The faster CPR is initiated within the first 5 minutes of collapse, the better the outcome. CPR can double or triple the victim’s chance of survival when it is performed immediately after collapse from sudden cardiac arrest.
When finding a collapsed person, establish responsiveness. It is important to differentiate cardiac arrest from respiratory arrest. For example, a person who is highly intoxicated can be roused when shaken and therefore does not need CPR.
Roll the victim over as one unit while supporting the neck, taking care to keep it aligned. Then call 911 or a resuscitation team. Check for a pulse. If there is a pulse, do not begin chest compressions on the adult.
Sudden collapse is more likely to be caused by an arrhythmia that may require shock delivery.
Sequence of Action:
Chest Compressions
Airway
Breathing
When there is more than one person at the scene of a cardiac arrest, at least one person should stay with the victim to begin CPR. Another should call 911 or a resuscitation team and retrieve an AED, if possible.
After witnessing a sudden collapse, the lone rescuer should verify the adult victim is unresponsive.
Determine whether breathing is absent or abnormal. It is reasonable to suspect cardiac arrest if the victim is not breathing or only gasping.
If no breathing can be detected, call 911 or a resuscitation team for equipment (monitor/defibrillator, etc).
Find the carotid artery on the neck and place two fingers over the artery to check for a pulse. Spend no more than 10 seconds doing so. (The old directive “look, listen and feel for breathing” to determine responsiveness is no longer recommended.)
If there is no pulse, begin CPR and use an AED as soon as one is available.
Initiate CPR with cycles of 30 chest compressions, compressing the chest at least 2 inches (5 cm) in adults. Push hard and fast. Allow complete recoil and minimize interruptions between compressions to less than 10 seconds.
On arrival of AED, apply patches and follow AED protocol. (See AED section below.)
Cardiac arrest remains a leading cause of death in many parts of the world.
The rescuer should give the unresponsive victim with a likely asphyxial cause of arrest (e.g. drowning) 5 cycles (2 minutes) of CPR (30 compressions and 2 ventilations) before leaving to call 911.
For the unresponsive infant or child, rescuers should:
Check for breathing and pulse.
If there’s no normal breathing (i.e. only gasping) or no pulse, the lone rescuer should begin CPR before calling 911. If there is more than one person at the scene, one can begin CPR while the other calls 911 and retrieves an AED.
Asphyxial arrest, including primary respiratory arrest, is more common than sudden cardiac arrest in children. Therefore, a child is more likely to respond to initial CPR and rescue breathing may be more important for children than for adults in cardiac arrest.
Avoid giving simultaneous compressions and ventilations to the newborn infant. The rescue breathing rate for the newborn infant with pulses is about 40 to 60 breaths per minute.
Effective chest compressions increase intra-thoracic pressure, creating critical blood flow and oxygen to the heart and brain.
Chest Compressions:
All rescuers of victims 8 years of age and older should compress the center of the chest at the nipple line, using the heel of the hand.
Push hard and fast, at a rate of at least 100 compressions per minute, allowing the chest to recoil completely between compressions.
On adults, compressions should depress the chest by at least 2 inches (5 cm).
On children, compressions should depress the chest by about 2 inches (5 cm).
On infants, compressions should depress the chest by about 1.5 inches (4 cm).
Because children vary so widely in size, rescuers my use one or two hands, as needed.
Begin CPR with 30 chest compressions, then open the airway. The lone rescuer should give 30 compressions to 2 ventilations. Two rescuers should give 15 compressions to 2 ventilations. Rescuers should rotate positions every two minutes to avoid fatigue.
For adults, compress over the lower half of the sternum using two hands. Use a 30:2 compression-ventilation ratio for adults, children and infants when acting alone.
When there is another rescuer, healthcare providers should use 30:2 for adults and 15:2 compression-ventilation ratio for infants and children.
For infants (up to one year of age), compress the sternum just below the nipple line.
The lone healthcare provider should use 2 fingers to compress the chest with a compression-ventilation ratio of 30:2. The “2-thumb encircling hands technique” may be used when feasible.
When 2 healthcare providers are performing CPR, the compression- ventilation ratio should be 15:2 until an advanced airway is in place.
Opening the Airway and Rescue Breaths:
Further assess breathing to determine whether assisted ventilation is necessary. Look for the presence or absence of breathing in infants and children, as they sometimes have breathing patterns that are not normal but adequate.
Observe the chest for movement while listening for breaths.
Open the airway using jaw thrust or head tilt-chin lift.
Follow with ventilations. This is particularly important if the likely cause of arrest is asphyxial (e.g. infant, child, or drowning instances).
Assessment of ventilation in the infant and child is covered in most PALS, APLS and general pediatric resuscitation courses.
Each rescue breath should be delivered in 1 second and should cause the chest to rise. It may be necessary to reopen the airway and reattempt ventilation. This may require several attempts to deliver 2 effective breaths for the infant and child.
Once an advanced airway is in place (e.g. endotracheal tube), during 2-rescuer CPR, the compressor should give at least 100 compressions per minute continuously, without pausing for ventilation. A single rescue breath should be given every 6 to 8 seconds, or about 8 to 10 breaths per minute.
Avoid excessive ventilation.
Automated External Defibrillator (AED):
An AED is an electronic device that diagnoses heart arrhythmias (ventricular fibrillation, ventricular tachycardia) and treats them by automatically delivering a shock to bring the heart back to a normal rhythm.
AEDs — models used by first responders as well as simpler models found in airports — are generally easy to use. Newer models have prompts for the operator to follow. The AED automatically analyzes the victim’s ECG and determines whether a shock is necessary. The device prompts the operator to press the shock button if one is necessary; it will repeat the process if additional shocks are necessary.
For children 8 years of age or younger, a pediatric AED system should be used, if available. If a manual defibrillator is used, a dose of 2 J/kg is recommended for the first shock and 4 J/kg for subsequent shocks.
Survival increases with shorter intervals between arrest and defibrillation. Outcomes are improved when there are fewer interruptions in chest compressions.
Choking:
Choking occurs when a foreign object gets lodged in the pharynx and blocks the flow of air to the trachea and lungs, resulting in a lack of oxygen to the brain. It is important intervene as soon as possible.
Often times, the person will have their hands clutched to the throat. Other signs a person may be choking include an inability to speak; an inability to cough forcefully; difficulty breathing; noisy breathing; lips and skin turn blue; and loss of consciousness.
Deliver abdominal thrusts to adults and children (> 1 year old) until the blockage is dislodged.
For infants, begin with chest compressions and continue there use intermittently until the obstruction is relieved.
To perform abdominal thrusts, stand behind the person with your arms wrapped around their waist, tipping the victim forward just slightly. Then make a fist and position it just above the victim’s navel. Grasp your fist with your other hand and press hard and quick into the abdomen with an upward thrust, almost as if you are trying to lift the person. Perform 5 abdominal thrusts, as needed. If the maneuver is not successful, repeat cycle 5 times. If you are the only rescuer, perform 5 back blows before calling 911 for help. If the victim becomes unconscious, perform CPR, starting with chest compressions.
To perform airway maneuvers on an obese person or pregnant woman, position your hands slightly higher, at the base of the breastbone. Press hard with a quick thrust into the chest and repeat until the blockage is dislodged or the victim becomes unconscious.
To clear the airway of a person who has become unconscious, lower the victim onto his or her back on the floor and clear the airway. There may be a visible blockage at the back of the throat that can be swept away with your fingers, but take care not to push the object deeper down.
If the object remains lodged in the throat, begin CPR as the chest compressions may dislodge the object. Recheck the mouth periodically.
To clear the airway of a choking infant, sit down and hold the infant facedown on your forearm, which should be resting on your thigh. Then firmly thump the middle of the infant’s back 5 times using the heel of your hand. The back blows and gravity should release the object.
If it is not released, hold the infant face up on your forearm, with the head positioned slightly lower than the rest of the body. Using 2 fingers in the middle of the breastbone, give 5 quick chest compressions. Repeat back blows and chest thrusts if breathing does not resume.
If the airway is open but the infant is still not breathing, call 911 and immediately begin infant CPR.
For children over one year of age, give abdominal thrusts only.
*Source: American Heart Association 2010 clinical recommendations
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