Cardio-Pulmonary Resuscitation (CPR)

The origins of cardiopulmonary resuscitation (CPR) can be traced back to 1740, when the Paris Academy of Sciences first formally recommended mouth-to-mouth resuscitation for near-drowning victims. Over a hundred years later in 1891, the first documented and effective chest compression in humans was performed by Dr. Friedrich Maass. Through the years the use of external chest compressions in human resuscitation was attempted and analyzed, and it was proven that expired air by a rescuer is sufficient to oxygenate an unresponsive person. CPR was then officially developed and instituted in 1960, and a program by the American Heart Association (AHA) provided CPR training and encouraged the use of CPR by the general public. The American Red Cross and other agencies came on board to institute performance standards, standardized training, and certification for CPR for intervention of sudden cardiac arrest and acute life-threatening cardiopulmonary problems.

The ABCs of First Aid
There are three critical steps in emergency first aid. A person needs all three common denominators to live, and basic life support or CPR, together with early defibrillation, is proven to improve long-term survival after a cardiac arrest. The ABCs of first aid is a mnemonic that stands for airway, breathing, and circulation:
  • Airway : Is the airway unobstructed? Use measures to clear the airway.
  • Breathing : Is the person breathing? Start rescue breathing.
  • Circulation : Is the person’s heart beating? Start chestcompressions.
The steps for performing CPR are:
  1. Open the airway using the head-tilt, chin-lift method—one hand on the forehead, fingers of the other hand under the bony part of the lower jaw, near the chin. Tilt the head back, gently lift the jaw, making sure not to close the mouth or push on soft parts beneath the chin. Avoid lifting the neck in the case of spinal injury.
  2. Check for normal breathing by putting your ear to the person’s mouth and turning your head to look for chest movement, while listening for air flowing through the mouth or nose and trying to detect breath on your cheek. A person with periodic gasping is most likely in cardiac arrest and needs CPR.
  3. If there are no signs of breathing, pinch the nose; make a seal over the mouth with yours and give the person a breath strong enough for you to see the chest rise. When the chest falls, repeat the rescue breath once more for a total of two breaths. If available, use a CPR mask as a barrier between your mouth and the person’s mouth that you are rescuing. These first three steps are called “rescue breathing.”
  4. Begin chest compressions by placing the heel of your hand in the middle of the chest, over the lower half of the breastbone at the nipple line. Place your other hand on top and lace your fingers together (heel of one hand on chest, heel of the other hand on top of that hand) and compress the chest about one to two inches. Allow the chest to recoil completely, and then perform thirty compressions, at a rate of 100 compressions per minute.
  5. After thirty chest compressions, immediately repeat the two rescue breaths. Open the airway with headtilt, chin-lift again. This time, go directly to rescue breaths without checking for breathing again. Give one breath, making sure the chest rises and falls, then give another.
  6. Perform the cycle of thirty compressions followed by two breaths for about two minutes. Then stop and recheck for breathing. If the person is not breathing, continue chest compressions and rescue breaths.
Steps of CPR

The AHA now recommends that a series of thirty compressions followed by two breaths (compressionventilation ratio of 30:2) be given to all persons, regardless of age. Continue the cycle of compressions and rescue breathing until professional help arrives or until the person
recovers and begins breathing. In children age one to eight, use one or two hands as necessary to compress the chest one-third to one-half the depth of the chest. For the unresponsive infant or child, perform five cycles of thirty compressions and two breaths for about two minutes
before leaving the child to call 911 and get an AED if one is available.

CPR for Newborns and Infants
Newborn CPR has different recommendations than those for infants. But the recommendations for newborn CPR only apply to newborns in the first hours after birth until the newborn leaves the hospital, so the general public needs only to be concerned with infant CPR guidelines
that apply to babies less than approximately one year of age. The rescue-breathing rate for infants with pulses is about forty to sixty breaths per minute, with chest compression to one-third the depth of the chest. Deliver ninety compressions and thirty ventilations per minute. Compress the infant chest just below the nipple line (on lower half of sternum) using two fingers (rather than a whole hand) to compress the chest with a compression-ventilation ratio
of 30:2.

Problems Associated with CPR
Some of the problems the AHA has identified regarding performing CPR are excessive ventilation given during CPR and compressions that are interrupted too frequently and that are often too slow and too shallow. It’s believed that bystanders may be reluctant to perform CPR because it seems too complicated and difficult to remember. That’s why in recent updates the AHA has made attempts to simplify the steps by making the compression-ventilation ratio used the same for infants, children, and adults. The same update has been issued for chest compressions in children and adults. While it’s been surmised that the public is afraid of contracting diseases and is therefore reluctant to perform mouth-to-mouth resuscitation, the data illustrates that transmission of infection is very low; nonetheless, use of a barrier device (CPR mask) while giving ventilations is still encouraged. If you are still reluctant to give mouthto-mouth ventilations, at least call for help and start chest compressions immediately.

Recovery Position
The recovery position is a technique used in first aid for all unconscious people who are breathing. This includes anyone over the age of one year old who has started breathing after being given CPR, those who may be unconscious or nearly unconscious but are still breathing, those who are too inebriated to assure their continued breathing, persons of near drowning, and in cases of suspected poisoning. An unconscious person who is lying face up is in a position that may result in obstruction to the airway. When a person is laying face up, the tongue may relax to
the back of the throat and fluids such as blood or vomit can pool in the back of the throat and obstruct the airway. Also, in the face-up position, the esophagus is tilting down slightly from the stomach toward the throat, and when combined with loss of muscular control that occurs
when someone is unconscious, this can lead to what is called passive regurgitation—when the stomach contents flow up into the throat. Aside from airway obstruction, any fluid collecting in the back of the throat can flow down into the lungs and the acid from the stomach that is in that fluid can damage the lungs, a condition known as aspiration pneumonia. In many instances, the actual injury or illness that caused unconsciousness will not be fatal, but the resulting passive regurgitation or aspiration pneumonia will be.

A very common cause of death is excessive consumption of alcohol that leads to unconsciousness followed by all or some of these events. While in the recovery position, the force of gravity keeps the tongue from obstructing the airway and prevents fluids from flowing the wrong way.
This, coupled with raising the chest above the ground, protects the person while aiding breathing.

As in all first-aid situations, assess the area for safety before approaching the unconscious person. Next, assess the person for the ABCs. If there is no need to perform CPR or if you already have performed CPR and the person begins breathing, then put the person into the recovery position. If there is no suspicion of spinal or neck injury, you want to place the person into what is called the lateral recovery position:
  1. With the person lying on his back with legs straightout, kneel on one side, facing him. Position the person’sarm that is closest to you perpendicular to hisbody, with his elbow flexed. Then position the otherarm across the body, resting the hand across thetorso.
  2. Bend the leg that is farthest from you up; the kneeelevated, reach behind the knee and pull the thightoward you.
  3. Use your other arm to pull the shoulder farthest from you while rolling the body toward you. Maintain theupper leg in a flexed position so that the body isstabilized.
Lateral recovery position

Because people who stay in this position for an extended period of time may experience nerve compression, you may move the person from side to side every thirty minutes if emergency rescue is taking a long time to arrive. In case of spinal injury, any other movement of the unstabilized neck will carry a risk of causing permanent paralysis or other injuries, so movement should be minimized. The only reason to move a person with a suspected spinal injury into a recovery position is if you must drain vomit from the airway. And then you should use what is
called HAINES modified recovery position (High Arm IN Endangered Spine). In this modified position, raise one of the injured person’s arms above the head (in full abduction) while turning the person’s body in order to support the head and neck for less neck movement.

In a suspected spinal or neck injury, your first priority is keeping the airway open, so if the person is breathing, leave them in the position you found them. But if breathing stops, regardless of potential for increased injury to the person, you must continue ABCs: airway, breathing, and circulation. Breathing is the first priority; everything else is second.An unconscious pregnant woman should always be positioned in the recovery position on her left side, and anyone with wounds to the torso should be placed with the wounds closest to the ground to decrease any
chance of blood pooling in the lungs. Place a baby less than a year old in a modified recovery
position by holding the infant in your arms, head tilted downward, in order to prevent the tongue from obstructing the airway or the infant from inhaling vomit. In all cases, continue to monitor the person’s level of response, pulse, and breathing until help arrives.

Signs of Heart Attack
Sometimes heart attacks are sudden and there is no doubt what is happening, but those are the minority. Most heart attacks begin slowly with very mild discomfort and pain. The biggest mistake is when people aren’t sure and they wait too long to seek help. If you or anyone you know has the following symptoms, seek help immediately:
  1. Chest discomfort such as uncomfortable pressure, squeezing, fullness, or pain in the center of the chest lasting more than a few minutes, or that comes and goes
  2. Discomfort in other areas of the upper body including pain or discomfort in one or both arms, the back, neck, jaw, or stomach
  3. Shortness of breath
  4. A cold sweat, nausea, or lightheadedness
Women are more likely to have some of the other common symptoms, in particular back or jaw pain, shortness of breath, nausea, and vomiting. Even if you are not sure, it’s wise to call 911. If you are not able to access Emergency Medical Services (EMS), have someone else drive you to the hospital immediately. Never drive yourself unless there is no other option.

Are the symptoms of a heart attack the same for both men and women?
Women have the same symptoms as men but, are more prone to also have back or jaw pain, shortness of breath, nausea, and vomiting. You need to seek immediate medical help for any symptoms, not just the “classic” symptoms of a heart attack.

What Is Happening In Heart Attack?
The heart functions both mechanically and electrically. It pumps blood by contracting, which you are able to feel as a pulse—the mechanical function. The heart also has cells that regulate the mechanical system by transmitting electrical signals through conduction pathways, stimulating the muscle tissue to contract—the electrical function. The rate of electrical stimulation or pulses
normally correlates with the rate of heart-muscle contractions or beats, and should be between sixty and eighty times per minute at rest, increasing with exertion. The pumping chambers of the heart are the ventricles. If they suddenly stop effectively contracting and pumping blood into the body, Sudden Cardiac Arrest (SCA) occurs. The heart then has a disorganized and abnormal rhythm and spasmodic twitching called “ventricular fibrillation” (VF) that is ineffective in pumping blood to the body. The person in VF or V fib usually has no pulse because the heart is not pumping blood, and they will then become unresponsive, stop breathing, and die within minutes without intervention.

Choking occurs when an object gets stuck in the throat and partly or completely blocks the airway. Signs of choking include:
  • Pointing to throat, hands crossed on throat (universalsign of choking)
  • Gasping or coughing
  • Signs of panic
  • Difficulty speaking
  • Red face that steadily turns blue
  • Loss of consciousness
When you suspect someone is choking, ask her, “Are you choking?” If the person is able to answer you, don’t do anything because it’s likely that she will free the food or object on her own. In the case of actual choking, the person will not be able to talk and you need to help them.
Call 911 if the person can’t talk, make noise, or breathe well or is unconscious, then perform the Heimlich maneuver as outlined below. If the person is unconscious, lay her on her back. Check the person’s mouth for any visible obstruction and try to dislodge it using a finger sweep.
If you are unable to do so, begin mouth-to-mouth resuscitation and CPR. Continue to check inside the person’s mouth for any signs of the foreign body as the chest compressions of CPR may dislodge it.

Heimlich Maneuver
The Heimlich maneuver (pronounced Hi-mlick) is a technique whereby you administer abdominal thrusts to yourself or to a person who is choking. The Heimlich maneuver is recommended for use in clearing a blocked airway in conscious adults and children over the age of one; it is not meant to be used for choking infants under age one. The act of abdominal thrust lifts the diaphragm and forces air from the lungs, similar to a coughing action, so that the foreign body in an airway may be moved and expelled. (Click here for Heimlich Maneuver steps)

Managing Shock
Preventing and managing shock is a matter of life and death in emergencies. When the circulatory system stops working to deliver blood to the body, shock occurs. If the heart beats irregularly, if blood vessels become too dilated, or if a person is losing too much blood, shock may occur. The symptoms of shock are a weak and rapid pulse; disorientation; dizziness or confusion; cold, clammy skin and hands and pale skin; extreme thirst; nausea and vomiting; high level of anxiety; and fingernails that do not blanch with applied pressure (turn white when pressed and color does not return within two seconds).

If someone is in shock, elevate her legs, keep her warm,
and turn her head to one side if neck injury is not suspected

In emergency situations you must guard the person against shock. Call 911 for help immediately, because you cannot manage shock alone for long, and the person is likely to go into cardiac arrest. Check the ABCs continually while waiting for help and begin CPR if needed. If the head, neck, back, hips, or legs are not injured, lay the person on the ground facing up and elevate the legs to keep critical blood flow to vital organs. Use a towel, a sanitary napkin, or a piece of clothing to apply pressure to open wounds to slow bleeding. Keep the person calm, comfortable,
and warm, but never give the person water, even if they claim to be very thirsty. Monitor the person for consciousness and ABCs continually until help arrives.

[ source : The Everything First Aid Book by Nadine Saubers, R.N. ]

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