Allina Emergency Medicine Education Healthcare Provider. CPR Study Guide. American Heart Association 2010 Guidelines

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1 Allina Emergency Medicine Education Healthcare Provider CPR Study Guide American Heart Association 2010 Guidelines The American Heart Association strongly promotes knowledge and proficiency in BLS< ACLS< and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association and any fees charged for such a course do not represent income to the Association Special Needs The sponsors of this course are fully committed to accommodating the special needs of participants and will do everything possible to do so for requests received in writing 14 business days in advance of the activity. Accommodations or special needs requested after that date cannot be guaranteed.

2 Healthcare Provider CPR --Study Guide C-A-B: C= Chest Compressions A= Airway B= Breathing ============================================================================= Healthcare Provider Basic Life Support Course Objectives for the 2010 Guidelines 1) Understanding the AHA ECC Adult Chain of Survival. The links in the AHA ECC Adult Chain of Survival are as follows; a) Immediate recognition of cardiac arrest and activation of the emergency response system. b) Early CPR with an emphasis on chest compressions. c) Rapid defibrillation. d) Effective advanced life support. e) Integrated post-cardiac arrest care. 2) How to perform CPR in a wide variety of in-and-out of hospital settings. a) Initiating the Chain of Survival b) Performing prompt, high-quality chest compressions for adult, child and infant victims c) Initiating early use of an AED (Automated External Defibrillator) d) Providing appropriate rescue breaths e) Practicing 2-rescurer team CPR f) Relieving choking 3) Describe the steps of CPR a) When to start, when to give breaths, including barrier devices, when to check for pulse b) How to give compressions at the proper depth and rate and with full chest recoil c) When to use an AED d) Describe the signs and actions for severe airway obstruction in the responsive and unresponsive victim 4) Critical Concepts for high-quality CPR a) Start compressions within 10 seconds of the recognition of cardiac arrest. b) Push hard, push fast: A rate of at least 100 compressions per minute. c) Allow complete chest recoil after each compression. d) Minimize interruptions in compressions. e) Give effective breaths that make the chest rise. f) Avoid excessive ventilation. 5) Describe the signs of 4 common life-threatening emergencies in adults: a) Cardiac arrest b) Choking c) Stroke d) Heart attack 6) Skills: a) Giving breaths for adult, child, and infant victims using i) Mouth-to-mouth ventilation ii) Mouth-to-mask ventilation iii) Bag-mask ventilation during 2-rescuer CPR only or when doing rescue breathing. b) Giving compressions for adult, child, and infant victims c) Performing 1-rescurer CPR and 2-rescuer CPR for adult, child and infant victims d) Using an AED for victims of all ages e) Relieving foreign body airway obstructions (FBAO) in the responsive an unresponsive victim of any age adult, child, infant Agonol Gasps---Not normal breathing. Agonol gasps may be present in the first minutes after sudden cardiac arrest. A person who gasps usually looks like he is drawing air in very quickly. The mouth may be open and the jaw, head or neck may move with gasps. Gasps may appear forceful or weak, and some time may pass between gasps because they usually happen at a slow rate. The gasp may sound like a snort, snore or groan. Gasping is not normal breathing. It is a sign of cardiac arrest in someone who doesn t respond. If a victim is not breathing or there is no normal breathing (only agonal gasps), you must activate the emergency response system, check the pulse and start CPR. Barrier Devices Personal protective device used to minimize your exposure to communicable diseases. Face shield devices utilize the rescuers mouth and the patient s mouth to create the seal. The rescuer needs to pinch the nose during ventilations with this device. These devices have a one- way valve and/or filter in the middle of the shield. Masks create a seal with the patients face, enclosing the nose so the rescuer does not need to pinch the nose. The masks have a non-rebreathing one-way valve, which should be used during mouth to mask ventilations. When ever possible a bag valve and oxygen should be used in conjunction with the mask.

3 Basic Life Support (BLS) Portion of Emergency Cardiovascular Care (ECC) that prevents respiratory and/or circulatory dysfunction through prompt recognition, intervention and early entry into the EMS system, or externally supports respiratory and/or circulatory system(s) through Cardiopulmonary Resuscitation (CPR). Cardiac Arrest---The heart stops pumping blood. It is a clinical diagnosis, confirmed by unresponsive, apnea (or agonal respiration), and the absence of a pulse. Compressions should be initiated within 10 seconds of recognition of the arrest. Child: for healthcare provider a child is defined as age 1 yr to onset of puberty. Signs of puberty include chest or underarm hair on males and any breast development in females. CPR rates and ratios Rates Adult: at least 100 compressions/minute Child: at least 100 compressions/minute Infant: at least 100 compressions/minute Ratios - each set of 30 compressions should take approximately 18 seconds or less. Adult - 1-rescurer and 2-rescuer: 30:2 Infant and Child - Single rescuer 30:2 Infant and Child two rescuer 15:2 Coronary Artery Disease (CAD) Includes cardiac and vascular disease. Leading cause of death in the United States. Angina is a common symptom of CAD and; Is a pain or discomfort caused by a temporary lack of blood flowing to the heart muscle Might be an early warning symptom of a heart attack May present as a pressure, crushing, or squeezing feeling. May be located in the center of the chest behind the breastbone, or may spread to or originate in either the shoulder, the neck, lower jaw or either arm. The duration usually lasts more than a few minutes. May be intermittent. Other signs may include; Fainting Sweating Nausea Shortness of breath Call 911 or code for cardiac arrest or the local emergency number if someone is experiencing any or all of these symptoms. Depth of Compressions Adult heel of 2 hands compress on lower half of the breastbone should be compressed at least 2 inches (5cm). Child heel of hands (1 or 2 hands) on center of victim s chest should compress at least 1/3 of the anterior-posterior depth of the child s chest or, at least 2 inches (5cm). Infant 2 fingers compress at least 1/3 the anterior-posterior depth of the infant s chest, at least 1 ½ inches (4cm). Emergency Medical Services (EMS) EMS is the system of emergency medical response to sudden illness or injury. This is the first link in the chain of survival. Respiratory Arrest Characterized by absent or agonal gasping respiratory effort. Possible causes include; Drug overdose Stroke Cardiac arrest Trauma

4 Rescue Breathing (for victims who have a pulse but are not breathing) Adult - 1 ventilation every 5 to 6 seconds (10 to 12 per minute) Infant and Child - 1 ventilation every 3 to 5 seconds (12 to 20 per minute) Breaths should be given at a rate of 1-breath per second and result in visible chest rise. Check pulse every 2 minutes. Risk Factors Identify characteristics that may lead to heart disease, a heart attack, or a stroke. Some risk factors can be modified and others cannot. Major risk factors include-- Smoking High blood pressure High cholesterol Risk factors that can not be changed--age, Gender, Heredity Stroke The third leading cause of death in the United States and the leading cause of disability. Results from the blockage or rupture of a blood vessel. Most strokes are caused by a blood clot in an artery in the brain. Symptoms may include; Sudden weakness or numbness of the face, arm, or leg on one side of the body. Loss of speech, unexplained dizziness, unsteadiness, dimness or loss of vision, or loss of consciousness. Call 911 or code for cardiac arrest or your local emergency access number if your recognize someone experiencing these symptoms. CPR Sequences--- C-A-B if rescuer is alone Check that the scene is safe. Assesses victim (assessment and activation must be completed within 10 seconds of arrival at scene). Checks for unresponsiveness by tapping and shouting (this MUST precede starting compressions). Checks for no breathing or no normal breathing (only gasps) Activates emergency response system (EMS) Adult Call for help (activate the EMS system) and get the AED. Child If you did not witness the arrest: Provide 2 minutes (5 cycles) of CPR before leaving the child to activate EMS and get the AED. If the arrest is sudden and witnessed: Leave the child to activate EMS get the AED and then return Infant to 1 year of age. Call for help (activate the EMS system) and get the AED after 2 minutes (5 cycles) of CPR. Checks for pulse: Pulse check-take NO MORE THAN 10 SECONDS Check carotid artery on adult and check carotid or femoral artery on a child. If there is a pulse in a child but it is less than 60 bpm (beats per minute) with signs of poor perfusion start CPR. Check the infant s brachial pulse. If there is a pulse in an infant but it is less than 60 bpm (beats per minute) with signs of poor perfusion start CPR. Delivers high-quality CPR (initiates compressions within 10 seconds of identifying cardiac arrest for Adult) Chest Compressions - Hand Placement Adult and child Put heel of one hand on the center of the victim s chest on lower half of the breast bone (between nipples). Put heel of other hand on top of first hand. Use 2 hands on an adult & 1 or 2 hands on a child. Infant Place 2 fingers in center of infant s chest just below the nipple line (two-finger chest compressions). Compression rate of at least 100/minute. Adequate depth for age (refer to depth of compressions). Complete chest recoil after each compression. Minimizes interruptions in compressions. Airway Open the airway using the head-tilt/chin-lift method. If neck injury is suspected use the jaw-thrust maneuver. Breathing Give 2 breaths - delivering each breath over 1 second. Delivers breaths that produce visible chest rise. Avoids excessive ventilation. If unable to ventilate, first reposition the head and try again. If still unable to ventilate go to obstructed airway procedures. Spend no more than 10 seconds on breathing before returning to compressions.

5 2-Rescurer BLS/CPR -- Team approach to CPR (Rescuers can perform several actions simultaneously) Second rescuer comes in and takes over compressions while the first rescuer ventilates. Use a compression-to-breaths ration of 30:2 in Adults. Use 15:2 compression-to-breaths ratio in children & infants. The 2 thumb-encircling hands chest compression technique is preferred if hands can fit around the infant s chest. Adults - switch after every 5 cycles (30:2) of CPR (about every 2 minutes) taking no more than 5 seconds to switch. Children & Infants switch after every 10 cycles (15:2) of CPR (2 minutes) taking no more than 5 seconds to switch. Automated External Defibrillator (AED) for Adults, Children and Infants Assess the victim for response and look for normal breathing or abnormal breathing (agonol gasps). If there is no response and no breathing or no normal breathing (only gasping), shout for help. If you are alone, activate the EMS and get an AED (or defibrillator) and return to the victim. Check the victims pulse (take at least 5 seconds but no more than 10 seconds) Check for pulse, if no pulse, start compressions-continue until ready to apply the AED electrode pads. Patient must be apenic and pulseless before using the AED. Power on the AED by either pushing the power button or on some models by lifting the lid. Attach AED pads (electrodes) to bare chest. Place one AED pad on the victim s upper-right chest (directly below the collarbone. Place the other AED pad to the side of the left nipple, with the top edge of the pad a few inches below the armpit. Attach the AED connecting cables to the AED box (some are pre-connected). Clear the victim and ANALYZE the rhythm. Analyze the rhythm-this will begin when the AED senses a solid connection from the electrodes or in some models after pushing the analyze button as directed. Make sure no one is touching the patient while doing so. With 2-rescuer CPR - switch when the AED is analyzing the victim. If shock is indicated AED will begin to charge. Loudly state to bystanders and rescuers that they should be All Clear, while checking from head to toe that no one is touching the patient. Press the shock button when all people are clear of patient. Begin CPR starting with compressions until the patient regains consciousness or help arrives and takes over. If no shock advised is indicated immediately begin CPR, starting with chest compressions. If pulse is present check for breathing, give rescue breathes if needed. AED s should be used on children ages 1-8 when the child remains breathless and pulseless after 5 cycles of CPR or when rescuer witnesses a sudden collapse. An AED with a pediatric dose-attenuator system should be used if available. If an AED with a dose attenuator is not available, a standard AED may be used. For infants (<1year of age), a manual defibrillator is preferred. If a manual defibrillator is not available, an AED with a pediatric dose attenuator is desirable. If neither is available, an AED without a dose attenuator may be used. Remove all clothing that may get in the way of placing the electrodes. Remove hair on chest where the electrodes will be placed with a razor if available. Remove medication patches in the area where you are going to place the electrodes. Remove patient from wet or metal surfaces before shocking. CPR With an Advanced Airway (endrotracheal intubation, laryngeal mask airway, supraglottic) Compression rate of at least 100/min without pauses for breaths. 1 breath every 6 to 8 seconds (8 to 10 breaths per minute). Complications and trouble-shooting Trauma from CPR (even when CPR is properly performed) Fractures of the ribs and /or sternum Punctured lungs, Abdominal injuries, Heart contusion Gastric inflation is most likely to occur if the rescuer gives breaths too quickly or with too much force. Turn the victim on their side if they start to vomit. Clear mouth and return to CPR. You may stop CPR when; The victim responds- you regain a pulse (circulation). You turn the care of the victim over to another responsible and qualified individual. You are exhausted and unable to continue. A physician tells you to stop. Spontaneous return of circulation If the victim regains a pulse, continue to maintain an open airway and ventilate if needed. Place victim in the recovery position if the victim is breathing and has a pulse continue to monitor the effectiveness of their breaths and circulation. Infant and Child factoid Infants & children who develop cardiac arrest often have respiratory failure or shock that reduces the oxygen content in the blood even before the onset of the of the arrest. For this reason, it is important to give both compressions and breaths for infants and children during CPR.

6 Relief of Choking - Obstructed Airway If a victim has a partial airway obstruction with adequate air exchange, encourage the victim to cough do not perform the abdominal thrusts (Heimlich maneuver) at this time. Abdominal thrusts (or Heimlich maneuver) on a responsive choking adult or child victim should be done in the middle of the abdomen, slightly above the navel and not over the ribs (placement for the child is the same, only using less force) Chest thrusts should be used instead of abdominal thrusts on choking victims if they are markedly obese, history of recent abdominal surgery, or in the late stages of pregnancy. If the victim becomes unresponsive begin CPR with compressions, checking the mouth before every cycle of breaths, if the object is visible use your fingers to remove it. DO NOT do a blind finger sweep. Activate EMS after 2 minutes. Relieving choking in a responsive infant - Deliver 5 back slaps and 5 chest thrusts until the object is removed or the infant becomes unresponsive. If you can see and reach the object, use a finger sweep or plucking to remove. When a infant becomes unresponsive - Begin CPR (starting with compressions) with 1 extra step: each time you open the airway, look for the obstructing object in the back of the throat. If the object is visible use a finger sweep or plucking to remove the object DO NOT do a blind finger sweep. After two minutes or 5 cycles of CPR (C-A-B), activate EMS (if no one has done so). Obstructed Airway Continued --- Most common cause is of obstruction in an unconscious person is the tongue. Other causes may include - Aspiration of foreign bodies, spasms of the vocal cords, inflammation of the trachea or other structures of the airway, laughing and talking while eating. Signs of Severe Airway Obstruction are poor or no air exchange, weak cough or no cough at all, high-pitched noise while inhaling or no noise at all, increased respiratory difficulty, possible cyanosis (turning blue), unable to speak, clutching neck with the thumb and fingers (making the universal choking sign). Good Samaritan law (604A.01 Good Samaritan law.) Subdivision 1. Duty to assist. A person at the scene of an emergency who knows that another person is exposed to or has suffered grave physical harm shall, to the extent that the person can do so without danger or peril to self or others give reasonable assistance to the exposed person. Reasonable assistance may include obtaining or attempting to obtain aid from law enforcement or medical personnel. A person who violates this subdivision is guilty of a petty misdemeanor. Subdivision 2. General immunity from liability. (a) A person who, without compensation or the expectation of compensation, renders emergency care, advice, or assistance at the scene of an emergency or during transit to a location where professional medical care can be rendered, is not liable for any civil damages as a result of acts or omissions by that person in rendering the emergency care, advice, or assistance, unless the person acts in a willful and wanton or reckless manner in providing the care, advice, or assistance. This subdivision does not apply to a person rendering emergency care, advice, or assistance during the course of regular employment, and receiving compensation or expecting to receive compensation for rendering the care, advice, or assistance. (b) For the purposes of this section, the scene of an emergency is an area outside the confines of a hospital or other institution that has hospital facilities, or an office of a person licensed to practice one or more of the healing arts under chapter 147, 147A, 148, 150A, or 153. The scene of an emergency includes areas threatened by or exposed to spillage, seepage, fire, explosion, or other release of hazardous materials, and includes ski areas and trails. (c) For the purposes of this section, "person" includes a public or private nonprofit volunteer firefighter, volunteer police officer, volunteer ambulance attendant, volunteer first provider of emergency medical services, volunteer ski patroller, and any partnership, corporation, association, or other entity. (d) For the purposes of this section, "compensation" does not include payments, reimbursement for expenses, or pension benefits paid to members of volunteer organizations. (e) For purposes of this section, "emergency care" includes providing emergency medical care by using or providing an automatic external defibrillator, unless the person on whom the device is to be used objects. "Automatic external defibrillator" means a medical device heart monitor and defibrillator that: (1) has received approval of its pre-market notification, filed pursuant to United States Code, title 21, section 360(k), from the United States Food and Drug Administration; (2) is capable of recognizing the presence or absence of ventricular fibrillation or rapid ventricular tachycardia, and is capable of determining, without intervention by an operator, whether defibrillation should be performed; and (3) upon determining that defibrillation should be performed, automatically charges and requests delivery of an electrical impulse to an individual's heart. HIST: 1994 c 623 art 2 s 1; 1995 c 205 art 2 s 8; 1998 c 329 s 1 Copyright 1999 by the Office of Revisor of Statutes, State of Minnesota.

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