CPR A step-by-step guide to Cardio Pulmonary Resuscitation

CPR
A step-by-step guide to Cardio Pulmonary Resuscitation Table of Contents
Section 1: Introduction Chain of Survival ... Physiology of Sudden Death .. The Anatomy and Function of the Heart .. The Anatomy and Function of the Lungs . Coronary Artery Disease . Risk Factors for Heart Attack .. Prudent Heart Living . How to Recognize a Heart Attack .. Section 2: Principles of CPR CPR Techniques ... Recovery Position . Section 3: Adult CPR Procedures 1 Rescuer Adult CPR ... 2 Rescuer CPR . Foreign Body Airway Obstruction Management (Conscious) Heimlich Maneuver ... Chest Thrust .. Foreign Body Airway Obstruction (Unconscious) Section 4: Infant CPR Procedures 1 Rescuer CPR: Infant (Under 1 year of age) .. Obstructed Airway: Unconscious Infant (Under 1 year of age) . Section 5: Conclusion Barrier Devices .. Complications of CPR .. Summary Performance Sheet This guide does not constitute a CPR course. You should attend a proper CPR course to gain skills in CPR, with practice on manikins and guidance from properly trained instructors. 23 26 28 29 30 14 17 19 20 20 21 2 3 4 4 5 6 7 8 10 13

SAF Medical Training Institute CPR Training Centre

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

Chain of Survival
CPR alone is not sufficient to save lives of victims who collapse due to cardiac arrest. However, each link in the Chain of Survival represents an intervention to support the victim until more advanced support is available. The Chain of Survival includes early access (activation of the emergency services), early CPR, early defibrillation and early advanced care.

A majority of victims die before they reach the hospital. You, as the rescuer, are an essential part of the chain as the first two links - early access and early CPR - are within your control. Trained medical personnel who provide early defibrillation and early advanced care can only respond after the phone call (early access) has been made. Each link in the Chain must be strong to ensure the effectiveness of the whole system. First Link: Early Access ("Call 995)

Second Link: Early CPR CPR is the best treatment that a cardiac arrest victim can receive until the arrival of the ambulance. This is because rescue breathing and chest compressions serve to provide blood and oxygen to the vital organs until defibrillation and advanced care can be provided. Even though CPR aids remarkably in saving the victim, it will not be effective if not rapidly followed by subsequent links. Conversely, not performing CPR spells certain death for the victim.

SAF Medical Training Institute CPR Training Centre

CPR A step-by-step guide to Cardio Pulmonary Resuscitation Third Link: Early Defibrillation Early access to the Emergency Medical Services (EMS) will ensure that the crew will arrive with a defibrillator. In adults suffering from sudden cardiac arrest, the most commonly observed heart rhythm is called ventricular fibrillation (VF). This is an abnormal, chaotic heart rhythm that prevents the heart from pumping blood Effective treatment for VF entails defibrillation. Early defibrillation is crucial as survival from VF falls by 7-10% every minute defibrillation is delayed. Fourth Link: Early Advanced Care Early advanced care refers to more specialized care which includes the use of equipment to support ventilation and administration of drugs to stabilize the heart rhythm. In Singapore, advanced care is normally rendered by doctors and nurses in the hospitals.

Physiology of Sudden Death

Clinical death occurs when breathing and circulation stop, whereas Biological death occurs when there is irreversible damage to the brain cells. Usually, there is a four to six minutes lapse between clinical and biological death. This is the crucial time when CPR may bring someone back to life. When breathing stops, the oxygen in the lungs and blood is still sufficient to support life for a few minutes as the heart will continue to circulate blood to the brain and other vital organs. However, all circulation of oxygen and blood ceases when the heart stops (Clinical death). We can prevent biological death if we can supply oxygen and maintain blood circulation. We can keep the victim alive long enough until professional help arrives render CPR immediately on collapse

SAF Medical Training Institute CPR Training Centre

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

The Anatomy and Function of the Heart

The heart, a muscular organ approximately the size of a clenched fist, lies in the center of the chest, in front of the spine and behind the sternum (breastbone). The main function of the heart is to pump blood to the lungs and to the rest of the body. Blood is circulated to and from the heart through veins and arteries respectively. The heart is a double pump. The right side of the heart receives oxygendepleted blood from all parts of the body. Oxygen-depleted blood, which contains waste products and carbon dioxide, will then be pumped into the lungs through the pulmonary arteries to pick up oxygen. The left side of the heart receives oxygen-enriched blood from the lungs and pumps it through the aorta (large blood vessel) and into smaller arteries, which then distribute the blood to all parts of the body. In a healthy adult at rest, heartbeats are triggered by natural electrical impulses sent through the heart between 60 and 100 times a minute. Heart rate and circulation can change to meet the demands of the body. When the heart stops pumping, circulation of blood, and hence oxygen, to the heart and other vital organs will cease. There is usually sufficient residual oxygen stored in the brain and other vital organs to support life, but only for a few minutes. If there is still no circulation to the brain within 4 to 6 minutes, permanent and irreversible brain damage will occur.

The Anatomy and Function of the Lungs

The lungs, the major component of the respiratory system, consist of many alveoli (tiny air sacs) surrounded by capillaries (small blood vessel processes involved in maintenance and function. On receiving the oxygen from the blood, the cells will produce carbon dioxide to be returned to the blood for removal from the body. The function of the lungs is hence to provide the avenue for the blood to be oxygenated and for the carbon dioxide to be removed. For a healthy adult, the respiratory center in the brain produces the stimulus to breathe. However, the rate and depth of breathing is dependent on the level of carbon dioxide in the blood. When the level of carbon dioxide increases, signals will be sent to the respiratory center in the brain. Breathing rate and depth increases until the level of carbon dioxide in the body decreases, then breathing rate starts to slow. This is a continuous loop to maintain a low level of carbon dioxide.

SAF Medical Training Institute CPR Training Centre

CPR A step-by-step guide to Cardio Pulmonary Resuscitation Only about a quarter of oxygen inhaled is absorbed by the blood. There is approximately 21% oxygen and 0.03% carbon dioxide in the atmospheric air, hence exhaled air will still contain about 16% oxygen. Thus, when mouth to mouth ventilation is performed on the unconscious victim, it will be sufficient to support the victim's life.

Coronary Artery Disease

The arteries supply oxygenated blood to the heart muscles for respiration. Diseases associated with the coronary arteries are commonly caused by atherosclerosis -the narrowing of the arteries. Atherosclerosis occurs when the inner lining of the arterial walls are thickened and roughened by the gradual build-up of fatty deposits (cholesterol). As a result, blood supply to the heart muscles decreases. When blood flow is severely reduced, a blood clot may form and completely block the narrowed artery, causing a complete stoppage of blood flow. The result is death of the heart muscle. Atherosclerosis is a progressive disease that usually begins at an early age, sometimes even before the age of 20. As the narrowing of the arteries is gradual, there are usually no signs or symptoms to suggest that the heart is affected. Risk factors such as smoking, lack of exercise, obesity and high blood pressure will increase the likelihood of heart disease as the process is hastened. However, progression of the disease may stop or revert if efforts are made to reduce risk factors. The following may result from artery disease: Angina pectoris: This occurs when there is a lack of supply of oxygen to meet the demand of the heart muscle. Victims normally experience discomfort at the center of the chest that may diffuse. This discomfort lasts for a few minutes and is brought on by an increase in the heart rate, caused by physical or emotional stress and its equivalent. The pain will disappear once the demand decreases. The pain can also be relieved by rest or by consumption of nitroglycerin (GTN). Acute Myocardial Infarction (AMI): AMI (Heart attack) occurs when an area of the heart muscle is deprived of oxygen for a prolonged period due to a blockage of a diseased coronary artery. The characteristic symptom of AMI is prolonged crushing pain not relieved by rest or GTN. Sudden death: Sudden death occurs when heartbeat and breathing stop abruptly and is usually the final symptom of coronary artery disease. It may occur within 1 to 2 hours after the onset of heart attack symptoms and as a complication of heart attack, but more often it occurs independent of a heart

SAF Medical Training Institute CPR Training Centre

CPR A step-by-step guide to Cardio Pulmonary Resuscitation attack. Other common causes of sudden death are ventricular fibrillation, electric shock, drowning, drug overdose, suffocation, severe allergic reactions, trauma and stroke.

Risk Factors for Heart Attack

There are several factors contributing to an increased risk of heart attack. The tnore risk factors present, the higher the chances the person will develop heart disease, which may lead to heart attack. Risk factors that cannot be changed Heredity: A history of heart disease in siblings or parents suggests a higher possibility of heart disease. Gender: Men are at a greater risk even though heart attack is still the leading cause of death among women. Age: Most heart attack victims are 65 or older. However, with the changes in lifestyle and eating habits, the number of heart attack victims have grown to include victims as young as 20. Risk factors that can be changed Smoking: Smokers have higher risk of heart attack compared to non- smokers. A smoker who gives up smoking will return to the same risk level as people who have never smoked before. Studies have shown that passive smoking (inhalation of environmental cigarette smoke) also increases the risk of smoking related diseases. High blood pressure: This is a major risk factor for stroke and heart attack and has no symptoms. Management includes weight reduction and lowering of salt intake. High blood cholesterol levels: Too much cholesterol in the blood can result in a cholesterol build-up along the walls of the coronary artery, effectively narrowing the vessel and leading to heart attack. Having a diet low in saturated fat will help lower the blood cholesterol. Physical inactivity: Only mild activity is required to decrease the risk of heart disease. Lack of exercise may lead to obesity, which is another contributing factor of heart attack.

SAF Medical Training Institute CPR Training Centre

CPR A step-by-step guide to Cardio Pulmonary Resuscitation Contributing risk factors Diabetes: Diabetics are usually middle-aged obese people. Even if diabetes remains undetected, it still greatly increases the risk of having a heart attack. Although the blood sugar levels can be controlled, the increased risk of heart disease cannot be eliminated. Obesity: Obesity is caused by overeating and a lack of exercise. Being overweight greatly influences blood pressure and cholesterol, which may be a precursor for many ailments. Stress: Stress affects everyone, but different people react differently. Prolonged excessive stress may create health problems for people.

Prudent Heart Living

Prudent heart living is leading a lifestyle that helps to minimize the risk of future heart disease. This includes weight control, avoiding smoking, regular exercise and having a balanced diet. Studies have shown that reducing the risk factors directly reduce the possibility of getting a heart attack. Even though it is important to educate the public to provide emergency treatment for victims who collapse due to cardiac arrest, prevention of cardiac arrest is still more desirable. Five specific ways on how to maintain prudent heart living are described in detail.

1. Quit Smoking
Statistics has shown that smokers suffer a greater risk of developing various diseases, and possess a significantly higher chance of suffering from cardiac arrest. Research also shows that the death rate of smokers who give up smoking is the same as non-smokers.

2. Control High Blood Pressure

Hypertension (high blood pressure) is one of the major risks for heart attack. If left untreated, this will lead to major health problems as the kidneys, heart and other vital organs will be damaged. Even though the cause of high blood pressure is unknown in most patients, it is still controllable. Changing your diet (reducing the sodium intake) and weight reduction (regular exercise) both help to moderate blood pressure.

SAF Medical Training Institute CPR Training Centre

CPR A step-by-step guide to Cardio Pulmonary Resuscitation Medication is also available if diet and exercise alone prove ineffective.

3. Reduce Saturated Fat and Cholesterol in the Diet

Cholesterol and saturated fat is present mainly in animal products. When there is an excessive intake of cholesterol, some of it is deposited on the inner walls of the arteries, leading to the narrowing of the channel through a process known as atherosclerosis. We should substitute saturated fat with polyunsaturated fats (e.g. liquid vegetable oils, except coconut and palm kernel oil) to lower the cholesterol intake.

4. Exercise Regularly
Studies have shown that regular exercise lowers the risk of getting a heart attack. Survival rates of heart attack victims are also higher in those who exercise regularly.

5. Weight Control
Adults usually reach their normal weight between the age of 21 and 25. As fewer calories are needed to maintain the weight as the years goes by, those who continue to eat as much and become physically inactive will store the excess calories as fat. The life expectancy of obese people tends to be shorter than the non-obese. Extreme dieting should be avoided as it usually causes the exclusion of essential nutrients for the body. Always consult a dietician/physician for advice before embarking on dieting.

How to Recognize a Heart Attack

The chance of survival depends largely on the prompt initiation of the Chain of Survival. Hence it is crucial for the rescuer to recognize the signs of a heart attack and react accordingly to the emergency. An obvious symptom of an impending heart attack is chest pain or discomfiture. The pain is described as a squeezing or tight sensation usually located in the chest and may spread to the left shoulder, down the and up the neck and lower jaw. The duration of the pain is usually more intense, lasting 20 to 30 minutes and is not relieved by rest or nitroglycerin.

SAF Medical Training Institute CPR Training Centre

CPR A step-by-step guide to Cardio Pulmonary Resuscitation Other signs and symptoms include any or all of the following: Shortness of breath Sweating Nausea Fainting Victims tend to deny the signs of a heart attack. Since the symptoms are not common and occur suddenly, victims may not realize that they are having a heart attack and tend to think the symptoms as those of indigestion or other factors. On recognition, have the victim rest, allowing the most comfort and easiest breathing. As the heart attack is caused by inadequate supply of oxygen to the heart muscles, the victim's activity and emotional and psychological stress should be kept to a minimum. If the chest discomfort lasts for more than a few minutes, have someone nearby activate the EMS system (Call ambulance 995) and be prepared to perform CPR if necessary.

SAF Medical Training Institute CPR Training Centre

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

CPR TECHNIQUES
There are three basic principles in CPR, which are commonly known as the ABCs of CPR: Airway, Breathing, and Circulation. For each principle an assessment phase precedes an execution phase.

Airway
When a victim is unconscious, the tongue may fall back and block the airway. However, before the airway is opened, the tongue-jaw maneuver should be done to check the airway for any foreign bodies like solid food particles or liquid vomitus.

With the victim facing up, the rescuer will open the victim's mouth by lifting the tongue and lower jaw simultaneously using the thumb. When this is performed, the tongue is lifted from the base of the throat to allow the rescuer to check for any foreign objects that might be lodged there.

If a solid material is seen, extract the foreign body with the index finger of the other hand using a finger sweep while maintaining tongue-jaw lift. Liquid/semi-liquid materials can be removed by turning the victim's head to the side (assuming no neck injury) and sweeping out with gloved fingers or a piece of cloth wrapped around the fingers.

The most common cause of obstruction in an unconscious victim is the tongue. This is because when a victim is unconscious, the tongue will fall backwards due to total muscle relaxation, thus obstructing the airway.

Head-tilt-chin-lift is performed to pull the tongue off the base of the throat to maintain an open airway This technique can be performed by placing one hand on the victim's forehead and apply firm backward pressure to tilt the head back while two fingers of the other hand will be placed under the bony part of the chin to the chin backwards.
SAF Medical Training Institute CPR Training Centre

10

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

Breathing

While maintaining an open airway, the rescuer will proceed to assess for breathing by placing his cheek close to the victim's face. The rescuer should Look (for the rise and fall of the victim's chest), Listen (for breath sounds) and Feel (for warm air during exhalation) for not more than seconds.

If the signs above are absent, the victim is not breathing and mouth to mouth resuscitation should be initiated immediately.

The rescuer is to maintain an open airway while delivering rescue breaths. Take a deep breath, pinch the victim's nose and make a tight seal around the victims mouth when giving ventilation. Each breath should be (approximately 1 seconds) and the rescuer is to observe for chest rise during ventilation. Release the pinch on the nostrils after each ventilation and allow the chest to fall before proceeding to give the second ventilation. Head-tiltchin-lift should also be maintained during exhalation to minimize the possibility of gastric distension.

Circulation
Determine pulse less-ness by checking the pulse at the carotid artery. The rescuer should proceed by placing two fingers at the victims Adams apple and slide down to the side nearer to him until he reaches a groove. Apply slight pressure and check for carotid pulse for not more than 10 seconds. Checking for pulse should be done while maintaining head-tilt-chin-lift with the other hand.

However do not rely on pulse check alone. The rescuer should also look-out for other signs of circulation (i.e. normal breathing, coughing or movement). If unsure, the rescuer should treat as cardiac arrest and begin chest compressions immediately.

SAF Medical Training Institute CPR Training Centre

11

CPR A step-by-step guide to Cardio Pulmonary Resuscitation Location of landmark for chest compressions can be done in the following steps:

Step 1: While maintaining the head tilt, use the middle finger of the other hand and feel for the edge of the victim's ribcage. Run your middle finger along the ribcage to the notch where the ribs meet the sternum (breastbone) in the centre of the lower part of the chest. Rescuer is to place his index finger beside his middle finger.

Step 2: Gently lift hand that is maintaining the head tilt, place the heel of that hand next to the index finger.

Step 3: Place one hand over the other and interlock fingers to keep them off the chest wall.

Step 4: Rescuer to move his body forward with shoulders directly above the victim and straighten his arms to keep the elbows locked during compressions. Compressions should be administered vertically downwards for approximately 4-5cm and rescuer should use his body weight for compressions.

SAF Medical Training Institute CPR Training Centre

12

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

RECOVERY POSITION

For an unconscious victim (lying in supine position) whose breathing and circulation are present, the airway might be obstructed by the tongue due to the loss of muscle reflex. The airway can be maintained by turning the victim to a recovery position. When the victim is placed in recovery position, vomitus (if any) can be drained out of the mouth easily. It is essential that the rescuer observe the victim closely until the victim regains consciousness or when ambulance crews arrive. The rescuer should turn the victim back to supine position and commence CPR if the victim stops breathing or shows no signs of circulation.

SAF Medical Training Institute CPR Training Centre

13

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

ONE RESCUER ADULT CPR

Establish unresponsiveness. Tap/shake the victim's shoulder gently and ask Hello! Are you OK?"

Activate EMS (Emergency Medical Service) System by calling 995! Shout for help if the rescuer is alone. If there are bystanders around, ask them to call for ambulance. If the rescuer is alone and the phone is nearby, EMS should be activated immediately. If the phone is far away, rescuer should commence CPR for 2 minute (approximately 5 cycles of external chest compressions) before calling for ambulance 995.

Position the victim in a supine position. CPR is only effective if performed on a flat and firm surface. If the victim is lying face down, roll him onto his back, supporting the head and neck while turning him.

AIRWAY
Check Airway Perform tongue-jaw-lift to check the mouth for any foreign body (e.g. solid food particles, liquid vomitus). Solid material can be extracted by using a finger of one hand to perform a finger-sweep while the other hand maintains the tongue-jaw-lift. Liquid/semi liquid materials can be removed by turning the victims head to the side and sweeping out using gloved fingers or a piece of cloth.

Open Airway Open the airway by performing head-tilt-chin-lift. Place one hand on the victim's forehead and apply firm backward pressure to tilt the head backwards while two fingers of the other hand will be placed under the bony part chin to lift the chin backwards.

SAF Medical Training Institute CPR Training Centre

14

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

BREATHING
Check Breathing Check for not more than 10 seconds. The head-tilt-chinlift should be maintained while we look, listen and feel for breathing. Look (for the rise and fall of the victim's chest) Listen (for breath sounds) Feel (for warm moist air during exhalation)

If there is no breathing, proceed to deliver 2 initial ventilations (approximately 1 second per breath). Take a deep breath, pinch the victim's nose and make a tight seal around the victim's mouth when giving ventilation. The rescuer is to observe the chest rise during ventilation. Release the pinch on the nostrils after each ventilation to allow the chest to fall before proceeding to give the second ventilation.

CIRCULATION
Check for Circulation Check for not more than 10 seconds. Place two fingers at the Adams apple and slide down to the groove at the side nearer to you. Apply a slight pressure and check for carotid pulse. Do not rely on pulse check alone. Check for signs of circulation (i.e. normal breathing, coughing or movement) If the pulse is present, commence Deliver 1 breath every 5 seconds approximately 12 cycles. Rescuer breathing while counting 3 one thousand, 5 one thousand." rescue breathing. for 1 minute, or should check for thousand, 4 one

If no pulse or unsure, begin the first cycle of external chest compressions. Locate for chest compression site on the lower half of (breastbone) Compress using your body weight in a downward direction for a depth of 4-5 cm, at a rate of approximately 100 compressions per minute. Rescuer should lock his elbows during compressions and count to establish rhythm: 1 and 2 and 3 and 4 and 5, and 1 and 2 and 3 and 4 and 10, and 1 and 2 and 3 and 4 and 15, and 1 and 2 and 3 and 4 and 20, and 1 and 2 and 3 and 4 and 25, and 1 and 2 and 3 and 4 and 30.
SAF Medical Training Institute CPR Training Centre

15

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

1 cycle: 30 chest compressions followed by 2 ventilations. Check for circulation after the end of 5 cycles.

Resume CPR, starting with chest compressions if there is still no pulse after 5 cycles. Perform rescue breathing if pulse is present but breathing is absent. If breathing is still absent after one minute of rescue breathing, the rescuer is to check pulse as the heart might have stopped while rescue breathing was being administered. Start the chest compressions again if pulse is absent. Only begin a second minute of rescue breathing if pulse is present. Place victim in recovery position once breathing and circulation are restored. the victim until professional help arrives. When to stop CPR: When professional help (i.e. ambulance) arrives When relieved by another qualified personnel When casualty is revived When transporting up/down stairs/obstacles. In this instance, CPR should NOT be interrupted for more than 30 seconds at a time.

SAF Medical Training Institute CPR Training Centre

16

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

TWO RESCUER CPR

The two common scenarios for two rescuer CPR are when two rescuers who are trained in two rescuer CPR come across a collapsed victim and initiate 2 rescuer CPR immediately, or when a rescuer starts CPR first followed by the entry of another rescuer. Two rescuer CPR is recommended (whenever possible) as changing of roles can be done and hence reduces rescuer fatigue.

The second rescuer can enter after any number of cycles done by the first rescuer. When the second rescuer appears at the scene, he is to identify himself and offer help. Activate the EMS system if it has not done previously. The first rescuer should not interrupt the compressions, but instead acknowledge by nodding his head and complete the cycle (30:2) he is doing.

The first rescuer will then proceed to take the role of the ventilator and reassess the circulation while the second rescuer takes on the role of compressor and locates the landmark for chest compressions.

If pulse is absent, the two rescuers will commence 2-man CPR (5 cycles of 30 compressions to 2 ventilations). The second rescuer (compressor) will administer chest compressions while the first rescuer (ventilator) will give 2 ventilations after every 30 chest compressions.

Change-over can only be initiated by the compressor and can be done after any number of cycles. The compressor when initiating the change will count 1 and 2 and 3 and 4 and 5, and 1 and 2 and 3 and 4 and 10, and 1 and 2 and 3 and 4 and 15, and 1 and 2 and 3 and 4 and 20, and switch and 2 and 3 and 4 and 25, and switch and 2 and 3 and 4 and 30 when performing chest compressions. The ventilator will complete the cycle by delivering two ventilations before taking the role of the compressor.

Pulse check must always be performed before commencing two rescuer CPR or after any changeover of roles. If no pulse is detected after the changeover, a new set of cycles is started.

SAF Medical Training Institute CPR Training Centre

17

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

The second rescuer (now the ventilator) moves to the head and assess for circulation. Two rescuer CPR will continue for another 5 cycles if no switch is initiated by the compressor. The ventilator will assess for circulation after 5 cycles and the compressor will maintain hand position on the chest wall until the ventilator confirms that pulse is present.

The compressor will lift his hand from the chest wall but remain at the scene as there might still be a need to commence two rescuer CPR. Ventilator will continue to assess for breathing if pulse is present.

SAF Medical Training Institute CPR Training Centre

18

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

FOREIGN BODY AIRWAY OBSTRUCTION MANAGEMENT (CONSCIOUS)

How to prevent choking: Chew your food slowly and thoroughly before swallowing. Avoid laughing and talking when there's food in the mouth. Keep small toys and objects (e.g. marbles, beads, sweet wrappers) away from infants and children. Withhold food that must be thoroughly chewed from children who are unable to do so.

Foreign bodies can cause partial or complete airway obstruction. For victims with partial airway obstruction, encourage the victim to cough forcefully to attempt to expel the foreign body. If the victim is unable to expel the foreign object, activate the EMS system or bring him to a nearby hospital.

A conscious choking adult whose airway is completely obstructed usually clutches his neck with his hands. He will not be able to speak, cough or breathe.

SAF Medical Training Institute CPR Training Centre

19

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

Heimlich Maneuver
You should stand behind the victim, with the victims legs spread shoulder width apart and one of your legs in between to maintain stability. Wrap your arms around the victim's waist and proceed as follows: Make a fist with one hand. Place the thumb side of the fist against the victims abdomen, on the midline slightly above the navel and well below the tip of the xiphoid process. Grasp the fist with the other hand and ask your victim to lean forward slightly. Administer quick upward thrusts until the foreign object is expelled from the airway or the victim becomes unconscious. Each thrust should be separate and distinct, done with the intention of dislodging the foreign object.

Chest Thrusts
This technique is performed on a choking victim who is obese or in the late stages of pregnancy. You should stand behind the victim, with the victim's legs spread shoulder width apart and one of your legs in between to maintain stability. Taking the victims armpits as a guide, wrap your arms under the armpits, and encircle the victim's chest. Make a fist with one of your hands and place the thumb side of the fist at the center of the chest, where the breastbone is located. Grab the fist with the other hand and administer quick inward/backward thrusts until the foreign object is expelled from the airway or the victim becomes unconscious.
SAF Medical Training Institute CPR Training Centre

20

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

FOREIGN BODY AIRWAY OBSTRUCTION MANAGEMENT: WHEN VICTIM BECOMES UNCONSCIOUS

Activate EMS Gently position the victim on the floor in a supine position, face up. Activate the EMS system - either send someone to call or the rescuer will call for ambulance himself if there is no bystander

Check for Foreign Body Perform tongue-jaw lift to check the mouth for any foreign body (e.g. solid food particles, liquid vomitus).

Open Airway Open the airway by performing head-tilt-chin-lift. Check Breathing (for not more than 10 seconds). Rescuer should place his cheek and ear close to the victim's mouth and nose and Look, Listen and Feel for breathing.

If there is no breathing, attempt to deliver 2 ventilations. If the chest does not rise after the first ventilation, the rescuer should suspect that an improper head-tilt- chin-lift has been performed. Rescuer should then reapply headtilt-chin-lift before attempting to ventilate again. If the chest does not rise, rescuer should suspect airway obstruction.

SAF Medical Training Institute CPR Training Centre

21

CPR A step-by-step guide to Cardio Pulmonary Resuscitation If the rescuer suspects that the victim's airway is obstructed by a foreign object, the rescuer is to perform 30 chest compressions. Rescuer is to locate for chest compression site and perform 30 chest compressions. The chest compressions will collapse the ribcage, thus forcing the remaining air in the lungs to dislodge the foreign body from the airway. Chest compressions also serve the function of circulating blood and oxygen to the brain when attempting to dislodge the foreign body.

Perform tongue-jaw-lift (checking of airway) Finger sweep if foreign body can be seen. Check for breathing and attempt to ventilate if there is no breathing. Perform 30 chest compressions if chest still does not rise after 2 ventilations. Repeat the maneuvers until 2 successful ventilations are observed.

SAF Medical Training Institute CPR Training Centre

22

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

ONE RESCUER CPR: INFANT

(LESS THAN 1 YEAR)
The most common cause of collapse for infants is respiratory arrest while cardiac arrest is the primary culprit for adult cases. Respiratory arrest may cause cardiac arrest in later stages when the heart does not receive sufficient oxygen. Infant CPR should be performed as soon as possible with extra care due to the infant's vulnerabilities.

Initial Assessment
1. Determine unresponsiveness by tapping the infant's shoulder or tickling the infant's feet. Rescuer should also speak loudly as infants respond to familiar voices.

2. Call out "Help! Somebody call ambulance 995! Lone rescuer should only activate the EMS after 2 minute of rescue support as rapid rescue support prevents infant from developing cardiac arrest which is secondary to respiratory failure However, if a bystander is nearby, ask him to activate EMS.

3. If the infant is lying face down, turn and place the infant supine on a flat, firm surface. The rescuer should support the head and neck with one hand while the other hand supports the groin while turning the infant.

Airway
4. Once the infant is properly positioned, the rescuer should check the airway by performing a tongue-jaw-lift. Rescuer is not allowed to perform a blind sweep if no foreign body is seen because there is a possibility of injuring the soft tissue in the infant's mouth.

SAF Medical Training Institute CPR Training Centre

23

CPR A step-by-step guide to Cardio Pulmonary Resuscitation 5. The rescuer proceeds to open the airway by performing a head-tilt-chin-lift. Rescuer should not hyperextend the neck infant as this may cause the trachea (windpipe) to kink and collapse, thus blocking the airway. It may even cause cervical injuries.

Breathing
6. While maintaining head-tilt-chin-lift, the rescuer will place his cheek and ear near the infant's nose and mouth and check for breathing (Look, Listen and Feel).

7. If the infant is not breathing, the rescuer is to deliver two initial ventilations (puffs). The rescuer should seal the infants nose and mouth simultaneously when delivering ventilations. Each puff (approximately 30cc per breath) should last for 1 second and the rescuer should observe for the rise and fall of the chest.

Circulation
8. Determine pulse-less-ness by checking for the brachial pulse. The rescuer can locate the brachial pulse by placing his thumb on the outside of the arm and gently pressing his index and middle finger on the inside of the upper arm. Checking for pulse should be done while maintaining the head-tilt with the other hand.

The short and chubby neck of an infant makes rapid location of the carotid artery difficult. Moreover, a baby's airway is very fragile and if excessive force is applied, the airway might be obstructed.

9. If pulse is present, proceed with rescue breathing (1 breath every 3 seconds, 20 rescue breaths per minute)

SAF Medical Training Institute CPR Training Centre

24

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

10. If pulse is absent, begin chest compressions. One hand will maintain head-tilt while the other hand will be used to administer chest compressions. Draw an imaginary line between the nipples and place your index finger on the imaginary line. Proceed to place the middle and the ring finger next to the index finger. Chest compressions are performed approximately one finger width below the imaginary nipple line. Using only two fingers (i.e. middle and ring fingers), compress on the sternum to approximately 2cm in depth, at a rate of at least 100 compressions per minute. The compression to ventilation ratio for one cycle is 30:2 and the rescuer is to complete 5 cycles of chest compressions. The rescuer should release the pressure on the chest wall without removing his fingers, even when giving ventilation in between compressions 11. After 5 cycles of chest compressions (approximately 2 minute), the rescuer should activate the EMS if it has not been done. 12. Check for brachial pulse after 5 cycles of compressions. If there is still no pulse, continue another 5 cycles of chest compressions. 13. When pulse returns, rescuer will check for spontaneous breathing. If breathing is absent, commence rescue breathing immediately. Rescue breaths should be administered once every 3 seconds (20 rescue breaths per minute) and the rescuer should check for signs of breathing after each rescue breath. When the infant resumes breathing, place the infant in the recovery position to maintain an open airway and monitor pulse and breathing until professional help arrives.

SAF Medical Training Institute CPR Training Centre

25

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

OBSTRUCTED AIRWAY: UNCONSCIOUS INFANT

(LESS THAN 1 YEAR)
The rescuer should determine airway obstruction when administering 2 initial ventilations at the Breathing stage. If the infants chest does not rise after the first ventilation, rescuer should reposition the head, open the airway again by performing head-tilt-chin-lift, and reattempt ventilation. If the chest still does not rise, rescuer should suspect that the infant's airway is obstructed. The following sequence is used to clear the foreign body that is obstructing the infant's airway:

1. Support the back of the infant's head with one hand while the other hand will support the infant's jaw between the thumb and fingers. Sandwich the infant firmly with both forearms before lifting him up from the ground.

2. The infant should be held resting on the forearm, facing down. The forearm should be resting on the rescuers thigh for stability. Ensure that the infants head is lower than his trunk. Five back blows should be administered between the infants shoulder blades using the heel of the palm of the free hand.

3. After delivering the back blows, the rescuer should sandwich the infant again using both arms and rest the infant gently on its back on the other thigh. The head remains lower than the trunk. Deliver 5 chest thrusts on the lower half of the sternum, using the landmarks for chest compressions.

SAF Medical Training Institute CPR Training Centre

26

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

4. After the 5 back blows and 5 chest thrusts, support the infant and place him down gently. Perform a tongue-jaw-lift to check the mouth for any foreign objects. Remove the foreign objects by performing a finger sweep using the last finger of the free hand. Only sweep what can be seen.

5. Perform a head-tilt-chin-lift to open up the airway and proceed to give two initial ventilations if there is no breathing. If the first attempt is unsuccessful, reposition the head and redo head-tilt-chin-lift before attempting the second ventilation.

6. If the rescuer is alone and EMS has yet to be activated, the rescuer should call for ambulance after 2 minute of effort in trying to clear the airway. 7. Repeat steps 1 through 5 until ventilation is successful. 8. Rescuer will proceed with the assessment once airway is clear. If breathing is present, place the infant in a recovery position.

9. If pulse is absent, proceed with 5 cycles of chest compressions. If there is no breathing while pulse is present, deliver rescue breathing. (1 breath every 3 seconds, approximately 20 cycles in 1 minute).

SAF Medical Training Institute CPR Training Centre

27

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

BARRIER DEVICES
Some rescuers are hesitant to perform mouth-to-mouth resuscitation for fear of disease transmission. Pocket masks prevent direct contact between the rescuer and the victim during ventilation, hence minimizing the risk of cross infection.

Compared to mouth-to-mouth resuscitation, it is slightly more difficult to use a pocket mask to ventilate a casualty because an ineffective grip will cause air leakage. The rescuer should be positioned at the head of the victim and the pocket mask is placed over the victim's nose and mouth (the sharp end of the mask over the bridge of the victim's nose; the base of the mask between the victim's lower lip and chin) There are two techniques in using the pocket mask. The first is to place the thumb of each hand on the mask to maintain a complete seal. An alternative is to seal the mask using the thumb and index finger of each hand.

With either method, the remaining fingers grasp the angle of the jaw on each side so the head can be tilted back to maintain an open airway. The rescuer can then blow into the mouthpiece and observe for chest rise.

SAF Medical Training Institute CPR Training Centre

28

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

COMPLICATIONS OF CPR
CPR will not be effective if not properly performed. In addition, complications may arise from improper application of CPR. The complications that might result are:

RIB FRACTURE
This usually occurs when the rescuer exerts excessive pressure on the ribs of the casualty. It can be avoided if the rescuer positions only the heel of the palm on the sternum of the casualty. The rescuer should interlock and pull back his fingers so that the fingers do not rest on the victim's ribs during chest compressions.

LACERATION OF THE LIVER

The base end of the sternum (xiphoid process) may cut into the liver and cause internal bleeding. This can be avoided by carefully identifying the landmark for chest compressions.

DISTENSION OF THE STOMACH

Gastric distention refers to the situation in which the casualty's stomach is bloated as a result of ventilations which are given too fast or at an excessive volume. When this occurs the casualty may regurgitate stomach contents and choke. Gastric distension will also result in ineffective ventilation as lung volume is reduced due to diaphragm elevation. If stomach distension occurs, continue giving long and slow breaths just sufficient to make the chest rise. Do not attempt to expel the contents if chest rise can still be seen. However if chest rise is not seen during ventilation, turn the victim to a lateral position and apply some pressure to the abdomen. If regurgitation occurs, turn the head to the side and clear the mouth of foreign bodies before resuming CPR. Despite the above-mentioned complications, rescuers should not fear performing CPR as it is an important skill.

SAF Medical Training Institute CPR Training Centre

29

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

SUMMARY PERFORMANCE SHEET CARDIO PULMONARY RESUSCITATION (CPR)

OBJECTIVES
A. Airway 1. Assessment: Determine unresponsiveness 2. Activate EMS 3. Position the casualty 4. Check airway Open the airway B. Breathing 5. Assessment: Determine breathlessness 6. Give 2 rescue breaths

ACTIONS ADULT (OVER 8 YRS)

Tap or gently shake shoulder. Say, Are you okay? Call for ambulance 995. Observe Only if second person available.

INFANT (UNDER 1 YR)

Turn on back as a unit, log-roll, supporting head and neck if necessary. Victim must be supine and on a flat firm surface. Perform a tongue-jaw-lift before a head-tilt-chin-lift. Same as adult but do not hyperextend neck.

Maintain open airway. Place ear over mouth, and observe the victims chest. Look, listen and feel for breathing (for not more than 10 seconds). Maintain open airway. Pinch nose. Seal mouth to mouth. Give 2 breaths (4001000ml of air per breath), approx 1 sec each. Ensure chest rises. Allow lung deflation between breaths (release nose). Seal mouth to nose & mouth.

Give 2 breaths (30cc per breath), 1 sec each. Observe chest rise. Allow lung deflation between breaths.

7. Option for obstructed airway

1. If chest doesnt rise, reposition victims head. Try again to give rescue breaths. 2. Give 30 chest compressions. 3. Tongue-jaw lift and sweep. Give 5 back blows. Give 5 chest thrusts. Tongue-jaw lift, but sweep only if you see a foreign object.

If unsuccessful, reassess ABC. Repeat steps 1, 2 and 3 until successful. Activate EMS. C. Circulation 8. Assessment: Determine pulselessness Feel for carotid pulse with one hand; maintain head-tilt with the other (not more than 10 seconds). Do not rely on pulse check alone. Check for signs of circulation.

Feel for brachial pulse; maintain head-tilt.

Begin external chest compressions:

SAF Medical Training Institute CPR Training Centre

30

CPR A step-by-step guide to Cardio Pulmonary Resuscitation

9. Landmarks check Run middle finger along bottom edge of rib cage to notch at centre (tip of sternum). Place index finger next to finger on notch. Place two hands next to index finger, with fingers interlocked and raised off chest wall. Depress 4-5cm. 11. Compression rate D. CPR Cycles 12. Compression to ventilation ratio 13. Number of cycles 14. Reassessment Approximately 100 per minute 30 compressions to 2 ventilations 5 Feel for return of carotid pulse (not more than 10 sec). If no pulse, continue CPR. Option for entrance of 2nd rescuer: I know 2-man CPR. Can I help? 1st rescuer ends cycle of CPR. 1st rescuer checks pulse not more than 10 seconds. 2nd rescuer who is at victims side performs chest compressions. 1st rescuer delivers 2 ventilations and observes rise and fall of chest. After 5 cycles of 30 compressions : 2 ventilations, ventilator (1st rescuer) checks for pulse. When the person doing chest compressions becomes tired, the rescuers should exchange positions as soon as possible. Option for pulse return If breathing still absent, give rescue breathing. 1 breath every 5 seconds, do for 1 minute. 1 breath every 3 seconds. Do 20 cycles per minute. Not applicable.

Imagine a line drawn between the nipples.

10. Hand position

Place 2 fingers on sternum, 1 fingers width below nipple line. Depress 2cm.

At least 100 per minute 30 compressions to 2 ventilation 5 Feel for return of brachial pulse (not more than 10 sec). If no pulse, continue CPR. Activate EMS if it is still not activated.

If breathing and pulse return, stop CPR. Place victim in recovery position. Note: If there is still no breathing after 1 minute of rescue breathing, proceed to check pulse. Continue CPR if there is no pulse. Continue rescue breathing if there is still no pulse and breathing.

SAF Medical Training Institute CPR Training Centre

31