CPR/AED for the Professional Rescuer Renewal
SELF STUDY EDITION (INCLUDES TEST)
The objective of this course is to familiarize you with the steps involved in providing
basic life support during emergencies along with rationales for these steps.
This course is the first step of a two-step process for renewing your professional-level
CPR certification. Step two is signing up and completing a hands-on training session.
After completing this course and the hands-on training, you'll be prepared to contribute
in important ways to the health and well-being of your patients, your family and the
community.
This course follows ILCOR and American Heart Association(R) 2005 Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. University of Minnesota Physicians BLS programs are administered through American Safety
and Health Institute (ASHI) and taught by certified instructors and certified instructor trainers.
Contents

Professional Rescuer Role and Responsibilities

Initial Assessment

Breathing Emergencies
o Rescue Breathing: adult, child, infant

Using a BVM

Airway Obstruction
o Conscious: adult, child, infant
o Unconscious: adult, child, infant

Acute Coronary Syndromes and CPR
o One Rescuer: adult, child, infant
o Two Rescuer: adult, child infant

Using an AED
o Adult and child

Summary
Authors: MWalsburg and MGross
© University of Minnesota Physicians
PROFESSIONAL RESCUER ROLE AND RESPONSIBILITIES
What is a professional rescuer?
A professional rescuer is anyone who may be called upon to provide basic life support during the
course of employment.
What is the difference between a professional rescuer and a lay rescuer?
The distinction is largely legal. Professional rescuers have a legal duty to provide care in the event of
an emergency.
Professional rescuers often provide leadership in emergencies. Most emergency situations are
chaotic. The leadership provided by a professional rescuer is essential to ensuring that the victim
receives proper, coordinated care and that others remain safe.
What if I help with an emergency outside of work?
In that case, you are legally considered a lay rescuer even if you use your great skills.
What happens if I take over for another rescuer?
If you are acting as a professional rescuer and you arrive at a situation in which a lay rescuer has
begun to provide care, you must conduct your own assessment. You can never rely on the
assessment performed by a lay rescuer. However, if you arrive at a scene where another professional
rescuer has started care, you can join in that care.
RESPONSIBILITIES
As a professional rescuer, you are expected to meet an appropriate standard of care when providing
basic life support. It is your responsibility to review your skills often enough to be proficient in
providing these skills when needed. It is also your responsibility to maintain current certification.
LEGAL ISSUES
It is important for you to understand the legal issues surrounding the
provision of basic life support services. As a professional rescuer,
provision of basic life support care is within your scope of practice. You
have a legal duty to act and must meet the appropriate standard of
care. Failure to do so may result in legal action for negligence. When
acting as a professional rescuer, you are not covered by the Good
Samaritan law.
Duty to act means that you may be called upon to provide basic life support services within your
duties on the job.
Scope of practice refers to the set of skills you have acquired through your training in school as well
as any ongoing training on the job. You are limited to providing only that care which is within the
scope of practice for your profession and your experience level.
Standard of care involves the range of correct ways to perform particular tasks and provide care. All
caregivers are required to practice within the accepted standard of care.
Negligence results when a caregiver fails to provide required care, fails to meet the standard of care
or acts outside the scope of practice.
Abandonment charges result when caregivers terminate care prematurely. Continue care until you
are relieved by another professional rescuer. Even if the victim appears to recover, continue to
monitor his or her condition until more advanced help arrives.
Good Samaritan Law exists in every state in the country. This law protects all people acting as
laypeople from ordinary liability charges when providing emergency care. In the state of Minnesota,
this law requires all people to at least act as "prudent laypeople,"--that is, all people should at least
call the emergency response number if they are aware of an emergency. People should also attempt
to give care they know how to give. Minnesota law has additional requirements for anyone who may
have caused the emergency (as in a car accident). Anyone involved in the emergency who is not hurt
is required to provide whatever care they know how to provide and they must remain on the scene
until an ambulance arrives.
CONSENT
Obtaining Consent
If the victim is conscious, you must always obtain consent before touching him or her. Say, "I'm
trained in first aid, can I help?" and wait for a reply. For children, request consent from a parent or
guardian. If no parent or guardian is around, don't delay care--consent is implied.
For unconscious, very confused or seriously injured people, consent may not be possible. In that
case, consent is implied.
Refusal of Care
At times, even the most seriously injured or ill person may refuse care. In that situation, you have a
few options:



Try to reason with the person, explain who you are and what is happening. Give reassurance.
This may convince the person to trust you and allow you to provide care.
Even without consent, always activate the EMS system and continue to monitor the victim until
the ambulance arrives.
If the person loses consciousness, begin care.
Battery
A caregiver can be charged with battery for touching a person without their consent. While these
charges are fairly rare, they can be avoided by simply obtaining consent.
ROLE IN EMS CONTINUUM
Professional rescuers fill an important role in the emergency medical services continuum.
Professional rescuers provide critical transitional care after a lay person's initial actions and before
the arrival of more advanced medical personnel.
Lay Responder’s
Initial Actions
Professional
Rescuer’s Care
Prehospital Care
by Advanced
Personnel
Hospital and
Rehabilitative Care
UNIVERSAL PRECAUTIONS AND PPE
Employees of University of Minnesota Physicians are required to observe universal precautions. This
means you must act as if all blood and bodily fluids are infected.
Part of observing universal precautions is the use of appropriate personal protective equipment
(PPE). At minimum, gloves must be worn when providing basic life support services. Always put on
gloves before approaching the patient. You are also required to use a resuscitation mask or bagvalve-mask set up to provide ventilations to patients. Unprotected mouth-to-mouth or mouth-to-nose
resuscitation is prohibited.
All of our clinics have resuscitation masks and/or bag-valve-mask set ups available. Locate these
items in your clinic today so you'll be able to get them quickly when you need them.
The risk of infection from providing basic life support is extremely low--about one in one million. Use
of PPE can reduce this risk even further.
PLEASE NOTE: It is difficult to find photographs and illustrations of people wearing gloves while performing BLS
procedures. Please do not take the absence of gloves in some of the pictures in this course as a sign that it is acceptable
to work without gloves. Gloves are always required.
AGE RANGES
For purposes of basic life support, age ranges are:



Infants are 0-1 year old
Children are 1 year old to 12 years old (or look for signs of puberty)
Adults are over 12 years old but if a child is adult-sized, treat him or her as an adult
For Automated External Defibrillator (AED) use, the age range changes slightly:


Children are 1 year old to 8 years old
Adults are over 8 years old
AEDs are not recommended for use on infants at this time
INITIAL ASSESSMENT
Initial assessment involves assessing the scene, assessing the victim, and activating the EMS
system.
ASSESSING THE SCENE
When approaching an emergency situation, start by sizing up the scene:



Look around for dangers that may affect your response. Are there downed power wires,
flammable materials or other hazards present? If the scene is unsafe GET OUT!
Look for clues as to what may have happened to the victim. There is a big difference between
finding a victim slumped on the floor and finding that same victim on the floor next to a toppled
ladder. In the second scenario, you might suspect head or neck injury.
Get a sense of the resources needed. Is there more than one victim? Is special equipment
needed?
Once you have assessed the scene, don personal protective equipment before approaching the
victim.
APPROACH THE VICTIM
Take note of the victim's appearance. Is he or she lying still or moving? Does the skin color appear
normal for the victim's ethnic group? Does the victim appear to be breathing and, if so, is the
breathing easy or labored?
CHECK FOR RESPONSIVENESS
Tap the victim on the shoulder (for an infant, tap the foot or rub the sternal area) and shout, "are you
okay?" Use the victim's name if you know it.
Shouting is important because as people lose consciousness, hearing is the last sense to go.
Shouting may help to arouse the victim.
If you are not alone, direct someone to call 911 or the emergency response number.
If the victim is not fully responsive, you will need to assess the ABCs: Airway, Breathing, Circulation.
THE ABCs
Open the Airway and Assess for Breathing and Blockage
Open the airway using the head-tilt, chin lift technique. For an adult, tilt the head far enough back that
the jaw is perpendicular to the floor. For a child, tilt the head back slightly past neutral. For an infant,
the head tilt is just at neutral and is sometimes referred to as "flat face."
If you suspect a spinal injury, use the jaw thrust maneuver to open the airway: Brace your elbows on
your legs, use your thumbs to press down on the cheeks and seal the mask, pull the jaw up into the
mask with your fingers without moving the head.
Once the airway is open, place your face close to the victim's nose and mouth and look, listen and
feel for breathing for between 5 and 10 seconds. Breaths need to be sufficient to ventilate the person
and make the chest clearly rise. Gaspy, shallow, gurgling or noisy breaths--agonal breaths--do not
count.
Place the resuscitation mask over the victim's nose and mouth and give two rescue breaths to assess
if the airway is open. If the breaths do not go in, retilt the head, reseal the mask and try two more
breaths. If the breaths go in, assess circulation. If the breaths do not go in, move to the unconscious
choking procedure.
Assessing Circulation
Check the victim's carotid artery for a pulse. This artery is found in the notch on the side of the neck.
For infants, check a brachial pulse by pressing lightly on the inside of the upper arm, against the
bone. Check for a pulse for no more than 10 seconds.
Blood Sweep
The last step in assessing the victim is a quick check for major bleeding. Visually scan up and down
the person's body and lower extremities for signs of bleeding.
From start to finish the assessment should take no longer than 30 seconds. It is meant to detect
life-threatening problems only.
CALL FIRST VS. CALL FAST
Do I call first or care first?
If you are alone, you have a difficult decision.
With an adult, the most common reason for collapse is a cardiac issue. It is vitally important to get an
AED (automated external defibrillator) on the scene within 6 minutes. It is the combination of high
quality CPR and early use of an AED that will save the person's life. Every minute of delay in using an
AED decreases the chance of survival by 10%. For an adult, as soon as you have completed your
assessment and find the victim has no breathing or pulse, call 911 BEFORE giving care.
Return to the victim after the call and start CPR.
With a child, the most common reason for collapse is a respiratory issue such as choking or asthma.
Children become dangerously hypoxic quickly. Once you complete your assessment, give 2
minutes of care before stopping to call 911. Try to bring the child with you to the phone or
otherwise continue care while calling 911.
In short: For adults, call first. For children and infants, call fast.
ASSESSING FOR STROKE
Stroke (also known as cerebrovascular accident or CVA) occurs when the blood supply to part of the
brain is interrupted either because of a clot or because a blood vessel ruptures. Brain cells past the
point of interruption die from a lack of oxygen and nutrients. Stroke is the third leading cause of death
in the United States.
A host of new fibrolytic/thrombolytic drugs can greatly reduce the effects of stroke and allow many
people to recover quickly and with far fewer long-term effects. However, successful treatment
depends on early recognition as these new treatments must be administered within two to three hours
of onset of symptoms.
Symptoms of stroke are sudden and include:





weakness or numbness of the face, arm, or leg, especially one-sided
confusion, trouble speaking or understanding
vision changes
difficulty walking, loss of balance or coordination, dizziness
severe headache
To assess for stroke, THINK F.A.S.T.:
Face: Ask the person to smile. Look for weakness or “pulling” to one side--an asymmetrical smile.
Arms: Have the victim close his eyes, and hold his arms out in front of him. Look for weakness or
drooping in one arm.
Speech: Ask the victim to repeat a common phrase such as “I scream, you scream, we all scream for
ice cream.” Look for difficulty with annunciation (indicating possible paralysis of the vocal muscles
and throat) or difficulty using common words (indicating issues in the speech formation area of the
brain).
Time: Note the time of onset of symptoms. The new medications must be administered quickly. The
American Heart Association stroke protocol calls for patients to be under a CT scanner within 45
minutes of onset of symptoms. If treated timely, some strokes can be reversed and the long-term
effects significantly reduced.
MOVING THE VICTIM
In general, it is best not to move the victim. Only move the victim to remove him or her from an unsafe
area or to enable you to provide care.
If you must move the victim, use the Clothes Drag method, as this allows you to secure the head and
neck and minimize spinal movement:




Stand behind the victim
Gather the victim’s collar and clothing in your hands on the sides of the neck
Secure the victim’s head and neck with your forearms
Pull the victim to safety
BREATHING EMERGENCIES
A victim who has stopped breathing is in respiratory arrest or failure. This can develop from
respiratory distress (difficulty breathing) or suddenly as a result of an obstructed airway, heart attack,
or other cause. A victim who has a pulse but is not breathing--or not breathing normally--needs
assistance with ventilation. This is called rescue breathing.
USING A MASK EFFECTIVELY
Remember that it is UMPhysicians policy that you always use either a resuscitation mask or a bagvalve-mask set up to provide ventilations.
Proper use of a Resuscitation Mask





Place the base (wide part) of the mask in the curve between the chin and the lower lip.
Rest your hand nearest the head on the victim's forehead and form a C with your thumb and
index finger to seal the top of the mask.
Place the thumb of your other hand on the base of the mask and use your fingers to grasp the
jaw and pull it up into the mask. This generally gives a very good seal.
If you are working at the top of the head (as in two-rescuer CPR), form the thumbs and fingers
of both hands into Cs on each side of the mask and use the other three fingers of both hands
to pull the jaw up into the mask.
For infants use a pediatric mask but if only an adult mask is available, reverse the direction of
the mask, placing the "nose point" on the infant's chin.
RESCUE BREATHING
Rescue breathing is the process of breathing air into a victim to give him or her the oxygen needed to
survive.







Inhale a normal breath
Deliver a breath to the victim via mask
Each breath should be expelled over 1 second
Each breath should cause gentle chest rise
Adult rate is 1 breath every 5 seconds. As you work, count "1-one thousand, 2-one
thousand, 3-one thousand" then breathe in on four and breathe out on five.
Child/infant rate is 1 breath every 3 seconds. As you work, count "1-one thousand" then
breathe in on two and breathe out on three.
Stop and check for a pulse every two minutes
Rescue breathing should continue until:





The victim can breath on their own
Another trained rescuer takes over for you
You are too exhausted to continue
The scene becomes unsafe
The victim has no pulse--then start CPR immediately or apply an AED
A Word about Speed and Volume: In an emergency, rescuers tend to breath too deeply and deliver
breaths forcefully over a brief period. This blast of air meets resistance in the trachea and ends up
going down the esophagus instead of into the lungs. This results in abdominal distention, which can
cause two problems. As the stomach fills with air it presses against the diaphragm, increasing
intrathoracic pressure. This added pressure makes it even harder to inflate the lungs and impedes
venous return to the heart, reducing the quality of CPR. The air also displaces stomach contents,
causing the victim to vomit. If this happens, roll the victim to one side, clear the mouth with your
(gloved) finger, shake out the mask, and resume rescue breathing. DO NOT allow the victim to
aspirate!
A Word about Dentures: If the victim is wearing dentures, do not remove them unless they become
dislodged. Dentures help to maintain the shape of the mouth and increase your ability to make a tight
seal with the mask.
USING A BVM
BVM stands for bag-valve-mask set up. This device is used to ventilate victims in respiratory distress
or respiratory arrest. These devices consist of a ventilation bag, a one-way valve and a mask to seal
over the victim's mouth and nose.
BVMs come in adult, child and infant sizes. As with masks, an adult BVM can be used with a child or
infant. Do not squeeze the bag as much. Avoid overventilation by paying close attention to the level of
chest rise.
The purpose of using a BVM is to increase the level of oxygen delivered to the patient. Breath
delivered by a rescuer through a face mask contains 16% oxygen. Room air delivered through a BVM
contains 21% oxygen.
THE BVM AND OXYGEN
Many BVMs include tubing and a reservoir for supplemental oxygen. This greatly increases the level
of oxygen delivered to the patient. Using a BVM with oxygen at 15 liters per minute can deliver nearly
100% oxygen, which benefits a patient who has been hypoxic.


Do not attach oxygen if you have not been trained to do so
Remove the BVM (keep the mask) and move the O2 tank away before shocking with an AED.
AED shocks have caused fires in the presence of oxygen.
USING A BVM FOR TWO RESCUERS
It can be tricky for one rescuer to use a BVM. It is preferred that two rescuers use a BVM.
Rescuer one completes the assessment and determines the need for ventilations while rescuer two
assembles the BVM (including oxygen, if used).
Rescuer one seals the mask on the victim's face and opens the airway. Rescuer two counts and
squeezes the bag to administer the ventilations. Ventilations are delivered over one second as
rescuer two watches for the chest to gently rise.
For adults: Deliver one ventilation every five seconds. Rescuer two counts "1-one thousand, 2-one
thousand, 3-one thousand, 4-one thousand" and delivers the ventilation on the fifth count.
For children and infants: Deliver one ventilation every three seconds. Rescuer two counts "1-one
thousand, 2-one thousand" and delivers the ventilation on the third count.
As with rescue breathing, stop every two minutes to check for a pulse.
USING A BVM FOR ONE RESCUER
While awkward, it is possible for one rescuer to use a BVM.


Seal the mask with one hand using the C-E method: place the thumb and forefinger in a C
shape around the side rim of the mask. Use the other three fingers in an E shape to grasp the
jaw and pull it up into the mask.
Squeeze the bag with the other hand. You may have to squeeze a bit more, as more air tends
to leak around the mask with one rescuer. Determine appropriate volume by watching for
gentle chest rise.
Small Study Illustrates Paramedic Bag-Valve-Mask Proficiency on Child/Infant Manikins
By J.M. Hendry
http://www.merginet.com/index.cfm?pg=pediatric&fn=bvmprof
July 2005, MERGINET—A two-person bag-valve-mask ventilation technique—one person using two hands to obtain an
airtight seal between the mask and the manikin while the other compresses the bag—was superior to one-person bagvalve-mask ventilation on infant and child manikins, according to a small study conducted in Pittsburgh, Pennsylvania.
However, among the healthcare professionals participating in the study, “the paramedic provider group generated higher
median tidal volumes per weight than all other groups for the infant- and child-manikin models,” wrote Lara Davidovic,
MD, MPH, of the Division of Pediatric Emergency Medicine and colleagues at Children's Hospital of Pittsburgh.
Paramedics were the only providers able to generate the target tidal volume per weight of 10 mL/kg while using the twoperson technique in the infant manikin and both techniques in the child manikin.
The researchers enlisted 70 healthcare providers—10 from each group of one-, two- and three-year postgraduate
pediatric residents, two-year postgraduate emergency medicine residents, pediatric emergency nurses, paramedics and
ambulance transport personnel—to perform the two bag-valve-mask ventilation techniques on an infant and a child
manikin set up to record tidal volume and peak pressure every 15 seconds during three minutes of ventilation. Oral
airways were not used.
The averaged data from each group reveals greater mean tidal volumes per weight, mean pressures and mean highest
peak pressures overall during two-person bag-valve-mask ventilation in both infant and child manikins. The paramedic
group achieved median tidal volumes of 8.4 mL/kg and 11.7 mL/kg, respectively, during one- and two-person infant
ventilation, and 11.2 mL/kg and 12.7 mL/kg, respectively, during one- and two-person child ventilation. By comparison,
none of the other groups achieved the target 10 mL/kg using either technique on either manikin.
“The importance of mastering the technique of bag-valve-mask ventilation cannot be overestimated,” the authors noted
since “An emphasis on providing sustained bag-valve-mask ventilation rather than endotracheal intubation in the out-ofhospital setting is increasing.”
In this study, both the paramedics and the ambulance transport personnel reported a median of 250 lifetime experiences
with bag-valve-mask ventilation. “One would expect the provider groups with the most experience to generate the best
outcome,” the authors wrote. “However, this did not hold true for the transport group,” which had median tidal volumes of
4.1 mL/kg, 7.3 mL/kg, 6.3 mL/kg, and 9.1 mL/kg in one- and two-person infant and one- and two-person child ventilation,
respectively.
While data from this study is limited due to the small sample size, the investigators reasoned “there is a paucity of studies
demonstrating the effectiveness for practicing bag-valve-mask on manikins.” This study revealed “that many current
providers did not generate recommended tidal volumes in a manikin model,” and that two-person ventilation with a bagvalve-mask in infants and children is generally preferable.
Reference
Davidovic L. LaCovey D. Pitetti RD. “Comparison of 1- Versus 2-Person Bag-Valve-Mask Techniques for Manikin Ventilation of Infants and
Children.” Annals of Emergency Medicine, July 2005, Volume 46, Number 1.
AIRWAY OBSTRUCTION
Foreign body airway obstruction is the most common cause of
respiratory emergencies. A person with a blocked airway can quickly
lose consciousness and die. Children are especially at risk because
their airways are much smaller than adults and because young
children tend to put small objects into their mouths.
Airways can be partially or fully obstructed. Professional rescuers
must be able to recognize signs of airway blockage. The universal
choking sign is two hands around the throat.
Fast action is the key to survival. Brain death can start as early as four minutes after total obstruction
and is complete in ten minutes or less.
Calling 911
Many people are embarrassed to call 911 "just for" choking. Calling 911 is vitally important because
even if a person is still conscious, you can't predict that you will be successful in clearing their airway
before they lose consciousness. Paramedics have devices that can help clear stubborn foreign
bodies from airways. It is important to get them on their way.
Prevention Matters
For children, hard foods such as candy and nuts, are the most common agents of choking. Hot dog
rounds have been cited in a number of choking episodes. Coins are involved in 18% of choking
incidents. Latex balloons can also be aspirated. Cut round foods like carrots and hotdogs long-ways
first before slicing. Keep coins, latex balloons and small toys/toy parts away from children.
For adults large pieces of food, especially meet, often causes choking. Alcohol consumption
increases the risk. Adults need to be reminded to cut meats into smaller pieces, to chew food
carefully, and not to talk or laugh while eating.
CONSCIOUS CHOKING: ADULT AND CHILD
Adult: When caring for a conscious choking adult, remember to identify yourself as someone who
can help. Ask if he or she is choking, and obtain consent. If the victim is coughing forcefully, some air
is still getting into the lungs. Encourage the victim to keep coughing. If the victim is no longer able to
cough or breathe, start the conscious choking protocol:

Place an arm under the victim's arm and across the chest; stand behind and to the side





Give 5 back blows between the shoulder blades. Each blow should be a distinct attempt to
dislodge the foreign object
If the back blows don't clear the object, make a fist and wrap your arms around the person,
placing the thumb side of your fist against the abdomen just above the navel. Grasp your fist
with your other hand and deliver 5 abdominal thrusts. Each thrust should be in a “J” motion of
up and back and should be a clear attempt to dislodge the foreign body.
If the victim is obviously pregnant or is too big for you to reach around them, use chest thrusts:
grasp your hands high on the center of the chest and give 5 thrusts straight back toward you.
Rotate between 5 back blows and 5 abdominal thrusts (or chest thrusts) until the object is
dislodged and the victim can breath on his or her own, or until the person becomes
unconscious.
If the victim becomes unconscious, step backward to lower him or her to the floor and proceed
to the unconscious choking protocol.
Abdominal Thrust--Adult
Chest Thrust--Adult
Child: Care for a choking child the same way you care for a choking adult except you will not deliver
the back blows or abdominal thrusts as forcefully on a child. If a parent or guardian is not around, you
have implied consent to help the child. You may need to get on your knees in order to adapt to their
size.
CONSCIOUS CHOKING: INFANT
For an infant you will use a combination of 5 back blows and 5 chest compressions.





While seated with extended leg, cradle the infant's face and neck on your hand and bring the
infant's body over that arm onto your extended leg. Hold firmly as the infant will likely be flailing
about.
Give five firm back blows between the shoulder blades. Each back blow should be a separate
attempt to dislodge the object.
Using the hand that gave the back blows, grasp the back of the infant's head and neck. Extend
the other leg and flip the infant over onto your arm and extended leg.
Give five chest thrusts: Place two fingers just below the nipple line and compress 1/2 to 1 inch.
Each compression should be a separate attempt to dislodge the object.
Continue alternating back blows and chest thrusts until the object clears and the infant is able
to cry on his or her own or until the infant becomes unconscious. If the infant loses
consciousness, move into the unconscious choking protocol.
UNCONSCIOUS CHOKING: ADULT AND CHILD
The treatment for unconscious choking is very similar to CPR.
Adult: If during assessment breaths do not go in, reopen the airway and try two breaths again. If they
still do not go in:





Kneel next to the victim.
Position your two hands on top of one another on the center of the sternum. Lace your fingers
together and lift them off the chest. Only the heel of your hand should touch the chest.
With shoulders over hands and elbows straight, deliver five chest thrusts at a depth of 1.5 to 2
inches. Allow the chest to recoil fully after each thrust so that each thrust is a separate attempt
to remove the object.
Open the victim's mouth by grasping the jaw and tongue. Look in the mouth for a foreign
object. If you see the object, remove it with your finger.
Replace the mask, open the airway and try two more breaths.
o If the breaths do not go in, continue cycles of five chest compressions, foreign object
check, two rescue breaths
o If the breaths go in, you have cleared the airway. Check for breathing and a pulse and
proceed based on what you find.
Child: Use the same pattern as above (5 chest thrusts, foreign body check, two breaths) but
compress the chest only 1 to 1.5 inches. You can also give chest thrusts using one hand. The other
hand remains on the forehead, maintaining the open airway.
UNCONSCIOUS CHOKING: INFANT
If during assessment breaths do not go in, reopen the airway and try two breaths again. Often with
infants we tilt the head back too far so try tilting a bit less. If breaths still do not go in:




Place two fingers on the center of the chest below the nipple line as you did during conscious
choking.
Deliver five chest thrusts at a depth of 1/2 to 1 inch. Allow the chest to recoil fully after each
thrust so that each thrust is a separate attempt to remove the object.
Open the victim's mouth by grasping the jaw and tongue. Look in the mouth for a foreign
object. If you see the object, remove it with your little finger.
Replace the mask, open the airway and try two more breaths.
o If the breaths do not go in, continue cycles of five chest compressions, foreign object
check, two rescue breaths
o If the breaths go in, you have cleared the airway. Check the pulse and proceed to care
for what you find.
ACUTE CORONARY SYNDROMES AND CPR
Cardiovascular disease is the leading cause of death for both men and women in the United States,
accounting for about 40% of all deaths. Over 927,000 people die in the U.S. of cardiovascular
disease each year--one person every 34 seconds.
The term "acute coronary syndromes" describes a number of conditions ranging from unstable angina
to myocardial infarction (MI--or heart attack). ACS occurs when coronary artery occlusion prevents
the heart muscle from receiving adequate flow of oxygenated blood. The heart muscle becomes
injured and will eventually die, causing disability or death. ACS is the cause of sudden cardiac arrest
in most patients.
In many cases, the coronary artery doesn't just become plugged. The plaque lining an artery ruptures,
spilling out loose fat. Thrombocytes (clotting cells) stick to the walls of the ruptured plaque and the fat
droplets and create clots in the vessel, which float down to and occlude smaller coronary artery
branches.
CARDIAC EMERGENCIES
Cardiac Chain of Survival
There are 4 links in the cardiac chain of survival:




Early recognition of the emergency and early access to EMS
Early CPR
Early defibrillation
Early advanced medical care
Most deaths following myocardial infarction occur before the patient reaches the hospital. About 50%
of these deaths occur due to failure to treat ventricular fibrillation in a timely manner. The most
important factors for survival after myocardial infarction are timely defibrillation followed immediately
by high-quality CPR.
Contrary to popular belief, CPR rarely restarts the heart. The goal of CPR is to move oxygen-rich
blood to the tissues, especially the brain, until a normal heart rhythm can be restored. Advanced
medical care is needed to address the underlying cause of the myocardial infarction and to restore a
normal rhythm.
Recognizing MI
Classic symptoms of myocardial infarction include:







Chest pain, pressure or discomfort behind the sternum that may spread to the shoulders, neck,
jaw, back, or epigastric area
Shortness of breath
Weakness, nausea, dizziness
Heavy sweating
Pale, ashen skin--especially around the face
Sense of impending doom
Uncertainty, embarassment and denial
Women, diabetics and the elderly often do not experience chest pain but may have some of the other
symptoms, particularly back and epigastric pain. They may also have pain in unusual places like
elbow pain. Women tend to downplay their symptoms, delaying care.
Care for Myocardial Infarction
The most important step to take when you suspect MI is to call 911. Do not let the victim dissuade
you from calling. While waiting for the ambulance to arrive:






Place the victim in a comfortable position and loosen clothing
Assist with the administration of the victim's prescribed nitroglycerin (unless they've used
Viagra or Cialis in the last 48 hours)
Ask the patient: "Have you ever been told by a doctor to NEVER take aspirin?" If the answer is
no, have the patient chew one adult aspirin or four baby aspirin.
Administer supplemental oxygen if trained to do so
Reassure the patient
Monitor vital signs and be prepared to administer an AED and CPR if the patient becomes
unconscious
ONE RESCUER CPR: ADULT
If an unconscious adult is not moving or breathing and has no pulse, begin CPR.

Kneel next to the victim and position yourself as you did for unconscious choking
o hands laced and heel of one hand on the center of the chest
o shoulders over hands
o elbows locked

Start cycles of 30 chest compressions and 2 rescue breaths, at the rate of 100
compressions a minute. Compress fast and hard!
Compress the chest to a depth of 1.5 to 2 inches
Let the chest recoil to its normal position after each compression by taking your weight off the
chest (but leave your hands in place)




DO NOT STOP CPR FOR PULSE CHECKS
Continue CPR until
o an AED is ready to use
o another rescuer relieves you
o the scene becomes unsafe
o you are too exhausted to continue
o you become aware of a sign of life--the patient moves, breathes or speaks
Why are we now giving 30 compressions?
When it comes to perfusing the tissues with oxygenrich blood, the name of the game is blood pressure.
What we now know is that it takes 11 or more
compressions before the blood pressure starts to
reach levels adequate to push blood into the fine
vessels. Thirty compressions are needed to get
adequate blood supply to all of the tissues.
Why are we saying push fast and push hard?
Chest compressions raise intrathoracic pressure
and mechanically squeeze the heart to move blood.
Pushing fast helps to maintain the intrathoracic
pressure level. Pushing hard ensures that the left
ventricle, which is mostly posterior to the right
ventricle, gets adequate mechanical compression to
push blood out to the body.
ONE RESCUER CPR: CHILD
Child CPR is very similar to that of an adult; however the depth of your compressions should be 1 to
1.5 inches. The cycle for a child is 30 compressions and two breaths, at a rate of 100
compressions per minute.
For a child, you can choose the one-handed method. Compress the chest with one hand, while
holding the forehead of the victim with your other hand to maintain an open airway.
ONE RESCUER CPR: INFANT
Infant CPR is very similar to adult and child CPR except the chest compressions are less deep and
you use a different chest compression technique.



The cycle for infant CPR is 30 compressions and two breaths, at a rate of 100 compressions
per minute.
Compress the chest 1/2 to 1 inch and allow it to recoil after each compression
Compress the chest using two fingers just below the nipple line. This is the same placement
you used for chest thrusts in unconscious choking.
TWO RESCUER CPR: ADULT
When an additional rescuer is available, provide two-rescuer CPR.
In adult two-rescuer CPR:




Rescuer 1 performs chest compressions
Rescuer 2 provides rescue breaths
A cycle consists of 30 compressions followed by 2 breaths, at a rate of 100 compressions per
minute
Compression chest depth remains 1.5 to 2 inches
The rescuer giving chest compressions counts out loud. Counting out loud is an essential form of
communication.
Rescuers should change positions every two minutes, as alternating reduces fatigue and improves
the quality of CPR. The rescuer performing chest compressions calls for the change by replacing the
word "change" on the last count, as in "28-one thousand, 29-one thousand, CHANGE."
Once the change has been called, rescuer 2 finishes the cycle with two breaths then moves quickly to
the patient's side and begins chest compressions while rescuer 1 moves to the head of the patient,
prepares a resuscitation mask and waits to give breaths. Changing positions should take less than 5
seconds.
When CPR is in progress by one rescuer and a second rescuer arrives on the scene, the second
rescuer should make sure advanced medical personnel have been summoned. If they have not been
summoned, the second rescuer should do this before getting the AED or assisting with care.
TWO RESCUER CPR: CHILD
Two-rescuer CPR for a child is similar to adult CPR except that the count changes to 15
compressions followed by 2 breaths at a rate of 100 compressions per minute. Chest depth
remains at 1 to 1.5 inches.
After two minutes of care, rescuer 1 calls for the change on the 15th compression. Rescuer 2
completes the cycle with two breaths then moves quickly to the patient's side and starts compressing
the chest while rescuer 1 moves to the patient's head, readies a resuscitation mask and waits to give
breaths.
TWO RESCUER CPR: INFANT
Two-rescuer CPR for an infant is similar to two-rescuer CPR for a child. The cycle for infant tworescuer CPR is 15 compressions followed by 2 breaths, at a rate of 100 compressions per minute.
Chest depth for compressions is still 1/2 to 1 inch. However the rescuer compressing the chest uses
the two-thumbs-encircling-hands technique.
In this technique, the rescuer wraps her hands around the infant with the two thumbs side by side on
the infant's chest just below the nipple line. During compressions the rescuer presses and releases
the chest with the thumbs, taking care not to squeeze the sides of the chest.
As with adult and child two-rescuer CPR, rescuers quickly change position every two minutes.
CPR RECAP
Summary of CPR Techniques
Adult
Hand position: Two hands on center of
1 rescuer
chest
Child
Two hands or one hand
on center of chest
Infant
Two fingers on center of
chest just below nipple
line
Hand position:
2 rescuer
Same
Same
Compression
depth
1.5 to 2 inches
1 to 1.5 inches
0.5 to 1 inch
Breathe
Over 1 second with
enough volume to cause
gentle chest rise
Over 1 second with
enough volume to cause
gentle chest rise
Over 1 second with
enough volume to cause
gentle chest rise
Cycle: 1
rescuer
30 compressions
2 breaths
30 compressions
2 breaths
30 compressions
2 breaths
Cycle: 2
rescuer
30 compressions
2 breaths
15 compressions
2 breaths
15 compressions
2 breaths
Rate
100 compressions
per minute
100 compressions
per minute
100 compressions
per minute
Two-thumbs-encirclinghands
USING AN AED
Use of an AED can significantly increase the chance of survival after myocardial infarction. However,
to be effective the rescuer must assess the victim quickly and be prepared to use an AED in all cases
of cardiac arrest. Each minute of delay in using the AED decreases the chance of survival by 10%.
In this section you will learn how an AED works and how to use it effectively with adults and children
THE HEART’S ELECTRICAL SYSTEM
The heart has a special nerve conduction system that provides electrical pathways to move
contractions through the heart.
In the heart, a contraction starts at the sinoatrial (SA) node, located in the right upper atrial wall. The
nerve impulse is conducted through the atria and down to the atrioventricular (AV) node located in the
posterior septal wall of the right atrium, behind the tricuspid valve. The impulse then proceeds toward
the ventricular septum along the Bundle of His, then down the septum via the right and left bundle
branches. From there, the impulse moves throughout the ventricular myocardium by way of the
Purkinje fibers.
HOW AN AED WORKS
During a cardiac emergency, clots in the coronary arteries (the arteries that feed the heart muscle)
cause the heart muscle to receive inadequate oxygen. As the muscle becomes starved for oxygen, it
starts to beat faster and faster to compensate. This rapid rhythm (generally greater than 150 beats
per minute) is called ventricular tachycardia or VTac. Because the heart is beating so rapidly, the
chambers don't have time to refill so the beats are not very productive. Therefore, even though the
person appears on an EKG to have a regular heart rhythm, their heart isn't moving blood adequately.
A person with VTac may have only a weak pulse or no pulse.
Eventually, the heart rhythm will devolve into ventricular fibrillation, also known as VFib. In
ventricular fibrillation, the heart muscles contract individually but don't work together to move the
blood. If the heart could be seen through the chest, it would look like a twitching bag of worms. A
person with VFib has no discernable pulse.
An Automated External Defibrillator (AED) works by detecting the heart rhythm and applying the
appropriate treatment. If the AED detects VTac or VFib, it will deliver a shock to stop the heart so that
it can restart with a more normal rhythm. If the AED detects either a normal rhythm or asystole (a
completely stopped heart), the device will instruct the user to continue CPR and will time the user for
two minutes. After two minutes, the device will reanalyze the heart rhythm and deliver another shock
if needed.
USING THE AED: ADULT AND CHILD
The Automated External Defibrillator (AED) can be used on adults, and children. For purposes of
using an AED, a child is defined as 1-8 years of age or up to 55 pounds.
If an AED is immediately available, use it as soon as you determine that the victim has no pulse. It is
imperative to get an AED on a victim as soon as possible.
To Use an AED
1) Turn on the unit and follow the instructions.
2) Pull or cut open the victim's shirt. If the victim is a woman, cut open the bra or pull it down to the
waist.
3) Dry the victim's chest with their clothing or other cloth.
4) Apply the pads




Place one pad on the victim’s upper right chest
Place the other pad on the victim’s left lower side--deep on the left side (centered over the midaxillary line)
If the patient is small, make sure the pads do not touch. If necessary, move the upper right pad
to the center of the chest and the lower left pad to the center of the back, between the shoulder
blades.
If the victim is a child, use pediatric pads. Otherwise check to see if the unit has a pediatric key
or pediatric setting that allows you to use adult pads with children.
Adult Placement
Child Placement
5) Once you have attached the pads, plug in the connector which will start the AED analyzing the
rhythm. When you hear, "analyzing rhythm, stand clear” loudly tell everyone to back away at least 18
inches.
6) If the AED detects VTac or VFib, the device will state, "charging" and will instruct you to "press the
shock button." Before you press the shock button, loudly state, "shocking, stand clear" and look to
ensure that everyone--including you--is at least 18 inches away from the patient. Press the flashing
button to deliver the shock.
7) The AED will announce "shock delivered" and tell you to begin five cycles of CPR. Immediately
start compressing the chest to start the CPR cycle. Leave the pads in place.
8) The device will time you for two minutes. After two minutes of CPR, the AED will announce,
“analyzing rhythm” and will start the sequence over again.
AED CONSIDERATIONS
AEDs use electricity to stop the heart. Therefore, there are a few important considerations to keep in
mind as you use the AED:





Make sure the victim's chest is dry. If the victim is in water, move the victim to a dry area and
strip off wet clothing.
Do not use alcohol to wipe the victim's chest as this could cause a fire.
Pads are very sticky and will generally work even on very hairy areas. If the victim has a hairy
chest, part the hairs and stick the pads down to the skin. If this doesn't work and you have a
second set of pads, stick the first pads down and remove them quickly to rip some of the hair
from the chest.
Do not use pediatric pads on an adult, as they will not deliver enough electricity to defibrillate.
If the victim is wearing a medication patch on the chest, remove the patch with a gloved hand.
Never place the pad over a medication patch.



Most implantable chest devices are on the upper left. However, if the patient has a device
implanted in the area where a pad would be placed, simply move the pad over to clear the
device. Never place a pad on top of an internal pacemaker or other implanted device.
NEVER use a cell phone within 6 feet of an AED. Cell phones interfere with the functioning of
an AED. Once you've activated the emergency response system, toss your cell phone well
away from the victim.
REMOVE oxygen from the victim before pressing the shock button. There have been many
reports of fires when oxygen tubing was present during a shock from a defibrillator.
USING AN AED WITH CPR IN PROGRESS
If another rescuer arrives on the scene with an AED after you have started CPR, continue your cycle
while the other rescuer prepares the AED, wipes off the chest and applies the pads. As soon as you
hear "analyzing rhythm," step back and wait for approximately 5 seconds. If a shock is advised,
resume chest compressions even while the device is charging. When the device is ready to shock,
step back while the shock is delivered then quickly resume chest compressions.
The combination of rapid use of an AED followed quickly with high quality CPR is the most effective
way to ensure survival for the victim of a cardiac emergency.
SUMMARY
You have now completed the knowledge portion of the basic life support course and are ready to
complete the attached test. Bring the test with you to the hands on portion of your training. Be sure to
schedule yourself for a hands-on class in NetLearning or through the training department.
UNIVERSITY OF MINNESOTA PHYSICIANS
CPR/AED for the Professional Rescuer
Self Study Test
Circle the letter for the best answer for each question. Bring the completed test with you to the
hands-on portion of your training.
1) If a child's chest does not clearly rise with the first two rescue breaths, you should
A. give 15 compressions and two breaths
B. reposition the airway and try the breaths again
C. perform five abdominal thrusts and look in the mouth for a foreign object
D. check the pulse and start CPR if the pulse is under 60 beats per minute
2) The proper hand position for chest compressions in a 7-year-old child is
A. One hand on the upper third of the breast bone
B. Two hands on lowest portion of the breast bone
C. One or two hands on the center of the chest between the nipples
D. Two fingers on the breast bone just below the nipple line
3) You have opened the airway of an unresponsive 47-year-old male. To assess for adequate
breathing, you should
A. feel for a carotid pulse.
B. look at the chest and listen and feel for air movement.
C. listen to the chest for equal lung sounds.
D. give two rescue breaths then look in the mouth for any obstructions.
4) The proper hand position for one-rescuer chest compressions on a 3-month-old infant is
A. 1 or 2 hands on the center of the chest at the nipple line
B. 2 fingertips just above the nipple line
C. 2 fingertips just below the nipple line
D. two thumbs encircling hands
5) You are attending to a child who has just been struck by an automobile. To open the airway, use
the
A. head tilt-chin lift method
B. bag-valve-mask device
C. jaw thrust maneuver
D. HAINES recovery position
6) The proper depth of chest compressions in a child is
A. 1/2 to 1 inch
B. 1 1/2 to 2 inches
C. 1 to 1 1/2 inches
D. 2 to 2 1/2 inches
7) Two rescuers are attending to a 9-year-old child who collapsed suddenly. An AED is available.
They should
A. Attach the AED only if it has the child pads/system
B. Attach the AED and follow the voice prompts
C. Start CPR at a ratio of 15 compressions to 2 breaths
D. Start CPR at a ratio of 30 compressions to 2 breaths
8) If you suspect a person may be having a stroke, think FAST by asking the person to perform these
three tests:
A. Inhale deeply, speak and drink water.
B. Cough, stand and write a simple sentence.
C. Smile, raise both arms and speak a simple sentence.
D. Walk a straight line, touch the nose, speak a simple sentence.
9) It is important to have everyone stand clear when delivering a shock from an AED because
A. the AED will not deliver the shock if people are touching the victim
B. the AED will not analyze the victim's rhythm
C. bystanders could be injured by the shock
D. the pads could become loose
10) The AED indicates that no shock is advised after analyzing the rhythm. You should
A. immediately reanalyze the rhythm
B. recheck pad placement on the victim's chest
C. reset the AED by turning it off and back on
D. continue CPR until the AED reanalyzes
11) During the initial assessment, you have checked the scene, checked for responsiveness, opened
the airway and checked for breathing and a pulse. The last step in the initial assessment is to
A. check for bleeding
B. check for signs of life
C. place the victim in the recovery position
D. open and prepare the AED
12) The two rhythms that are shockable by the AED are
A. ventricular fibrillation and asystole
B. ventricular tachycardia and asystole
C. ventricular tachycardia and ventricular fibrillation
D. ventricular systole and ventricular fibrillation
13) On an adult, AED pads are placed
A. on the lower left side of the chest and the lower right side of the chest
B. on the upper right side of the chest and the lower left side of the chest
C. on the center of the chest and on the lower right side
D. over medication patches and implanted devices
14) As a single rescuer giving CPR to an adult, you should
A. compress the chest about 1/2 inch
B. compress the chest straight down for 1 inch
C. give cycles of 15 compressions and 2 breaths
D. give cycles of 30 compressions and 2 breaths
15) Chest compressions are performed at a rate of
A. about 60 compressions per minute
B. less than 90 compressions per minute
C. about 100 compressions per minute
D. at least 130 compressions per minute
16) Where do you position your hands to give abdominal thrusts for a conscious child who is
choking?
A. We don't use abdominal thrusts on conscious children who are choking
B. In the middle of the abdomen, just above the navel
C. In the middle of the abdomen, just below the navel
D. Higher on the center of the chest
17) The advantage of using a BVM to ventilate a patient is
A. rescuers get less tired
B. higher volume ventilations
C. it's easier to seal the BVM than a regular mask
D. the patient gets more oxygen
18) If a child is small, the correct positioning for AED pads is
A. right upper chest, left lower chest
B. center of chest, center of back between shoulder blades
C. parallel on the center of the chest
D. right upper chest, center of back between shoulder blades
19) You are by yourself when you come upon a young child who is not breathing and has no pulse.
As soon as you finish the initial assessment, you should
A. provide 2 minutes of care before calling for advanced medical personnel
B. immediately call advanced medical personnel
C. attempt two rescue breaths
D. place the child in a recovery position
20) For University of Minnesota Physicians employees performing basic life support, resuscitation
masks (or BVM setups) are
A. available
B. mandatory
C. optional
D. wasteful
21) You and another rescuer are attending to a 17-year-old found unresponsive with inadequate,
gasping breaths. After giving two rescue breaths and checking for a pulse, you are not certain if the
pulse is present or not. You should
A. Start CPR in cycles of 15 compressions and two breaths
B. Start CPR in cycles of 30 compressions and two breaths
C. Attach the AED and follow the voice prompts
D. Continue to check for a pulse
22) You are a member of an emergency response team. You arrive on the scene and find a
coworker, who is not a professional rescuer, performing CPR. What do you do?
A. Begin questioning bystanders about what they witnessed
B. Inform the coworker that you will take over chest compressions
C. Offer to get an AED since the coworker seems to know what to do
D. Reassess the victim and provide appropriate care
23) You and another professional rescuer find an unconscious adult on the floor. You send the other
rescuer to summon advanced medical personnel and get an AED. As you perform the initial
assessment you find the victim is not moving or breathing and has no pulse. You should
A. reposition the airway and give two more breaths
B. give 5 back blows and 5 chest thrusts
C. begin CPR until the AED arrives
D. wait until the AED arrives
24) Immediate care for a person experiencing symptoms of a heart attack includes
A. drinking enough water to remain hydrated
B. administering an adult aspirin if it is not contraindicated
C. having the person take a nap
D. driving the person to the hospital
25) When two rescuers are performing CPR on a child, the rescuer giving chest compressions calls
for a change on the
A. 1st breath
B. 2nd breath
C. 15th compression
D. 30th compression
26) If you must move a victim, the one method that allows you to limit head and neck motion is the
A. blanket drag
B. foot drag
C. clothes drag
D. two-person seat carry
27) When giving rescue breaths, giving too much volume or delivering the breaths too quickly can
lead to
A. bloody nose and headache
B. chest recoil and intrathoracic pressure
C. hyperventilation and respiratory suppression
D. vomiting and aspiration
28) A child has become unconscious after choking. To treat this child, you
A. give 5 abdominal thrusts followed by finger sweep and two rescue breaths
B. give 5 back blows and 5 abdominal thrusts followed by a finger sweep
C. give 5 chest compressions followed by foreign body check and two breaths
D. place the child in the HAINES recovery position
29) You assess an unconscious infant and find a pulse but no breathing. You should
A. begin back blows and chest thrusts to clear the airway
B. deliver one rescue breath every five seconds
C. deliver one rescue breath every three seconds
D. begin CPR on the infant at a rate of 100 compressions per minute
30) While crawling around on the floor, an 11-month-old suddenly starts gagging and coughing
forcefully. You should
A. Watch closely and be ready to take action if the symptoms worsen
B. Give abdominal thrusts rapidly until the object is expelled
C. Give five back blows and five chest thrusts until the object is expelled
D. Give forceful rescue breaths until the chest clearly rises