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Cardiopulmonary resuscitation

CPR or Cardiopulmonary resuscitation is an emergency first aid procedure to
help someone who has lost their ability to breathe and their pulse, ie:
their heartbeat. It is a response to a condition known as cardiac arrest, in
condition which heartbeat and breathing have stopped. Cardiac arrest is a
condition nearly everyone experiences in the last few minutes of life, after
drawing their last breath, and refers to a period in which the heart muscle
still has some residual life in it and may sometimes be brought back to
normal functioning by emergency techniques. CPR is appropriate for otherwise
healthy persons experiencing sudden cardiac death, due perhaps to massive
heart attacks or heart rhythm disturbances, and can keep the victims alive
until emergency personnel arrive. It is also used effectively for victims of
drowning, electrocution or choking, or those suffering from drug or other
substance overdoses. CPR is commonly taught to ordinary people who may be
the only persons present in the crucial few minutes before emergency
personnel are available.

CPR is not usually effective on its own. When someone has lost their
heartbeat (cardiac arrest), the most effective remedy is a technique known
as "defibrillation", using an electronic shock to try to restore the correct
heart rhythm. However, in cases in which the victim has gone into
respiratory arrest but still has a heartbeat (as might happen in drowning,
choking or overdosing on depressive drugs such as opiates or tranquilizers)
the rescue breathing part of CPR is a certain life saver.

In cardiac arrest, CPR can keep the victim "viable" for a few extra minutes,
to allow the arrival of a defibrillator on the scene. When CPR is started
within minutes of the victim's collapse, and when a defibrillator is used
within ten minutes of the victim's collapse, the save rate is about a third.
CPR is almost never effective on a victim after more than about 15 minutes
after collapse, due to brain damage, except in some cases of "hypothermia" -
cardiac arrest due to overexposure to cold temperatures. The cold seems to
exert a protective effect on the victim and there are instances of
hypothermia victims being revived through CPR, defibrillation and advanced,
hospital-based warming techniques, after a half an hour or more.

CPR was first promoted as a technique for the public to learn in the 1970's.
Early marketing efforts oversold the effectiveness of CPR in rescuing heart
attack and other victims. The standards for CPR, in the United States, are
established by the American Heart Association. Re-written every several
years, most recently in 2000, these standards now have a more conservative
view of the potential of CPR as a bystander intervention, and now stress
defibrillation as the more definitive intervention.

FIRST send someone to call for help using the Emergency telephone number
(911 in the US and Canada, 112 in Europe) to activate the emergency medical
services. CPR can only buy time to apply advanced cardiac life support.
Without advanced cardiac life support, CPR is useless. If you are alone,
administer one minute of CPR -- use 1 to 2 minutes to call for help -- then
return and continue CPR until help arrives.

Three simple steps to CPR

AIRWAY

Try to get a response by shaking and yelling at the victim. If there's no
reaction, place victim flat on his or her back on a hard surface. Open the
victims' airway by tilting their head back with one hand while lifting up
their chin with the other hand. If there is a chance of neck injury just
lift up the chin. Tilting of the head in the presence of injury to the spine
or the neck could result in further injury to the spinal column.

BREATHING

(also known as "rescue breathing")

Put your cheek close to the victims' nose and mouth while looking at the
victims' chest, to

look, listen, and feel for breathing (5-10 seconds) If there's no breathing,
pinch victim's nose closed and breath two full breaths into the victim's mouth.

If breaths won't go in, reposition their head and try again to give breaths.
If the airways are still blocked, perform abdominal thrusts (Heimlich
maneuver). In the event the head tilt/chin lift maneuver was not performed
due to suspected neck/spine injury and the breaths do not enter the lungs,
head tilt/chin lift should be done anyway.

CIRCULATION

Check for a pulse by feeling for 5-10 seconds at side of the victims' neck.

   * If there is a pulse but the victim is not breathing, give breaths at
     rate of 1 breath every 5 seconds (12 breaths a minute).
   * If there is no pulse, begin chest compressions as follows. The
     compressions will pump blood around manually until hopefully the body
     can take over:

     Kneel next to the victim's chest. To find the correct hand position,
     place the heel of the hand closest to the feet on the lower part of the
     ribcage. Place your other hand on top of the first. You can either
     interlace your fingers or keep them straight, but to avoid injuring the
     ribs, only the heel of your hand should touch the chest.

     Shift your weight forward on your knees until your shoulders are
     directly over your hands and your elbows are locked. Bear down and then
     come up, bear down and come up, keeping your elbows locked. In order to
     create enough pressure to circulate the blood, you must depress the
     chest of an average adult 1 1/2 to 2 inches with each compression.
     You should compress the chest at a rate of 80-100 times a minute. To
     get the right speed and rhythm, count out loud as you do the
     compressions, saying "1 and 2 and 3 and three and four and five!" Rest
     on each "and," then compress on each number. Each series of 5 should
     take about 3 seconds.

     After each 15 compressions (counting to 5, 3 times), perform 2 rescue
     breaths. Take your hands off the chest, place them on the chin and
     forehead as before, pinch the nose, seal the mouth, and give 2 strong
     breaths, watching out of the corner of your eye for the chest to rise.
     Also have someone check for you if possible.

     Go back to the chest, find the correct hand position again, and do 15
     more compressions, followed by 2 more breaths. Repeat this cycle of 15
     and 2 for a total of 4 times, which takes about 1 minute. Then check
     again for pulse and breathing. If neither has returned, you must
     continue alternating compressions and breathing until the patient
     revives, qualified help comes, or you are too exhausted to continue.

Common mistakes in performing chest compressions include rocking back and
forth and bending the elbows. It is also important to note that,
particularly in elderly patients, crepitations will often occur.
Crepitations are the shattering of bones in the rib cage and sternum. They
can be both heard and felt.

CPR for children age twelve months to eight years

Children have less lung capacity and a somewhat faster respiration rate.
Also, compressions should be considerably less forceful than those used on
adults.

The sequence of CPR for children is as follows:

1. ESTABLISH UNRESPONSIVENESS (4-10 SECONDS)

You must quickly determine if injury is present and determine consciousness.
If head, neck, or spinal injury is suspected, great care must be exercised
in positioning the child on her back on a firm flat surface. Turn and
position the child, supporting the head and neck to avoid spinal cord injury
caused by rolling, twisting, or tilting the head and neck.

A conscious child struggling to breathe will often find the best position to
keep a partially obstructed airway open and should be allowed to maintain
that position until medical help is available. If the young victim is
unresponsive, position the child or infant on the back on a firm, flat
surface and begin CPR.

Call for help after conducting CPR for 1 minute as below. If the child is
conscious but suffering respiratory distress, do not waste time on CPR
maneuvers but get the child to medical help as soon as possible.
(Unresponsive children should receive CPR as they are rushed to the
hospital.)

2. OPEN THE AIRWAY AND CHECK FOR BREATHING (3-5 SECONDS)

If you are certain the child has not suffered a spinal injury, place your
hand on the child's forehead and gently tilt the head slightly backward.

Augment the head tilt by placing 1 or 2 fingers from the other hand under
the chin and gently lifting upward (see figure 13.13). If you are not sure
whether the child is breathing, while maintaining an open airway place your
ear near the child's mouth and listen for breathing, look at the chest and
abdomen for movement, and feel for air flow from the mouth. If the victim is
breathing, maintain the airway; if no breathing is detected, CPR must
proceed.

3. BREATHE FOR THE VICTIM (3-5 SECONDS)

While continuing to maintain an open airway, take a breath in, then hold it,
open your mouth, and seal it over the mouth of the victim.

Remember that an infant will need much less air than a larger child. A
proper amount of air will move the chest up and down between breaths. A
slow, deliberate delivery will reduce the likelihood of forcing air into the
stomach, causing distention.

Rescue breathing is the single most important maneuver in rescuing a
nonbreathing child or infant. If repeated rescue breathing attempts do not
result in airflow into the lungs, evidenced by chest movement, a foreign
body obstruction should be suspected.

4. CHECK FOR PULSE (5-10 SECONDS)

In children over 1 year the heartbeat can be felt at the side of the neck.
While maintaining the head tilt with one hand, find the windpipe at the
level of the Adam's apple with two fingers of the other hand. Slide the
fingers into the groove between the windpipe and neck muscles, as for
adults. If no pulse is felt, proceed with chest compression and rescue
breathing as below.

If a pulse is felt but there is no breathing, initiate and continue rescue
breathing 15 times a minute for a child.

5. CALL EMERGENCY

If someone is available to help, have him call as soon as possible. If you
are alone, complete 4 cycles of rescue breathing, or of breathing and chest
compression, before taking time to call for help.

6. CHEST COMPRESSIONS

The child must be on her back on a firm surface such as the floor.

If the child is over 1 year of age, compression is applied to the breastbone
by the heel of one hand, located in the midline, 2 fingers'-breadth above
the tip of the breastbone. With one hand, the chest is compressed to a depth
of 1 to 1 1/2 inches at a rate of 80 to 100 compressions per minute, as for
an adult. Compression and relaxation time should be equal and the rhythm
smooth and even. The fingers must be kept off the chest.

External compression should be accompanied by rescue breathing in a 5:1
ratio of compressions to ventilation breaths for an infant or child.
Continue compression and rescue breathing until the child revives, help
arrives, or you become too exhausted to continue.

CPR for infants

Infants under twelve months of age have significantly higher pulse and
respiration rates than adults. CPR must be modified significantly to account
for the differences.

Tilting the head and lifting the chin will not work in infants, as they have
little or no neck. The infant should be cradled in the dominant arm, with
the head resting in the rescuer's palm. As in children, the
respiration/compression ratio should be 5:1, not 15:2 as in adults.
Respirations are easiest if performed with the mouth covering the entire
nose and mouth, given in short puffs of air and not full exhalations. Chest
compressions must be swiftly performed, with two fingers bearing down on the
sternum at the nipple line (where a line between the two nipples meets the
sternum, halfway between both).



Continue CPR until help arrives or your life is placed in danger by
continuing to perform CPR.

Also note that it may be inappropriate to perform CPR in a disaster or
triage situation with mass casualties.

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