Cardiopulmonary resuscitation - CPR
CPR or cardiopulmonary resuscitation is an emergency first aid procedure used to help a person who has lost their pulse and their ability to breathe normally, a condition known as cardiac arrest. Cardiac arrest is a condition nearly everyone experiences in the last few minutes of life, and refers to a period in which the heart muscle, although failing, still has some residual life in it and may sometimes be brought back to normal functioning by emergency techniques. CPR is appropriate for otherwise healthy persons experiencing sudden cardiac death, due perhaps to massive heart attacks or heart rhythm disturbances, and can keep the victims alive until emergency personnel arrive. It is also used effectively for victims of drowning, electrocution or choking, or those suffering from drug or other substance overdoses. CPR is commonly taught to ordinary people who may be the only persons present in the crucial few minutes before emergency personnel are available.
FIRST send someone to call for help using the Emergency telephone number (911 in the US and Canada, 112 in Europe) to activate the emergency medical services. CPR can only buy time to apply advanced cardiac life support. Without advanced cardiac life support, CPR is useless.
Three simple steps to CPR
If possible, place victim flat on his or her back on a hard surface. However, the airway can still be cleared if the victim is sitting upright or floating in water.
Open the victims' airway by tilting their head back with one hand while lifting up their chin with the other hand. If there is a chance of neck injury just lift up the chin. Tilting of the head in the presence of injury to the spine or the neck could result in further injury to the spinal column.
Put your cheek close to the victims' nose and mouth while looking at the victims' chest, to look, listen, and feel for breathing (10 seconds) If there is no breathing, pinch victim's nose closed and breath two full breaths into the victim's mouth. Each should last about 2 seconds.
If breaths won't go in, probable causes are:
- The victim's tongue is still obstructing the airway because you have not opened the airway properly. This is by far the most common explanation.
- Air is escaping elsewhere, because you are not sealing around the mouth or pinching the nose fully.
- There is a foreign body obstructing the airway.
In this situation, reposition their head and look in the mouth for obstructions. Try to give up to three more breaths. If these do not cause the chest to rise, begin chest compressions (see below) immediately - doing so may force an obstruction from the windpipe into the mouth. After 15 chest compressions, check the mouth for foreign objects which can be removed, and then try to give two rescue breaths. If they go in, assess the casualty's circulation and act as appropriate. If they do not go in, try 15 chest compressions again. The recommended ratio of chest compressions to rescue breaths is 15:2 if you are alone. If two people are resuscitating then one should manage the chest compressions while the other should manage the rescue breaths at a ratio of 5:1.
In the event the head tilt/chin lift maneuver was not performed due to suspected neck/spine injury and the breaths do not enter the lungs, head tilt/chin lift should be done anyway.
Check for a pulse by feeling for 5-10 seconds at side of the victims' neck.
If there is a pulse but the victim is not breathing, give breaths at rate of 1 breath every 5 seconds (12 breaths a minute).
If there is no pulse, begin chest compressions as follows. The compressions will pump blood around manually until a defibrillator is available to restart the heart:
Place victim flat on his or her back on a hard surface.
Kneel next to the victim's chest. To find the correct hand position, place the heel of the hand closest to the feet on the lower part of the ribcage. Place your other hand on top of the first. You can either interlace your fingers or keep them straight, but to avoid injuring the ribs, only the heel of your hand should touch the chest.
Shift your weight forward on your knees until your shoulders are directly over your hands and your elbows are locked. Bear down and then come up, bear down and come up, keeping your elbows locked. In order to create enough pressure to circulate the blood, you must depress the chest of an average adult 1 1/2 to 2 inches (4-5cm) with each compression.
You should compress the chest at a rate of 80-100 times a minute (plus have time to do rescue breathing, if required). To get the right speed and rhythm, count out loud as you do the compressions, saying "1 and 2 and 3 and four and five!" Rest on each "and," then compress on each number. Each series of 5 should take about 3 seconds.
After each 15 compressions (counting to 5, 3 times), perform 2 rescue breaths. Take your hands off the chest, place them on the chin and forehead as before, pinch the nose, seal the mouth, and give 2 strong breaths, watching out of the corner of your eye for the chest to rise. Also have someone check for you if possible.
Go back to the chest, find the correct hand position again, and do 15 more compressions, followed by 2 more breaths. Repeat this cycle of 15 and 2 for a total of 4 times, which takes about 1 minute. Then check again for pulse and breathing (but see below - this is not universally recommended). If neither has returned, you must continue alternating compressions and breathing until the casualty's condition changes, qualified help comes and you are asked to stop, or you are too exhausted to continue.
Recent studies have suggested that, for some patients, the time lost due to switching back and forth between mouth-to-mouth breathing and compressions may be harmful. Rescue breathing is important for patients whose oxygen levels are low (drowning victims).
Common mistakes in performing chest compressions include rocking back and forth and bending the elbows. It is also important to note that, particularly in elderly patients, crepitations will often occur. Crepitations are the shattering of bones in the rib cage and sternum. They can be both heard and felt. CPR should not be discontinued due to crepitations, although the position of the hands should be checked if bone breakage appears to be excessive.
Current advice (at least in the United Kingdom: from the Resuscitation Council (UK), and from the current First aid manual (8th ed., Dorling Kindersley, ISBN 0751337048), is that a layperson should not check for a pulse, but rather "look for signs of a circulation". You should look, listen, and feel for normal breathing, coughing, or movement for up to 10 seconds. If you are not confident that one or more of these signs of circulation are present, you should begin chest compressions immediately. This advice is given to laypersons because it has been shown that assessment of the carotid pulse is time consuming and leads to an incorrect conclusion in up to 50% of cases. (The exception to this is if you are a qualified Health professional, in which case you are still advised to perform a carotid pulse check, taking no more than 10 seconds, whilst also checking the other signs of a circulation. Volunteer or appointed first aiders are not counted as health professionals).
This advice does not seem to be universal, however, so you should follow the instruction given in your CPR Training.
The Resuscitation Council also says: "Only stop to recheck for signs of a circulation if the victim makes a movement or takes a spontaneous breath; otherwise resuscitation should not be interrupted". This is on the basis that if a person's heart has stopped it is extremely unlikely to restart spontaneously without defibrillation, so rechecking just wastes time.
CPR for children age twelve months to eight years
Children have less lung capacity and a somewhat faster respiration rate. Also, compressions should be considerably less forceful than those used on adults.
The sequence of CPR for children is as follows:
1. ESTABLISH UNRESPONSIVENESS (4-10 SECONDS)
You must quickly determine if injury is present and determine consciousness. If head, neck, or spinal injury is suspected, great care must be exercised in positioning the child on her back on a firm flat surface. Turn and position the child, supporting the head and neck to avoid spinal cord injury caused by rolling, twisting, or tilting the head and neck.
A conscious child struggling to breathe will often find the best position to keep a partially obstructed airway open and should be allowed to maintain that position until medical help is available. If the young victim is unresponsive, position the child or infant on the back on a firm, flat surface and begin CPR.
Call for help after conducting CPR for 1 minute as below. If the child is conscious but suffering respiratory distress, do not waste time on CPR maneuvers but get the child to medical help as soon as possible. (Unresponsive children should receive CPR as they are rushed to the hospital.)
2. OPEN THE AIRWAY AND CHECK FOR BREATHING (3-5 SECONDS)
If you are certain the child has not suffered a spinal injury, place your hand on the child's forehead and gently tilt the head slightly backward.
Augment the head tilt by placing 1 or 2 fingers from the other hand under the chin and gently lifting upward. If you are not sure whether the child is breathing, while maintaining an open airway place your ear near the child's mouth and listen for breathing, look at the chest and abdomen for movement, and feel for air flow from the mouth. If the victim is breathing, maintain the airway; if no breathing is detected, CPR must proceed.
3. BREATHE FOR THE VICTIM (3-5 SECONDS)
While continuing to maintain an open airway, take a breath in, then hold it, open your mouth, and seal it over the mouth of the victim.
Remember that an infant will need much less air than a larger child. A proper amount of air will move the chest up and down between breaths. A slow, deliberate delivery will reduce the likelihood of forcing air into the stomach, causing distention.
Rescue breathing is the single most important maneuver in rescuing a nonbreathing child or infant. If repeated rescue breathing attempts do not result in airflow into the lungs, evidenced by chest movement, a foreign body obstruction should be suspected.
4. CHECK FOR PULSE (5-10 SECONDS)
In children over 1 year the heartbeat can be felt at the side of the neck. While maintaining the head tilt with one hand, find the windpipe at the level of the Adam's apple with two fingers of the other hand. Slide the fingers into the groove between the windpipe and neck muscles, as for adults. If no pulse is felt, proceed with chest compression and rescue breathing as below.
If a pulse is felt but there is no breathing, initiate and continue rescue breathing 15 times a minute for a child.
5. CALL EMERGENCY
If someone is available to help, have him call as soon as possible. If you are alone, complete 4 cycles of rescue breathing, or of breathing and chest compression, before taking time to call for help.
6. CHEST COMPRESSIONS
The child must be on her back on a firm surface such as the floor.
If the child is over 1 year of age, compression is applied to the breastbone by the heel of one hand, located in the midline, 2 fingers'-breadth above the tip of the breastbone. With one hand, the chest is compressed to a depth of 1 to 1 1/2 inches at a rate of 80 to 100 compressions per minute, as for an adult. Compression and relaxation time should be equal and the rhythm smooth and even. The fingers must be kept off the chest.
External compression should be accompanied by rescue breathing in a 5:1 ratio of compressions to ventilation breaths for an infant or child. Continue compression and rescue breathing until the child revives, help arrives, or you become too exhausted to continue.
While the 5:1 ratio has been used in the U.S. for decades "because oxygen is more important for children," a March 2002 study by Norwegian Air Ambulance recommends that children and infants receive the same 15:2 ratio as adults, because the 5:1 approach provides exactly the same number of breaths per minute in actual practice, but fewer chest compressions, as a substantial amount of time is lost due to switching positions.
CPR for infants
Infants under twelve months of age have significantly higher pulse and
respiration rates than adults. CPR must be modified significantly to
account for the differences.
Tilting the head and lifting the chin will not work in infants, as they have little or no neck. The infant should be cradled in the dominant arm, with the head resting in the rescuer's palm. As in children, the compression/respiration ratio should be 5:1, not 15:2 as in adults.
Respirations are easiest if performed with the mouth covering the entire nose and mouth, given in short puffs of air and not full exhalations. Chest compressions should be delivered at a rate of at least one hundred per minute using two fingers on the sternum at the nipple line, with a compression depth of half an inch to an inch depending on the size of the child.
- Continue CPR until help arrives or your life is placed in danger by continuing to perform CPR.
- See also wilderness first aid for situations where it may be impossible to continue CPR and guidelines for how to proceed in such a situation.
- Also note that it may be inappropriate to perform CPR in a disaster or triage situation with mass casualties.
CPR training is available through the American Red Cross as well as many other volunteer and governmental organizations worldwide.
CPR is a practical skill and needs to be regularly practiced on a resuscitation manikin to ensure full competency. Where knowledge of CPR is a job requirement, six monthly refresher courses are recommended.
CPR training should not be confined to just the medical professionals. Almost anyone is able to perform CPR and there are numerous reports of where CPR used by people first on the scene has saves a life.
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