60beatsperminutewithsignsofpoorperfusion(paleorbluishdiscolorationintheface,extremitiesornailbeds),startCPR,beginningwith30compressionsfollowedbytwobreaths.

a. Placetheinfantonhisbackonthegroundoronafirmsurface.b. Place2fingersinthecenteroftheinfant’schestjustbelowthenippleline;do

notpressontheendofthebreastbone.c. Provide100-120chestcompressionsperminutetoadepthof1/3thedepthof

thechestorapproximately1½inches.d. Theprinciplesofprovidingbreathsforinfantsarethesameasforchildrenand

adults.Usethecorrectsizedfacemaskfortheinfant(themaskshouldcoverthemouthandnosewithoutextendingpastthechinorcoveringtheeyes).Eachbreathshouldgoinover1secondandshouldcausevisiblechestrise.Abreathshouldrequireonlyasmallpuffofairintothemouthpieceofthedevicetocausechestrise-avoidexcessiveventilations.Whenthesecondpersonreturns,changetheratioofcompressionstoventilationsto15:2.

4. Rescuer2shouldplacethethumbsofbothhandsonthelowerhalfoftheinfant’sbreastbone,whilebeingcarefulnottopressontheendofthebreastbone(xiphoidprocess).Putthefingersofbothhandsaroundtheinfant’sbacktoprovidesupport.Usethethumbstodepressthesternumapproximately1/3thedepthofthechest,orapproximately1½inches.Compressatarateof100-120compressionsperminute.

5. Rescuer1shouldprovidebreathsasdescribedabove.

6. ContinueCPRataratioof15compressionsto2breathsandswitchrolesevery

2minutestoavoidfatigue.

7. UsetheAEDwhenavailable.

Mouth-to-Mouth-andNoseBreathing Toprovidebreathstoaninfantwhenthereisnofacemaskavailable:

1. Useaheadtilt-chinlifttomaintainanopenairway(sniffingposition),beingcarefulnottohyperextendtheneck,whichcouldblocktheairway.

2. Placeyourmouthoverthevictim’smouthANDNOSEtocreateatightseal.3. Blowintotheinfant’snoseandmouthover1second,withjustenoughvolumeand

forcetocausethechesttorisewitheachbreath.Becarefulnottoventilatetooforcefully,asdoingsomaycauselungdamage.

4. Ifthechestdoesnotrise,repeattheheadtilt-chinliftandtrytoventilatethevictimagain.Youmayneedtotrytoprovidebreathsatafewdifferentpositionsbeforeyouachieveairwaypatency(airwayisinanopenposition).

5. Iftheinfantisolderandyoucannotcoverboththeinfant’smouthandnose,pinchthenostrilsclosedandplaceyourmouthoverthevictim’stoformatightseal-justthesameasyouwoulddoforachild.

You may wonder how mouth-to-mouth or mouth-to-mouth-and-nose breathing can sustain thevictim.Inactualfact,yourexpiredaircontainsabout17%oxygen-thisisjustenoughoxygentomeetthevictim’sneedsforabriefperiodoftime. Whenprovidingmouth-to-mouthormouth-to-mouth-and-nosebreathing,itisimportantnottoprovidebreathsthataretooforcefulortoorapid.Doingsomaycauseairtoenterthestomachratherthanthelungs,whichcancausegastricinflation.Gastricinflationmayresultinvomiting,andanunconsciousvictimmaydeveloppneumoniaifvomitusmakesitswaytothelungs.Toavoidgastricinflation,giveeachbreathslowlyover1secondanddeliverjustenoughairtomakethechestrise.

RescueBreathing Respiratoryarrestisdefinedasthecessationofbreathing.Duringrespiratoryarrest,aswellaswhenthereisinadequatebreathing,thevictimwillstillhavesomeamountofcardiacoutput,whichyouwillbeabletodetectasapalpablepulse. Itisimportanttobeabletorecognizerespiratoryarrest,orimpendingrespiratoryarrest,whichmaybeseenasslow,irregularorgaspingrespirations.Theseabnormalrespirationsareinadequatetosupportlife. Respiratory arrest inevitably leads to cardiac arrest if not treated, therefore rescuers shouldintervene quickly to prevent this deterioration by providing rescue breathing. For children andinfants,giveonebreathevery3-5seconds(12-20breathsperminute).Checkforapulseevery2minutes-ifthevictimlosestheirpulse,beginchestcompressionscombinedwithbreaths.

ChokingintheConsciousChild(olderthan1yearofage)

1. STAND(ORKNEEL)BEHINDTHEVICTIMANDWRAPYOURARMSAROUNDTHE

VICTIM’SWAIST.2. IFSTANDING,PUTONEFOOTINBETWEENTHEVICTIM’SFEETANDONEFOOT

BEHINDYOU-THISPOSITIONPROVIDESSTABILITYSHOULDTHEVICTIMBECOMEUNCONSCIOUSANDYOUNEEDTOEASETHEVICTIMTOTHEGROUND.

3. PLACEYOURFISTWITHTHETHUMBSIDEINJUSTABOVETHEVICTIM’SBELLYBUTTONANDBELOWTHESTERNUM(BREASTBONE).

4. GRABYOURFISTWITHYOUROTHERHAND.5. ADMINISTERABDOMINALTHRUSTS,PULLINGINWARDANDUPWARDUNTILTHE

FOREIGNOBJECTCOMESOUTORTHEVICTIMBECOMESUNCONSCIOUS.EACHTHRUSTSHOULDBEFORCEFUL,DISTINCTANDSEPARATE.

ChokingintheConsciousInfant(lessthan12monthsofage)

1. SITORKNEELWITHTHEINFANTINYOURLAP.2. IFNOTDIFFICULTTODO,REMOVETHEINFANT’SCLOTHINGTOEXPOSETHE

INFANT’SCHEST.3. RESTTHEINFANT’SBODYONYOURFOREARMWITHTHEINFANT’SHEADLOWER

THANTHEBODY.SUPPORTTHEJAWANDHEADWITHYOURHAND.RESTYOURFOREARMONYOURTHIGHORLAPTOPROVIDESUPPORT.

4. GIVE5BACKBLOWSFORCEFULLYWITHTHEHEELOFYOURHANDBETWEENTHEINFANT’SSHOULDERBLADES.

5. SUPPORTTHEBACKOFTHEINFANT’SHEADWITHTHEPALMOFYOURHANDANDTHEINFANT’SJAWANDHEADWITHTHEOTHERPALMWHILETURNINGHIMOVER(FACEUP)ONTOYOUROTHERFOREARM.KEEPTHEINFANT’SHEADLOWERTHANITSBODY.RESTYOURFOREARMONYOURTHIGHFORSUPPORT.

6. GIVE5CHESTTHRUSTS,JUSTASYOUWOULDWHENPERFORMINGCHESTCOMPRESSIONSINCPR.CHESTTHRUSTSSHOULDBEDELIVEREDATARATEOF1CHESTTHRUSTPERSECONDANDSHOULDBEGIVENWITHENOUGHFORCETODISLODGEAFOREIGNBODY.

7. REPEATBACKBLOWS/CHESTTHRUSTSUNTILTHEOBJECTCOMESOUTORTHEVICTIMLOSESCONSCIOUSNESS.

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