How long will you check the breathing and pulse of the victim?

In this section you will learn the emergency action steps to follow to safely assess and care for a victim or patient.

First, assess the scene for safety. If the scene is not safe or at any time becomes unsafe, GET OUT! You will be of no use to that person or anyone else if you become a victim too. If you cannot safely care for the victim…CALL 9-1-1.

If the scene is safe, assess the patient. Quickly observe the victim. Is he/she lying still or moving around. Is the skin color normal or is it bluish or ashen, especially around the lips. Kneel down by the patient and tap or squeeze, not shake, the patient's shoulder and ask, "Are you ok?" In an infant, you may tap the foot. If the patient responds but is badly hurt, or appears to be very ill, call 9-1-1.

If you are alone and the patient does not respond to your tap and shout, you must act quickly. If the patient is an adult, which is anyone from the approximate age of puberty on up, you must first call 9-1-1, then check for breathing and pulse and if neither is present, begin CPR. If the patient is a child, which is anyone from the approximate age of one year to puberty, or if the patient is an infant, birth to one year and breathing and pulse are absent, you must first give 5 cycles of CPR, (about two minutes), before making your call to 9-1-1. Children and infants are much more likely to respond to early CPR so it is very important to follow these guidelines.
When two or more rescuers are present, procedures should occur simultaneously. One or more rescuers remain with the patient and begin the steps of CPR, while another is alerting EMS, and if possible gets an AED and/or oxygen.

Beginning CPR
The first step in beginning CPR is to look for no breathing or no normal breathing (such as gasping). FOR ADULTS AND CHILDREN: If breathing is absent, palpate for a carotid pulse in the neck for no more than 10 seconds. If there is no sign of breathing or pulse, begin CPR starting with compressions. FOR INFANTS: If breathing is absent, palpate for a pulse, using the brachial artery located in the upper inside aspect of the infant's arm. If there is no sign of breathing or pulse, begin CPR starting with compressions. If the patient definitely has a pulse but is not breathing adequately, provide ventilations without compressions. This is also called "rescue breathing." Adults: give 1 breath every 5 to 6 seconds. Children/Infants: give 1 breath every 3 to 5 seconds. Reassess the pulse every 2 minutes.

External Chest Compressions
Chest Compression Techniques (adults and children) Single Rescuer
To make blood flow to the heart and brain effective, the patient must be face up and lying on a firm surface. It is best to remove clothing from the chest area. Place the heel of one hand in the center of the chest on the lower half of the breastbone. Place the other hand on top of the first. Fingers should be interlaced and should be kept off the chest. Position your body so your shoulders are directly over your hands. Straighten your arms and lock your elbows. Use your upper body weight to help compress the chest. Push straight down on the chest at least 2 deep inches for a normal sized adult. Use either one or two hands to compress the child's chest about 1/3 the diameter of the chest or about 2 inches in depth. Give 30 compressions at a speed of at least 100 per minute. After 30 compressions, open the patient's airway by tilting the head and lifting the chin then give 2 rescue breaths. Use the jaw thrust for a suspected neck injury. Quickly resume chest compressions. To help create the best blood flow possible, you must "Push Hard, Push Fast" and minimize interruptions between compressions and rescue breathing.

When adult compressions are given properly, you may hear popping and cracking sounds. This is caused by cartilage or ribs cracking and occurs frequently during adult CPR. In infants and toddlers, CPR may not cause such injuries. However, as unpleasant as this may seem, it is important to remember that a person in cardiac arrest is dead. You cannot make them any worse.

Chest Compression Technique (Infants)
Compress the breastbone with 2 fingertips placed just below the nipple line. Press down on the breastbone about 1/3 the diameter of the infant's chest or about 1 ½ inches in depth. Give 30 compressions at a speed of at least 100 per minute. After 30 compressions, open the infant's airway and give 2 rescue breaths. Quickly resume chest compressions. When more than one rescuer is present, use two thumbs with your fingers encircling the chest and supporting the back for chest compression.

CPR with Two or More Rescuers
When more than one healthcare provider or other professional rescuer is available to perform CPR, one gives chest compressions while the other keeps the airway open and performs rescue breathing. The rescuer compressing the chest should pause briefly to allow the two breaths to be given by the other rescuer. For adults the ratio of compressions to breaths stay the same 30:2, but interruption between compressions and breaths is lessened as there are two rescuers. In children and infants, the ratio of compressions to breaths is 15:2. Rescuers should change positions every couple of minutes to avoid fatigue and maintain effective chest compressions.

Defibrillation

Before attaching an AED, make sure the patient has been moved out of any freestanding water.  Also if the patient’s chest is wet, sweaty or dirty, quickly clean and dry it before attaching the AED.  If the patient has a hairy chest it may interfere with the effectiveness of the AED.  If there is no razor available to shave the chest area, a set of pads may be applied then ripped off quickly to remove hair.  Quickly apply a second set of pads and proceed with attaching the AED.  Remove any medication patches and watch for pacemakers and implantable cardioverter defibrillators.  Place the electrode pad at least 1 inch away from an implantable device.  And remember, oxygen should not be used when shocks are being delivered with an AED.  It is possible for oxygen to ignite if it is too close to an AED that is being used.  Oxygen should be shut off and placed several feet away from the patient.

Three Simple AED Steps

There are many different brands of AEDs, but the same basic steps apply to all of them.  If the patient is unresponsive and not breathing adequately, follow these steps. 

1. Turn on the AED. This activates the voice prompts.  Bare the patient’s chest.
2. Follow the voice and visual prompts.  Remove the disposable electrode pads from the packaging, making sure to choose the correct ones, (adult or child).  Do not use child pads on an adult.  Look at the picture on the electrode that will show where to correctly place the pad.  Remove the adhesive backing and attach electrodes to the patient’s bare chest. Most AEDs wil automatically begin to analyze a patient’s heart rhythm when the electrodes are placed. Some will prompt you to push a button to analyze.  Do not touch or move patient while the AED is analyzing the heart rhythm.
3. Shock/ No Shock.  If a shock is indicated, check to make sure no one is touching the patient.  Loudly say “CLEAR” .  Push the shock button and immediately resume CPR.  If no shock is indicated, immediately resume chest compressions.

Perform 5 cycles of 30 compressions and 2 breaths and then very briefly reassess the rhythm. Continue as directed by the AED.

AEDs may be used for children older than 1 year who have no signs of life.  Always look at the pictures on the pads and place them as shown.  Some AED pads for children may require the rescuer to place one pad on the child’s chest and one on the back.  The rescuer may also be required to insert a key or turn a switch to deliver a lower, child sized amount of electricity.  If a child specific AED is not available, use a standard AED.

When to Activate Emergency Response System

If possible, send someone to activate the Emergency Response System, and begin CPR immediately. As soon as it’s available to use an AED. If you’re not with someone (and you do not have a mobile phone), leave the patient to activate the Emergency Response System while also retrieving an AED.

Team Resuscitation: HCP’s can use flexibility when activating the emergency response to fit the provider’s clinical setting, for better management.

Adult and Adolescents CPR

Scene Safety and Recognition of Cardiac Arrest: Check for safety and responsiveness, no breathing, gasping, check pulse for more than 5 seconds but within 10 seconds (breathing and pulse check can occur simultaneously).

Check Pulse: You can test the pulse by placing two fingers on the carotid artery (press your index and 3rd finger on the side of the neck, against the windpipe). You can also check the wrist by placing the same two fingers on the inside of the wrist below the thumb.

C is for Circulation – Adult and Adolescent Compressions

Circulation - chest compressions circulate the blood within the patient. It's important to place your hands correctly upon the patient’s chest. Chest Compression Tempo: perform CPR while matching the tempo of the song, "Staying Alive" while making sure to push hard and fast.

Compression-ventilation ratio without Advanced Airway

Make sure the adult or adolescent is resting upon a firm, solid surface. Perform chest compressions on the lower half of the breastbone (sternum). Once in position, lock your elbows and use your body’s weight to compress at least 2 inches (5 cm) upon the patient’s chest. Do not lean on the patient’s chest in between compressions and make sure the chest ultimately recoils. Limit all interruptions to less than 10 seconds while performing CPR.

It’s important to note: that when performing chest compressions on an adult or adolescent you should compress at least 2 inches (5 cm). The compression rate is 100-120/min. 2 Rescuers: Perform tasks simultaneously. Administer compressions over breathing 30:2.

Chest Compression Fraction: is the total percentage of resuscitation time when performed by the rescuer(s) during cardiac arrest. Whether intended or unintended interruptions (such as real-world delays) occur Chest Compression Fraction aims to minimize pauses in chest compressions. Chest Compression Fraction Goal: target of at least 60%.

Compression-ventilation ratio with Advanced Airway

• Continuous compressions at a rate of 100-120/min
• One breath every 6 seconds (10 breaths/min)

A is for Airway - Clear the Airway

Airway - Make sure the patient is on a solid surface (on the backside). Next, kneel next to the patient’s neck and shoulders. Open the patient’s airway by tilting the head back with the palm of one hand while gently lifting the chin with your other hand. For no more than 10 seconds, check for life: listen for any sounds, put your cheek next to the patient’s mouth to feel any breaths while also looking for any motion. Rescuers can check steps simultaneously. If the patient is assumed lifeless begin Mouth-to-Mouth procedure.

Jaw-Thrust Maneuver: 1. Kneel above the patient’s head. 2. Rest your elbows on the surface. 3. Place one hand on both sides of the patient’s jaw. 4. Stabilize the patient’s head with your forearms. 5. Use your index finger to lower the patient’s jaw as you use your thumb to retract the patient’s lower lip. If the patient is assumed lifeless, perform mouth-to-mouth.

B is for Breathing - Mouth-to-Mouth

Rescue Breathing is widely known to be performed mouth-to-mouth—it can also be performed mouth-to-nose but in rare cases. While still performing the Airway technique pinch the patient’s nose shut. With a complete seal over the patient’s mouth, with your mouth, breathe until you see the chest inflate. If the chest does not rise, repeat the Airway technique. Once the chest swells, breathe into the patient a second time (30:2).

Once the breathing technique is applied, continue Circulation, Airway, Breathing (C-A-B’s).

CPR on obese patients

Yes, perform Chest Compressions

CPR on pregnant patients

Yes, perform Chest Compressions and a modification if the pregnant woman’s fundus height (baby-bump) is at or above the level of the umbilicus. If the woman’s fundus height is at or above the umbilicus, then High-quality CPR with manual left uterine displacement will be beneficial for relieving aortocaval compression during, the chest compression task. To perform manual left uterine displacement: push the uterus to the patient’s left side with 1 hand while still providing CPR.

Oxygenation and airway management should be prioritized during resuscitation from cardiac arrest in pregnancy because pregnant patients are more prone to hypoxia.

Fetal monitoring should not be undertaken during cardiac arrest in pregnancy because of potential interference with maternal resuscitation.

Opioid poisoning CPR for healthcare providers

1. Suspected opioid poisoning

• Check for responsiveness
• Shout for nearby help
• Activate the emergency response system
• Get naloxone and an AED if available

If yes, prevent deterioration:

• Tap and shout
• Open the airway and reposition
• Consider naloxone
• Transport to the hospital

If no, does the patient have a pulse? Assess for 10 seconds.

If yes, support ventilation:

• Open the airway and reposition
• Provide rescue breathing or bad-mask device
• Give naxolone

If no, start CPR:

• Use an AED
• Consider naloxone
• Use high-quality CPR

Rescuers Should Never

• Compress slower than 100/min or faster than 120/min
• Compress in-depth less than 2 inches (5 cm) or more than 2.4 (6 cm)
• Lean on victim’s chest during compressions
• Allow interruption during compressions more than 10 seconds
• Provide excessive ventilation during breathing task, ie., excessive breathing with force or too many breaths

Click for Summary of Adult & Adolescent CPR

CPR – Components for Adults & Adolescents Scene safety

1. Check the environment – making sure it’s safe for rescuers and victims

1. Check responsiveness
2. No breathing or only gasping – ie., no normal breathing
3. Within 10 seconds – no positive pulse
   1. (You can check for a pulse and breathing simultaneously in less than 10 seconds)

• If you do not have a mobile phone – leave the victim and activate the emergency response system while retrieving an AED before performing CPR.
• Have someone activate the emergency response system. Perform CPR immediately and use the AED as it becomes available.

• Chest compressions – 100-120/min
• Give 1 breath every 6 seconds (10 breaths/min)

• 2 hands on the breastbone (sternum) on the lower half

• Make sure not to lean on the chest of the victim – Allow a full recoil after each chest compression

• Compression interruptions – limit to less than 10 seconds

• Compress slower than 100/min or faster than 120/min
• Compress in-depth less than 2 inches (5 cm) or more than 2.4 (6 cm)
• Lean on victim’s chest during compressions
• Allow interruption during compressions more than 10 seconds
• Provide excessive ventilation during breathing task, ie., excessive breathing with force or too many breaths