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Emergency Action Steps
The emergency action steps are intended
to help the rescuer respond to an emergency and manage life
threatening problems of the airway, breathing and circulation
in an adult, child or infant. Concerning age, children differ
in size from infancy through adolescence. No single factor
can distinguish an infant from a child and a child from an
adult. I order to simplify training, CPR guidelines use the
following age ranges.
Adult: About onset of puberty
Child: about one year to onset of puberty
Infant: Less than about 1 year
Newborn: Birth until baby leaves hospital
It is important to note the use of
the word about in the table above. When it comes to basic
life support, determining age can be very difficult. Exactness
is not necessary.
The following pages contain integrated recommendations for
adults, children and infants. For quick reference, refer to
the Skill Guides.
Assess
Assess Scene- Assess the scene for
safety. If the scene is not safe or at any time becomes unsafe,
GET OUT
Assess Patient - Get a First Impression
If it is safe, pause for a moment as
you approach the
Patient. What is your first impression? Is the patient lying
still
or moving around? Does skin color appear normal for the patient
s ethnic group? Does it look difficult for the patient to
breathe? Normal breathing is quiet and easy. Signs that BLS/
CPR may be needed include
patient is not moving, is unresponsive,
or looks dead.
Bluish or ashen tissue color, especially around the lips.
Cold and pale tissue color.
Breathing is shallow, gasping, or absent.
Pink or frothy discharge from the mouth.
Gently tap or squeeze the patient's shoulder and ask, “are
you all right?'' In an infant you may tap the foot. Use the
patient's name if you know it.
Alert
lf the patient responds but is badly hurt, looks/acts very
ill or quickly gets worse, in the USA and Canada call 9-1-1
or activate your emergency action plan. .
Rescuer Alone
A healthcare provider or first responder
who is alone should modify the approach to the patient based
on the most likely cause of the problem.
If the patient collapsed suddenly (all ages), first - shout
for help, and send a second rescuer to alert EMS or activate
the emergency action plan and an AED (and oxygen when readily
available). Then, attend to the patient. If no one responds
to your shout for help, alert EMS or activate the emergency
action plan yourself. Quickly return to attend to the patient.
Getting the AED as soon as possible is important because a
sudden collapse in adults and children is almost always caused
by sudden cardiac arrest and requires early defibrillation.
On the other hand, when a healthcare provider or first responder
who is alone discovers an unresponsive patient who suffocated
(drowning, Smoke inhalation, etc.), the rescuer should first
attend to the patient. Give 5 cycles of CPR (about 2 minutes)
before leaving to alert EMS or activate the emergency action
plan and get the AED and oxygen. This is because a patient
who suffocated is more likely to respond to early CPR due
to the low oxygen levels in blood and tissues (hypoxia).
Rescuer Not Alone
If more than one rescuer is present,
procedures should occur Simultaneously. One or more rescuers
remain with the patient and begin the steps of CPR. Another
alerts EMS or activates the emergency action plan and gets
the AED and oxygen.
EMS Providers
When arriving on the scene of a potential cardiac arrest,
always bring the appropriate equipment to the patient, including
the AED, oxygen and ventilation devices. After sizing up the
scene and forming a general impression of the patient, consider
requesting that additional personnel and resources respond
to the scene.
Attend to the ABCDs
To properly attend to the patient, he or she must be face
up, on a firm flat surface. If the patient is lying face down,
roll them over. Try to minimize turning or twisting of the
head and neck.
A=Airway.
Open Airway
The airway is the passageway between
the mouth and lungs. The airway must be open so air can enter
and leave the lungs freely. Blockage of the airway in an adult
or child is commonly caused by the tongue. To open the airway,
tilt the head and lift the chin. If you suspect a cervical
spine injury, open the airway using a jaw thrust without the
head tilt. However, because maintaining an open airway and
providing adequate ventilation is a critical priority, if
the jaw thrust does not open the airway, use the head tilt,
chin lift maneuver. In an infant, the chin lift and jaw thrusts
are proven and effective methods for opening an obstructed
upper airway.
B=Breathing check for breathing
While keeping the airway open, look, listen and feel for breathing
for at least 5 seconds, but no longer than 10. Opening the
airway may allow the patient to start breathing adequately
at any time, consider placing them in recovery position .
In this position, there is less chance of obstruction by the
tongue and secretions.
Make sure the patients body position
is stable so they do not roll onto their face or back. Also
make sure there is no pressure on the chest that could make
it harder to breath. Because blood flow in the lower arm may
be impaired, turn the patient to the opposite side if they
are in the recovery position for more than 30 minutes. If
the patient is injured, use a modified recovery position called
the HAINES position. (See skill guide #7).
It may be difficult to determine whether
the patient is breathing adequately or not. Occasional gasps
are not normal and are not capable of supplying the patient
with enough oxygen to sustain life.
If. the chest does not rise and fall
and no air is exhaled, or
if-the patient is making strange gasping, noisy, snorting
or gurgling sounds and you are not positive that the patient
is breathing adequately, give 2 rescue breaths immediately.
Give each breath in 1 second and make the chest visibly rise.
lf the patient's chest does not rise with the first rescue
breath, reposition the head, make a better seal, and try again.
In children you may have to try a couple of times to give
2 rescue breaths that make the chest visibly rise. It is critical
that rescue breaths make the infant or child's chest rise
during rescue breathing and CPR.
Mouth to Barrier Device Breathing
Face shields, face masks and bag-mask
devices allow you to perform rescue breathing without compromising
your own health.
Rescue Breathing with a face shield
Tilt the patient's head and
lift the chin. Place the face shield right over the patient's
mouth and nose. Place your mouth on the face shield over the
patients mouth. Pinch the patient’s nose either under
or over the shield. Give 2 rescue breaths that make the chest
visibly rise, but no more than that. Switch to a mask or bag-mask
device as soon as possible.
Rescue Breathing
With a Mask
The rescuer who is alone should position themselves at the
side of the patient. Tilt the patient's head and lift the
chin. Place the mask over the patient's mouth and nose. Place
your mouth around the one way valve on the mask and give 2
rescue breaths that make the chest visibly rise. Remove your
mouth from the mask with each rescue breath and allow the
patient to exhale. In an Infant or small child it is Important
to select the proper size mask.
Take Regular (Normal), Not Deep Breaths
Do not take deep breaths when performing rescue breathing
Taking deep breaths is unnecessary and may cause hyperventilation.
If you suddenly feel breathless, experience tiny prickling
sensations, become dizzy or have muscle spasms in your hands
or feet, you are breathing too fast and deep Slow down or
have another rescuer take over for you
Rescue Breathing with a Bag-Mask
A bag-mask is a device that has four main components: The
bag, and oxygen reservoir, a one-way valve, and a mask. When
used alone, the bag-mask will allow delivery of 21% oxygen
(room air) to the patient. This oxygen concentration is more
than that delivered to a patient when you exhale during rescue
breathing (17%).
The amount of oxygen delivered with a bag-mask can be increased
by attaching an oxygen supply to the bag. When an oxygen source
is used, a reservoir should be attached to the bag. The use
of a bag-mask with supplemental oxygen flowing at a rate of
15 liters per minute delivers approximately 100% oxygen to
the patient. When using a bag-mask device, open the air-way
with a Jaw lift and place the mask over the patient’s
mouth and nose While keeping the airway open, hold the mask
tightly against the patient’s face and squeeze the bag
Give each breath In 1 second. Give enough air to make the
chest visibly rise, but no more than that. In an Infant or
small child it is Important to select the proper size bag-mask
device.
It is possible for a single rescuer to use a bag-mask effectively,
but it is recommended that it be used by two rescuers when
possible. When two rescuers are used, one rescuer should hold
the mask In place and maintain an open air-way while the other
squeezes the bag If rescuers have difficulty with the bag-mask,
they should use mouth-to-mask rescue breathing
Caution:
Ventilations are important for patients in cardiac arrest,
but rescuers should not give too many breaths or breaths that
are too large or too forceful. Excessive ventilation is unnecessary
and harmful because it increases pressure in the patient’s
chest. This pressure decreases blood flow to and from the
heart and reduces the already marginal flow of blood and oxygen
during CPR, decreasing survival. It is critically important
to avoid excessive ventilation.
Advanced
Airways
When professional rescuers are appropriately trained and authorized,
advanced airway and ventilation devices such as the laryngeal
mask airway, Esophageal-Tracheal-combitube and endotracheal
tube may be used. When an advanced airway is in place, give
rescue breaths at a rate of 1 breath every 6-8 seconds (8-10
breaths per minute) Do not pause chest compressions to ventilate.
Air in Stomach
Air is often blown into the stomach instead of the lungs during
rescue breathing. This can cause the patient to vomit and
can limit lung movement, reducing the effectiveness of rescue
breathing. To reduce the risk of inflating the stomach, give
each breath In 1 second. Give enough air to make the chest
visibly rise, but no more than that Allow the patient to exhale
completely between breaths. If the patient vomits, turn them
on their side (or use suction equipment when available) so
they don't Inhale the fluid.
Mouth-to-Mouth Rescue Breathing
A rescuer's exhaled air contains about
17% oxygen and 4% carbon dioxide. This oxygen concentration
is less than that delivered to the patient when using a bag-mask
device without supplemental oxygen (21%), but enough to support
life.
To provide mouth-to-mouth rescue breathing for an adult, child
or large infant, hold the patient's airway open, pinch the
nose, and make a seal with your mouth over the patient's mouth.
Give 2 breaths that make the chest visibly rise. Due to the
risk of the rescuer being poisoned, do not perform mouth-to-mouth
rescue breathing for patients who have been poisoned by phosphorus
compounds, include insecticides and herbicides.
Mouth-to-Nose Rescue Breathing
Mouth-to-nose rescue breathing may be used when the rescuer
has difficulty with mouth-to-mouth. To give mouth- to-nose
rescue breathing, tilt the patient's head back with one hand
and use the other hand to close the patient’s mouth.
Seal your lips around the patient's nose, and give slow breaths
that make the chest rise. If the patient is an infant, place
your mouth over the infant's mouth and nose.
Tracheostomy
A stoma is a surgical opening at the front o the neck that
extends into the windpipe. When an adult or child with a stoma
requires rescue breathing, give mouth-to-stoma rescue breaths.
Optionally, you can cover the stoma with a child-sized face
mask, place your mouth around the one-way valve on the mask,
and give rescue breaths.
Minimize Unprotected Rescue Breathing
Unprotected rescue breathing (i.e., mouth-to-mouth) is a quick
and effective way to provide oxygen to he patient. However,
according to the U.S. Department o Labor, Occupational Safety
& Health Administration (OSHA), unprotected mouth-to-mouth
resuscitation should not be used by any emergency response
personnel. Bag-masks and other equipment designed to isolate
emergency response personnel from contact with the patient's
saliva, respiratory secretions, vomit, blood or body fluids
should be available on all emergency vehicles and provided
to all emergency response personnel that respond or potentially
respond o medical emergencies or patient rescues.
Supplemental
Oxygen
Even the best chest compression provides only about 25%-33%
of the normal blood and oxygen flow from the heart. The combination
of low blood flow and low oxygen causes organs to fail and
leads to death. Giving rescue breathing with supplemental
oxygen permits the rescuer to give rescue breaths with a higher
concentration of oxygen.
Oxygen-rich breaths deliver critically needed oxygen to the
heart and brain. For this reason, when available , healthcare
providers, first responders and professional rescuers should
use supplementary oxygen when performing rescue breathing.
Ideally a bag-mask device should be attached to an oxygen
reservoir to allow delivery of 100% oxygen to the patient.
Cricoid Pressure
Cricoid pressure (or the Sellick maneuver) is a means of preventing
an unconscious patient from aspiration - inhaling stomach
contents or foreign material into the lungs. Aspiration is
dangerous because it can cause acute respiratory failure,
pneumonia and airway obstruction. Pressure is applied to the
patient's Cricoid cartilage. This pressure pushes the airway
backwards and squeezes the esophagus against the spine, preventing
fluids or material from getting out of (and air from getting
into) the stomach. To perform Cricoid pressure:
1. Locate the thyroid cartilage (Adam's
apple) with your index finger.
2. Slide your index finger downward to the bottom of the
thyroid cartilage and feel for the indentation immediately
below it. Just below the indentation is the Cricoid cartilage
(prominent horizontal ring).
3. Using the tips of your thumb and index finger, firmly
press the Cricoid cartilage directly backwards. Do not push
to one side or the other. If the patient gags, release the
pressure.
The technique is often improperly applied. Safe and effective
use requires knowledge of neck anatomy, proper training and
experience. It should only be performed by a trained and experienced
rescuer, and only when enough rescuers are present so there
is no interruption in chest compressions or destinations.
C=circulation. Check Pulse
If there is no response to the initial rescue breaths, feel
for a pulse. Use the carotid pulse (neck) in adults, brachial
(inside upper arm in an infant and carotid or femoral (groin)
in a child. Studies show that healthcare providers, first
responders and professional rescuers take too long to check
for a pulse and have difficulty determining if a pulse is
present or absent. For that reason, take at least 5, but no
more than 10 seconds to check for a pulse. If a pulse is not
definitely felt or if you are uncertain, immediately begin
chest compressions - even if the patient is still taking occasional
gasps. In a child, start chest compressions if the pulse is
less than 60 beats per minute and there are signs of reduced
blood flow (i.e., poor color). Note: Lay persons are not taught
to check a pulse before starting chest compressions.
Ventilation
Without Compression
If the patient definitely has a pulse but is not breathing,
or not breathing adequately, provide ventilation without compression.
This is also called rescue breathing. Adult: 10-12 breaths
per minute or about 1 breath every 5-6 seconds. Each breath
should make the chest visibly rise. Reassess the pulse every
couple of minutes for no more than 10 seconds. Children/infants:
lf the pulse is 60 beats per minute or more and the patient
is not breathing or not breathing adequately, give rescue
breaths, about 12-20 breaths per minute (1 breath every 3-5
seconds). Note: Laypersons are usually not taught to provide
rescue breathing without chest compressions.
External Chest Compressions
External chest compression is a rhythmic
application of pressure over the breastbone. Chest compressions
create blood flow to the heart, brain and other organs by
increasing pressure inside the chest and arteries and by direct
compression of the heart. Creating and maintaining this pressure
not only keeps vital organs alive, it also increases the chances
that defibrillation will be successful. Once chest compressions
are started, it takes time for the pressure to build up enough
to make blood flow. When chest compressions are stopped, the
pressure and blood flow drops quickly. Frequent interruption
of chest compressions may be contributing to poor survival
rates. For that reason, frequent interruptions in chest compressions
during CPA must be avoided. Pauses in chest compressions should
be as infrequent as possible. Limit interruptions to no linger
than 10 seconds, except when it is necessary to use a defibrillator
or to perform advanced life support procedures such as intubation.
Chest Compression
Technique
(adults and children)
To make blood flow to the heart and brain effective, the patient
must be face up and lying flat on a firm surface. Remove any
clothing from the chest. Place the heel of one hand in the
center of the chest between the nipples.
Put the other hand on top of the first.
Your fingers can be straight or fastened together, but 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 approximately 1-2 inches
(4-5 cm) for a normal-sized adult. Use either 1 or 2 hands
to compress the child's chest about 11 to 11 the depth of
the chest. Release pressure and completely remove your weight
at top of each compression.
Chest compressions and relaxation should
be about equal. Give 30 chest compressions at a speed of about
100 per minute. Keeping up the force, length and speed of
compressions helps create the best blood flow possible. Do
not push over the lowest portion of the breastbone. After
30 compressions, open the patient's airway and give 2 rescue
breaths that make the chest visibly rise. Quickly resume chest
compressions.
When adult chest compressions are given properly, you may
hear an unpleasant sound like knuckles cracking. You may feel
the breastbone fall in a bit. This is caused by cartilage
or ribs cracking. Any damage done is not serious so don't
worry about it. Forceful external chest compression is critical
if the patient is to survive without brain damage. In infants
and toddlers, chest compressions rarely cause cracked ribs.
Chest Compression Technique (infants)
Single Rescuer
Compress the breastbone with 2 fingertips
placed just below the nipple line. You may place your other
hand under the infant's chest to create a compression surface.
Press down on the breastbone about 1/3-1/2 the depth of the
infant's chest. After each compression, completely release
the pressure on the breastbone and allow it to return to its
normal position. Give 30 chest compressions at a speed of
about 100 per minute.
When more than one rescuer is present, use 2 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,
first responder 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. However, once an
advanced airway is inserted, the rescuer giving compressions
should do so continuously - without pausing for ventilations.
In children (up to the age of puberty), the ratio for compressions
to breaths for two rescuers is 15:2 (3:1 for newborn infants).
When an advanced airway is in place, give rescue breaths at
a rate of 1 breath every 6-8 seconds (8-10 breaths per minute).
Do not pause chest compressions to Ventilate.
Studies have shown that rescuers quickly become tired performing
chest compressions. compressions may become inadequate within
as little as 1-3 minutes. To prevent fatigue and maintain
the quality of chest compressions, rescuers should change
positions at least every couple of minutes. This should be
done quickly, in less than 5 seconds, so there is as little
interruption in compression as possible. AED rhythm checks
should be very brief, and pulse checks should generally be
performed only when an advanced life support provider recognizes
an organized rhythm (regular or narrow QRS complexes). If
there is any doubt about the presence of a pulse, immediately
resume chest compressions. Rescuers should continually monitor
and encourage each other to perform quality chest compression
(hard, fast, complete recoil, minimal interruption).
Defibrillation
Adult
If an AED is available, expose the
chest, turn on the AED and immediately attach it. Whenever
possible, position it next to the rescuer who will be operating
it. If feasible, continue CPR while the pads are being applied.
Listen carefully and follow the machine's instructions.
For an unwitnessed cardiac arrest,
local protocol may instruct EMS providers to provide a couple
minutes of CPR to oxygenate the heart and brain before attempting
defibrillation.
Children
Ventricular fibrillation is an uncommon
cause of cardiac arrest in infants, but increases with age.
AEDs may be used for children older than 1 year who have no
signs of life. Some AED pads may require that the rescuer
place on pad on the child's chest and one on the back. Always
look at the pictures on the pads and place them as shown.
The rescuer may need to use different cables or 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.
Before Attaching an AED
Before attaching the AED, quickly check for the following
situations:
1. Hairy
Chest. If the patients chest is covered with hair,
it may prevent the electrode pads from making effective contact
with the skin. If the AED voice prompt continues to say “check
pads” or something similar after you attach the pads,
quickly remove the pads, tearing out the hair under the pad.
Apply a second set of electrodes. If the problem continues,
quickly shave the chest in the area of the pads and attach
another set of electrodes.
2. Water.
Move a patient out of freestanding fresh or salt water before
attaching the AED. Water or sweat on the patient’s chest
may also conduct energy from one electrode pad to the other,
reducing the potential for a successful shock. If the patient’s
chest is wet, sweaty or dirty, quickly clean and dry it before
attaching the AED.
3. Medication patches. Remove
medication patches and wipe the skin area clean before the
AED electrode pad is attached. Medication patches left in
place may block the shock and can cause small burns to the
skin.
4. Medical Devices. Watch
for pacemakers and implantable cardioverter defibrillators.
(ICDs). Place the electrode pad at least 1 inch (2.5 cm) away
from an implanted device. Look for a lump beneath the skin
of the upper chest or stomach. If the patient is receiving
internal shocks from the ICD (looks similar to muscles contracting
from external shocks from an AED), allow30-60 seconds for
the ICD to complete its cycle before attaching the AED. Rescuers
touching the patient will not be harmed if the implanted device
discharges.
5. Oxygen.
Oxygen should not be used when shocks are delivered with an
AED. There have been reports of patients and their bedding
being set on fire during defibrillation. The oxygen concentration
necessary to produce ignition will typically extend less than
a foot in any direction and will quickly disperse when removed.
Therefore, rescuers should remove or shut off the oxygen flow
when delivering shocks. Leaving a device that continues to
discharge oxygen near the patient’s head before defibrillation
is dangerous.
Other Considerations
Metal surfaces pose no shock hazard to either the patient
or CPR providers. Cell phones do not interfere with the AED.
Always follow the manufacturer's recommended safety precautions
Attaching and operating an AED
Research has shown that people can use AEDs adequately and
safely without any instruction. This includes sixth grade
students using an AED for the first time in a simulated cardiac
arrest. These untrained students were able to use the AED
safely, and only modestly slower than paramedics. However,
training is still recommended. Getting as little as 15 minutes
of training on an AED has been shown to significantly improve
the ability to operate it. Healthcare providers, first responders
and other professional rescuers should practice CPR and AED
as a team to make sure their actions are well-timed and effective.
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