BASIC LIFE SUPPORT. CPR First Aid Choking AED BBP 2010 GUIDELINES STUDENT MANUAL PROFESSIONAL RESCUER EDITION. Health & Safety Training LLC

Transcription

1 BASIC LIFE SUPPORT CPR First Aid Choking AED BBP 2010 GUIDELINES STUDENT MANUAL PROFESSIONAL RESCUER EDITION Health & Safety Training LLC Matthew A. Carter

2 What is Cardiopulmonary Resuscitation (CPR)? Cardiopulmonary Resuscitation or CPR is an emergency medical procedure indicated in victims of cardiac arrest and in limited victims of severe symptomatic cardiovascular and circulatory compromise. A victim of cardiac arrest is defined as a person who is unresponsive, pulseless, and apneic or exhibiting agonal respirations. Agonal respirations are ineffective breaths produced with poor respiratory effort, volume, quality, or rate that are unsustainable of life. CPR technique typically includes external delivery of chest compressions and ventilations/breaths. CPR produces circulation in the absence of spontaneous cardiac output and allows for delivery of oxygen rich blood throughout the body. Effectively delivered CPR prolongs cellular death and may allow time for more definitive care to be delivered in a cardiac arrest situation.

3 THE SAD FACTS: Cardiopulmonary Resuscitation (CPR) Facts & Statistics The Sad Facts: There are approximately 383,000 out of hospital cardiac arrests each year in the United States. -88% occur in a private residential setting at someone's home. -50% of the time there is another person present or immediately available during the event. -6-8% survive. The number one reason for this terrible statistic is the lack of public CPR knowledge and training. Over 70% of Americans will have no idea what to do when a cardiac arrest strikes. The Life You Save: Statistically if you are to ever perform CPR outside of a professional setting the chances are you ll be at home. Paying it Forward: We ask you to consider who would be there to take care of you if you were the victim of cardiac arrest. Would they know what to do? If not - Share the knowledge. Knowledge is power and knowledge can make the difference between life and death. The life you help save, might be your own.

4 Personal Safety Your number 1 priority in any situation should be your own personal safety. You should never put yourself in extreme danger to help someone else. You can not do any good for anyone if you become injured or hurt. If you are uncomfortable or in fear for yourself immediately retreat to safety and await additional appropriate assistance. Nature of Emergencies & Staying Calm Emergencies by nature are stressful and take a toll on everyone involved. To be able to help someone else you must remember to remain calm. You must make rational decisions based upon processing rapid information related to the situation you're in without influence of emotion. Failure to remain calm and/or separate emotion may cause you to make poor decisions. These poor decisions may cost you or someone else their life. Calm rescuers equate to calm victims / bystanders. Emergency Preparedness Before an emergency happens is the proper time to start preparing for it. Once the situation occurs there is little opportunity for planning and organization. Evaluate today in your daily life how you would respond to common emergency situtations. EXAMPLE: What would you do if a coworker collapsed while at work? Do you know the address to your workplace? Do you have an AED or First Aid Kit available? If so, where are they located? Are you familiar with their contents and operations? Overcoming Hurdles: Persons faced with a cardiac arrest situation are often hesitant to provide care due to the fear of doing something wrong or making things worse. Remember that persons in cardiac arrest are clinncally dead. There is nothing you can do hurt them. Doing something is always better than doing nothing. The opportunity of survival you provide by providing CPR can mean the difference between life and death. REAL LIFE ADVICE: If you suspect someone needs CPR = Start CPR. If they don't move, wake-up, or tell you to stop = Continue CPR.

5 CALLING 911 ff presented with an emergency situation that exceeds your available resources or you're unsure what to do someone needs to call is a universal number across the United States that should connect you to your local Police/Fire/EMS dispatch center. When you call 911 remember to stay calm and answer each and every question asked to the best of your ability. Remember Who, What, Where, and How! WHO? This includes who you are and who needs help. WHAT? What is going on? This determines if a fire truck, police officer, or ambulance is needed. WHERE? Give the complete address if known. If not, describe the location by looking around and giving any information you can see. HOW to reconnect? Always give the telephone number in which you are calling from or can be reached at should you become disconnected. In addition the 911 dispatcher may ask you a seemingly endless list of questions. Try to remember to stay calm and patient when talking to a 911 dispatcher. Each question is important and helps deliver the most appropriate help to you and those in need. Based on your answers and the given situation the 911 dispatcher may help walk you through any steps that need to be completed before help arrives. Remember to listen carefully and do as instructed. Always ask questions if you do not understand what you are supposed to do. NEVER PUT YOURSELF IN DANGER. NEVER HANG UP FROM 911 UNLESS TOLD TO DO SO BY THE DISPATCHER. Know How To Use The Phone: If you have to dial 9, 7, or * to get an outside line may be 9911, 7911, or *911.

6 Cardiopulmonary Resuscitation (CPR) for Adults Quick Guide of Steps of CPR for Adults: Ensure Personal Safety Assess Victim (Tap and Shout) Assess Breathing Call 911/Get Additional Help Circulation: Begin Chest Compressions Airway: Open the Victims Airway Breathing: Provide Rescue Breaths Scene Assessment/Personal Safety: You must make your personal safety the top priority in any emergency situation. If you become injured or killed you will not be able to do any good for anyone else. You becoming injured will take resources away from the original victim possibly worsening their outcome. Things may not be as they appear. Evaluate the scene to make sure there is no risk to yourself. Never put yourself in a situation you are not comfortable with. Think BEFORE Acting/Responding. Evaluate the scene for clues, resources, and additional victims as you approach. Maintain situational awarenress throughout the event. Remember who's emergency it is. THERE IS NO WAY OF CHANGING THE PAST OR REVERSING WHAT HAS HAPPENED TO ANY VICTIM. YOU WANT TO MAKE THINGS BETTER - NOT WORSE. TRY TO REMAIN CALM. Assess the Victim: Upon finding a suspected victim of cardiac arrest you should assess the victim for responsiveness to determine the next appropriate action. To assess the victim, you should tap and gently shake the person to evaluate for signs of life. Physically shaking the vicitim is reqiured as the the vicitm may be hard of hearing or deaf. Yell at the vicitim: "ARE YOU OKAY?". Use appropriate volume and physical force that would awake the average person. Tap, Shake, Yell - Hey! Hey! Are you Okay? Remember that things may not be as they appear. Consider: Is every person found laying on a sidewalk or in a public place in need of CPR? They may be sleeping, under the influence of drugs or alcohol, homeless, or mentally ill. Assess before ACTING. Assess Breathing After Tapping/Shouting you should assess the victim for breathing. Remember Look, Listen, & Feel. Lower your head down and LOOK at the victims chest; LISTEN for sounds coming out the victims mouth and nose; and FEEL for movement on the victims chest. You should Look, Listen, and Feel for 5 to 10 seconds unless it obvious the victim is not breathing (Blue, etc.). If the victim is NOT breathing or breathing normally - you should continue with the steps of CPR.

7 Cardiopulmonary Resuscitation (CPR) for Adults Call 911 / Getting Additional Resources: If your assessment of the victim determines that they're unconscious & unresponsive or not acting appropriately, you must call 911 and/or obtain additional resources. If you fail to call 911 or obtain additional resources, you will be responsible for providing care indefinitely. An ambulance does not magically appear when someone is injured, hurt, or in cardiac arrest. You must remember to activate Emergency Medical Services (or other appropriate resources) as soon as possible. ABC's of Life: A = Airway, B = Breathing, C = Circulation - Now C.A.B. ABC is now CAB: CPR Compressions now are performed prior to opening the airway and giving breaths. Circulation: Chest Compressions The fundamental principle of CPR is that we want blood and oxygen circulating throughout the body at all times. Circulation equates to potentially prolonging and mitigating cellular injury and death. The primary intervention to be performed for circulation is Chest Compressions. Chest Compressions circulate blood and oxygen. When performing CPR with rescue breathing, give 30 compressions followed by 2 breaths (30:2 Compressions to Breaths Ratio). Transition from compressions to breaths and back to compressions as quickly as possible. Your goal should be to begin chest compressions within 10 seconds of discovery of the victim. Attempt to not interrupt compressions for more than 10 seconds, for any reason, unless absolutely necessary. Circulation: Checking For A Pulse: Layperson rescuers shouldn't check for a pulse while performing CPR. The average person has little practice in obtaining a pulse. Therefore it is unrealistic to expect accuracy during an emergency situation. You should assume that the vicitm is pulseless unless the vicitim wakes up or shows other signs of life. Healthcare providers may check for a pulse if they feel comfortable. If you check for a pulse and don't feel a pulse; or are unsure; begin the steps of CPR without delay. If a person is unresponsive, has a pulse, and CPR is performed: no ill effect or cardiovascular damage will occur (other than possible rib fracture). Therefore, always error on the side that the victim is pulseless when in doubt and begin CPR as soon as possible.

8 Cardiopulmonary Resuscitation (CPR) for Adults How to Perform Chest Compressions Make sure the victim is laying flat on their back, face up, on a HARD FIRM SURFACE. The floor is typically the best option in most situations. The transition of the victim from their location to the floor does not have to be a graceful one. You must get them on the floor (or other firm surface) as quickly as possible. Recognize that if the victim is not on a firm surface compressions will likely move the body up and down and not compress the chest (Visualize doing compressions on a water bed). Next, quickly remove any clothing covering the chest. This allows us to find the correct location to perform compressions and use an AED when it arrives. Locate the center of the chest, between the breasts and place the palm of one hand on top of the lower half of the sternum. Place the second hand on top of the first hand in a manner that is comfortable for you. You may overlay or interlock your fingers. Position yourself over the victim and use your entire body to push up and down on the persons chest. Keep you elbows locked and think of moving at the waist. This ensures you use your entire body to perform compressions. If you use your arms and not your body - your arms will become fatigued quickly and you will not be pushing at the right rate and depth. Compress the chest at the rate of at least 100 compressions per minute. Think of the beat of the song "Staying Alive" by the Bee Gees. The beat of "Staying Alive" is 100 beats per minute. If you match compressions with this song - you will be performing compressions at the right speed. Remember to pace yourself so not to get fatigued. After each compression, allow the chest to return to its normal position before compressing again. This chest recoil allows the heart to refill with blood and provide the most effective CPR possible.

9 Cardiopulmonary Resuscitation (CPR) for Adults How to Perform Chest Compressions If performing rescue breathing, perform 30 compressions, perform a head-tilt/chin-lift, give two rescue breaths (looking for chest rise and fall) and resume compressions as quickly as possible. If performing "Compression Only CPR" simply compress the chest at the rate of 100 compressions per minute without interruption or delay. Remember that when CPR is not being performed, blood and oxygen are not circulating, and cellular injury and death may occur.

10 Cardiopulmonary Resuscitation (CPR) for Adults How To Practice At Home Place a pillow flat on the floor. Visualize as demonstrated in the above picture. Place you hands near where the X is located. Practice compressing at the rate of 100 compressions per minute. Think "Staying Alive". Push Hard and Push Fast.

11 Cardiopulmonary Resuscitation (CPR) for Adults How to Perform Chest Compressions 2 Rescuers Present: If another rescuer arrives or is present during the rescue effort perform CPR as described above except you may alternate and switch roles as needed. One rescuer should perform 30 compressions and the second rescuer provide 2 rescue breaths. You should change roles every 2 minutes (or 5 sets of 30:2) or as needed to prevent fatigue. When working with another rescuer counting out loud when doing compressions will allow them to know when to give breaths. Teamwork is very important and each rescuer should evaluate the rescue effort and provide feedback as needed. Rib Fracture: While performing CPR rib fracture is common. You may feel ribs break. You may feel orhear bone rubbing on bone, or see free floating ribs on the victims chest. Chest compressions should continue without delay or modification. If the person survives the cardiac arrest their ribs will heal. Savining their life out weighs the risk of rib fracture. To perform chest compressions effectively: 1.) Push Hard and Push Fast. Pushing hard and pushing fast helps keep circulation moving. 2.) Continue CPR continuously without delay or pause unless absolutely required. Reasons to stop or pause CPR include: The person wakes up/shows signs of life, someone else takes over, to use an AED, or you can no longer continue. 3.) Aim for the rate of at least 100 compressions per minute. Think "Staying Alive". 4.) Compress at the depth of 2 inches (or 5 cm). Airway: Opening the Airway When a person becomes unconscious, they loose all muscle tone. The tongue being a muscle relaxes and may block the airway (trachea/windpipe) of the victim. The tongue is the most common cause of airway obstruction in an unconscious adult. To mitigate this and reopen the victims airway, we must perform a physical intervention to lift and move the tongue out of the way. The maneuver used to open a victims airway is called a head tilt/chin lift. With the victim laying face up on a hard firm surface place one hand on the forehead of the victim while grasping the bony portion of the chin with the other. Tilt the head and lift the chin at the same time. This lifts the tongue and creates a pocket for oxygen to travel. When you open the victims airway you may hear sounds of oxygen or gases escaping and/or may see fluid, vomit, or froth escape from the victims mouth. Anything blocked from the tongue in the trachea will potentially escape when the airway is opened. Do not confuse this with breathing or stop CPR if this occurs.

12 Cardiopulmonary Resuscitation (CPR) for Adults Airway: Opening the Airway Breathing: Rescue Breaths Rescue breaths are the process of giving artificial breathing to someone who isn't breathing on their own. When giving rescue breathing, give just enough air (volume) to see the chest rise. Giving too much volume may cause harm to the victim. Simply think of lungs as nothing more than balloons. If you over inflate/hyperventilate a balloon it pops; the same is potentially true with a human lung. In addition to causing injury to the lung from over inflation and hyperventilation - may cause air to enter the stomach which may induce or cause vomiting. Vomiting is dangerous as it may lead to aspiration and development of pneumonia if the victim survives. Breathing: Mouth to Mouth Mouth to Mouth breathing is considered the easiest and most readily available option as it does not require any special equipment to perform. Mouth to Mouth breathing is performed by opening the victims airway (head-tilt/chin-lift), covering the victims mouth completely with your mouth, pinching the victims nose (to keep the oxygen from escaping back out the nose), and giving a regular breath for about 1 second into the victim. When giving the breath you should see the chest rise. Let the victim exhale and give the second breath just as you did with the first breath. If you do not see the chest rise and fall with each breath, readjust the head, making sure you have the airway open and attempt the breaths again. If the breaths do not make the chest rise and fall for a second time - move on to circulation and compressions. Despite the typically low risks of exposure during mouth to mouth breath many people are hesitant to provide mouth to mouth breathing to someone who they do not know. Mouth to Mouth breathing risks are real and may expose the rescuer to viral infections such as H1N1, the Flu, or Herpes. Rescuers should use their judgment and internal comfort when considering who and when to provide rescue breathing.

13 Cardiopulmonary Resuscitation (CPR) for Adults Breathing: Mouth to Mask Mouth to Mask Breathing is the delivery of rescue breaths through a barrier mask to protect the rescuer from becoming exposed to the victims bodily fluids. Barriers devices such as a pocket mask should be used to provide rescue breathing when available and delivering rescue breaths. Pocket Masks are usually made of plastic and contain a one way valve designed to limit exposure to the rescuer to exhaled air, bodily fluids, and disease process. To use the mask, place it on the victims face with the pointy end over the bridge of the nose. Place one hand over the top of the mask holding it firmly on the face, Place the second hand on the bottom portion of the mask while grasping the chin; perform a head tilt/chin lift. Deliver breaths as in mouth to mouth breathing except place your mouth on the one way valve. Deliver each breath for about 1 second; looking for the chest to rise. Breathing: Rescue Breathing without Compressions: During a major medical event and sometimes prior to cardiac arrest, you may be faced with a victim who is not breathing or not breathing effectively but still is maintaining adequate circulation and perfusion. When faced with these types of situations if in your opinion the victim does not yet need CPR with compressions but exhibits any signs or symptoms of poor oxygen exchange, Rescue Breathing should be considered. To provide rescue breathing: (after contacting 911 or obtaining additional resources): 1.) Open the victims airway with a head-tilt chin-lift as in CPR; 2.) Give 1 Rescue Breath Every 5 to 6 Seconds for Adults OR Every 3 to 5 Seconds for Pediatric Victims. Be sure with each breath to witness the chest rise and fall. Count each second slowly (One- One Thousand, Two-Mississippi) between rescue breaths to avoid hyperventilation or gastric inflation (air getting into the stomach) which may induce vomiting. If while facing an emergency, you can not remember how often to deliver a Rescue Breath to a victim of any age: 1.)Remain Calm 2.)Focus on Your Own Breathing 3:)Provide a Rescue Breath to the victim each time you breath (You Breath - They Breath) until other trained help arrives.

14 Cardiopulmonary Resuscitation (CPR) for Adults Hands Only Cardiopulmonary Resuscitation (CPR) Compression Only Cardiopulmonary Resuscitation (CPR) Hands Only CPR / Compression Only CPR is a research tested alternative method of delivering CPR without rescue breaths. Rescuers during Hands Only CPR / Compression Only CPR should focus on continued non-stop effective compressions. How It Works: Hands Only CPR / Compression Only CPR works by primarily circulating the oxygen inspired by the victim prior to collapse. This preexisting oxygen is circulated during compressions to attempt to delay desaturation and cellular death. The success with Hands Only CPR / Compression Only CPR is variable upon the history of the victim and a variety of circumstances related to the cardiac arrest. Compressions may produce tidal inspiration/ exhalation providing some oxygenation. When to Perform: Hands Only CPR / Compression Only CPR is a viable alternative option for providing cardiac arrest care over doing nothing; and is perfect for situations in which you discover or witness a sudden cardiac arrest, have no barrier device, and you do not feel comfortable giving unprotected mouth to mouth ventilations. Hands Only Cardiopulmonary Resuscitation (CPR) Compression Only Cardiopulmonary Resuscitation (CPR) 1.) CALL ) PUSH HARD / PUSH FAST DOING SOMETHING IS ALWAYS BETTER THAN DOING NOTHING.

15 Cardiopulmonary Resuscitation (CPR) for Children & Infants Differences in CPR for Children & Infants: Defining a child: A child is a victim who is over the age of 1 and up to the age of puberty. Puberty for this context is defined as breast development in females and underarm or facial hair in males. Puberty is used as the establishment of adulthood as developmental changes may effect aspects of CPR. In addition to puberty the overall size of the victim should be considered due to the current epidemic of obese children in the United States. If the victim is the size of an adult - treat them as an adult and not a child - regardless of age or puberty status. Reason for Cardiac Arrest in Children/Infants: Children and Infants suffer from cardiac arrest typically as a result of a respiratory event such as choking or respiratory arrest. Not from a cardiac condition - It is uncommon to hear of a child or infant having a heart attack. Children and Infants typically do not have a history of high blood pressure, smoking, or other conditions that are applicable to adults. Due to children and infants likely going into cardiac arrest due to respiratory event, we must recognize that oxygenation and circulation need to be initiated as quickly as possible for these age groups. Hypoxia (or lack of oxygen inside the body) is a reversible cause of cardiac arrest. If oxygenation and circulation are performed quickly and effectively the cardiac arrest may improve or allow the person to recover. When to Call or Get Help for Children and Infants in Cardiac Arrest: Due to children and infants going into cardiac arrest most likely to respiratory cause; one must consider the value of outside resources in the life saving effort. You should recognize that time is the enemy, especially in pediatric victims, and delay in treatment or care may result in a poor outcome. The sooner care is initiated for a child or infant - the higher the chance of survivability. Therefore there are special guidelines for when to obtain or call 911 when faced with a pediatric cardiac arrest.

16 Cardiopulmonary Resuscitation (CPR) for Children & Infants If you are ALONE and FIND an infant or child in cardiac arrest: Perform the steps of CPR immediately without delay f or 2 minutes or 5 sets of 30:2 before leaving the pediatric victim to get help or call 911. Due to finding the child and the unknown time involved since collapse, delaying starting CPR may result in cellular injury or death. By performing the steps of CPR for 2 minutes or 5 cycles of 30:2, we circulate blood and oxygen potentially restarting the clock on a poor outcome. This allows us to build the pediatric victim back up with oxygenation before leaving to call 911 or obtain help without fear of causing more harm (at least for a few minutes). If you witness the pediatric victim collapse or have someone else around: Treat the victim as an adult. Get additional resources and Call 911 (or have someone else do it) immediately then return to the victim and begin CPR. Cell Phones: If you are alone and have a cell phone it may be possible to call 911 & begin the steps of CPR at the same time regardless if you witness the arrest or not. Remember that time is the enemy. ABC's of Life for Children (1 to Puberty): CAB - Compressions, Airway, Breathing Circulation: Same as an Adult. Remember to Push Hard and Push Fast. Do not hesitate or restrict compressions due to the smaller size of the child. Recognize that performing poor compression equates to poor circulation and cellular injury and death. Attempt to push 1/2 to 1/3 the chest depth of the child (approximately 2 inches). If the child is small in size, you may use one hand instead of two when performing compressions. You may use the second hand to maintain an open airway to allow for potential CPR induced ventilation; and stabilize the child from moving during compressions, if you prefer. Airway: Same as an Adult except look in the airway for a potential choking object that potentially could be removed. Breathing: Same as an Adult. If giving rescue breaths, give a lower volume of air when giving breaths. Give just enough breath to see the chest rise.

17 Cardiopulmonary Resuscitation (CPR) for Children & Infants ABC's of Life for Infants (Birth to Age 1): CAB - Compressions, Airway, Breathing Circulation: Compressions have to be performed differently for infants than they would be for larger children and adults due to their smaller size. To perform compressions on an infant, place the infant on a flat hard surface, face up, and locate the middle of the chest between the breasts. Place two fingers of one hand on top of the sternum about a fingers tips length below the nipple line. Place the second hand on the infants head to maintain an open airway and to stabilize the victim. Push on the chest using the two fingers at the rate of at least 100 compressions per minute at a depth of 1/3 the chest depth. If giving CPR with rescue breathing perform 30 compressions to 2 breaths (30:2 ratio). Airway & Breathing: Same as a Child. Automated External Defibrillators Automated External Defibrillator's (or AED's) are devices that treat the most common cause of sudden cardiac arrest by delivering a electrical shock to a persons body. What an AED treats is an abnormal heart rhythm called Ventricular Fibrillation (or V-Fib) that causes the heart to stop circulating blood. V-Fib is a heart condition in which the ventricles of the heart quiver instead of mechanically pumping. The most effective treatment for V-Fib is CPR and use of a defibrillator. The longer it takes for CPR and an AED to be used, the less likely a person is to survive V-Fib. CPR should be stopped and an AED applied and used as soon as it is available. Automated External Defibrillator s are designed to allow anyone to use them regardless if they have been formally trained on their operations. AED's accomplish this through use of voice instructions, pictures, and prompts. An AED will only deliver a shock if indicated and is safe when used correctly.

18 Automated External Defibrillators Quick Guide to Using an AED: 1.) Open AED and Turn Unit On. 2.) Attach AED Pads to victims bare chest. 3.) Ensure AED Pads are attached to AED. 4:) Follow Prompts of the AED. 5:) Clear the Victim when Analyzing and Deliver Shock if indicated. 6:) Continue CPR starting with Chest Compressions. 7.) Follow AED instructions until emergency personnel arrive.

19 Automated External Defibrillators AED's function by taking an EKG of the victims heart to analyze the electrical activity in an attempt to determine if the victim is in V-Fib or another heart rhythm. If the AED analysis indicated V-Fib, a shock will be indicated and may be delivered by the rescuer and AED according to the device's operating instructions. If the AED analysis finds any other rhythm than V-Fib - a "No shock" instruction will be issued - and the AED will not allow a shock to be delivered. Pad Placement: AED pads typically go around the heart and are placed on the upper right side of the chest below the collar bone and on the lower left side below the nipple line near the armpit. The electricity delivered by an AED will travel in both directions between these two pads in most modern AEDs. Rescuers using an AED must always listen to the instructions of an AED. The AED will advise not to touch the patient while it is analyzing the victims heart and again if a shock is indicated. If the victim is touched or moved during analysis, the AED may interrupt those movements and cause a potential false positive for V-Fib. If any person is touching the victim when a shock is actually delivered, they may receive some of the shock - which may cause injury or even death. If you are operating an AED: verbally yell and physically look head to toe to make sure no person is touching when the victim when the AED advises not to touch the victim. The electricity delivered by an AED during a shock stuns the heart in an attempt to stop the abnormal rhythm. This stunning of the heart may halt the abnormal ventricular quivering and allow the heart to recover back into a regular rhythm. An AED does NOT restart the heart or fix a "flat line" as often shown on television. A flat line represents that there is no heart electrical activity at all. A flat line usually represents clinical death as it is rare to recover from a flat line rhythm. Recognize an AED attempts to correct the electrical system of the heart that is malfunctioning - not jump start it. If an AED recognizes a "flat line" it will indicate "No Shock Advised" and instruct you to resume CPR. Shocking a flat line will NOT benefit the patient and will not be allowed by an AED. If a shock is indicated and delivered, the heart may take up to 10 minutes to recover from the cardiac arrest. Therefore, immediately after delivering a shock (or a "No Shock" indication) the rescuers must resume CPR with compressions to help mechanically get the heart beating again. Effectiveness of a shock is greatly affected by how well CPR is performed immediately thereafter. Do 5 sets of 30:2 or 2 minutes of CPR. The AED will automatically stop and give instructions exactly every 2 minutes. Repeat the process of operation and perform the tasks indicated by the AED. Remember when resuming CPR after AED usage to always begin CPR with chest compressions.

20 Automated External Defibrillators When a shock is delivered the victim will often convulse. You may also witness an arch of electricity travel across the victims body, smell burning hair or skin, or see smoke. This is normal as a large amount of electricity is entering the victims body. Continue with CPR and AED usage as indicated. Once an AED is placed, never remove the pads from the victims chest or turn the AED off until instructed to by trained healthcare professionals. If the victim wakes up or recovers they may suffer from V-Fib again and require additional AED treatment. Special Considerations When Using an AED: 1:) Hairy Chest: If the victim has a hairy chest you will need to remove the hair prior to placing the AED pads on the victims chest. You may do this with a razor that is typically found with an AED or by attaching one set of AED pads and pulling them off forcibly removing the hair. You should ensure you have another set of AED pads prior to using one set to remove hair or you may not be able to use the AED. Leaving hair in place may cause the AED pads not make contact with the patients chest and cause the shock to be ineffective. 2:) Medication Patches: If the victim has a medication patch on their skin in the area the AED pads are to be placed you must remove them prior to attaching the AED pads. Use gloved hands to remove the medication patch. Medications patches may divert the shock or represent a burn hazard if not removed. 3:) Covered in water: If the victim is covered in water or sweat attempt to dry the chest prior to applying the AED pads. Moisture may divert the shock from the heart. 4:) Implanted Pacemakers or Defibrillators: If the victim has an implanted pacemaker or defibrillator continue to use an AED as otherwise indicated for other patients. Ensure the AED pads are at least an inch away from the victims device prior to delivering a shock. You continue to use an AED as it is unknown if the implanted device is functioning correctly. An implanted pacemaker or defibrillator will look like a small lump underneath the skin usually on the upper left side of the chest near the heart. 5:) Pediatric Patients: An AED may be used for any victim of any age. Pediatric pads deliver a smaller shock and should be used if available when dealing with infants and children. If pediatric pads are not available, use the adult pads as long as they do not overlap or touch. You may place AED pads with one pad on the front and one pad on on the back of very small victims. It should be noted many AED's will not have pediatric pads due to financial and logistical reasons. 6:) Fully Automated AEDS: Fully automated AED's are devices they do not require a rescuer to push a button to deliver a shock to a victim once applied. It is imperative to always listen to an AED and follow the instructions given. If using a fully automated AED it may deliver a shock at anytime and pose injury or death to you or other rescuers if touching the victim when a shock is delivered.

21 Healthcare Provider CPR / Professional Rescuer CPR Considerations Healthcare Providers and Professional Rescuers when performing CPR should consider the following considerations: The mask supplied with a BVM is similar to that used in a pocket mask. With one hand use the thumb and index finger to grasp the mask. Place the thumb over the raised portion of the mask. This visually looks like the letter C. Standing at the victims head, place the pointed end over the bridge of the victims nose. Place the remaining three fingers on the victims chin. This visually looks like an E. This technique is called the EC clamp technique and is the preferred method of using a BVM. Use of BVM or Bag Valve Mask: A bag valve mask is a device that is commonly used in healthcare settings to deliver rescue breathing to person who is not breathing or is breathing ineffectively. A BVM delivers positive pressure ventilation and forces the volume of the air in the device into the victims lung. The device may be used with or without oxygen. If used with oxygen, high flow oxygen (greater than 12 liters per minute) should be used. Room air contains approximately 21% oxygen; with high flow oxygen attached to a BVM, approximately 90% oxygen is delivered with each breath. A BVM should be used in rescue situations with two or more rescuers. With the second hand attach the bag portion of the device to mask and squeeze the bag slowly - touching finger to finger to deliver the majority of the volume of air within the bag device. Upon delivering a breath and seeing the chest rise, slowly release the bag allowing it to refill while holding the mask firmly on the victims face. Deliver additional breaths as indicated. Do not hyperventilate or forcefully squeeze the bag. BVM's come in Adult, Pediatric, and Neonate sizes - You should use the most appropriate sized mask/device dependent on patient size.

22 Healthcare Provider CPR / Professional Rescuer CPR Considerations Checking for a Pulse: Healthcare Providers should check for a pulse if they feel comfortable before performing chest compressions on a suspected victim of cardiac arrest. For Adults and Children, a pulse should be assessed in the carotid artery for 5 to 10 seconds. The carotid artery is assessed due to it being central and likely to be palpable if a pulse exists. During cardiac compromise the body shunts circulation to the heart, lungs, and brain as they are most important for survival of life. Therefore it is possible a carotid pulse may be present while a peripheral pulse such as the radial may not. In an infant, a brachial pulse should be assessed as it will be larger and easier to evaluate. Ratio of Compressions for Infants and Children: Healthcare Providers should recognize that children likely are hypoxic and are in need of oxygen during CPR. Therefore, in a healthcare setting with two or more rescuers present, compressions should performed at the ratio of 15 compressions to 2 breaths instead of the traditional 30:2. By using 15:2, the victim receives breaths twice as frequent, increasing the overall oxygenation of the patient. This method is used when multiple rescuers are present to help reduce fatigue. If alone, use 30:2 until additional rescuers arrive. Compressions for Infants with two or more rescuers: Healthcare providers providing CPR to an infant in a healthcare setting may use an alternative technique to the standard two finger compression method. The alternative method is called the two thumbs encircling technique and allows for more effective compressions when working with another rescuer. The compressing rescuer encircles the infants body with both hands as in going to pick up the child. The rescuer compresses the chest while on a hard firm surface with both thumbs. The second rescuer delivers breaths every 15 compressions. The compressing rescuer never removes the hands from the victims body while breaths are being delivered to allow for immediate resumption of compressions. Advanced Airway: When an advanced airway such as an ET or Combitube is placed; CPR changes slightly. Compressions are performed at the rate of at least 100 compressions per minute without interruption and breathing is performed every 6 seconds (10 times per minute) continually. Compressions and breaths are performed simultaneously once an advanced airway is in place.

23 Choking Choking is a common medical occurrence and typically does not require emergency intervention. Rescuers should initiate care in cases of severe choking such as when a person is unable speak, makes the universal choking sign, or is turning blue. When witnessing someone believed to be in severe choking you should ask them if they are okay. If they are unable to respond, initiate care without delay. In adults the most effective way to relieve severe choking is to deliver abdominal thrusts by performing the Heimlich maneuver. The Heimlich maneuver uses abdominal thrusts to place force on the diaphragm simulating a coughing reflex in the choking victim to help expel the object. To perform the Heimlich maneuver stand behind the victim and wrap your arms around their abdomen. Create a fist with one hand and place the thumb side against the victim's stomach above the belly button but below the rib cage. Place your other hand over the fist and thrust inward, hard and fast, until the victim begins breathing or goes unconscious. ressure IF the victim goes unconscious and falls to ground, begin the steps of CPR with one exception. When opening the airway, look and see if you see an object inside the victims airway. If you see an object and you feel comfortable you may perform a finger sweep to attempt to remove the object. If you do not see something, are uncomfortable, or think you are unable to sweep the object out - do not attempt a finger sweep. Continue CPR until professional help arrives. The Heimlich maneuver can be applied to any person or child who is unable to stand. For children you should kneel down to perform abdominal thrusts. Pregnant & Large Adults: For persons who are pregnant or of large size, choking relief may have to be modified. Chest thrusts may be used instead of abdominal thrusts when faced with these situations. Hand technique should be the same with placement being moved to the middle of the chest on top of the sternum.

24 Choking Choking Relief for Infants: Choking relief for infants must be modified from the methods used on adults due to their small size. Signs of severe choking in infants include: inability to cry, grunting, nasal flaring, and cyanosis. To relieve severe choking in an infant, place the child face down on your arm while supporting the head with the palm of the hand. Perform 5 back slaps, striking the infant between the shoulder blades, with sufficient force to attempt to dislodge the object. Turn the child over and perform 5 chest compressions with the two finger chest compression technique. Repeat 5 back slaps and 5 chest compressions until the infant begins breathing normally or goes unconscious. If the infant become unconscious, begin the steps of CPR with one exception. When opening the airway, look and see if you see an object inside the victims airway. If you see an object and you feel comfortable you may perform a finger sweep to attempt to remove the object. If you do not see something, are uncomfortable, or think you are unable to sweep the object out - do not attempt a finger sweep. Continue CPR until professional help arrives.

25 Emergency First Aid First Aid is the initial medical care delivered to a person in emergency need before the arrival of more qualified rescuers and healthcare professionals. Anytime you provide first aid you should remember to protect yourself FIRST, then care for the victim. Your personal safety is the #1 priority. When providing care do your best with the resources available. Call 911 anytime you are unsure what to do or believe that the situation may be life threatening. Do want you can to make the situation better until other rescuers arrive and take over. Breathing Problems Any person suffering from severe difficulty breathing should be treated as if they are suffering from a potential life threatening condition. The body requires oxygen to work properly. Signs of severe breathing difficulty include: an inability to speak in complete sentences; has noisy breathing; irregular breathing rate, rhythm, or quality; or is turning blue. People with breathing problems will often sit in a tripod position. This allows them to breath easier and should be encouraged. Many people with chronic breathing problems will know about their condition and may be able to assist you in assisting them. You should call 911 anytime you suspect someone is having severe difficulty breathing or you are unsure what to do. Keep the person in a position of comfort and try to calm the person until help arrives. If they are on home or portable oxygen - increase the liter flow to the highest tolerated level. Allergic Reactions Allergic reactions can range from minor to life threatening. Many people have allergies to environmental substances, bee stings, and foods (such as peanuts). All allergic reactions have the potential to become life threatening. Signs of a serious allergic reaction include: red raised itchy skin, trouble breathing, swelling of the tongue and face, and loss of consciousness or altered mental status. If you believe someone is having a serious allergic reaction call 911 immediately, ask the patient if they have had this reaction in the past, and attempt to gain as much information as possible. Ask the patient if they have an EPI-Pen which can be used to help the victim. Be prepared to start the steps of CPR if needed. Gather as much information as possible to assist responding rescuers to help the victim. Epinephrine Pen: Some states and organizations allow first aid rescuers to assist or administer an EPI-Pen to a person who is experiencing a severe allergic reaction. An EPI-Pen is a spring loaded device that delivers a low dosage of epinephrine which will help the victim's condition from worsening until trained rescuers arrive.

26 Allergic Reactions Epinephrine Pen: Emergency First Aid To use an EPI-Pen remove the safety cap and follow the instructions printed on the EPI-Pen. As standard practice, never place your hand over either of the device to avoid getting stuck with the needle. Grasp the EPI-Pen in the palm of one hand and press the injection end hard in to the victims thigh below the waist and above the knee. The device is designed to go through clothing and into the victims body. Hold the EPI-PEN in place for several seconds so that all the medication enters the victims body. Rub the area of the injection to speed the absorption into the body. Properly secure the device in a sharps container if available or in a location so that no other person gets stuck by the exposed needle. Be sure to give the used EPI-Pen to EMS personnel when they arrive. Note the time the injection was given and continue to monitor the victim. Heart Attack A heart attack is a life threatening medical emergency in which the heart muscle suffers an event in which part of the heart is damaged or dies. A person having a heart attack may have chest discomfort, pain, or pressure; discomfort in the upper body including the arms, back, neck, or jaw; shortness of breath; cold sweat; nausea; or lightheadedness. The pain or discomfort is usually lasting. Pain is felt throughout the upper body as it is deferred from the brain as it may be confused as where the pain signals are coming from. Women, the elderly, and people with diabetes may have less obvious signs of heart attack. They may complain of not feeling well or become nauseous, sweaty, or short of breath without the classic chest discomfort.

27 Emergency First Aid Heart Attack: If you suspect someone is having a heart attack call 911 immediately. Many people suffering from chest discomfort may be in denial that are having a medical emergency. You must act quickly even if they fail to act for themselves. Time is again the enemy. Delays in seeking medical attention may limit medical treatments or lead to permanent injury or death. After calling 911 have the victim rest and not move or exert themselves. If there is an AED available bring it near the victim, monitor them, and be ready to start CPR and/or use an AED if needed. If you suspect someone is having a heart attack and they are not allergic to aspirin; you should have the victim chew two baby aspirin or one regular adult aspirin if available. Aspirin has proven to be beneficial during a heart attack. Chewing the aspirin instead of swallowing it helps get it into the bloodstream faster. Fainting: Fainting is an occurrence were an individual looses consciousness. Fainting may be an indication of a serious medical condition. Many times however a person faints after standing or moving too quickly; or after standing without moving for a long period of time. This occurs due the capacity of the heart not meeting the demand of the body and brain due to the effects of gravity. A fainting situation should be evaluated upon the factors related to the situation. If a person faints and regains consciousness & soon returns to normal - that person has likely experienced a non life threatening fainting episode. Usually the person recovers upon collapsing due to the appropriate return of blood flow to the brain. If a person collapses and doesn't start to feel better within a few minutes you should be concerned about other potential more serious causes. Evaluate the person and call 911 if you are unsure what to do. Have the person lay still and not to attempt to get up if dizzy or nauseous. Diabetic Emergencies: A diabetic emergency is a situation in which a victim is ill due to a problem with their blood sugar. Any victim with an altered mental status should always be evaluated for a potential diabetic emergency. Persons with diabetes are unable to properly regulate or manage their blood sugar levels. A victim may have high or low blood sugar. Most commonly persons who experience acute diabetic emergencies have low blood sugar. Therefore we assume that most people having signs of a diabetic emergency have low blood sugar and treat it accordingly.

28 Diabetic Emergencies: Emergency First Aid Low blood sugar may occur if a person has not eaten or has vomited; has not eaten enough food in proportion to their activity; or has mismanaged their insulin. Insulin is a hormone inside the body that is used to help turn sugar into energy. Some diabetics may have to inject insulin into their body to help regulate their blood sugar. Signs of a diabetic emergency include: a change in behavior, change in level of mental status, confusion, aggression, hunger, weakness, sweating, pale or other abnormal appearance. Persons suffering from a diabetic emergency will not act themselves and may have trouble communicating or speaking. If you suspect a person is suffering from a diabetic emergency and has low blood sugar you should act quickly and attempt to help to raise their blood sugar if possible. If the victim is able to sit up and swallow you should give the victim a beverage containing simple sugars; such as regular soda or orange juice. The simple sugars will help rapidly raise the victims blood sugar. To maintain an elevated blood sugar over time you should give the victim more complex sugars, carbohydrates, and proteins. A peanut butter and jelly sandwich is a great quick complex meal that will be broken down by the body into sugar over an extended period of time. If the victim does not respond or get better after being given sugars or is unable to speak, swallow, or sit up you should active 911 immediately. Some diabetics may become hostile or violent when having a diabetic related emergency. Use caution. Stroke Stroke is a condition in which the brain is deprived of oxygen and blood flow due to a clot or bleed inside the brain. A person suffering from a stroke will have neurological symptoms or deficits usually isolated to one side or part of the body. They may become confused, be unable to speak, or be disoriented. Many victims will be unable to use one side of their body. Often victims will have reported or complained of a headache prior to the event. If you think someone is having a stroke you should call 911 immediately. Time is very important as certain treatments can only be given in the first few hours of a stroke. Like heart attack, many victims will be in denial that they are suffering from a stroke. You as a rescuer must act if they fail to act for themselves.