BASIC LIFE SUPPORT (formerly HCP)
CPR REFERENCE GUIDE
Illustrated by Barney Wornoff
Cover Design by Royce Grayer
Photography by Vicki Cossarini
Editing by Adam Bulkiewicz and Angeli Desaulniers
Proofreading by Daisy Desaulniers
PUBLISHED BY PERRI-MED FIRST AID/CPR TRAINING
BLW Provider (formerly HCP) Reference Guide, 2019. Revised March 24, 2019.
.
Cialis® is a registered trademark of Lilly ICOS pharmaceuticals
Chain of Survival® is a registered trademark of the American Heart and Stroke
Association (AHA).
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COPYRIGHT © 2019 PERRI-MED FIRST AID/CPR TRAINING
All rights reserved. No part of the material protected by this copyright notice may be
reproduced or utilized in any form, electronic or mechanical, including photocopying or
by any information storage and retrieval system or on any website without permission
from the copyright owner. Any request should be directed in writing to Perri-Med First
Aid/CPR Training, 2277 Howard Ave., Windsor, ON, Canada N8X 3V2.
ACKNOWLEDGMENTS
This reference manual is the result of input from many technical resources. The authors
acknowledge certain graphics and images were referenced from both the “Training
and Implementation Guide”, the Operating Manuals for the CPR Plus® AED produced
by the Medtronic Physio-Control Corporation and the Lifeline® AED produced by the
Defibtech Corporation.
CERTIFICATION
Knowledge of the information contained in this book does not constitute an endorsement
of a user’s qualifications by Perri-Med First Aid/CPR Training. A user’s qualifications are
recognized by Perri-Med First Aid/CPR Training only after the successful completion of
a Perri-Med training course, which includes practical training and formal assessment
of knowledge and skills, and the issuance of a training certificate.
TRADEMARKS
Trademarks are used in various locations within this resource manual, with no intention
of infringement. The trademark was used to the benefit of the trademark owner.
Canadian Cataloging in Publication Data:
Main entry under title:
Perri-Med First Aid Reference Guide
ISBN 978-0-9680982-3-3
Printed in Canada
i
ACCREDITATION
Perri-Med First Aid/CPR programs are recognized by the following
organizations:
FEDERAL
Employment and Social Development Canada (ESDC) approved by
the Minister of Labour in accordance with Part XVI, First Aid, of the
Canada Occupational Health and Safety Regulations.
PROVINCIAL
Ontario - Approved under First Aid Regulation 1101 of the Workplace
Safety & Insurance Board and the Ministry of Health and Long-Term
Care of the Ontario Public Pools Regulation, 565/90 under the Health
Protection and Promotion Act, R.S.O.1990, c.H.7.
Nova Scotia - Approved under subsection 5(4); Clause 3(aa) added:
O.I.C. 2001-401, N.S. Reg. 104/2001, under the Canada Labour Code.
New Brunswick - Approved under Regulation 2004-130 of the
Occupational Health and Safety Act (O.C. 2004-471).
Manitoba - Approved under MB Regulation 217/2006 of the Workplace
Safety and Health Act.
Northwest Territories and Nunavut - Approved under Occupational
Health and Safety Regulation R-039-2015.
INTERNATIONALLY
Perri-Med First Aid/CPR programs are approved and accredited by
the Dubai Health Authority, UAE.
MEDICAL ADVISOR
Dr. J. Curtis Fedoruk, B.A., LL.B., M.D., C.C.F.P. (E.M.), A.C.E.P,
F.C.L.M.
ii
TABLE OF CONTENTS
Foreword
Sec 1 Introduction ............................................. 1
Sec 2 Emergency Scene Assessment................ 4
Sec 3 Adult/Child CPR ...................................... 8
Sec 4 Infant CPR .. ............................................ 23
Sec 5 Public Access Defibrillation (PAD). . ........31
Sec 6 Choking (Airway Obstruction).. .............. 37
Sec 7 Cardio Concepts .. ................................ 48
CPR Skills Performance Sheets............. 21, 22, 29
Airway Obstruction Skills Performance Sheets 45
Public Access Defibrillation Guide. . ...................36
Student Quiz ................................................55, 56
iii
FOREWARD
OUR MISSION
Perri-Med First Aid/CPR Training is committed to reducing the
incidence and prevalence of death and disability from cardiopulmonary
failure, cardiovascular disease, stroke and workplace injuries in
all age groups. We are dedicated to provide common-sense and
practically based first aid, Cardiopulmonary Resuscitation (CPR),
defibrillation and safety training in Canada.
TRAINING
Our goal is to take the stress out of learning by providing a fun and
relaxed training atmosphere. The focus is on practical training skills
with an emphasis on hands-on skill practice. Candidates remember
these practical skills through repetition and practicing a variety of
scenarios most likely to be encountered at home, outdoors or in the
workplace.
INSTRUCTORS
Our instructors are qualified and experienced in providing pre-hospital
emergency care with such diverse backgrounds as paramedics,
firefighters, nurses and lifeguards. We also offer complete training
for in-house trainers. Our focus is to promote an enjoyable training
session with practically-based skills. This approach allows candidates
to recall these lifesaving skills more easily when an actual emergency
takes place.
PROGRAMS
Perri-Med has developed a variety of programs which meet or exceed
the current provincial and federal government standards. This
reference guide complies with the guidelines set by the Workplace
Safety and Insurance Act of Ontario; the Occupational Health and
Safety Act of Nova Scotia; the Occupational Health and Safety Act
of New Brunswick; Human Resources & Skills Development Canada;
Health Canada; and is in accordance with the International Liaison
Committee on Resuscitation (ILCOR) Consensus on Science.
iv
Sec 1 Introduction
CARDIOPULMONARY RESUSCITATION
Cardiopulmonary Resuscitation (CPR) is the provision of Basic
Life Support (BLS) skills to a casualty who is unresponsive and
not breathing or only gasping. The prompt use of CPR may prevent
permanent brain death due to a lack of oxygen to the brain cells. The
three basic rescue skills are as follows:
C
Chest Compressions
By squeezing the chest of a casualty who is unresponsive and
not breathing or only gasping, chest compressions provide vital
blood flow to the heart and brain. 30 hard and fast chest compressions
will be delivered about every 18 seconds. Every effort should be made
to continue chest compressions and rescue breaths until the casualty
revives or until advanced medical support takes over.
A
B
Airway
Open the airway with a head-tilt chin-lift. The rescuer briefly
checks for breathing.
Breathing
Once a casualty stops breathing, brain cells can start to die
within 4 to 6 minutes. Rescue breaths supply oxygen to a
casualty who is unable to breathe on their own. By using a barrier
device or direct mouth to mouth rescue breathing, you can deliver 600
to 800 mI of air over 1 second to provide enough oxygen to produce
visible chest rise.
Continue to emphasize providing
high-quality chest compressions:
• Push hard, push fast
• Minimize interruptions
• Allow full chest recoil
• Avoid excessive ventilation
1
Sec 1 Introduction
CPR
Approximately 2/3 of deaths from
cardiac arrest occur before the
patient reaches the hospital.
Your prompt assistance can help
prevent or reduce the near 60,000
deaths from cardiac arrest each
year. Approximately 45% of all
cardiac arrests occur in people
under age 65. About 60% to 70% of
cardiac arrests take place outside
the hospital.
CPR alone is not effective in
reviving patients of cardiac arrest.
It is important to begin CPR to
circulate the blood and oxygen to
keep the brain alive. In addition
to CPR, an Automated External
Defibrillator
(AED)
is
often
required to shock the patient and
attempt to return the quivering
heart muscle to a normal rhythm.
ANATOMY OF THE CHEST
When performing CPR on an adult
or child casualty, the rescuer will
place the heel of one hand on the
center of the chest (lower half of
the sternum or breastbone) with
the other hand on top of the first
hand. Rescuers must avoid the
xiphoid process. The xiphoid, or tip
of the sternum, is a strong piece of
cartilage. Pressing on the xiphoid
can damage underlying organs
such as the heart or liver.
0 to 4 minutesClinical death,
breathing and
pulse stop.
4 to 6 minutesBiological death,
brain cells may
start to die.
6 to 10
minutesBrain damage
very likely.
10 minutes or moreBrain cells die, irreversible
damage to brain.
Ribs
Heart
Sternum
Xiphoid
Process
The Xiphoid Process
2
Sec 1 Introduction
AGE GUIDELINES
The following age guidelines are used to help determine which
technique to use. Other considerations include size and body weight.
• Infant - 1 month to 1 year of age
• Child - 1-8 years of age
• Adult - 8 years of age and older
LEGALITIES OF FIRST AID/CPR
Volunteer first aid/CPR rescuers must use reasonable knowledge, skill
and care in providing assistance. The risk of successful legal action
against a volunteer rescuer performing reasonable skills in Canada is
remote.
Good Samaritan laws or acts in Canada offer legal protection to
rescuers who willingly give emergency care without remuneration and
have been passed in Ontario (Bill 20, Good Samaritan Act, April 27,
2001), Nova Scotia (the Volunteer Services Act R.S., c. 497, s.1),
Newfoundland, Saskatchewan, Alberta, British Columbia and Nanavut.
Mandatory Assistance Good Samaritan Laws exist in Quebec.
GUIDING RULES
• Identify yourself as a first responder.
• Do only what you are qualified and trained to do!
• Never abandon the casualty once you have started to help.
• Ask for permission to give first aid before touching the casualty.
Consent is permission to provide care given by an ill or injured person
to a rescuer.
Implied consent is where a person who is unresponsive, confused
or seriously ill or injured cannot grant consent. The law assumes the
person would grant consent if they were able to do so.
Minors: First aiders should obtain permission from parent or guardian
for child or infant casualties if possible to do so.
Negligence is an act or omission of an act that a reasonable person
would or would not have done under similar circumstances thereby
causing harm to another.
3
Sec 2 Scene Assessment
EMERGENCY SCENE ASSESSMENT
When arriving at an accident scene remember, Watch Out Everyone
(WOE)! Use the following guidelines when checking for hazards that
may endanger your life or the casualty’s life.
RESCUER SAFETY
Your first priority is to save yourself
and not become a second victim.
Stop and do a complete visual
check of the surrounding area for
hazards that may endanger you or
the casualty.
Check for hazards such as
• Fire
• Electrical wire
• Broken glass
• Gas leakage
• Chemical spills
• Knives, guns or bad guys
Always be aware of potential hazards
and dangers.
PERSONAL PROTECTION
All rescuers should take the following
precautions
to
protect
against
the
transmission of potential diseases through
contact with blood and other body fluids:
• Wear protective gloves (vinyl/nitrile).
• Use a pocket mask or face shield when
performing rescue breathing.
• Always wash your hands with soap and warm
water after treating a casualty even when
protective gloves have been worn.
• Use an alcohol-based waterless hand
sanitizer with 60 to 95 percent alcohol if soap
and water is not available.
• Keep immunizations up to date to protect
against the flu, Hepatitis A/B, measles,
mumps, rubella, diphtheria, tetanus and
pertussis.
4
Sec 2 Scene Assessment
GLOVE REMOVAL & DISPOSAL
During the scene assessment, rescuers should put on gloves to protect
themselves from potential exposure to blood, bodily fluids, open
wounds or unknown substances. After any incident or rescue, assume
all gloves are contaminated and a hazard to safety. Follow these
guidelines to remove and dispose of contaminated gloves properly:
1. P
inch the outside cuff
of one glove and peel
down towards finger
tips.
2. G
rab the removed
glove in the palm of
the hand that is still
gloved.
3. S
lide
bare
fingers
under cuff of second
glove and peel towards
fingertips.
4. T
he first glove is now
inside second glove.
Knot the top of the
second glove.
5. D
iscard contaminated
items in the proper
receptacle. Put nonsharps in a plastic
bag labeled “infectious
waste.”
6. U
se soap and water to
wash hands, wrists and
forearms. A waterless
hand sanitizer may be
used if soap and water
are not available.
BIO-TIPS
1. Always use a bio-hazard container or double garbage bags to dispose of
contaminated objects.
2. Always use disposable first aid items.
3. Remove torn gloves immediately, wash hands immediately with antibacterial
soap and put a new pair of gloves on.
4. Report any suspected exposure to blood, body fluids, sharps or possible
disease immediately and seek medical treatment.
5. Record date and time of exposure, type of exposure, amount and other
related details of the incident.
6.Bring soiled materials used during the emergency (e.g.. rags, mops,
dressings, gloves, etc.) in a garbage bag or biohazard container to the
hospital with the casualty.
5
Sec 2 Scene Assessment
THE ADULT LINKS FOR SURVIVAL
The Chain of Survival™ was developed by the American Heart
Association to describe the sequence of steps, or links, necessary
to give the best chance of survival to someone suffering from cardiac
arrest, whether out-of-hospital, or in-hospital.
1
2
3
4
5
OUT- OF- HOSPITAL STEPS INCLUDE:
1.Immediate recognition of the cardiac arrest and activate 911 for EMS.
Use a cell phone if available and put the cell phone on speaker.
2. Early CPR starting with chest compressions.
3. Use an AED immediately or as soon as available.
4.Early access to emergency medical services (EMS) and advanced life
support.
5. Access to post-cardiac arrest care from Emergency Department or ICU
.
1
2
3
4
5
IN- HOSPITAL STEPS INCLUDE:
1. Surveillance, prevention, and treatment of pre-arrest conditions.
2.
I mmediate recognition of the cardiac arrest and activation of the
emergency response system.
3. Early CPR starting with chest compressions.
4. Use an AED immediately or as soon as available.
5. Access to post-cardiac arrest care from Emergency Department or ICU.
6
Sec 2 Scene Assessment
STEPS FOR HIGH-QUALITY CPR
This CPR sequence instructs rescuers to start chest compressions
early in the sequence. The delay in giving compressions should be
minimal. Rescuers check briefly for responsiveness and breathing
before giving compressions. The goal is to start high-quality CPR
compressions within 10 seconds of recognizing the cardiac arrest.
• Provide chest compressions of adequate rate (100-120 compressions per minute).
• Provide chest compressions of adequate depth:
• For adults, a compression depth of at least 2 inches (5 cm) not
more than 2.4 inches (6 cm).
• For children, at least one third the depth of the chest or at least 2
inches (5 cm).
• For infants, least one third the depth of the chest or at least 1 1/2
inches (4 cm).
• Allow complete chest recoil after each compression.
• Minimize interruptions in compressions to no more than 10
seconds.
• Avoid excessive ventilation. Give effective breaths that deliver
just enough air to make the chest rise.
AGONAL BREATHS
Agonal breaths, or gasps, are irregular, gasping breaths seen during
cardiac arrest and may sound like gasping or snoring. Rescuers
previously delayed giving chest compressions when they observed
agonal breaths. Agonal respirations may continue for several minutes
after the heart stops. These respirations do not provide adequate
oxygen to the body and should be considered the same as no breathing
at all (respiratory arrest).
The skills listed in this section will improve the training and confidence
of each rescuer in an effort to improve the outcome of CPR.
7
Sec 3 Adult/Child CPR
Adult/Child - Bystander CPR - No Barrier Available
1. Begin with the scene survey
Rescuers should:
• Take charge
• Assess hazards, make sure area is safe
• Wear protective equipment, latex/vinyl gloves
• Determine number of patients, what happened
and the mechanism of injury
• Identify yourself as a rescuer and offer to help
(obtain consent)
2. Determine unresponsiveness
By asking “are you ok?” while touching the casualty
on the arm or shoulder. Ask are you all right, can I
help you? If the patient remains unresponsive, this
is a life threatening condition.
3. Phone EMS 911 and get an AED
Rescuers should tell a bystander; “You, call 911, I
have an unresponsive adult/child at [location]. Get
an AED if available.” Ask “Do you understand?”
If the rescuer is alone, activate the emergency
medical system and get an AED (defibrillator) if
available and return to the casualty. If available,
use a cell phone and put cell phone on speaker for
operator assistance.
Child: Witnessed collapse; activate EMS (if
not already called), retrieve and apply an AED if
available, check breathing, then start CPR.
Child: Unwitnessed collapse; check breathing,
begin CPR, 30:2 (15:2 if a second rescuer who
is trained in HCP CPR assists). After 2 minutes,
if still alone, activate EMS and get an AED, then
resume CPR.
4. Check for breathing and carotid pulse
Open the airway using a head-tilt chin-lift and
check for breathing or no normal breathing or only
gasping and carotid pulse (5 to 10 seconds)
8
Sec 3 Adult/Child CPR
Adult/Child - Bystander CPR - No Barrier Available
5. Position hands for chest compressions
If the casualty remains unresponsive:
Prepare to perform compressions
• Quickly move or remove clothes from the
front of the chest that will get in the way of
doing compressions and using an AED
• Place 2 hands on the lower half of the
breastbone (sternum).
• One or two hands may be used for children
depending on child size
6. Position the rescuer
The rescuer should move their knee, closest
to the casualty’s head, in line with the
casualty’s shoulder.
• Place the heel of one hand on the lower
half of the breastbone
• Place the other hand on top of the hand
that is already on the chest
• Interlock fingers, lock elbows, look into the
opposite armpit
7. Start chest compressions
If the casualty remains unresponsive and nonbreathing or only gasping, start compressions
until an AED is available. Give 30 chest
compressions (rate of 100-120 compressions
per minute,about 30 compressions in 15-18
seconds.
Adult: Compress the adult chest 2 inches (5
cm) not exceeding 2.4 inches (6 cm).
Child: Compress child’s chest at least 1/3
the depth of chest or 2 inches (5 cm).
If a pocket mask becomes
available use it.
9
Sec 3 Adult/Child CPR
Adult/Child - First Responder CPR Without Mask
1. Begin with the scene survey
• The First Responder should assess hazards while
approaching scene and ensure the scene is safe
• Wear protective equipment, nitrile gloves
• Determine number of casualties, what happened and
the mechanism of injury
• Identify yourself as a first responder, take charge
2. Determine unresponsiveness
Tap and shout and ask “Are you ok? Can I help you?”
If the casualty remains unresponsive, this is a life
threatening condition.
3. Call for help and use radio if available
Call for backup on radio if available e.g. One person
down, possible cardiac arrest, medical assistance
is required, my location is. Dispatch should activate
EMS if not already done.
If the rescuer is alone, ensure EMS 911 is called
and get an AED (defibrillator) if available. If present,
rescuers should tell a bystander; “You, call 911.
I have an unresponsive adult at [location]. Get an
AED if available and report back to me. “Do you
understand?” Put cell phone on speaker.
Child: Witnessed collapse; activate EMS (if not
already called), retrieve and apply an AED if available,
check breathing, then start CPR.
Child: Unwitnessed collapse; check breathing,
begin CPR, 30:2 (15:2 if a second rescuer who is
trained in HCP CPR assists). After 2 minutes, if still
alone, activate EMS and get an AED, then resume
CPR.
4. Check for breathing and carotid pulse
Open the airway using a head-tilt chin-lift and check
for breathing or no normal breathing or only gasping
and carotid pulse (5 to 10 seconds) and expose the
chest (No pulse check for Lay Rescuers) Rescuers
trained in HCP CPR should perform a breathing and
pulse check simultaneously).
10
Sec 3 Adult/Child CPR
Adult/Child - First Responder CPR Without Mask
5. Position hands for chest compressions
If the casualty remains unresponsive:
Prepare to perform compressions
• Quickly remove clothes from the front of
the chest that will get in the way of doing
compressions and using an AED
6. Position the rescuer
The rescuer should move their top knee in line
with the casualty’s top shoulder.
• Place the heel of one hand on the lower half
of the breastbone
• Place the other hand on top of the hand that
is already on the chest
• Interlock fingers, lock elbows, look into the
opposite armpit
• One or two hands may be used for children
depending on child size
7. Start chest compressions
If the casualty remains unresponsive and nonbreathing or only gasping, start compressions
until an AED is available. Give 30 chest
compressions (rate of 100-120 compressions
per minute,about 30 compressions in 15-18
seconds.
Compress the adult chest at least 2 inches
(5 cm) not exceeding 2.4 inches (6 cm).
Compress a child’s chest at least 1/3 the
depth of chest or 2 inches (5 cm). If you are
alone with a child with no phone, call 911 after
giving 5 cycles of CPR.
Continue with “compression-only” CPR until
the pocket mask and AED arrive from additional
first responders or health care professionals.
11
Sec 3 Adult/Child CPR
Adult/Child - First Responder CPR With Mask
8. If an additional First Responder
arrives with pocket mask and AED
• Ensure bystanders are clear of the area
• Open AED, turn unit on and apply pads
• Give pocket mask to the initial responder
9. Defibrillation
•
•
•
•
•
If the AED arrives, turn the unit on
Apply pads according to diagrams
Follow audible voice prompts of AED
If indicated, give 1 shock
Resume CPR immediately until advised to
stop by the AED or until the casualty shows
signs of life. Minimize interruptions (10
seconds)
AED voice prompts include:
• “Apply pads to patient’s bare chest”.
The second responder would apply pads
to casualty’s bare chest while the initial
responder continues giving CPR.
• “Analyzing - do not touch patient”.
The second responder would state: “Stop
compressing, clear the patient”.
• “Shock advised, AED charging,
Do Not Touch patient”. The second
responder would state: “I’m clear, you’re
clear, everyone is clear, shocking now” and
press the shock button.
• “No shock advised. If needed,
begin CPR”. Rescuers should
reassess for breathing (and pulse if
HCP-trained). If no breathing (and no
pulse), continue CPR.
12
Sec 3 Adult/Child CPR
Adult/Child - First Responder CPR With Mask
10. Continue CPR.
• The first responder would resume CPR with
30 chest compressions, counting out loud
• The second responder would give 2 breaths
using a pocket mask as described below
11. Open the Airway (head-tilt chin-lift).
• Place the “head” hand on the forehead
• Place 2 fingers of the “foot” hand on the
chin
• Tilt backward on the forehead and lift the
jaw upwards. The tongue will lift out of the
airway
12. Give 2 Breaths
• Place a barrier device such as a pocket
mask or face shield over the mouth and
nose
• Place the “head” hand on the forehead with
thumb and pointer finger over the top of
the mask, the “foot” hand (using and “E-C
clamp” over the lower pocket mask and tilt
the head back
• Give 2 breaths (approx. 1 second each),
just enough to make the patient’s chest rise
• Allow the lungs to deflate between the two
ventilations. Avoid excessive breaths
• Resume chest compressions, reassessing
every 2 minutes (see step 4)
13. When EMS Arrives
• Prepare to give a verbal report to EMS
• Continue providing CPR until directed by
EMS to stop
CPR is in progress - Allow responding EMS to take over
13
Sec 3 Adult/Child CPR
Adult/Child CPR - Health Care Professionals
Team rescue with health care professionals
• A team of health care professionals can help
with specific duties such as pulse checks, bagvalve-mask (BVM) ventilation, compressions,
use of the AED and other emergency rescue
equipment
• In teams, rescuers should switch compressors
after every 5 cycles of 30 compressions and 2
ventilations (about every 2 minutes).
• In child CPR, two rescuers perform CPR at a
ratio of 15 compressions to 2 breaths.
Duties of the first rescuer (compressions)
1. Begin with the scene survey
• Assess hazards, make sure area is safe
• Wear protective equipment, nitrile gloves
• Determine number of patients, what happened
and the mechanism of injury
2. Determine unresponsiveness
• Tap the patients’ shoulder and ask “are you ok”.
3. Activate EMS 911 and get an AED
• Call 911 from you phone, activate the code
team or notify advanced life support. If alone,
get the defibrillator. If another rescuer is
available, send that person to get it.
4. Check for breathing and pulse
• The patient remains unresponsive
• Check for breathing or no normal breathing or
only gasping and carotid pulse at the same time
(5 to 10 seconds).
• State “Patient is not breathing and has no
pulse, starting CPR”
• If pulse is present and breathing is absent give
rescue breaths only (see pg 16).
• Position hands for chest compressions and start
chest compressions until an AED is ready.
Give 30 chest compressions (rate of 100-
14
Sec 3 Adult/Child CPR
Adult/Child CPR - Health Care Professionals
120 compressions per minute,about 30
compressions in 15-18 seconds, counting
out loud.
• Compress the adult chest 2 inches (5 cm)
not exceeding 2.4 inches (6 cm). Compress
child’s chest at least 1/3 the depth of chest
or 2 inches (5 cm).
• Switch compressors every two minutes
(when the AED is reanalyzing). Switch
sooner if the rescuer is fatigued.
Duties of the additional rescuers
Breaths
• Maintain an open airway by using either a
head tilt-chin lift or jaw thrust.
• Give 2 breaths using a bag-valve-mask,
watching for chest rise and avoiding
excessive ventilation.
• Support the first rescuer by encouraging
deep and fast compressions and allowing
the chest to completely recoil between
compressions.
Defibrillation
•
•
•
•
•
•
Prepare the chest as necessary
Turn the AED on
Attach the AED pads
Follow audible voice prompts of AED
If indicated, clear patient and give 1 shock
Resume CPR immediately for 5 cycles of
30:2. Minimize interruptions (10 seconds)
EMS will Provide Ongoing Care
• Prepare patient to be moved to hospital to
receive post-cardiac arrest care
• Load patient onto stretcher
• Transport patient to hospital
• Continue CPR as indicated
15
Sec 3 Adult/Child CPR
Adult/Child CPR - Health Care Professional(s)
Rescue Breathing
1. Begin with the scene survey and ensure the scene is safe
2. Determine unresponsiveness (tap and shout)
3. Call for help and use cell phone or radio if available
4. Check for breathing and pulse
• The patient remains unresponsive
• Check for breathing or no normal breathing or only gasping and
carotid pulse (adult/child) or brachial pulse (infant) at the same
time (5 to 10 seconds).
If the patient is not breathing and has a pulse, start RESCUE
BREATHING
• Use a BVM to provide rescue breaths
(see page 16)
• Adult: Give 1 breath every 5-6 seconds,
or about 10-12 breaths per minute
• Infant and Child: Give 1 breath every
3-5 seconds, or about 12-20 breaths per
minute.
— Start compressions if pulse remains ≤
60 beats per minute with signs of poor
perfusion* and is unresponsive.
— Call 911 (if not already done after 2
minutes of CPR)
— Continue rescue breathing
• Check the carotid pulse (adult/child) or
brachial pulse (infant) about every 2
minutes
• If there is no pulse and no breathing or
only agonal breaths, start CPR
* Signs of poor perfusion: pale/cool skin,
weak pulse, decrease in responsiveness, blueness (cyanosis)
and patchy skin (mottled).
16
Sec 3 Adult/Child CPR
Adult/Child CPR - Health Care Professional(s)
Health Care Professionals will use a Bag-ValveMask (BVM) device for ventilations. The BVM is
used to provide positive-pressure ventilation to
a patient who is not breathing or not breathing
normally (agonal gasps). Proficiency in the use
of a BVM requires practice.
It is recommend that 2 rescuers use the BVM.
One rescuer seals the mask onto the face and
opens the airway. The second rescuer squeezes
the bag. The BVM come in 3 sizes, adult (large),
child (medium) and infant (small).
How to Use BVM with head tilt-chin lift
The First Responder should:
• Move to the top of the patient’s head
• Position the mask over the patient’s nose and
mouth, pointy part to nose
• Position the mask over the patient’s nose and
mouth, pointy part to nose
• Place one hand over the mask (using an “E-C
clamp” over the mask and tilt the head back
• The “E-C clamp” place the thumb and pointer
finger around the top of the mask while using
the 3 remaining fingers to grasp the jaw
• Put downward pressure from the thumb and
pointer finger to seal the mask onto the face
and use the other 3 fingers to lift the jaw
forward at the same time.
The rate of ventilation for an adult is 10-12
breaths per minute or, approximately 1 bag
squeeze every 5-6 seconds. The bag should
be depressed slowly, about 1/3 the depth
of the bag, for a full 1-2 seconds and then
released. Chest rise should be seen with
adequate tidal volumes, approximately 500600 mL.
17
Sec 3 Adult/Child CPR
Adult/Child CPR - Health Care Professional(s)
Some bags are equipped with a pressure
valve. Some bags have one-way expiratory
valves to prevent the entry of room air; these
allow for delivery of greater than 90% oxygen
to ventilated and spontaneously breathing
patients. Bags lacking this feature deliver a
high concentration of oxygen during positive
pressure ventilation but only deliver 21%30% oxygen during spontaneous breaths
The bag-valve mask unit should be attached
to high-flow oxygen at 15 liters per minute,
at which a typical device delivers between
95-100% oxygen.
Obstacles to quality BVM use:
• The presence of facial hair
• Lack of teeth
• A body mass index (BMI) greater than
26%
• Facial trauma and/or deformity
• A history of snoring
How to Use BVM with Jaw Thrust
The Jaw Thrust is another more comfortable
technique to hold the mask with prolonged
ventilation:
• Works best with 2 rescuers
• May be used concurrently with head tiltchin lift or without head-tilt of a spinal
injury is suspected.
• Place both thumbs parallel over the
mask and cheek
• Place the other four fingers under the
angle of the mandible to apply jaw lift
• A Jaw Thrust (without head tilt) should
be attempted any time a spinal injury is
suspected or can not be ruled out.
18
Sec 3 Adult/Child CPR
Adult/Child CPR - Health Care Professional(s)
Oral Airway
Nasal Airway
BVM ventilation requires a good seal and
a patent airway. Adjuncts such as oral and
nasal airways (which are NOT advanced
airways, as discussed below) can aid with
ventilation by preventing the tongue from
occluding the airway. Incorrect insertion of
an oropharyngeal airway can displace the
tongue into the hypopharynx, causing airway obstruction. To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be used in unconscious
(unresponsive) patients with gag reflex and
should be inserted only by persons trained
in their use.
The use of an advanced airway (e.g.,
endotracheal tube or supraglottic airway)
is acceptable during CPR. There are times
when ventilation with a bag-mask device is
inadequate, so advanced providers may be
trained and experienced in the insertion of
an advanced airways.
BVM use with an advanced airway:
• Compression rate of 100 to 120 per minute
• Continuous compressions without pauses for
breaths
• 1 breath every 6 seconds (10 breaths per
minute) for adults, children, and infants
King LT™
(A supraglottic airway)
Healthcare providers must maintain their
knowledge and skills through frequent
practice to maintain proficiency. It may
be helpful for trained providers to master
one primary method of airway control with
a second (backup) strategy for airway
management and ventilation if they are
unable to establish the first-choice airway
adjunct, such as a BVM.
19
Sec 3 Adult/Child CPR
Alternative techniques for rescue breaths include cheek to nose, mouth
to nose, mouth to stoma. Use barrier devices whenever possible.
MOUTH TO NOSE RESCUE BREATHS
Mouth to Nose means blowing air into the casualty’s nose when
• The mouth cannot be opened
• The casualty has serious injuries around the mouth or jaw
• Your mouth cannot fully cover the casualty’s mouth
Mouth to Nose rescue breathing is the same as mouth to mouth
rescue breathing except that you close the casualty's mouth and only
breathe into the casualty’s nose. This technique is safe and effective.
Mouth to Stoma rescue breathing is given to a casualty with a tracheal
stoma who requires rescue breathing. A round, pediatric face mask
will make an effective, tight seal over the stoma.
GASTRIC DISTENTION & VOMITING
Gastric distension and vomiting are complications of rescue breathing.
Gastric Distention occurs during rescue breaths, where air may
enter the casualty's esophagus (the tube leading from the throat to the
stomach) and cause the stomach to inflate. As a result the casualty
may vomit and have decreased lung volume.
Causes of gastric distention:
• The rescuer blowing air into the casualty too forcefully and too quickly
• Improperly positioning the casualty's head (airway not open)
• An obstruction in the casualty's airway preventing the lungs from filling
quickly
Steps to reduce gastric distention:
• Reposition the casualty's airway.
• Watch for the rise and fall of the casualty's chest and breathe just hard
enough to cause the chest to visibly rise.
• Do not push on the casualty's abdomen in an attempt to reduce the
distention since the pressure could cause the casualty to vomit.
Vomiting (Regurgitation). If the casualty vomits, roll the casualty onto their
side of that their front is toward you and administer a finger sweep to wipe
out their mouth. Then return them to the supine position (flat on their back).
20
Sec 3 Adult/Child CPR
ADULT/CHILD 1 – RESCUER CPR
1
2
Scene Safety. Watch Out Everyone (WOE)! Look for
fire, wire, gas, glass, no knives, guns or bad guys.
Personal Protective Equipment. Pocket mask & gloves.
Identify yourself and offer to help.
3
Determine Unresponsiveness (tap and shout). Ask “are
you alright? Can I help you?” There is no response.
4
Phone EMS 911 and get an AED or tell bystander. Put
cell phone on speaker for operator assistance.
Open the airway and check for breathing, no normal
breathing or only gasping and a carotid pulse (5
to 10 seconds). If a child has a pulse of <60 and is
unresponsive with signs of poor perfusion, begin CPR.
Begin compressions. If the casualty remains
unresponsive, no pulse and no breathing or only gasping,
start compressions until an AED is available. Give 30
chest compressions at a rate of 100-120 compressions
per minute. Compress the adult chest 2 inches (5 cm)
not exceeding 2.4 inches (6 cm). Compress child’s
chest at least 1/3 the depth of chest or 2 inches (5 cm).
If you are alone with a child with no phone, call 911 after
giving 5 cycles of CPR.
Give 2 breaths with a barrier device, 1 second each,
just enough to make the chest rise. Each breath should
be about one second apart.
Defibrillation. If the AED arrives, apply pads to casualty
ASAP. Follow voice prompts. Shock, if advised and
resume CPR ASAP. If no shock advised, check for
breathing. If not breathing resume CPR immediately for
5 cycles of 30:2. Minimize interruptions to no more than
10 seconds. Continue care until arriving EMS take over.
5
6
7
8
21
Sec 3 Adult/Child CPR
ADULT/CHILD 2 – RESCUER CPR WITH AED
AED Arrives, CPR is in progress. Rescuer 1 continues
1 CPR. Ensure you have gloves and pocket mask or face
2
3
shield.
Open AED unit, turn unit on and follow voice prompts.
Some AED units turn on automatically once the cover is
opened.
Prepare casualty: expose chest, remove metal, remove
excess hair, observe for pacemaker/patches, water, etc.
Select AED pads and place pads correctly on casualty.
Adult pads are for casualties 8 years of age and older.
Clear casualty to analyze when prompted (must be a
5
visual and verbal check).
If advised, clear casualty to shock. Press shock button
(must be a visual and verbal check) and resume CPR
ASA). Maximum time from AED arrival < 90 seconds. If
6
no shock advised, check for breathing. If not breathing
resume CPR immediately for 5 cycles of 30:2 (child 15:2).
Minimize interruptions to no more than 10 seconds.
Resume chest compressions after 1 shock. Place hands
in the center of the chest between the nipple line. Give
7 30 chest compressions, at least 100 to 120 compressions
per minute (adult or child) at a depth of about 2 inches (5
cm) not exceeding 2.4 inches (6 cm).
Open Airway. The second rescuer uses a head-tilt chin-lift
8
to open the airway.
Give 2 breaths (with pocket mask or face shield), 1 second
9 each, just enough to make the chest rise. Each breath
should be about one second apart
After 2 minutes of CPR, the AED will prompt you to analyze.
10
Switch compressors and follow all voice prompts.
4
22
Sec 4
3 Infant
Adult/Child
CPR CPR
Infant CPR - Bystander - No Barrier Available
1. Begin with the scene survey
Rescuers should:
• Assess hazards, make sure area is safe
• Wear protective equipment, latex/vinyl gloves
• Determine number of patients, what happened
and the mechanism of injury
• Identify yourself as a rescuer and offer to help
(obtain consent)
2. Determine unresponsiveness
CALL
OUT
By asking “baby, are you ok?” while tapping the
infant on sensitive areas - feet, hands or face.
If the infant remains unresponsive, this is a life
threatening condition. Place the infant on a firm
hard surface.
3. Phone EMS 911 and get an AED
Infant: Witnessed collapse; activate the EMS (if
not already called) get an AED, then start CPR.
Infant: Unwitnessed collapse; begin CPR, 30:2
(15:2 if a second rescuer assists) after 2 minutes,
if still alone, activate EMS and get an AED, then
resume CPR.
If a bystander is nearby, say; “You, call 911, I
have an unresponsive baby, [location], get an
ambulance and ask “Do you understand?”
Put cell phone on speaker for operator assistance
while giving chest compressions.
4. Check for breathing and brachial pulse
CALL
911
Open the airway using a head-tilt chin-lift and
check for breathing, no normal breathing or only
gasping and a brachial pulse (5 to 10 seconds).
• If both pulse and breathing are absent begin CPR
• If pulse is present and breathing is absent
give rescue breaths only (see pg 16 for rescue
breathing).
23
Sec 4
3 Infant
Adult/Child
CPR CPR
Infant CPR - Bystander - No Barrier Available
6. Position finger tips for compressions
If infant remains unresponsive:
Prepare to perform compressions
• Quickly move or remove clothes from the
front of the chest that will get in the way of
doing compressions and using an AED
• Position the infant on your upper leg or on a
hard flat surface
• Place 2 fingers in the center of the chest
below the nipple line, on the lower half of
the breastbone (sternum).
7. Start chest compressions
If the infant remains unresponsive and nonbreathing or only gasping, start compressions
until an AED is available. Give 30 chest
compressions (rate of 100-120 compressions
per minute,about 30 compressions in 15-18
seconds.
Compress the infant’s chest at least 1/3 the
anterior/posterior diameter of chest or 2
inches (4 cm).
8. Give 2 breaths (puff of air)
• If no barrier is available
• Open the airway with a head tilt-chin lift
• Cover the infants nose and mouth with your
mouth to make a complete seal
• Give 2 breaths (puffs) 1 second each to
make the infant’s chest rise
• Allow the lungs to deflate between the two
puffs. Avoid excessive breaths
• Perform 5 cycles of 30 compressions
: 2 breaths until the infant revives or
advanced medical support takes over.
CPR is in progress - First
Responders arrive to assist
24
Sec 4
3 Infant
Adult/Child
CPR CPR
Infant CPR - First Responder CPR With Mask
1. Begin with the scene survey
• The First Responder should assess hazards
while approaching incident, make sure area is
safe
• Wear protective equipment, latex/vinyl gloves
• Determine number of casualties, what
happened and the mechanism of injury
• Identify yourself as a first responder, take
charge
2. Determine unresponsiveness
Tap and shout and ask “are you ok?” If the
casualty remains unresponsive, this is a life
threatening condition.
CALL
OUT 3. Phone EMS 911 and get an AED
Call 911 on mobile phone and put speaker on if
available. Call for backup on radio if available
e.g. One person down, possible cardiac arrest,
medical assistance is required, [my location is].
Dispatch may also call 911 to activate EMS.
If a bystander or second rescuer is nearby, say;
“You, call 911, I have an unresponsive infant,
location, get an ambulance and ask “Do you
understand?”
Infant: Witnessed collapse; activate the EMS
(if not already called) get an AED, then start
CPR.
Infant: Unwitnessed collapse; begin CPR,
30:2 (15:2 if a second rescuer assists) after 2
minutes, if still alone, activate EMS and get an
AED, then resume CPR.
CALL
911
4. Check for breathing and brachial pulse
Open the airway using a head-tilt chin-lift and
check for breathing or no normal breathing or
only gasping and brachial pulse (5 to 10 seconds)
and expose the chest (No pulse check for Lay
Rescuers)
25
Sec 4
3 Infant
Adult/Child
CPR CPR
Infant CPR - First Responder CPR With Mask
5. Position finger tips for compressions
If the infant remains unresponsive, prepare
to perform compressions
• Quickly move or remove clothes from the
front of the chest that will get in the way of
doing compressions and using an AED
• Position the infant on a hard flat surface
• Place 2 fingers in the center of the chest
below the nipple line, on the lower half of
the breastbone (sternum).
6. Start chest compressions
If the infant remains unresponsive and
non-breathing or only gasping, start
compressions until an AED is available.
Give 30 chest compressions (rate of 100120 compressions per minute,about 30
compressions in 15-18 seconds.
Compress the infant’s chest at least 1/3 the
anterior/posterior diameter of chest or 2
inches (4 cm).
7. Give 2 breaths (puff of air)
• Use an infant barrier if available (see
page 13 for use of a pocket mask)
• Open the airway with a head tilt-chin lift
• Cover the infants nose and mouth with an
infant barrier device or use your mouth to
make a complete seal
• Give 2 breaths (puffs) 1 second each to
make the infant’s chest rise
• Allow the lungs to deflate between the
two puffs. Avoid excessive breaths
• Perform 5 cycles of 30 compressions
: 2 breaths until the infant revives or
advanced medical support takes over.
26
Sec 4
3 Infant
Adult/Child
CPR CPR
Infant CPR - Health Care Professionals
Team rescue with health care professionals
• A team of health care professionals can help with
specific duties such as pulse checks, bag-valvemask (BVM) ventilation, compressions, use of
the AED and other emergency rescue equipment
• In teams, rescuers should switch compressors
after every 2 minutes.
• In infant CPR, two rescuers perform CPR at a
ratio of 15 compressions to 2 breaths.
Duties of the first rescuer (compressions)
1. Begin with the scene survey
• Assess hazards, make sure area is safe
• Wear protective equipment, nitrile gloves
• Determine number of patients, what happened
and the mechanism of injury
2. Determine unresponsiveness
• Tap the infant’s shoulder and ask “are you ok”
• The infant remains unresponsive.
3. Activate EMS 911 and get an AED
• Call 911 from you phone, activate the code team
or notify advanced life support. If alone, get the
defibrillator. If another rescuer is available, send
that person to get it.
4. Check for breathing and pulse
• Check for breathing or no normal breathing or
only gasping and brachial pulse at the same time
(5 to 10 seconds). The brachial pulse is felt by
placing two fingers on the brachial artery on the
inside of the upper arm.
• State “infant is not breathing and has no
pulse, starting CPR”
5. Position finger tips for compressions
• Prepare to perform compressions
• Quickly move or remove clothes from the front
of the chest that will get in the way of doing
27
Sec 4
3 Infant
Adult/Child
CPR CPR
Scenario 2 - First Responders Arrive
compressions and using an AED
• Position the infant on a hard flat surface
• Encircle the infant’s chest and use 2 thumbs
side-by-side or one on top of the other to provide
compressions. The method used will depend on the
size of the infant and the rescuer’s thumbs.
6. Start chest compressions (15:2)
Start compressions counting out loud, e.g. 1, 2, 3, 4,
etc. Give 15 chest compressions (rate of 100-120
compressions per minute. Compress the infant’s
chest at least 1/3 the anterior/posterior diameter of
chest or 1 1/2 inches (4 cm).
Duties of the additional rescuers
Breaths (2 rescuers are best with BVM)
• Maintain an open airway by using either a head
tilt-chin lift or jaw thrust.
• Give 2 breaths using an infant bag-valve-mask,
watching for chest rise and avoiding excessive
ventilation.
• Support the first rescuer by encouraging deep
and fast compressions and allowing the chest to
completely recoil between compressions.
Defibrillation
•
•
•
•
•
Prepare the chest as necessary
Turn the AED on and attach the AED pads
Follow audible voice prompts of AED
If indicated, clear infant and give 1 shock
Resume CPR immediately for cycles of 15:2.
Minimize interruptions (10 seconds)
EMS will Provide Ongoing Care
• Prepare infant to be moved to hospital to receive
post-cardiac arrest care
• Load infant onto stretcher
• Transport infant to hospital
• Continue CPR as indicated
28
Sec 4
3 Infant
Adult/Child
CPR CPR
INFANT 1 – RESCUER CPR
1
2
3
4
5
6
7
8
9
Scene Safety. Ensure the scene is safe.
Personal Protective Equipment. Infant pocket mask or
face shield & gloves.
Determine unresponsiveness. Ask “baby, are you okay?”
while tapping the infant on sensitive areas - feet, hands or
cheek. The infant remains unresponsive.
Call 911 and for an AED. Send a bystander if available. If
you are alone with an infant, call 911 after giving 5 cycles
of CPR.
Use a head-tilt chin-lift to check for breathing or no normal
breathing or only gasping and brachial pulse (5 to 10
seconds).
Compressions. If the infant remains unresponsive with no
pulse or breathing, start compressions. Place two fingers
in the center of the chest below the nipple line. Give 30
chest compressions (rate of 100-120 compressions per
minute). Squeeze the infants chest at least 1/3 the depth
of chest, or 1 1/2 inches (4cm). If you are alone with an
infant with no phone, call 911 after giving 5 cycles of CPR.
Open Airway using a head tilt-chin lift to sniffing position.
Give 2 breaths or puffs (with pocket mask or face shield),
just enough to make the chest rise. Each breath should be
about one second apart.
Defibrillation, for infants less than 1 year of age. Apply
infant/child pads ASAP. If infant/child pads are not
available, apply adult pads ASAP. Follow voice prompts.
Shock, if advised and resume CPR ASAP. If no shock
advised, check for breathing. If not breathing resume CPR
immediately for 5 cycles of 30:2. Minimize interruptions to
no more than 10 seconds.
29
Sec 4
3 Infant
Adult/Child
CPR CPR
THE PEDIATRIC LINKS FOR SURVIVAL
The Pediatric Chain of Survival™ was developed by the American
Heart Association to describe the sequence of steps, or links,
necessary to give the best chance of survival to an infant suffering
from out-of-hospital cardiac arrest.
It is rare for a child or an infant to initially suffer a cardiac emergency.
Usually, a child or an infant has a respiratory emergency first and then
a cardiac emergency develops. If untreated, respiratory arrest will
quickly lead to cardiac arrest and death
Causes of cardiac arrest in children and infants may include:
• Aspiration of foreign bodies such
as hot dogs, peanuts, candy or
small toys into the airway.
• Airway infections, such as croup
and epiglottitis
• Traumatic injury or an accident
(e.g., motor-vehicle collision,
drowning, electrocution or
poisoning).
• Congenital heart disease.
1
2
• A hard blow to the chest.
• Sudden infant death syndrome
(SIDS) .
3
4
5
PEDIATRIC STEPS INCLUDE:
1. Prevention of arrest..
2. Early CPR starting with compressions.
3. Rapid activation of the emergency response system.
4. Effective advanced life support with transport to post cardiac arrest care.
5. Integrated post-cardiac arrest care.
30
Sec 5 Defibrillation
PUBLIC ACCESS DEFIBRILLATION (PAD)
Early CPR and early defibrillation prior to
EMS arrival are two important links in the
chain of survival to improve the casualty’s
chance of survival.
Defibrillation is the process of applying an
electric shock through the heart muscle to
try and restore a normal heart rhythm. An
Automated External Defibrillator (AED) is
a computerized device that is attached to
an unresponsive casualty with no breathing
or with agonal breaths. Adhesive pads are
placed on the casualty and plugged into the
AED. The AED gives the rescuer visual and
voice prompts to guide the rescuer through
each step.
Automated External
Defibrillator (AED)
ELECTRICAL
ACTIVITY OF
THE HEART
The heart has a
built-in electrical
system
which
causes the heart
to contract. The
stimulus for the
heart muscle to
contract is involuntary and begins at the Sinoatrial (SA) Node.
The SA node, known as the heart’s natural pacemaker, is located in the
right atrium. Impulses travel from the SA Node to the Atrioventricular
(AV) node located on the junction between the left and right sides of
the heart. Impulses fire at a rate of 60 to 100 impulses per minute.
The impulses spread through the middle of the heart (septum) and
out the Purkinje Fibers causing the chambers of the heart to contract
and pump blood. Without the electrical signal the heart will not pump
blood.
31
Sec 5 Defibrillation
Heart rhythms can be viewed on electrocardiograms (ECG). An ECG
measures the electrical activity in the heart. The following ECGs are
analyzed by each defibrillation unit:
Normal Sinus Rhythm (NSR) - Electrical activity of the heart is
coordinated, giving normal muscle contractions that produce a regular
pulse.
Electrical problems affecting the heart rate or rhythm are called
dysrhythmias and may impair the ability of the heart to pump blood
effectively. The following are some causes of dysrhythmias:
•
•
•
•
•
•
•
Coronary heart disease
Oxygen deficiencies
Trauma to the heart
Electrocution
Drugs and medications
Chemical imbalances
Central nervous system damage
Ventricular Fibrillation (VF) - A chaotic heartbeat that occurs when
the heart beats rapidly and erratically causing the ventricles to quiver
uselessly instead of pumping blood.
When the heart is in fibrillation, the heart muscle is uncoordinated like
a bowl of jello shaking. No effective blood is being supplied to any
part of the body. Breathing stops and cardiac arrest occurs. The most
common heart rhythm at the beginning of a cardiac arrest is VF. The
AED unit will indicate a shock is advised.
Pulseless Ventricular Tachycardia (VT) - A pulse of more than 120
beats per minute with at least three irregular heartbeats in a row not
allowing the ventricles to fill adequately or pump blood normally.
32
Sec 5 Defibrillation
Asystole (flat line) - There is no electrical activity of the heart muscle
and no muscle contractions producing a pulse. This dysrhythmia
cannot be treated with electrical shocks from AEDs. No shock will be
advised.
AED - PROTOCOLS
• Assess the scene, casualty responsiveness and breathing.
• Call 911/ EMS for the unresponsive adult.
• Start chest compressions until the AED arrives. If the casualty does not
respond and is not breathing, attach the AED and stand clear.
SHOCK ADVISED PROTOCOL
• AED unit is powered on and attached to the casualty. It will state
“analyzing - shock advised.”
• Clear the casualty - State “I’m clear, you’re clear, everyone is clear”.
• State “shocking now”. Press the shock button.
• CPR - After the shock, begin CPR starting with chest compressions for
5 cycles, approximately 2 minutes. After 2 minutes, the AED will reanalyze.
• If “no shock advised”, go to no shock advised protocol.
NO SHOCK ADVISED PROTOCOL
• Power on AED unit and attach pads to the casualty ASAP. It will state
“Analyzing - no shock advised.”
• Check for breathing (5-10 seconds). If not breathing, begin CPR at a
ratio of 30 compressions to 2 breaths until advised by the AED to reanalyze.
• Minimize interruptions to no more than (10 seconds).
• Follow all visual and/or voice prompts from the AED.
33
Sec 5 Defibrillation
SPECIAL CONSIDERATIONS FOR AED USE
ICE, SNOW
AND WATER
No change in protocol for ice and snow. If the person is
lying in a puddle or other pool of water, do the "splash
test". If you jump in the water and it splashes, it is deep
enough to conduct an electrical charge, so you must
remove the person from the water before you use the
AED. Wipe off the casualty's wet chest before applying
the pads.
METAL
SURFACES
Defibrillation on metal or conductive surface should
be cautioned. Ideally, casualties should be treated
on concrete surfaces that do not conduct electricity:
however, metal platforms, grading and stretchers should
not pose a risk to responders.
IMPLANTED
PACEMAKER
Place the electrode pad at least 2.5 cm (1 in.) away.
Rescuers may notice a hard lump rising from under the
skin of the upper chest (usually on the left side).
MEDICATION
PATCH ON
CHEST
Medication patches on the chest, including nitroglycerin
for angina, should be removed. Wear gloves and wipe
the area clean with a cloth. Apply pads once the area
is clean.
HYPOTHERMIC
CASUALTY
Severe hypothermia is when the casualty’s core body
temperature is below 35° degrees Celsius. Remove
casualty from the cold, remove wet clothing and cover
with blankets. If the casualty is unresponsive and not
breathing start CPR. When an AED becomes available,
apply pads. If shock advised, deliver one shock only.
Continue with CPR until EMS arrive.
PREGNANCY
There is no change in defibrillation protocol for pregnant
casualties. Continue with normal AED protocols.
OXYGEN &
FLAMMABLE
AREAS
INFANT/ CHILD
34
Defibrillation in flammable areas or in oxygen-enriched
areas should not be attempted. Move casualty to a safe
area if necessary. Remove oxygen from the casualty
before shocking.
Attach and use AED as soon as available. Follow the
pictures on the pads to attach the pads to the casualty's
bare chest. One infant/child pad is placed on the front
chest and one on the back for infants and small children.
If infant pads are not available use adult pads.
Sec 5 Defibrillation
PROPER PAD SELECTION &
PLACEMENT
MAINTENANCE CONSIDERATIONS
Resuscitation equipment should be inspected daily. Check the status
indicator; look for low battery power, cracks or damage; and review
pad and battery expiry dates. It is recommended that a defibrillator
unit have a pocket mask, gloves, razor, scissors and
towel stored beside the unit.
Maintenance and testing of AED units shall be
conducted at each workplace in accordance with the
manufacturer’s guidelines. Records of maintenance
and testing shall be kept with the AED in a central
location at the workplace.
Although AEDs are rugged, low maintenance and easy to use,
problems may occur. Poor pad contact is possible, so ensure the skin
is dry and pads are attached firmly. The battery life may be low. If
so, the unit may indicate that the battery must be replaced. The unit
may indicate that service is required. If service is required, turn the
defibrillator off and on. If the problem persists, turn the AED off and
continue with CPR. The unit will need to be serviced.
After using an AED, restock any used electrode pads, memory cards,
razors or protective gloves. Check or replace the batteries before
use. Follow the manufacturer’s instructions for disinfection of the
unit, as well as how to download incident-related information from
the device’s memory card prior to placing the AED back into service.
These are key factors in AED maintenance procedures. It is highly
important that these devices are kept in proper working condition and
checked regularly so that no incident will take you by surprise.
35
Sec 5 Defibrillation
PUBLIC ACCESS DEFIBRILLATION GUIDE
1
2
3
Personal Protective Equipment. Use a pocket mask &
gloves, identify yourself and offer to help.
Determine Unresponsiveness. Tap and shout. Ask “are
you alright? Can I help you?”
4
Call 911. Send a bystander to call and find an AED, if
available.
5
Use a head-tilt chin-lift to check for breathing, no normal
breathing or only gasping and pulse (5 to 10 seconds).
6
Compressions. If the casualty remains unresponsive and
not breathing or only gasping, start compressions until an
AED is available. Give 30 chest compressions at a rate of
100-120 compressions per minute. Compress the adult or
child’s chest at least 2 inches (5 cm) but not exceeding
2.4 inches (6 cm). If you are alone with a child, call 911
after giving 5 cycles of CPR.
7
Open Airway. Use a head-tilt chin-lift to open the airway.
8
Breaths. Give 2 breaths of 1 second each. Watch chest
rise and allow for exhalation between breaths.)
9
10
36
Scene Safety. Watch Out Everyone (WOE)! Look for fire,
wire, gas, glass, knives, guns or bad guys.
Defibrillation Protocol. When the AED arrives, perform
the following steps: Step 1 - Turn AED on. Step 2 - Apply
electrode pads to casualty's bare chest. Step 3 - Clear the
casualty to analyze and follow visual and voice prompts.
Shock, if advised and resume CPR ASAP. If no
shock advised, check for breathing. If not breathing
resume CPR immediately for 5 cycles of 30:2.
Minimize interruptions to no more than 10 seconds.
Continue care until arriving EMS take over.
Complete incident reports and Critical Incident Stress
Debriefing after rescue.
Sec 6 Choking
AIRWAY OBSTRUCTION / CHOKING
In Canada, about 1,200 deaths are attributed to airway obstruction
each year. Common factors that lead to obstruction include attempting
to swallow large, poorly chewed pieces of food, consuming alcohol
and wearing dentures. In restaurants, airway obstructions have been
mistaken for heart attacks, giving rise to the phrase “cafe coronary.”
When the casualty’s airway is completely blocked and the responsive
casualty cannot speak or breathe, the obstruction must be removed
immediately. To remove an object from a responsive casualty,
repetitive abdominal thrusts and back blows are used, while chest
thrusts and back blows are used on a large or pregnant casualty.
SIGNS OF CHOKING
MILD AIRWAY
OBSTRUCTION
Signs:
• Good air exchange
• Responsive and can cough
forcefully
SEVERE AIRWAY
OBSTRUCTION
Signs:
• Clutching the neck with the
thumb and fingers, making the
universal choking sign
• Inability to speak or breathe
• Poor or no air exchange
• Weak, ineffective cough or no
cough at all
• High-pitched noise while
inhaling or no noise at all
• Increased respiratory difficulty,
blueness of lips, fingernails and
earlobes
• Tears in eyes
• Unable to move air in or out
37
Sec 6 Choking
CAUSES AND PREVENTION OF CHOKING
1. Common causes of choking include
• Food or other objects getting stuck in throat
• Tongue relaxing and blocking airway
• Blood or vomit collecting in back of throat if casualty is unresponsive
The tongue relaxes and blocks the
back of the throat.
Fluids pool in the throat (blood,
vomit, saliva).
2. Factors associated with choking include
• Swallowing large pieces of food
• Consuming alcohol with food
• Placing large objects in mouth
Adults and elderly
people may obstruct
on assorted foods
Infants and children may
obstruct on assorted
common objects
3. Factors to help prevent choking include
•
•
•
•
38
Cutting food into small pieces
Reducing alcohol consumption while eating
Avoid talking and laughing while eating
Avoid physical activities while eating
Sec 6 Choking
SAVE -YOURSELF CHOKING TECHNIQUES
1. Using Furniture
• Place your abdomen on the back of a chair.
• Use both arms on the chair to support your body.
• Thrust your abdomen into the back of the chair
to create air pressure to relieve the obstruction.
Repeat until effective.
2. Using Abdominal Thrusts
• Place one fist on your abdomen (thumb knuckle
above navel).
• Use your other hand to grab your fist.
• Use both hands to pull your fist into your
abdomen in an inward and upward direction to
create air pressure to relieve the obstruction.
Repeat until effective.
Straddle a Chair
3. Using Chest Thrusts
• Place one fist on your sternum (chest bone
above xiphoid).
• Use your other hand to grab your fist.
• Use both hands to pull your fist into your chest
in an inward thrust to create air pressure to
relieve the obstruction. Repeat until effective.
TECHNIQUES FOR A LARGE OR
PREGNANT CASUALTY
Use chest thrusts and back blows on an
large or pregnant casualty.
Abdominal Thrusts
• Ask the casualty if they are choking.
• Give 5 back blows with the heel of your hand
between the should blades.
• Give 5 chest thrusts. Stand behind casualty.
Place one finger above where the ribs join,
place one fist above the finger, thumb to
chest, grab your fist and thrust backward.
• Continue alternating between 5 back blows
and 5 chest thrusts until the object is expelled
or until the person becomes unconscious.
Chest Thrusts
39
Sec 6 Choking
RESPONSIVE AIRWAY OBSTRUCTION - ADULT
1. RECOGNIZE OBSTRUCTION
Approach
and identify
yourself.
Assess
for airway
obstruction.
Call out
for help.
If choking
casualty
leaves room, follow them.
2. OFFER ASSISTANCE
Ask “are you
choking? I
am trained
in first aid.
Can I help?”
If casualty
can cough
forcefully,
speak, or breathe, do not
interfere, encourage coughing.
3. 5 BACK
BLOWS
Deliver 5 blows
on the back with
the heel of your
hand. Your hand
should land
right between
the shoulder
blades.
40
4. LOCATE ABDOMEN
Stand behind the choking casualty
and wrap your arms around
the waist, thumb side of fist on
abdomen, mid-line above naval
and well below breastbone.
5. 5 ABDOMINAL THRUSTS
Grab your fist
with your other
hand. Squeeze
abdomen with 5
quick, forceful
upward thrusts.
Continue 5
back blows and
5 abdominal
thrusts until
the casualty
begins coughing, the object is
dislodged or casualty becomes
unresponsive.
6. SPECIAL CONSIDERATIONS
For a large or pregnant casualty
perform a combination of 5 back
blows and 5 chest thrusts. Place
wedge under pregnant casualty’s
right hip if laying down.
Sec 6 Choking
UNRESPONSIVE AIRWAY
OBSTRUCTION - ADULT
1. CALL 911
Casualty was
choking. Look
for an object
in the mouth.
If a bystander
is available,
send them
to call 911,
put cell on
speaker phone
and get an
AED.
2. LOWER
CASUALTY
TO
GROUND
Protect the head
and neck as you
assist casualty
to the floor.
3. BEGIN CPR
Place two
hands on
chest and
give 30 chest
compressions
(see steps for
CPR on page
8). Attach and
use an AED
as soon as
possible.
4. HEAD TILT /
CHIN LIFT
Look in the mouth
for any foreign
objects. If you
see an object,
use a finger
sweep to remove
it. Do not perform
a blind finger
sweep.
5. GIVE 2
BREATHS
If one breath does
not go in, reposition
the airway, look
for an object and
attempt a second
breath. If you see
an object, use a
finger sweep to
remove it.
6. CONTINUE
CPR
If the airway
remains blocked,
continue CPR.
7. MONITOR CASUALTY
If casualty
regains signs of
life, monitor vitals
and give ongoing
casualty care
until EMS arrive
and take over.
41
Sec 6 Choking
ONGOING CASUALTY CARE UNTIL HAND OVER
The rescuer may face the following scenarios once the airway of a
choking casualty has been cleared:
1. A casualty who remains responsive
• Monitor responsiveness and breathing frequently.
• S tay with the casualty until breathing is well established and skin color
has returned to normal.
• Urge the casualty to seek a medical doctor.
2. A
•
•
•
3. A
•
•
•
casualty who regains responsiveness
Monitor responsiveness and breathing frequently.
Treat for shock.
S tay with the casualty until medical help takes over.
casualty who remains unresponsive
Monitor responsiveness and breathing frequently.
Place the casualty into the recovery position.
Treat for shock and stay with the casualty until medical help takes over.
RECOVERY POSITION
All unresponsive casualties must be placed in the recovery or sidelying position, injuries permitting. The recovery position prevents
the casualty’s tongue, food or vomit from blocking their airway. The
rescuer extends the casualty’s arm above the head and rolls the
casualty to the side, onto that arm, and then bends the casualty’s
knees. If spinal cord injury is suspected (head, neck or back injury),
do not move the casualty unless their life is in danger.
Pregnant women: always put an unconscious pregnant woman in
recovery position on her left side. This prevents compression of the
Inferior vena cava by the uterus, which could be fatal for both the
mother and the child.
Steps for the recovery position
• Kneel on the floor beside the casualty.
Recovery Position
• Move both arms above the head.
• Cross the far leg across the close leg, or bend far knee up.
• Grab the far hip with one hand and the far should with the other hand.
• Roll the casualty towards you onto their side.
• Bend the top knee forward with the ankle touching the bottom knee.
• Place the top hand under the chin into a head-tilt chin-lift position.
42
Sec 6 Choking
RESPONSIVE AIRWAY OBSTRUCTION - CHILD
1. RECOGNIZE
2. BEGIN CPR
OBSTRUCTION
If alone, give 5 sets
of 30 compressions
Approach and identify yourself.
and 2 breaths. Go get
Assess for airway obstruction.
an AED, return and
Call out for help. Kneel, shouldercontinue CPR. Attach
to-shoulder, at the child’s height.
and use an AED as
soon as possible.
2. 5 BACK BLOWS /5
ABDOMINAL THRUSTS
Ask “are you choking?
I am trained in first aid.
Can I help?” If casualty
can
cough,
speak
or breathe, do not
interfere. If obstructed,
give 5 back blows and
5 abdominal thrusts.
UNRESPONSIVE
AIRWAY
OBSTRUCTION
1. CALL 911
If
bystander
is
available with a cell
phone have them
call 911, put the cell
phone on speaker
and get an AED (or
go call 911 and get
an AED). If you are
alone, call 911 on
your cell and put cell
on speaker.
3. HEAD TILT/
CHIN LIFT
Every time you open
the airway for breaths
with a head-tile chinlift, look in the mouth
for the object. If you
see it use a finger
sweep to remove it.
4. GIVE 2 BREATHS
Keep the airway open
and give 2 breaths.
5. CONTINUE CPR
If airway remains
blocked, continue
CPR. After 5 cycles (2
minutes), call 911 if
not already activated.
6. MONITOR
CASUALTY
If breathing is
present, provide
ongoing casualty
care until EMS arrive
and take over.
43
Sec 6 Choking
RESPONSIVE AIRWAY
OBSTRUCTION - INFANT
1. ASSESS AIRWAY
Assess for airway obstruction by
looking at the infant and listening
for breathing:
• If infant can breathe or cough there
is a partial obstruction. Standby
and allow infant to cough.
• If the nose, lips, or earlobes are
blue, or you cannot hear any
breathing, there is a complete
obstruction.
2. GIVE 5 BACK BLOWS/ 5
CHEST COMPRESSIONS
If the airway is completely
obstructed, attempt to relieve the
obstruction. Place infant on lap,
head lower than chest, and give 5
back blows between the shoulder
blades.
UNRESPONSIVE AIRWAY
OBSTRUCTION - INFANT
1. CALL 911
If bystander is available with
a cell phone have them call 911
and get an AED. If you are alone,
call 911 on a cell and put the cell
phone on speaker.
2. BEGIN CPR
Place 2 fingers on chest and give
5 sets of 30 compressions and 2
breaths. Go get an AED, return
and continue CPR.
3. HEAD TILT / CHIN LIFT
Every time you open the airway
for breaths with a head-tilt chinlift, look in the mouth for the
object. If you see it, use a finger
sweep to remove it.
4. GIVE 2 BREATHS
Open the airway and give 2
breaths.
Then roll the infant on their back
and give 5 chest compressions
between the nipples.
Repeat until the object is
removed, or until the infant
becomes unresponsive.
44
5. CONTINUE CPR
If
airway
remains
blocked,
continue CPR. Attach and use an
AED as soon as possible.
6. MONITOR INFANT
If breathing is present, provide
ongoing casualty care until EMS
arrive and take over.
Sec 6 Choking
RESPONSIVE AIRWAY OBSTRUCTION - ADULT/CHILD
1
2
3
4
5
Ask “are you choking?” If the adult or child can speak,
breathe or cough, do not interfere. If they indicate that
they are choking and cannot breathe, tell them you are
trained and get their consent.
Back Blows & Abdominal Thrusts. Give 5 back blows
and 5 abdominal thrusts for adults and children. Give 5
back blows and 5 chest thrusts for pregnant women or
overweight casualties.
Repeat 5 back blows/5 chest thrusts until effective or until
the person becomes unresponsive.
Removal. When the object is dislodged, the casualty
should be seen by a physician as a precaution.
Unresponsiveness. Should the adult or child become
unresponsive, follow the skills for unresponsive airway
obstruction: call 911 and begin CPR.
RESPONSIVE AIRWAY OBSTRUCTION - INFANT
1
2
3
4
5
Look for signs of airway obstruction: breathing attempts
(high-pitched sound), blueness (lips, nose, earlobes),
coughing or gagging.
Back Blows & Chest Thrusts. Give 5 back blows between
the should blades and 5 chest thrusts between the nipples.
Repeat sets of back blows and chest thrusts until effective
or the infant becomes unresponsive.
Removal. When the object is dislodged, the infant should
be seen by a physician as a precaution.
Unresponsiveness.
Should
the
infant
become
unresponsive, follow the skills for unresponsive airway
obstruction: call 911 and begin CPR.
45
Sec 6 Choking
UNRESPONSIVE AIRWAY OBSTRUCTION - ADULT/CHILD
1
2
3
4
Unresponsiveness. The responsive casualty becomes
unresponsive.
Obstruction. This casualty was previously choking. Look
for an object in the mouth.
Call 911 and get an AED (put phone on speaker). If you are
alone with a child without a cell phone, call 911 after giving
5 cycles of CPR.
Lower the casualty to the ground and begin CPR.
5
Compressions. If the casualty remains unresponsive and
not breathing, start compressions. Place your hand in the
center of the chest on the lower half of breastbone. Give
30 chest compressions (rate of 100-120 compressions per
minute). Compress the adult at least 2 inches (5 cm) but not
more than 2.4 inches (6 cm) or child’s chest at least 1/3 the
depth of chest or at least 2 inches (5 cm)
6
Open Airway*. Use a head-tilt chin-lift to open the airway.
Remove any object in the mouth if visible. Check for an
object in the mouth every time you open the airway for
breaths.
7
Breaths. Open the airway and give 2 breaths. If the first
breath does not go in, look for an object in the mouth, remove
the object if visible and try a second breath. Continue CPR,
30:2 for 5 cycles.
Defibrillation. If the airway is clear and CPR is still required,
prepare to defibrillate. When the AED arrives, apply
8
9
pads to casualty ASAP. Follow voice prompts and
shock if advised. If no shock advised, resume CPR
immediately for 5 cycles of 30:2. Minimize interruptions
to no more than (10 seconds).
Continue Care until the casualty responds and is breathing
or medical support takes over.
*If casualty is breathing or resume effective breathing, place in recovery position.
46
Sec 6 Choking
UNRESPONSIVE AIRWAY OBSTRUCTION - INFANT
1
Unresponsiveness. The responsive casualty becomes
unresponsive.
2
Obstruction. This casualty was previously choking. Look
for an object in the mouth.
3
Call for help. If someone responds, send that person to
call 911 and get an AED. If a cell phone is available put
it on speaker. If you are alone with a infant without a cell
phone, call 911 after giving 5 cycles of CPR.
4
5
6
7
Start CPR. Place infant on a hard, flat surface. If alone,
give 5 sets of 30 compressions and 2 breaths. Go get an
AED, return and continue CPR.
Compressions. If the infant is not breathing, place 2
fingers on chest below the nipple line. Give 30 chest
compressions (rate of 100-120 compressions per minute).
Squeeze the infant's chest at least 1/3 the depth of chest
or at least 1 1/2 inches (4 cm)
Open Airway. Every time you open the airway for breaths
with a head-tile chin-lift, look in the mouth for the object.
If you see it use a finger sweep to remove it.
Breaths. Open the airway and give 2 breaths. If the first
breath does not go in, look for an object in the mouth,
remove the object if visible and try a second breath.
Continue CPR, 30:2 for 5 cycles.
Defibrillation. If the airway is clear and CPR is still
required, prepare to defibrillate. When the AED arrives,
8
9
apply pads to casualty ASAP. Follow voice prompts
and shock if advised. If no shock advised, resume
CPR immediately for 5 cycles of 30:2. Minimize
interruptions to no more than (10 seconds).
Continue Care until the infant responds and is breathing
or medical support takes over.
47
Sec 7 Cardio Concepts
CARDIOVASCULAR DISEASE
Cardiovascular disease, commonly known as coronary artery
disease (CAD), is the second leading cause of death and disability
in Canada. The most common cause of CAD is a process called
atherosclerosis, a gradual build up of fatty deposits or plaque on
the inner lining of the blood vessel walls and arteries of the heart. As
we age, the artery walls become narrow and less elastic and the fat
deposits increase. If an artery around the heart is partially blocked
you may experience angina pectoris (temporary pain in the chest)
often developing with physical exertion.
CAD may progress into arteriosclerosis, where the artery wall
hardens. Calcium deposits become hard and fibrous and eventually
may block an artery in the heart causing a heart attack (myocardial
infarction) or block an artery in the brain causing a stroke
(cerebrovascular accident).
EMERGENCY MEDICAL
SERVICES (EMS)
The EMS is a coordinated
system to get emergency
aid
to
casualty
and
transport them to a hospital
quickly.
Emergency
personnel
can
begin
treatment
immediately,
defibrillate a heart, give
medication, obtain an
EKG, and improve the
speed of effective care.
Faster
treatment
may
result
in
less
heart
damage and quicker recovery. EMS is activated by the bystander
calling 911.
If available, rescuers should use mobile phones to immediately call
911. Place phones on speaker mode so the dispatcher can help
bystanders check for breathing, obtain the precise location and
provide instructions for performing CPR.
48
Sec 7 Cardio Concepts
HEART ATTACK / ANGINA
A Heart Attack
Myocardial Infarction occurs when an artery supplying oxygenated
blood to the heart muscle becomes totally blocked or ruptures
(aneurysm). A portion of the heart muscle dies from the lack of oxygen.
The location and amount of heart muscle involved will determine the
severity of the heart attack.
Angina Pectoris occurs when the heart muscle receives an
insufficient blood supply causing
temporary pain in the chest.
This
pain is often relieved with rest and
medications. Angina often has the same
signs and symptoms as a heart attack.
Signs and Symptoms
• Denial of a heart attack
• Pain in chest, often radiating to arms,
stomach or neck
• Vague pain often described as “tingling”
by women
• Sweating (forehead)
• Ashen-grey or bluish skin color
• Feeling of weakness
• Shortness of breath
• Nausea or vomiting
PAIN MAY BE DESCRIBED AS:
•
•
•
•
•
•
Crushing
Burning
Squeezing (like the chest is in a vice)
Bad indigestion
Pain/aching in jaw
Sore shoulder/arms
TREATMENT FOR HEART ATTACK/ANGINA
Three priorities for all cardiovascular emergencies
• Get medical help quickly
49
Sec 7 Cardio Concepts
•
•
•
•
•
•
•
•
•
•
•
Place casualty at rest to reduce the workload of the heart
Provide CPR if necessary
Perform a scene survey.
Perform a primary survey:
• Check responsiveness, airway, breathing and circulation.
• Perform a rapid body check and control any deadly bleeding
Call 911 or local EMS or have a bystander call.
Place casualty at rest in a comfortable position and reassure often.
If a casualty has angina, assist casualty with administration of
nitroglycerin (Nitro spray or tablets under the tongue) using the 5 rights
(see below).
Medical follow-up (if pain persists after nitroglycerin). Maximum of one
spray every 5 minutes (up to three doses).
If the first spray is not effective, suggest the casualty chew 1 adult (325
mg) or two low-dose Aspirin® (160 mg) while waiting for EMS to arrive.
Contraindications for Aspirin® include
1. Casualties 18 years of age or younger.
2. Casualties with allergies or sensitivities to Aspirin® (ASA) or who
have been told not to take Aspirin® by their doctor.
3. Active bleeding, stroke or brain injury in the past 24 hours.
If the casualty is unresponsive and not breathing, begin CPR and attach
and use an AED as soon as one is available.
CARDIAC ARREST
Cardiac arrest occurs when the heart stops beating. This condition
can happen suddenly or may follow a period of stopped or ineffective
Medication Tips :
Only assist a casualty with medication if casualty is fully conscious and specifically
requests your help.
The Five Rights of Medication Administration. One mnemonic to reduce
medication errors and harm is to use the “five rights”: the right person, the right
drug, the right dose, the right route and the right time.
Erectile Dysfunctional Mediations:
Ask casualty if medications such as Viagra®, Cialis®, Revatio® or Levitra® have
been taken within 24 hours. If yes, do not assist casualty to take nitroglycerin
(nitro). Nitro may cause the blood pressure to drop dangerously.
50
Sec 7 Cardio Concepts
STROKE
Stroke (cerebrovascular accident; CVA) occurs
when an artery supplying blood and oxygen to the
brain becomes totally blocked or ruptures (aneurysm).
As a result of the stroke, brain cells lack oxygen and
die. The location and amount of brain cells involved
will determine the severity of the stroke.
Transient Ischemic Attack (TIA) or “mini stroke”
occurs when a blood vessel to the brain is temporarily blocked and a
part of the brain is not getting enough blood to function properly. The
TIA does not result in permanent brain damage. Signs and symptoms of
TIAs are the same as for stroke, may last from a few minutes to a few
hours and may warn of a future stroke.
Signs to Act FAST:
Facial Droop
Arm Drift
Speech Impairment
Time to get help
immediately
Treatment for Stroke
Signs & Symptoms
•
•
•
•
•
•
Severe headache
Weakness
Slurred speech
Difficulty swallowing
Unequal pupil size
Changes in level of
consciousness
•
•
•
•
•
•
Blurred vision
Dizziness
Difficulty speaking
Paralysis
Confusion
Numbness/
weakness in arms/
legs
• Perform a scene survey.
• Perform a primary survey. Check responsiveness, airway, breathing,
circulation and control deadly bleeding.
• Call 911 immediately if one or more of the above signs are present.
• Note the time of stroke symptoms/signs of onset.
• Treatment should be received ASAP (less than 3 hours from onset).
• Maintain an open airway and assess breathing.
• Conduct a secondary survey with SAMPLE history and treat injuries found.
• Give nothing by mouth and treat for shock.
If Casualty Is Responsive
• Assist the casualty to lay or sit in a
comfortable, semi-sitting position.
• If casualty complains of thirst, wet
their lips or tongue with wet cloth.
• Do not offer Aspirin® as it may cause
bleeding in the brain.
If Casualty Is Unresponsive
• Place in recovery position on
the unaffected side (paralyzed
or weakened side up).
• Give nothing by mouth.
• Begin CPR if casualty is not
breathing.
51
Sec 7 Cardio Concepts
ONGOING CASUALTY CARE
Rescuers are responsible for ensuring casualty’s safety and continued
care after giving immediate treatment and until advanced care takes
over.
• Maintain manual support of head and neck if head/spinal injuries are
suspected.
• If needed, continue to steady and support any injuries manually.
• Give first aid for shock:
• Reassure the casualty often.
• Loosen tight clothing.
• Place casualty in comfortable position depending on injuries.
• Cover the casualty to preserve body heat.
• Monitor the casualty’s condition and note any changes.
• Record casualty’s condition, any changes that may occur and the first
aid given.
• Protect the casualty’s personal belongings.
• Do not leave the casualty until medical help takes over.
• Transfer care to medical help and report on the incident, the casualty’s
condition and the first aid given.
CRITICAL INCIDENT STRESS
MANAGEMENT
SUPPORT FOR CISM
• Remain calm; know
your limitations.
Critical Incident Stress Management (CISM)
• Recognize the
is a method to deal with the psychological
emotional injury.
reaction to a traumatic event. The casualty,
• Establish rapport with
rescuer, co-workers, friends and relatives
casualty.
may experience difficulty in coping with the
• Listen and avoid
situation and their feelings.
interrupting.
• Encourage casualty to
TRAUMATIC EFFECTS
SIGNS AND SYMPTOMS
speak freely.
• Guilt or shame
• Rapid pulse
• Try not to agree,
• Tension and fears
• Dry mouth
disagree or argue.
• Trouble thinking clearly
• Cool skin
• Seek help from
• Eating & sleeping
• Hair stands up
professionals, friends,
problems
• Pupils dilate
Employee Assistance
• Job stress
• Respiration (short, rapid
Programs (EAP) or a
• Relationship problems
panting)
family physician.
• Disruptions to daily living • Digestion is halted
• Anxiety and anger
• Spasms of stomach,
• Haunting memories
vomiting
52
Sec 7 Cardio Concepts
COMPRESSION-ONLY CPR
If a bystander is not trained in CPR, the bystander should provide
“Chest Compression-Only CPR,” or “Hands-Only CPR” for the adult
casualty who suddenly collapses. Compression-Only CPR is easier
for an untrained rescuer to perform and is easily taught by dispatchers
over the telephone.
Some bystanders are reluctant to help treat a
medical emergency due to a lack of training
and the fear of doing something wrong. These
bystanders should perform CPR compressions
without rescue breaths when confronted with a
person in possible cardiac arrest.
The same hand position and compression rate
is used for compression-only CPR as CPR
including breaths. Bystanders are encouraged
to push hard and fast in the center of the chest
or follow the directions of the 911 dispatcher.
Compressions are to be given for as long as possible until EMS
personnel arrive, an AED is available and voice prompts can be
followed. If a bystander gets tired and someone else is available to
help, bystanders are encouraged to switch out as needed. This is
about every 2 minutes (about 200 compressions) or until the casualty
shows signs of life.
THIS TECHNIQUE IS NOT SUGGESTED TO BE USED BY ALL
RESCUERS OR FOR ALL CASUALTIES OF CARDIAC ARREST.
IT IS TO BE USED
•
•
•
•
•
During dispatch-assisted CPR.
By laypersons witnessing an adult collapse (possible cardiac arrest).
By those who are not trained in CPR.
By those trained in CPR but uncertain of the steps.
During rescues where no barrier device is present (pocket mask, face
shield).
Conventional CPR is still taught in CPR programs. Trained rescuers
should provide chest compressions at a minimum. If the rescuer is
able to perform rescue breaths, compressions and breaths should be
provided at a ratio of 30 compressions to 2 breaths.
53
Sec 1Skills
CPR
Introduction
Summary
CPR SKILLS
C-A-B
SEQUENCE
Adult and
Adolescents
Child
Infant
Age
Adolescent +
1 yr - puberty
1 month -1 year
Scene Safety
Check the scene is safe for rescuers and patient
Check
Responsiveness
Tap and shout to determine if unresponsive
Call EMS - 911
Phone EMS 911
and get an AED
or tell bystander.
Put cell phone on
speaker
Same as Adult steps. If you are alone
and have no phone, give 5 cycles
of CPR 30:2 (1 rescuer) or 15:2 (2
rescuer child or infant). Then go call
EMS get an AED and continue CPR.
Check pulse (carotid-adult, brachial infant) and breathing
Check Breathing
and Pulse
Hand Position
CPR
C-A-B (5 cycles)
Depth of
Compression
• If both pulse and breathing are absent begin CPR
• If pulse is present and breathing is absent give rescue
breaths only (see pg 16 for rescue breathing).
2 hands on lower
half breastbone
2 hands or 1
hand on lower
half breastbone
2 fingers in center
of chest, below
nipple line, or 2
thumbs-2 rescuers
30 Compressions : 2 Breaths
Push Hard, Pushing
Fast 15:2 for infant/child (2 rescuer)
At least 2 inches
(5 cm) but not
more than 2.4
inches (6 cm)
At least 1/3 the
depth of chest,
or At least 2
inches (5 cm)
At least 1/3 the
depth of chest, or
At least 1.5 inches
(4 cm)
Compression Rate
100-120 compressions per minute
(30 compressions in 15 to 18 seconds)
Open Airway
Head-tilt/chin-lift (Jaw Thrust if spinal injury suspected)
Breaths
Give 2 breaths, approx. 1 second each, watch chest rise,
allow for exhalation between breaths.
Compressions Only
Ventilations are not performed when rescuer is untrained
or trained & not proficient.
Defibrillation
Attach and use AED as soon as available. Minimize
interruptions (<10 seconds) in chest compressions
before and after shock; resume CPR beginning with
compressions immediately after each shock. If no
shock, check breathing. If not breathing, continue CPR.
54
Sec 1 CPR
Team
Introduction
Duties
Team
of
3
Team
of
4
R-1
R-1
R-1
R-1
Compressor
• Assess scene
R-1
• Assess patient
• Activate code/911
• Compress
5 cycles 30:2
• Switch with AED
as required
R-2
R-3
R-2
R-2
R-2
AED
• Bring/operate
AED
• Alternate with
compressor
• Open and maintain airway
• Uses BVM
R-1
Open
Airway
R-2
BVM
R-2
Open
Airway
R-3
BVM
R-3
Open
Airway
R-2
BVM
R-3
Open
Airway
R-4
BVM
R-3
Open
Airway
R-4
BVM
• Assign roles
R-1
• Direct members
• Make decisions
• Quality assurance
• Other rescue
skills
R-1
R-4
R-5
R-5
• EMS or medical
R-2
If applicable
R-3
If applicable
R-4
If applicable
R-5
If applicable
R-6
If applicable
R-1 &
R-2
R-3
R-4
R-5
R-5 &
R-
Team
Roles
Airway
Team
Leader
Duties
Adminisrole
ter Medi- • Administer
required medicacations
Team
of
2
Team
of
5
Team
of
6
tions
• Take notes
• Record time
• Record events,
Timer/
procedures and
Recorder medications
• Communicate to
team
55
Sec 7 Cardio
Student
Quiz Concepts
MULTIPLE CHOICE - Circle the best answer.
1. The correct rate for giving compressions is at least:
A) 100-120 compressions per minute C) 10 compressions per minute
B) 80-100 compressions per minute
D) 70 compressions per minute
2. The correct compressions/ventilation ratio for all ages is:
A) 15:2
C) 50:2
B) 30:2
D) 100:2
3. Interruptions in CPR should be no longer than:
A) 80-100 seconds with exceptions C) 50-60 seconds when tired
B) 20 seconds if you are alone
D) 10 seconds at any time
4. Before blowing air into an unresponsive choking victim:
A) Give 30 compressions
C) Do not look for an object
B) Open mouth to look for object
D) Call 911
5. The technique to open an airway with suspected spinal injury:
A) Modified jaw thrust
C) Head-tilt chin-lift
B) Jaw thrust
D) 2-thumb encircling technique
6. This is the most common cause of cardiac arrest in children:
A) Cardiac arrest, shock
C) Respiratory arrest, shock
B) Airway obstruction, hypoxia
D) Drowning, anoxia
7. Agonal breaths can best be described as:
A) Normal breaths after cardiac arrest
C) Rapid breathing
B) Not normal breaths after cardiac arrest D) Quick gasps
8. The best method to use for a BVM is:
A) Two rescuers use jaw thrust and E-C clamp
C) One rescuer only
B) One rescuer using jaw thrust and E-C clamp D) Rapid squeezing
56
Sec
7 Cardio
Student
Quiz Concepts
9. Ventilations with advanced airways does not include:
A) Compression rate of 100-120/minute
C) 1 breath every 6 seconds
B) Continuous compressions, no pauses
D) Pause every 6 seconds
10. Which statement does not describe pulseless rescue breaths:
A) Give 1 breath every 5-6 seconds
C) Give 5 breaths/minute
B) Check the pulse about every 2 minutes D) Call EMS after 2 minutes
True or False - Circle the best answer
11.A choking victim will always be able to cough forcefully?
T
F
12.A dult AED pads can be used on a child if necessary?
T
F
13.“ Clearing the victim” before shocking means shaving hair?
T
F
14.T he heel of one hand is used to compress the infant chest? T
F
15.I f no pocket mask is available do compression only CPR?
F
T
Sort these CPR steps - Place the following steps in the best order,
knowing that some steps are missing.
16. Perform CPR 30 compressions
1st.
17. Open the airway
2nd. ____
18. Check breathing & responsiveness
3rd.
____
19. Call 911, put cell phone on speaker
4th.
____
20. Give 2 breaths
5th.
____
____
Fill in the Blanks - Write down the best answer.
21. A child is defined as 1 year of age to _______________________
22. The most important thing to do for a dispatcher ______________
23. The chest of a child should be compressed this deep __________
24. The number of shocks given before compressing is ___________
25. The rate of 30:2 continues for this many cycles ______________
57
Sec
7 Cardio Concepts
Index
A
Bystanders
Abdominal thrusts
39, 40
Adult chain of survival
6
Advanced airway
19
A.E.D.
2, 31-36
Advanced airway
19
AED protocols
33
Defibrillation guide
36
Maintenance
35
Special considerations
34
Age guidelines in CPR
3
Agonal breaths
7
Airway
1, 8, 15, 38
Cardiopulmonary resuscitation
Choking
Head-tilt chin lift
8
37
8, 10, 23, 25
Airway obstruction
37-47
Mild airway obstruction
37
Severe airway obstruction
37
Save-your-self techniques
39
Airway, open
38
Airway, closed
38
Aneurysm
49
Angina pectoris
49
Aspirin® (ASA)
50
Asystole
33
Automated external defibrillator
2
B
8, 23, 48, 53
C
CAB
1
Cardiac arrest
50
Cardiopulmonary resuscitation
1
Adult
8-21
Child
8-21
Infant
23-31
Cardiovascular disease
48
Casualty care
41, 43
Classification by age
3
Chain of survival™
6
Adult - out of hospital
6
Adult - in hospital
6
Infant
Chest compressions
30
1, 9, 22, 44
Chest pain, signs of
49
Chest thrusts
37, 39, 40
Chin lift
13, 17, 18
Choking
37-47
Abdominal thrust
39, 40, 43
Back blows
40, 43, 44
Common causes of choking
38
Factors associated with choking 38
Mild airway obstruction
37
Prevention
38
Save-your-self techniques
39
Severe airway obstruction
37
Back blows
40, 43, 44
Treatment (large/pregnant)
39
Bag-valve-mask (BVM)
14, 17, 27
Responsive airway obstruction
40
BVM with advanced airway
Basic life support (BLS)
Barrier devices
Biological death
Bio-tips
Brachial pulse
58
19
Adult
40, 45
1
Child
43, 45
4, 13, 20
Infant
44, 45
2
Unresponsive airway obstruction 41
5
Adult
41, 46
16, 27
Child
43, 46
Index
Index
Infant
44, 47
Compression-only CPR
8, 9, 53
Consent (to give first aid)
3
Clinical death
Electrical activity of the heart
31, 32
Emergency Scene Assessment
4
EMS (Emergency Medical Services)
48
2
CPR
Adult/child one rescuer
Adult/child two rescuer/AED
1, 12
F
8, 21
Factors associated with choking
12, 22
Bystander - no barrier device
8, 23
38
FAST, stroke recognition
51
Fibrillation
32
First responder arrives
10, 25
G
HCP responder arrives
14, 27
Gasps, agonal breathing
Infant CPR one rescuer
23, 29
Gastric distention
Infant CPR team rescue
27
Gloves
7
20
4, 5
Summary of CPR skills
54
Good samaritan principles
3
Critical incident stress (CIS)
52
Guiding rules
3
CVA (stroke)
51
D
H
Hand washing (precautions)
Defibrillation (A.E.D.)
2, 15, 31-36
Head-tilt chin-lift
AED protocols
33
Heart
Hypothermic
34
Heart attack
Infant
28, 29
Heart rhythms
Maintenance considerations
35
High quality CPR
Metal surfaces
34
Hypothermic patient
Medication patch
34
No shock advised protocol
33
I
Oxygen and flammable areas
34
Implanted pacemaker
PAD guide
36
Implied consent
Pad placement
35
Infant AED use
Pacemaker
34
Infant CPR
Pregnancy
34
Infectious waste
Shock advised protocol
33
Special considerations
34
J
Wet surfaces
34
Jaw thrust
Disease transmission
4
Disposal of gloves, soiled materials
5
Duties of additional rescuers
15, 28
E-C clamp technique
31
49
32, 33
7
34
34
3
23-26, 28
23-30
5
18
L
Legalities
Laryngeal tube
E
4, 5
8, 13, 17, 23
3
19
13
59
Index
M
Rescuer safety
Medication tips
50
Nitroglycerin
50
Mini stroke
51
Minors
3
Mouth-to-nose rescue breaths
20
Mouth-to-stoma rescue breathing
20
Myocardial infarction (heart attack)
49
S
SA node
3
Nitroglycerine
Normal sinus rhythm
4
Severe airway obstruction
37
Signs of heart attack
49
Skills comparison (CPR skills)
54
Stroke
51
19
Negligence
31
Scene safety
N
Nasal airways
4
Responsive treatment
51
Unresponsive treatment
51
T
50
Tachycardia
32
Team CPR
32
14, 15, 27
T.I.A. (mini strokes)
O
Obstructed airway
37-47
Ongoing casualty care
15, 42, 52
Two-rescuer CPR
51
12, 14, 27
Two-thumb encircling technique
Oral airways
19
U
Oxygen and flammable areas
34
Universal precautions
27, 28
4, 5
V
P
34
Ventilations
18
PAD, placement and selection
35
Ventricular fibrillation
32
Pediatric chain of survival
30
Ventricular tachycardia
32
Pacemaker
Personal protection
Personal protective equipment
Pocket mask
Public access defibrillation
4
Viagra®
50
4, 5
Vomiting
20
4
31
Q
Washing hands.
Wet surfaces - AED
Quiz
55, 56
R
Recovery position
42
Adult
42
For pregnancy
42
Removal of gloves
Rescue breaths
60
W
5
1, 16, 14, 23
Mouth to nose
20
Mouth to stoma
20
4, 5
35
X
Xiphoid process (sternum)
2
Notes:
Index
61
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