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8/2/2019 CPR Pro Handbook
http://slidepdf.com/reader/full/cpr-pro-handbook 1/43
Student
Handbook
A M E R I C A N S A F E T Y & H E A LT H I N S T I T U T E
CPR Pro
for the Professional Rescuer
E L E C T R O N I C S T U D E N T H
A N D B O O K
—
O n l i n
e V e r s i o
n
8/2/2019 CPR Pro Handbook
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American Safety & Health Institute
1450 Westec Drive
Eugene, OR 97402 USA
800-246-5101
ashinstitute.org
Copyright © 2009 by American Safety & Health Institute. All Rights Reserved. Revised September 2009.
No part of the material protected by this copyright notice may be reproduced or utilized in any form, electronic or mechanical, including pho-
tocopying, recording or by any information storage and retrieval system, without written permission from the American Safety & Health Insti-
tute. Some images used under license ©2006 Custom Medical Stock Photo. The procedures and protocols in this book are furnished for
informational use only and are subject to change without notice. The publisher, however, makes no guarantee as to, and assumes no respon-
sibility for, the correctness, sufficiency or completeness of such information or recommendations. Other or additional emergency, safety or
health measures may be required under particular circumstances.
Printed in the United States of America. PRN2007 (9/09)
La certificación de American Safety and Health Institute (ASHI) sólo puede seremitida cuando un Instructor autorizado por ASHI verifica que usted haculminado competente y exitosamente el conocimiento esencial y los objetivosen habilidades del programa.
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Preface
Preface CPR Pro for the Professional Rescuer 1
Table of Contents
Section 1 — Introduction Sudden Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Circulatory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Barrier Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Proper Removal of Contaminated Gloves — Skill Guide #1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 2 — Cardiovascular Disease Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Acute Coronary Syndromes (ACS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Sudden Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Chain of Survival for Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Chain of Survival for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 3 — Resuscitation Skills
Resuscitation Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Opening the Airway — Skill Guide #2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Protecting the Airway — Skill Guide #3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Rescue Breaths — Skill Guide #4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Bag-Mask — Skill Guide #5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
External Chest Compressions — Skill Guide #6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Section 4 — Defibrillation Defibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Section 5 — Emergency Action Steps Assess, Alert, and Attend to the ABCD’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
When Using Advanced Airways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Summary of CPR/AED Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Adult Rescue Breathing — Skill Guide #7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Child Rescue Breathing — Skill Guide #8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Infant Rescue Breathing — Skill Guide #9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Adult CPR/AED — Skill Guide #10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Child CPR/AED — Skill Guide #11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Infant CPR — Skill Guide #12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Section 6 — Choking Foreign Body Airway Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Adult Choking: Severe Blockage — Skill Guide #13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Child Choking: Severe Blockage — Skill Guide #14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Infant Choking: Severe Blockage — Skill Guide #15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Section 7 — Legal and Emotional Aspects Legal Aspects of Providing Basic Life Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Emotional Aspects of Providing Basic Life Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
End Notes End Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
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Section 1 — Introduction
CPR Pro for the Professional Rescuer Introduction2
Sudden Cardiac Arrest
Sudden cardiac arrest is one of the leading causes of
death among adults in North America. It can occur
randomly, to anyone, at any time. It occurs when the
heart’s electrical system malfunctions and the heart’snatural electrical signals become disorganized. The
coordinated mechanical contraction of the heart mus-
cle is lost and a chaotic quivering condition known as
ventricular fibrillation occurs.
The heart abruptly stops pumping blood and oxygen
to the body. Brain tissue is especially sensitive to a
lack of oxygen. When oxygen is cut off, brain deathcan occur quickly, within a matter of minutes.
The lack of available oxygen to the brain causes the
patient to quickly lose consciousness, stop breathing,
and collapse. Unless immediate care is provided to
restore the heart’s regular rhythm, the chance to sur-
vive is lost.
Cardiopulmonary resuscitation, or CPR, allows a
trained bystander to immediately begin restoring
some circulating oxygen to the brain through a com-
bination of external chest compression and rescuebreaths. By itself, CPR is only a stop-gap measure
that can buy critical time in which to provide more
specific treatments to re-establish a normal heart
rhythm.
The most effective treatment to end ventricular
fibrillation and restore a normal heart rhythm is defib-rillation, an electrical shock sent through the heart
muscle. The sooner defibrillation can be provided, the
greater a chance that patient can survive.
An Automated External Defibril lator, or AED, is a
small, portable computerized device that is designed
to allow initial responders to defibrillate.
Attached with wires and adhesive pads to the chest
of a sudden cardiac arrest patient, the AED checks
the heart’s electrical activity, decides if ventricular fib-
rillation is present, and allows for a defibrillation
shock to be delivered.
Sudden cardiac arrest victim.
Cardiopulmonary resuscitation (CPR).
Defibrillation with an AED.
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Introduction CPR Pro for the Professional Rescuer
Respiratory System Because the body cannot store oxygen, it must con-
tinually supply itself through the actions of the respi-
ratory and circulatory systems.
The respiratory system brings air, containing oxygen,
into the body, and removes carbon dioxide, a waste
product created by the body’s use of oxygen. When
you take a breath, muscles in the chest contract, and
create a vacuum that draws air through the windpipe,
and into the lungs. In the lungs, oxygen from the air is
absorbed into the bloodstream and circulated
throughout the body. Carbon dioxide is transferred
from the bloodstream back into the lungs. Chest
muscles relax and air is exhaled out of the lungs and
back into the environment. Carbon dioxide is released
in the exhaled air.
Not all of the oxygen is used by the body in the
breathing process. Inhaled air contains approximately
21% oxygen. Exhaled air contains about 16–17%
oxygen. When delivered through rescue breaths,
there is still enough oxygen to support life.
Circulatory System
The circulatory system uses the blood stream to
deliver oxygen and nutrients to body tissues and
remove waste products.
The driving force of the circulatory system is the
heart. Special tissue runs throughout the heart that is
capable of creating and conducting electric current.
This electric current triggers the rhythmic mechanical
contractions that create the flow of blood through the
body.
Arter ies carry oxygenated blood from the heart to
body tissues. Veins return used blood back to the
heart where carbon dioxide is released and fresh oxy-
gen is picked up. The fresh blood is returned to theheart and the cycle repeats.
If the heart stops, it is possible to return at least some
of the blood flow through the circulatory system by
compressing the chest cavity. Increased pressure in
the chest and direct compression of the heart causes
blood to move out of the chest and into the rest of the
body.
CPR, the combination of rescue breaths and external
chest compressions, has proven to be capable of
providing oxygenated blood flow to vital organs dur-
ing cardiac arrest. Immediate CPR by a bystander
could double or triple a patient’s chance of survival.
Respiratory system.
Circulatory system.
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Infectious Diseases
Bloodborne pathogens are viruses or bacteria that
are carried in blood and can cause disease in people.
There are many different bloodborne pathogens, but
Hepatitis B (HBV), Hepatitis C (HCV), and the Human
Immunodeficiency Virus (HIV) are the ones most com-
monly addressed.1,2
The estimated risk for acquiring HIV, HBV, or HCV
infection from performing CPR is extremely low,
about one in one million. There have been no reports
of infection acquired during CPR training.3
“Universal precautions” is a way to limit the spread of
infectious diseases by preventing contact with blood
and certain body fluids. To “observe universal precau-
tions” means that whether or not you think the patient’s
blood or body fluid is infected, you act as if it is.
Barrier Devices
Simple infection-control measures, including the use
of barrier devices, can reduce the risk of an infectious
disease during CPR.
A simple but effective barrier for skin-to-skin contact
is the use of disposable gloves. Quickly inspect
gloves before putting them on. If a glove is damaged,
don’t use it. When taking contaminated gloves off, do
it carefully. Don’t snap them. This may cause blood to
splatter.
Make sure gloves are always available. If you find
yourself in an emergency and you don’t have any
gloves, improvise. Use a plastic bag, or some otherbarrier to help avoid direct contact.
Masks allow you to provide rescue breaths without
direct skin-to-skin contact. They come with a replace-
able one-way valve and possibly a filter to block con-
CPR Pro for the Professional Rescuer Introduction4
Never wash or reuse disposable gloves. Throw away
both gloves in an appropriate container.
Use an alcohol-based hand rub, or soap and water, to
clean your hands and other exposed skin.4
Disposable gloves.
Compared with soap and water, alco-hol–based hand rubs are more effec-tive in reducing bacteria on hands andcause less skin irritation.
Mask and shield.
Blood spill.
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Introduction CPR Pro for the Professional Rescuer
taminated fluids. All emergency response kits should
include at least one mask.
Disposable face shields do not prevent contamination
of the rescuer’s side of the shield. To reduce the risk
of transmitting infection, professional rescuers should
use a face shield only as an emergency substitute for
mouth-to-mouth breathing, and should switch to a
mask or bag-mask device as soon as possible.
Bag-mask devices are designed for use in clinical and
emergency settings to provide oxygen and ventilation
to a patient who is not breathing or is not breathing
adequately. When used with supplemental oxygen,
the bag-mask device can provide up to 100% oxy-
gen. They are available in different sizes for adult,
child, and infant patients.
Any time there is a risk of spraying or splatter of blood
or body fluids, you should use goggles or safety
glasses with side protection to help protect your
eyes.
Eye protection.
To reduce the risk of infection,
you should:• Always wear barrier protection in
emergency situations.
• Carefully remove gloves, clothingand any other contaminated mate-rial. Place them in appropriatelylabeled bags or containers.
Decontaminating SurfacesDecontaminate all surfaces, equip-ment, and other contaminated objectsas soon as possible. Clean with adetergent and rinse with water. Use ableach solution of one quarter cup
(.06 liter) of household bleach per one gallon (3.79liters) of water to sanitize the surface. Spray on thesolution and leave it in place for at least 2 minutesbefore wiping.
Bag-mask devices.
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CPR Pro for the Professional Rescuer Introduction6
Proper Removal of Contaminated Gloves
2
Skill Guide #1
• Gently pulling the glove away from the palm and towardthe fingers, remove the glove inside out. Hold on to theglove removed with the fingers of the opposite hand.
1
• Without touching the bare skin, grasp either palm withthe fingers of the opposite hand.
3• Without touching the outside of the contaminated glove,
carefully slide the ungloved index finger inside the wristband of the gloved hand.
4
• Gently pulling outwards and down toward the fingers,remove the glove inside out.
5• Throw away both gloves in an appropriate container.
• Use an alcohol-based hand rub to clean your hands andother exposed skin after providing first aid. If an alcohol-based hand rub is not available, wash with soap andwater.
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Section 2 — Cardiovascular Disease
Cardiovascular Disease CPR Pro for the Professional Rescuer 7
Cardiovascular Disease
Cardiovascular disease directly affects the heart and
the large vessels of the circulatory system. The term
generally reflects a progressive deterioration of the
tissues involved.
The most common problems associated with cardio-
vascular disease are stroke and acute coronary syn-
dromes. They are the leading causes of death for
both men and women in the United States, and
account for nearly 40% of all deaths.5
You can lower your risk for cardiovascular disease by
making healthy lifestyle choices.
• Eat a healthy diet to prevent or reduce high
blood pressure and high blood cholesterol.
• Maintain a healthy weight.• Control your alcohol intake.
• Don’t smoke.
• Exercise as directed by your doctor.
Stroke A stroke occurs when the blood supply to part of the
brain is suddenly interrupted, or when a blood vessel
in the brain bursts and spills blood into the surround-
ing tissue.6 A stroke can result in serious issues with a
patient’s ability to feel, move, or communicate. Dam-
age can be limited by early recognition and promptprofessional medical treatment.7
Signs and symptoms of a stroke may occur suddenly:8
• Numbness or weakness on one side of the body
• Trouble speaking or understanding
• Trouble seeing in one or both eyes
• Loss of balance or coordination• Severe headache
If you suspect a stroke may be occurring, ask the
patient to:
• Smile.
• Raise both arm.
• Speak a simple sentence.
If the patient has any trouble with any of these tasks:
• Alert EMS immediately.
• Position the patient comfortably.
• Comfort, calm, and reassure the patient.
• Provide supplemental oxygen if it is available.
Acute Coronary Syndromes (ACS) The term acute coronary syndromes applies to a
number of serious conditions involving the heart.
These include unstable chest pain, or angina, and
myocardial infarction (heart attack).9 A heart attack
occurs when oxygenated blood flow to part of the
heart is severely diminished or cut off. If not resolved,
heart tissue will die. This could result in a serious dis-
ability or sudden cardiac arrest.
Stroke graphic.
Heart attack.
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Chain of Survival for Adults
The Chain of Survival is a concept that is used to
communicate the key factors that must be in place to
increase survival from sudden cardiac arrest.11 The
links in the chain of survival include:
• Early recognition and activation of EMS
• Early CPR
• Early defibrillation
• Early advanced life support
The chain of survival begins with early recognitionand rapid activation of EMS or an Emergency Action
Plan. Early activation may include assistance by an
emergency operator, specially trained to provide CPR
instructions over the phone.12
Early CPR will buy some time for a defibrillator to
arrive and improve the chance that defibrillation will
work.
CPR Pro for the Professional Rescuer Cardiovascular Disease8
Signs and symptoms can vary in intensity. Suspect a
heart attack if the following signs and symptoms
appear:
• Chest pain or a dull discomfort behind the
breastbone that may spread to the arms, back,
neck, jaw, or upper abdomen
• Shortness of breath
• Weakness, nausea, or dizziness
• Heavy sweating
• Anxiety
• Uncertainty and embarrassment
• Denial that something serious is occurring,
which can delay treatment and increase the risk
of death
If you suspect a heart attack is occurring, do the
following:
• Alert EMS immediately.
• Have the patient sit and rest quietly.
• Loosen any tight clothing.
• Help patient take existing heart medication. Usu-
ally this is nitroglycerin, placed or sprayed under
the tongue.
• If the patient does not have a history of aspirin
allergy, advise the patient to chew and swallow a
half or whole adult aspirin tablet (162–325 mg).
• Provide supplemental oxygen if it is available.
Sudden Cardiac Arrest
Sudden cardiac arrest is an emergency that occurs
abruptly and without warning.10
Without early recogni-tion and treatment, most likely from a bystander, a
patient will not survive.
Suspect a sudden cardiac arrest has occurred if
someone:
• Collapses without warning,
• Is unresponsive to voice and touch,
• Appears to not be breathing or is making shal-
low, ineffective attempts to breath, and
• Looks dead.
If you suspect a sudden cardiac arrest has occurred,
immediately alert EMS, perform CPR, and defibrillate
as soon as possible with an AED.
Sudden cardiac arrest (SCA).
Family members ofpatients who havehad a recent heartattack should takeCPR training andbe familiar with the
use of an AED. Employers shouldconsider the use of AEDs at their worksites to reduce
the time to defibrillation, with the goal of improving sur-vival.
All professional responders should be equipped withand trained in the use of an AED.
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Cardiovascular Disease CPR Pro for the Professional Rescuer
Early defibrillation can return the heart to a normal
rhythm. Survival rates are highest when CPR is start-
ed immediately and defibrillation occurs within three
to five minutes.
Advanced life support involves medical procedures
and medications used by paramedics, nurses, or
doctors to help protect survival and recovery.13
If any one of these links is weak or missing, the
patient is unlikely to survive. When all the links are
strong, the greatest chance for survival occurs.
Chain of Survival for Children
A chi ld’s heart does not usually stop suddenly, as is
most often the case in adults. Typically, a child’sbreathing will be lost first, by a situation such as
drowning or choking. In these cases, the heart slows
over an extended time and then stops from the lack
of oxygen in the blood. Rapid treatment should
include CPR with a particular emphasis on establish-
ing an open air passage to the lungs and providing
rescue breaths that create a visible rise of the chest.
Early care could reverse the effects of a weakening
heart.
The Chain of Survival in children emphasizes:
• Prevention
• Early CPR
• Early activation of EMS
• Early pediatric advanced life support
Injury is a leading killer of children aged 14 and under
worldwide. Most injuries can be prevented by taking
simple safety measures.14 Death rates for drowning
are highest in children less than five years old. Placing
infants on their backs to sleep and giving them a
pacifier significantly reduces the risk of Sudden Infant
Death Syndrome.15,16
When a child is found unresponsive and not breath-
ing, performing CPR is the priority. Immediate CPR,
with effective rescue breaths, has been shown to sig-
nificantly increase survival for infants and children.17
When available, have another bystander alert EMS.
However, if you are alone, provide about two minutes
of CPR before alerting EMS yourself. As with an adult,prompt professional treatment will help protect sur-
vival and recovery.
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Jaw Thrust with head-tilt can be a convenient and
effective method of opening the airway when using aventilation mask, or bag-mask, during rescue breath-
ing or multi-rescuer CPR.
If a patient is unresponsive or semi-responsive and
fluids are endangering his airway, immediately turn
the patient on his side to allow fluids to drain. Roll the
patient like a log without twisting the spine or head
out of alignment. Sweep the mouth with your finger to
remove any foreign material collecting there.
Placing an unresponsive person in a recovery position
uses gravity to help protect the airway from becoming
blocked by the tongue, vomit, or secretions. Use the
recovery position only if the patient is uninjured and
breathing normally.
Section 3 — Resuscitation Skills
CPR Pro for the Professional Rescuer Resuscitation Skills10
Resuscitation Skills
Before looking at the process of resuscitation, it is
helpful to focus on each of the individual skills that
are involved.
Because patients will vary in age, CPR guidelines use
the following age ranges:
• Infants are less than about 1 year of age.
• Children are about from 1 year of age to about
the onset of puberty.
• Adults begin with the onset of puberty.
Airway
The airway is the passageway between the mouth
and lungs. The airway must be open so air can enter
and leave the lungs freely. Blockage of the airway ismost commonly caused by the relaxation of the
tongue when a patient becomes unresponsive. The
Head-tilt, Chin-lift airway maneuver will pull the
tongue away from the back of the throat and open the
airway.
When the potential for a neck injury exists, Jaw
Thrust without head-tilt can be used to open the air-way. If the Jaw Thrust does not open the airway, use
the Head-tilt, Chin-lift maneuver.
Jaw Thrust maneuver.
Log-roll.
Opening the airway.
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Using a barrier device such as a mask or bag-mask to
give rescue breaths is recommended for professional
healthcare providers. Rescuers can consider using a
face shield until a mask or bag-mask is available.
Face shields minimize direct contact with a patient
but may not reduce the risk of infection.
Do not take deep breaths when providing rescue
breaths. Taking deep breaths is unnecessary. It could
result in over ventilation and may cause you to hyper-
ventilate. When working with other rescuers, rescue
breaths can be done from above the patient’s head
using Jaw Thrust. When supplemental oxygen is avail-
able, attach a connecting tube to the mask and pro-
vide a minimum flow rate of 10-12 liters per minute.
A bag-mask device allows rescuers to provide posi-
tive pressure ventilations without having to blow into
it. Bag-masks come in adult, child, and infant sizes.
Use the size most appropriate for the size of the
patient. It takes significant practice to effectively use
bag-mask and that should be a consideration in its
use. A bag-mask can be used by a single rescue but
is ideally used by two.
When available, use supplemental oxygen with a bag-
mask. Provide a minimum flow rate of 10-12 liters per
minute. Use a reservoir system to provide 100% oxy-
gen delivery.
Depending on your relationship to a patient and the
availability of a barrier device, you may elect to pro-
vide mouth-to-mouth rescue breaths, using the same
technique as with a face shield.
Mouth-to-nose rescue breaths may be useful if a res-
cuer has difficulty with mouth-to-mouth. Tilt the
patient’s head back with one hand and use the other
hand to lift the chin and close the patient’s mouth.
Seal your lips around the patient’s nose and blow.
11Resuscitation Skills CPR Pro for the Professional Rescuer
Recovery position.
Once in the recovery position, check the patient’s
breathing regularly. Make sure there is no pressure on
the chest that could make it harder to breath. Also
make sure the patient’s body position is stable so he
does not roll onto his face or back.
As a rule, you should not move an injured patient
unless you determine you absolutely have to.
When you suspect injuries are present, use a modi-
fied recovery position called the HAINES position.
HAINES stands for “High Arm In Endangered Spine.”
When using the HAINES position, there is less neck
movement and less risk of spinal-cord damage.
Breathing
Rescue breaths use your exhaled air to force oxygen
into the lungs of a person who has stopped breath-ing. Not all of the oxygen is used by the body in the
breathing process. Inhaled air contains approximately
21% oxygen. Exhaled air contains about 16–17%
oxygen. When delivered through rescue breaths,
there is still enough oxygen to support life.
Rescue breaths using a mask.
Bag-mask with two rescuers.
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A stoma is a surgical opening in the front of the neck
through which a person can breathe. Rescue breaths
can be directly given into the stoma using a child-
sized face mask. Direct mouth-to-stoma rescue
breaths can be considered if a mask is not available.
Air can be forced into the stomach instead of the
lungs when giving forceful breaths. This can reduce
the effectiveness of the breaths and may cause a
patient to vomit. To prevent this, give each breath in
one second and give only enough air to see a visible
chest rise, but no more than that. Allow the patient to
exhale completely between breaths.
Pressure applied to the cricoid cartilage in the neck
can compress the esophagus against the spine and
help prevent air from being forced into the stomach
with ventilation. This will lower the chance that vomit-
ing will occur.
Locate the patient’s Adam’s apple, or thyroid carti-
lage, with your finger. Sliding your finger downward,
you will feel an indentation just below the thyroid car-
tilage and then another rigid structure. This is the
cricoid cartilage. Using the tips of your thumb and
index finger, firmly press the cricoid cartilage directly
backwards and hold it in place. Take care to not push
to one side or the other. If the patient coughs or gags
at anytime, release the pressure.
Circulation
To assess for circulation of an adult or child, try to
locate the carotid pulse found on either side of the
windpipe in the neck. Locate the thyroid cartilage.
Slide your fingers into the groove between the wind-
CPR Pro for the Professional Rescuer Resuscitation Skills12
pipe and the muscles on the side of the neck and
compress inward. Pulse checks can be difficult in
emergency situations, even for experienced rescuers.
If you are not certain that a pulse is present within 10
seconds, assume it is absent.
For infants, use the brachial pulse in the inside of the
upper arm. Lay your fingers across the arm and com-
press inward.
External chest compressions are done by applying a
rhythmic application of pressure over the lower half of
the breastbone. Chest compressions result in forward
blood flow as a result of increased pressure in the
chest and direct compression of the heart.
Cricoid pressure.
Child/infant pulse check.
Adult chest compressions.
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CPR Pro for the Professional Rescuer Resuscitation Skills14
Opening the Airway
Skill Guide #2
Head-Tilt, Chin-Lift• Blockage of the airway is most commonly caused by the
relaxation of the tongue when a patient becomesunresponsive.
1• Tilting the head and lifting the chin will pull the tongue
away from the back of the throat and open the airway.
2• Don’t press too hard on the soft area under the chin.
Doing so can block the airway. Don’t push the mouthcompletely closed.
3Jaw Thrust
• When the potential for neck-injury exists, Jaw Thrustwithout head-tilt can be used to open the airway.1
• Positioned above the patient, place your hands on eitherside of the head. Hook your fingers underneath theangles of the jaw, just below the ear.
2• Use counter pressure against the cheeks to displace the
jaw and move it upward without tilting the head.
• If the Jaw Thrust does not open the airway, use theHead-tilt, Chin-lift maneuver instead.3
Jaw Thrust with Head-Tilt• The Jaw Thrust maneuver with head-tilt can be a con-
venient and effective method of opening the airwaywhen using a mask, or bag-mask, during rescue breath-ing or multi-rescuer CPR.4
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Resuscitation Skills CPR Pro for the Professional Rescuer 15
Protecting the Airway
Skill Guide #3
Log Roll• When a patient is unresponsive or semi-responsive and
fluids are endangering the airway, immediately turn thepatient on his side to allow fluids to drain.
• Roll the patient to avoid twisting of the spine. Keep thehead in line with the body.
• Sweep the mouth with your finger to remove any foreignmaterial collecting there.
12
Recovery Position (No Injuries)• Kneel beside patient and make sure legs are straight.
• Place arm nearest to you out at a right angle to thebody, palm up.
• Bring far arm across chest and hold back of handagainst patient’s cheek nearest you.
• Grasp far leg just above knee and pull it up.
• Keeping patient’s hand pressed against the cheek, pullon far leg to roll the patient toward you.
• Adjust the upper leg so both the hip and the knee arebent at right angles.
• Adjust upper leg so patient’s body is stable.
• Assess breathing and monitor patient.
12
3HAINES Position (Suspected Injury)
• Kneel beside patient. Place patient’s closest arm abovehead and furthest arm across chest.
• Lift patient’s nearest leg just above the knee.
• Place your hand under hollow of patient’s neck to helplift and control head.
• Roll patient toward you and rest head on the extendedarm.
• Bend legs at knees to stabilize patient’s body.
• Assess breathing and monitor patient.
1
23
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CPR Pro for the Professional Rescuer Resuscitation Skills16
Rescue Breaths
Skill Guide #4
Using a Face Shield• Place face shield over patient’s mouth and nose.
• Tilt patient’s head and lift chin. Pinch patient’s nose.
• Take a normal breath, open your mouth wide, and placeyour mouth on the face shield around patient’s mouth.
• Press down to create an air tight seal, and blow throughthe opening on the shield. Make chest visibly rise, butno more than that.
• Remove your mouth from shield with each rescue breathand allow patient to exhale.
• If the patient is an infant, place your mouth over theinfant’s mouth and nose.
Using a Ventilation Mask• Place mask over the patient’s mouth and nose.
• Tilt patient’s head and lift chin into mask to create an air
tight seal.
• Take a normal breath and place your mouth around theone–way valve on the mask.
• Blow through valve and make chest visibly rise, but nomore.
1
2
3
12
• Remove your mouth from the valve with each rescue
breath and allow patient to exhale.
3
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Resuscitation Skills CPR Pro for the Professional Rescuer 17
Bag-Mask
Skill Guide #5
2 or More Rescuers
Rescuer 1
• Position yourself above patient’s head. Place maskover patient’s mouth and nose.
• Place your hands on either side of the head. Use yourthumbs and heels of your hands to hold mask inplace. Hook your fingers underneath the angles of the
jaw, just below the ear.
• Lift and tilt head backward. If you suspect a neckinjury, do not tilt head.
• Use counter pressure against cheeks to displace jawand move it upward.
Rescuer 2
• Squeeze bag to ventilate. Give each breath in 1 sec-ond. Make chest visibly rise, but no more.
1 Rescuer
• Position yourself above patient’s head. Place mask overmouth and nose.
• Use thumb and first finger of one hand around valve in a“C” position to press mask against patient’s face.
• Use your remaining three fingers in an “E” position to liftup jaw.
• Tilt head back to open airway. If patient is injured, useJaw Thrust only.
• Squeeze bag with your free hand to ventilate. Give eachbreath in 1 second. Make chest visibly rise, but no more.
1
2
3
12
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CPR Pro for the Professional Rescuer Resuscitation Skills18
External Chest Compressions
Skill Guide #6
Adults
• Place heel of one hand in center of chest between nipples. Put other
hand on top of first. Your fingers can be straight or fastened together, butkept off chest.
• Position your shoulders directly over your hands. Straighten your armsand lock your elbows. Use upper body weight to help compress chest.
• Push straight down on chest approximately 11 ⁄ 2–2 inches or 4–5 centi-meters. Release your pressure and allow for full recoil of chest. Withoutinterruption, compress at a rate of about 100 times per minute.
• Do not push over the lower part of the breastbone. Keep up the force andspeed of compressions.
Children
• Use heel(s) of either 1 or 2 hands to compress. Place hand(s) on the cen-
ter of the chest, between the nipples.• Using upper body weight, compress about 1 ⁄ 3–1 ⁄ 2 the depth of the chest at
a rate of about 100 compressions per minute.
Infants
• Compress the center of chest with two fingertips just below the nipple
line.• Compress about 1 ⁄ 3–1 ⁄ 2 the depth of the infant’s chest at a rate of about
100 per minute.
• With two or more rescuers, compress the breastbone using two thumbs,with your fingers encircling the chest.
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Defibrillation
Ventricular fibrillation is the most common heart
rhythm that occurs in sudden cardiac arrest.
AEDs allow healthcare providers who are not trainedin advanced techniques to defibrillate. Integrated
voice prompts help make them simple to operate.
Survival rates for sudden cardiac arrest are highest
when immediate CPR is performed and defibrillation
is provided within 3–5 minutes.
If you witness the collapse of a patient who is found
to be in cardiac arrest, initiate CPR and defibrillate as
soon as an AED is available.
If you respond to an arrest that you have not wit-
nessed, your protocols may require you to perform
about 2 minutes of CPR prior to using an AED.
There are many different brands of AEDs, but the
same basic steps apply to all of them.
• Turn on the AED.
• Adhere the AED pads to the patient’s bare chest.
• Allow the AED to automatically analyze the heartrhythm.
• Deliver a shock if directed to by the AED.
Turning on an AED wil l begin voice prompts that will
help guide you through the steps of care.
Defibrillation is provided through adhesive pads
attached to the patient’s bare chest and connected
by wires to the AED. These pads typically have pic-
tures on them that indicate the proper placement of
Section 4 — Defibrillation
Defibrillation CPR Pro for the Professional Rescuer 19
the pads on the chest. Pads need to be removed from
their protective lining to ensure proper adherence to
the chest wall.
When pads are properly attached, an AED will auto-
matically begin to analyze a patient’s heart rhythm to
decide if a shock is needed. No one should touch the
patient during analysis.
A voice prompt and warning sound will inform you a
shock is recommended. All rescuers need to be safe-
ly “cleared” from the patient before delivering the
shock. Immediate CPR is recommended following an
initial defibrillation shock. Additional shocks may berequired. Listen carefully to the AED voice prompts
and provide any indicated care.
Automated External Defibrillator (AED).
Placing pads.
Deliver shock.
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Ventricular f ibrillation is uncommon in children, but it
can occur. AEDs can be used for children older than 1
year of age.18 An AED may have special pads or a key
to deliver a lower, child-sized amount of electricity.19 If
a child-specific AED is not available, it is okay to use
an AED set up for an adult.
Troubleshooting
Troubleshooting prompts from the AED can help
guide you through some common problems with its
use. Stay calm and do what the AED tells you to do.
Hair on the chest may prevent the electrode pads
from making effective contact. If a voice prompt indi-
cates a pad problem, press the pads firmly against
the chest. If the prompt continues, quickly remove the
pads tearing out the hair, and apply a second set ofpads. If the problem continues, quickly shave the hair
off of the chest underneath and attach another set of
pads.
CPR Pro for the Professional Rescuer Defibrillation20
Moisture on the victim’s chest can reduce the ability
of the pads to adhere. If the victim’s chest is sweaty
or wet, quickly dry it before attaching the pads. Move
a victim out of standing water before attaching the
pads.
If a message indicating motion occurs, make sure
CPR has been stopped and the cables are not being
moved.
If a message regarding the battery is displayed, the
battery is probably low. If the AED will not charge to
deliver a shock, change the battery.
Remove medication patches and wipe the skin clean
before attaching pads. Medication patches may block
the shock and can cause burns to the skin.
A noticeable scar and lump on the chest may indicate
an underlying implanted medical device such as a
pacemaker or defibrillator. Place the edge of the pads
at least 1 inch or 2.5 centimeters away from any
implanted device.
To prevent the accidental ignition of bedding or
clothes divert emergency oxygen away from the vic-
tim when shocks are delivered with an AED.
AEDs can be used safely on metal surfaces as long
as the electrode pads do not come into contact with
the metal.
Children defibrillation devices.
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Section 5 — Emergency Action Steps
Emergency Action Steps CPR Pro for the Professional Rescuer 21
Assess, Alert, and Attend tothe ABCD’sThe emergency action steps are intended to help you
manage life-threatening problems of the airway,
breathing and circulation.
Always pause for a moment as you approach and
assess the scene for safety. If the scene is not safe,
make sure it is before you enter. Assess any patients.
Form an initial impression of the severity of their
problems.
Signs that CPR may be needed include:
• Patient is not moving.
• Tissue color is bluish or ashen, especially around
the lips.
• Breathing is shallow, gasping, or absent.
Adults
Kneel next to the patient. Gently tap or squeeze the
patient’s shoulder and ask, “Are you all right?” Use
the patient’s name if you know it.
If the patient is unresponsive, have another person
alert EMS if it has not already been done. If available,
have the person return with an AED and emergency
oxygen. If you are alone with an unresponsive adult,
immediately alert EMS yourself. Get an AED and
oxygen, if they are available, and quickly return to the
patient.
Attend to the ABCD’s. Make sure the patient is face
up on a firm, flat surface. If the patient is on his face,
roll him over but minimize twisting of the head and
neck.
Attend to the airway. Open the airway using Head-tilt,
Chin-lift. Use the Jaw Thrust if you suspect a neck
injury.
Attend to breathing. Lean close to the patient and
look for chest movement, listen for air leaving the
mouth and nose, and feel for air blowing on your
cheek. Check for at least 5, but no more than 10
seconds.
Assess victim.
Alert EMS.
Open the airway.
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It may be difficult to determine whether an adult
patient is breathing normally or not. Normal breathing
is effortless, quiet, and regular. Occasional gasps are
not normal and are not capable of supplying the
patient with enough oxygen to sustain life.
If the patient is breathing normally, place him on his
side in a recovery position. If you are not positive that
the patient is breathing or breathing normally, quickly
give two rescue breaths. If the patient’s chest does
not rise with the first rescue breath, re-tilt the patient’s
head, lift the chin, and give the second breath.
Attend to circulation. After the delivery of the two res-cue breaths, check the patient’s pulse. Check the
pulse for no more than 10 seconds. If a pulse is pres-
ent, perform rescue breathing. Provide 1 rescue
breath about every 5 to 6 seconds.
If the pulse is absent, or you are not sure after 10 sec-
onds, perform CPR. Give 30 chest compressions at a
speed of about 100 per minute. Keeping up the force,
length, and speed of compressions helps create the
best blood flow possible. After 30 compressions,
open the patient’s airway and give two rescue breaths
that make the chest visibly rise. Without delay, return
to the chest and begin compressions again.
Compressions need to be hard and fast. Allow the
chest to fully recoil at the top of each compression
and minimize any interruptions to compressions. Pro-
vide continuous cycles of 30 compressions to 2 res-
cue breaths until an AED is available, you are relieved
by another rescuer, or the patient responds.
When another rescuer is available, perform CPR with
2 rescuers. One rescuer performs rescue breaths and
the other performs chest compressions. When giving
rescue breaths, pause compressions, and allow the
breaths to be given. Change places every few min-
utes to prevent fatigue. Do this quickly, in less than 5seconds.
When an AED becomes available, use it immediately,
unless your protocols indicate otherwise. Turn the
AED on and listen to the voice prompts. Expose the
chest by tearing or cutting the shirt.
Check for breathing.
Give two rescue breaths.
Single rescuer CPR.
Two-rescuer CPR.
CPR Pro for the Professional Rescuer Emergency Action Steps22
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Emergency Action Steps CPR Pro for the Professional Rescuer
Attend to the child. Open the airway. Check for the
presence or absence of breathing. Take at least 5
seconds and no longer than 10. If the child is breath-
ing, place her in the recovery position.
If breathing is absent give 2 rescue breaths. For chil-
dren, you may have to try a couple of times to give
breaths that make the chest visibly rise. It is critical
that rescue breaths make an infant or child’s chest
rise during resuscitation.
Check the child’s pulse for no longer than 10 sec-
onds. If the pulse is present and is 60 beats per
minute or greater, perform rescue breathing, providing
1 rescue breath every 3 to 5 seconds.
If the pulse is less than 60 beats per minute, absent,
or you are not sure, begin CPR. Provide continuous
cycles of 30 compressions to 2 rescue breaths until
an AED is available, you are relieved by another res-
cuer, or the child responds.
When performing CPR on a child with 2 rescuers,
provide continuous cycles of 15 compressions to 2
breaths. When giving rescue breaths, pause com-
pressions and allow the breaths to be performed.
If the collapse of the child was witnessed, use an AED
as soon as one is available. If the collapse was not
witnessed, perform about two minutes of CPR before
using the AED.
Turn the AED on and listen to the voice prompts.
Expose the chest. Remove the defibrillation pads
from their packaging, peel them from their backing,
and apply them to the child’s bare chest. With most
AEDs, place one pad on the center of the chest, just
below the collarbones. Place the other pad on the
center of the back between the shoulder blades.
Remove the defibrillation pads from their packaging.
Look at the pictures on the pads to see exactly how
to place them. Remove the self-adhesive backing and
attach the electrodes to the patient’s bare chest.
Make sure the electrode attaches firmly to the skin.
Allow the AED to analyze the patient’s heart rhythm.
Ensure nobody touches the patient during analysis. If a
shock is indicated, warn everyone out loud to stay
“CLEAR” of the patient. Make sure no one, including
you, is touching the patient. Press the shock button on
the AED to deliver the shock. Immediately resume CPR
and follow any instructions given by the AED. If the
patient becomes responsive at any time, stop CPR.
Defibrillation.
Child CPR.
Supplemental Oxygen
Even the best chest compression pro-vides only about 25%–33% of the nor-mal blood and oxygen flow from theheart. The combination of low bloodflow and low oxygen causes organs to
fail and leads to death. Giving rescue breaths withsupplemental oxygen permits the rescuer to provide ahigher concentration of oxygen. Oxygen-rich breathsdeliver critically needed oxygen to the heart and brain.For this reason, when available, healthcare providers,first responders, and professional rescuers should usesupplementary oxygen when performing rescuebreathing. Ideally a bag-mask device should beattached to an oxygen reservoir to allow delivery of
100% oxygen to the patient.
Children
The emergency action steps for children are similar to
adults with a few key differences. Assess the scene
for safety. Assess the child for response. Have a
bystander alert EMS. When alone, stay with the child
and, if indicated, provide about two minutes of CPR
before leaving to call for EMS.
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Allow the AED to analyze the child’s heart rhythm.
Ensure nobody touches the child during analysis. If a
shock is indicated, warn everyone to stay “CLEAR” of
the child. Make sure no one, including you, is in con-
tact with the child. Press the shock button on the
AED to deliver the shock.
Immediately resume CPR and follow any instructions
given by the AED.
Infants The emergency action steps for an infant are similar
to an adult or child. Assess the scene for safety.
Assess the infant for response. You may try tapping
the foot.
Have a bystander alert EMS. When alone, stay with
the infant and, if indicated, provide about two minutesof CPR before leaving to call for EMS.
Attend to the infant. Open the airway. Check for the
presence or absence of breathing. Take at least 5
seconds and no longer than 10. If the infant is breath-
ing, place him in the recovery position. If breathing is
absent, provide 2 rescue breaths.
Check the infant’s brachial pulse for no longer than 10
seconds. If the pulse is present and is 60 beats per
minute or greater, perform rescue breathing, providing
1 rescue breath every 3 to 5 seconds.
If the pulse is less than 60 beats per minute, absent,
or you are not sure, begin CPR.
Provide continuous cycles of 30 compressions to 2
rescue breaths until you are relieved by another res-
cuer or the infant responds.
When performing CPR on an infant with 2 rescuers,
provide continuous cycles of 15 compressions to 2
breaths. When giving rescue breaths, pause com-
pressions to allow the breaths to be performed.
When Using Advanced Airways Professional rescuers may use an advanced airway
device such as the laryngeal mask airway,
esophogeal-tracheal-combitube, or endotracheal
tube to provide rescue ventilations. When an
advanced airway is in place, remove the mask from
the bag-mask device and attach the bag directly to
the airway to ventilate.
Give ventilations at a rate of 6 to 8 times a minute,
regardless of the patient’s age.
When performing CPR with an advanced airway in
place, it is no longer necessary to pause compres-
sions. Ventilations and compressions can be per-
formed independently.
CPR Pro for the Professional Rescuer Emergency Action Steps24
Child defibrillation. Infant two-rescuer CPR.
Bag-mask to advanced airway.
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Emergency Action Steps CPR Pro for the Professional Rescuer
Special CPR ConsiderationsPregnancy — Chest compressions may not be effective when a woman who is 6 months pregnant ormore is lying flat on her back. This is because the baby puts pressure on a major vein that returns bloodto the heart. If possible, prop up the woman slightly on her left side using a rolled blanket (or similar)when performing chest compressions. This will reduce this pressure and provides the most blood flow tomother and baby. Perform chest compressions higher on the breastbone, slightly above the center.
Hypothermia — Get inside or out of the wind. Prevent additional heat loss by removing wet clothes and insulating thevictim from further exposure. If the body is frozen solid, the nose and mouth are blocked with ice, and chest compres-sion is impossible, do not start CPR. When defibrillating, if the victim does not respond to one shock, focus on continu-ing CPR and re-warming the victim to a range of 30°C–32°C (86°F–89.6°F) before repeating the defibrillation attempt.
Submersion/Near-Drowning — Because the scene may be unsafe (waves, currents, cold water, bad weather), propertraining in the use of personal lifesaving equipment, such as torpedo buoys and personal flotation devices, is critical fora safe rescue. If available, get the victim into a boat or other vessel. If no boat is available, get the victim to shore. StartBLS/CPR when indicated, as soon as it is safe to do so.
Expect vomiting. When it occurs, turn the victim’s mouth to the side and remove the vomit with a gloved finger sweep orcloth.
If a head, neck, or back injury is suspected, use the HAINES method or roll the victim like a log. Minimize movement. Avoid twisting the head, neck, or back.
Do not attempt to drain water from the lungs using abdominal thrusts. They are unnecessary and potentially dangerous.Move victim out of freestanding water and dry chest before attaching AED.
Electric Shock — Consider any fallen or broken wire extremely dangerous. Do not touch (or allow your clothing to touch)
a wire, victim, or vehicle that could be energized. Do not approach within 8 feet of it.
Notify the local utility and have trained personnel sent to the scene. Metal or cable guard-rails, steel wire fences, andtelephone lines may be energized by a fallen wire and may carry the current a mile or more from the point of contact.Never attempt to handle wires yourself unless you are properly trained and equipped.
Start CPR if indicated, as soon as it is safe to do so.
Lightning Strike — When multiple victims are struck by lightning at the same time, give the highest priority to those with-out signs of life. Start CPR if indicated, as soon as it is safe to do so. Because many victims are young, they have a goodchance for survival if immediate CPR is given. Remove smoldering clothing, shoes, and belt to prevent burns.
Cardiac Arrest and Injury — Be sure to clear mouth of blood, vomit, and other secretions. It is unlikely for someone whois in cardiac arrest caused by a serious injury to survive.
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Adult
Begins with onset
of puberty
Child
About 1 year of age to
onset of puberty
Infant
Less than
1 year of age
Assess
Assess Scene If the scene is unsafe or at
anytime becomes unsafe,
GET OUT!
If the scene is unsafe or at any-
time becomes unsafe,
GET OUT!
If the scene is unsafe or at any-
time becomes unsafe, GET
OUT!
Assess PatientTap shoulder, shout name. Tap shoulder, shout name. Tap foot, shout out.
Alert
Alert EMS or Emergency PlanGet an AED and/or emergency oxygen
Send a bystander. When
alone, do it yourself
immediately.
Send a bystander.
When alone, perform about
2 minutes of care before doing
it yourself.
Send a bystander.
When alone, perform about
2 minutes of care before doing
it yourself.
Attend
Open Airway • Head-tilt, Chin-lift
• Jaw Thrust for
suspected neck injury
• Head-tilt, Chin-lift
• Jaw Thrust for
suspected neck injury
• Head-tilt, Chin-lift
• Jaw Thrust for
suspected neck injury
Check Breathing Look, listen, and feel for at
least 5 seconds, but no
more than 10.
Look, listen, and feel for at
least 5 seconds, but no
more than 10.
Look, listen, and feel for at
least 5 seconds, but no
more than 10.
Breathing Present? Place patient in recovery
position and monitor
breathing.
Place patient in recovery
position and monitor
breathing.
Place patient in recovery
position and monitor
breathing.
Breathing Absent? Provide 2 rescue breaths. Provide 2 rescue breaths. Provide 2 rescue breaths.
Rescue Breaths • 1 second in length
• Make chest visibly rise,
but no more
• 1 second in length
• Make chest visibly rise,
but no more
• 1 second in length
• Make chest visibly rise,
but no more
Check Circulation Palpate carotid pulse in
neck for no more than
10 seconds.
Palpate carotid pulse in
neck for no more than
10 seconds.
Palpate brachial pulse in
upper arm for no more than
10 seconds.
Pulse Present? Perform Rescue Breathing;
1 breath every 5–6 seconds.
Perform Rescue Breathing;
1 breath every 3–5 seconds.
Perform Rescue Breathing;
1 breath every 3–5 seconds.
Pulse Absent? Perform CPR
• 1 Rescuer — 30:2
• 2 Rescuer — 30:2
Perform CPR
• 1 Rescuer — 30:2
• 2 Rescuer — 15:2
Perform CPR
• 1 Rescuer — 30:2
• 2 Rescuer — 15:2
Compressions • Center of chest, between
nipples; 2 hands
• 11 ⁄ 2 to 2 inches
• 100 times per minute
• Hard, fast, complete
recoil, minimize
interruption
• Center of chest, between
nipples;
1 or 2 hands
• 1 ⁄ 3 to 1 ⁄ 2 depth of chest
• 100 times per minute
• Hard, fast, complete
recoil, minimize
interruption
• Center of chest,
2 fingers just below
nipple line or 2 thumbs
with hands encircling
chest (2 rescuers)
• 1 ⁄ 3 to 1 ⁄ 2 depth of chest
• 100 times per minute
• Hard, fast, complete
recoil, minimize
interruption
Defibrillation with an AED
• Turn on power
• Attach pads
• Analyze
• If indicated, deliver shock
• Resume CPR and
follow voice prompts
• Use Child system; if not
available, use an AED
• Turn on power
• Attach pads
• Analyze
• If indicated, deliver shock
• Resume CPR and follow
voice prompts
No recommendation
CPR Pro for the Professional Rescuer Emergency Action Steps26
Summary of CPR/AED Procedures
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Emergency Action Steps CPR Pro for the Professional Rescuer 27
Adult Rescue Breathing
Perform these steps quickly — in a minute or less Emergency Action Steps
• Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT!
• Assess Patient. Tap shoulder, shout name. Not moving? No response?
• Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, do this yourself.
• Attend to the ABCs.
Skill Guide #7
Airway — Open Airway• Tilt head, lift chin.
• If you suspect a neck injury, use Jaw Thrust.
Breathing — Check Breathing• Look, listen, and feel for 5, but no more than
10 seconds. No breathing!
• If the patient is not breathing, or not breathing ade-quately, give 2 rescue breaths that make chest visiblyrise.
Circulation — Check Pulse• Check the carotid pulse in the neck for no more than 10
seconds. Pulse is present!
A
B
C
Perform Rescue Breathing• Give each breath in 1 second. Make the chest visibly
rise each time.
• Perform 1 breath every 5–6 seconds (10-12 breaths perminute).
• Reassess the carotid pulse about every 2 minutes. Takeno longer than 10 seconds to do so.C
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Child Rescue BreathingPerform these steps quickly — in a minute or less Emergency Action Steps
• Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT!
• Assess Child. Tap shoulder, shout name. Not moving? No response?
• Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, stay with the child
and provide 2 minutes of care before doing this yourself.
• Attend to the ABCs.
Skill Guide #8
Airway — Open Airway• Tilt head, lift chin.
• If you suspect a neck injury, use Jaw Thrust.
Breathing — Check Breathing• Look, listen, and feel for 5, but no more than
10 seconds. No breathing!
• If the child is not breathing, or not breathing adequately,give 2 rescue breaths that make chest visibly rise.
Circulation — Check Pulse• Check the carotid pulse in the neck for no more than 10
seconds. Pulse is present and ≥ 60 bpm!
A
B
CPerform Rescue Breathing
• Give each breath in 1 second. Make the chest visiblyrise each time.
• Perform 1 breath every 3–5 seconds (12–20 breaths perminute).
• Reassess the carotid pulse about every 2 minutes. Takeno longer than 10 seconds to do so.C
CPR Pro for the Professional Rescuer Emergency Action Steps
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Infant Rescue BreathingPerform these steps quickly — in a minute or less Emergency Action Steps
• Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT!
• Assess Infant. Tap shoulder, shout name. Not moving? No response?
• Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, stay with the infant
and provide 2 minutes of care before doing this yourself.
• Attend to the ABCs.
Skill Guide #9
Airway — Open Airway• Tilt head, lift chin.
• If you suspect a neck injury, use Jaw Thrust.
Breathing — Check Breathing• Look, listen, and feel for 5, but no more than
10 seconds. No breathing!
• If the infant is not breathing, or not breathing adequate-ly, give 2 rescue breaths that make chest visibly rise.
Circulation — Check Pulse• Check the brachial pulse on the inside of the upper arm
for no more than 10 seconds. Pulse is present and≥ 60 bpm!
A
B
CPerform Rescue Breathing
• Give each breath in 1 second. Make the chest visiblyrise each time.
• Perform 1 breath every 3-5 seconds (12-20 breaths perminute).
• Reassess the brachial pulse about every 2 minutes.Take no longer than 10 seconds to do so.C
Emergency Action Steps CPR Pro for the Professional Rescuer
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Adult CPR/AED
Perform these steps quickly — in a minute or less Emergency Action Steps
• Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT!
• Assess Patient. Tap shoulder, shout name. Not moving? No response?
• Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, do this yourself.
• Attend to the ABCDs.
Skill Guide #10
Airway — Open Airway• Tilt the head, lift the chin.
• If you suspect a neck injury, use Jaw Thrust.
Breathing — Check Breathing
• Look, listen, and feel for 5, but no more than 10 sec-onds. No breathing!
• If the patient is not breathing, or not breathingadequately, give 2 rescue breaths that make chestvisibly rise.
Circulation — Check Pulse• Check the carotid pulse in the neck for no more than
10 seconds. No pulse!
DPerform CPR
1 Rescuer (30:2)
– Push hard and fast (100x per min.) 11 ⁄ 2–2 inches deep.
– Allow chest to recoil completely. Minimize interruptions.
– Provide continuous cycles of 30 compressions and2 rescue breaths until AED arrives, EMS arrives, orpatient responds.
2 or More Rescuers (30:2)
– One rescuer performs compressions; the other rescuebreaths. Pause compressions when breaths are given.
– Quickly change positions at least every two minutes.
A
B
Defibrillation — Use an AED if Available• Turn on AED and follow voice prompts.
• Attach pads to bare chest; allow AED to analyze heart.
• If shock advised, CLEAR patient and deliver shock.
• Immediately resume CPR. Follow AED voice prompts.D
C
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Child CPR/AED
Perform these steps quickly — in a minute or less Emergency Action Steps
• Assess Scene. If scene is not safe or at any time becomes unsafe, GET OUT!
• Assess Child. Tap shoulder, shout name. Not moving? No response?
• Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, provide two minutesof care before doing this yourself.
• Attend to the ABCDs.
Skill Guide #11
Airway — Open Airway• Tilt head, lift chin.
• If you suspect a neck injury, use Jaw Thrust.
Breathing — Check Breathing• Look, listen, and feel for 5, but no more than
10 seconds. No breathing!
• If the child is not breathing, or not breathing adequately,give 2 rescue breaths that make chest visibly rise.
Circulation — Check Pulse• Check the carotid pulse in the neck for no more than 10
seconds. No pulse!
DPerform CPR
1 Rescuer (30:2)
– Push hard and fast (100x per min.) 1 ⁄ 3 to 1 ⁄ 2 the depthof chest.
– Allow chest to recoil completely. Minimize interruptions.
– Provide continuous cycles of 30 compressions and2 rescue breaths until an AED arrives, EMS arrives, orchild shows signs of life.
2 or More Rescuers (15:2)
– One rescuer performs compressions; the other rescuebreaths. The compressor pauses while breaths are
given.– Quickly change positions at least every two minutes.
A
B
Defibrillation — Use an AED if Available• Turn on AED and follow voice prompts.
• Attach pads to bare chest; allow AED to analyze heart.
• If shock advised, CLEAR child and deliver shock.
• Immediately resume CPR. Follow AED voice prompts.D
C
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CPR Pro for the Professional Rescuer Emergency Action Steps32
Infant CPR
Perform these steps quickly — in a minute or less Emergency Action Steps
• Assess Scene. If the scene is unsafe or at anytime becomes unsafe, GET OUT!
• Assess Infant. Tap foot, shout. Not moving? No response?
• Alert. Have someone alert EMS and get an AED and emergency oxygen. If alone, stay with the infant
and provide 2 minutes of care before doing this yourself.
• Attend to the ABCDs.
Skill Guide #12
Airway — Open Airway• Tilt head, lift chin.
• If you suspect a neck injury, use Jaw Thrust.
Breathing — Check Breathing• Look, listen, and feel for 5, but no more than
10 seconds. No breathing!
• If the infant is not breathing, or not breathingadequately, give 2 rescue breaths that make chestvisibly rise.
A
BCirculation — Check Pulse
• Check the brachial pulse on the inside of the upper armfor no more than 10 seconds. No pulse!
C
DPerform CPR
1 Rescuer (30:2)
– Push hard and fast (100x per min.) 1 ⁄ 3 to 1 ⁄ 2 the depthof the chest.
– Allow chest to recoil completely. Minimizeinterruptions.
– Provide continuous cycles of 30 compressions and2 rescue breaths until EMS arrives or infant showssigns of life.
2 or More Rescuers (15:2)
– One rescuer performs compressions; the otherrescue breaths. Pause compressions when breathsare given.
– Compress with thumbs and fingers encircling chest.
– Quickly change positions at least every two minutes.
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For adults and children, repeated abdominal thrusts
are recommended to relieve the blockage until
the object is expelled or the patient becomes
unresponsive.
For infants, repeat a combination of back blows and
chest thrusts.
If the choking patient is in the late stages of pregnan-
cy or is obese, and you cannot get your arms aroundthe abdomen, you can perform chest thrusts to
remove the blockage.
Section 6 — Choking
Choking CPR Pro for the Professional Rescuer 33
Foreign Body AirwayObstructionChoking occurs when an object blocks the passage
that allows air in and out of the lungs.
Food, especially large pieces, is the most common
cause of choking. Young children are particularly at
risk because of the small size of their air passages,
inexperience with chewing, and a natural tendency to
put objects in their mouths.20,21
Rescuers must be able to recognize the difference
between a mild blockage and a severe blockage of
the airway. A mild blockage can typically be cleared
by the patient through a natural coughing reaction. If
a patient can speak, or has strong coughing or gag-
ging, stay with them and encourage them to try and
cough the foreign object out. Be ready to take actions
if symptoms worsen. If the blockage is not easily
relieved and the patient is struggling, alert EMS.
When a severe blockage occurs, it is impossible to
clear the airway through natural means. Help from a
bystander is required to save the patient’s life.
Signs of a severe blockage include:
• Hands clutching throat
• Patient cannot speak, cough, or make any
sound
• Blue lips, nails, skin
To assess a patient you think may be choking simply
ask, “Are you choking?” If patient nods yes or is
unable to speak, cough, or cry — act quickly!
Choking victim.
Back blows and chest thrusts for infants.
Abdominal thrusts for adults.
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If you are alone, it is possible to relieve the blockage
yourself. Attempt to give yourself abdominal thrusts
until the object is expelled. If that does not work,
press your abdomen quickly over any firm surface
(back of a chair, side of a table, etc.).
If a choking patient becomes unresponsive during
treatment, change your approach to care. Carefully
get the patient to the ground and alert EMS. If alone
with a child, give about 2 minutes of CPR, then alert
EMS.
Begin CPR. Each time the airway is opened for res-
cue breaths, look for an object in the patient’s throat.If you see it, remove it. Continue CPR until the AED or
EMS arrives or the patient shows signs of life.
CPR Pro for the Professional Rescuer Choking34
Pregnant choking victim.
Adult CPR.
Abdominal thrusts have been associ-ated with severe and fatal complica-tions. Complications may occur evenwhen abdominal thrusts are per-formed correctly. DO NOT performabdominal thrusts on an adult or child
unless it is necessary. A patient who has had an air-way obstruction that was removed by abdominal orchest thrusts should be evaluated by EMS and seenby a physician to assure no internal injuries resulted
from the event. Abdominal thrusts are not recommended for infants
because you may damage internal organs.
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Choking CPR Pro for the Professional Rescuer 35
Adult Choking: Severe Blockage
Skill Guide #13
Responsive• Quickly ask, “Are you choking?”
• If patient nods yes or is unable to speak or cough — actquickly.
• Stand behind patient.
• Make a fist. Place thumb side against patient’sabdomen, just above the navel and below ribs. Graspfist with other hand.
• Quickly thrust inward and upward into abdomen.
• Repeat thrusts until object is expelled or patientbecomes unresponsive.
Becomes Unresponsive• Carefully get patient to ground. Alert EMS.
• Begin CPR. Each time airway is opened for rescuebreaths, look for an object in patient’s throat. If seen,remove it.
• Continue CPR until an AED arrives, EMS arrives, orpatient shows signs of life.
1
23
1
23
Perform these steps quickly — in a minute or less Emergency Action Steps
• Assess Patient. Suspect severe blockage if patient reacts suddenly and is clutching throat.
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CPR Pro for the Professional Rescuer Choking36
Child Choking: Severe Blockage
Skill Guide #14
Responsive• Quickly ask, “Are you choking?”
• If child nods yes or is unable to speak or cough — actquickly.
• Stand or kneel behind child.
• Make a fist. Place thumb side against child’s abdomen, just above the navel and below ribs. Grasp fist withother hand.
• Quickly thrust inward and upward into abdomen.
• Repeat thrusts until object is expelled or child becomesunresponsive.
Becomes Unresponsive• Carefully get child to ground. Alert EMS.
• Begin CPR. Each time airway is opened for rescuebreaths, look for an object in child’s throat. If seen,remove it.
• Continue CPR until an AED arrives, EMS arrives, or childshows signs of life.
1
23
1
23
Perform these steps quickly — in a minute or less Emergency Action Steps
• Assess Child. Suspect severe blockage if child reacts suddenly and is clutching throat.
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Choking CPR Pro for the Professional Rescuer 37
Infant Choking: Severe Blockage
Skill Guide #15
Responsive• Quickly look at infant’s face.
• If the infant is silent and unable to cry, and has blue lips,nails, and skin — act quickly.
• Lay infant face down on your forearm. Support headand tilt it downward.
• Give 5 firm back blows between shoulder blades.
• Sandwich infant between your arms and roll over ontoother forearm.
• Using two fingertips just below nipple line, give fivechest thrusts.
• Repeat 5 back blows and 5 chest thrusts until object isexpelled or infant becomes unresponsive.
Becomes Unresponsive• Place infant on a firm flat surface. Alert EMS.
• Begin CPR. Each time airway is opened for rescuebreaths, look for an object in infant’s throat. If seen,remove it.
• Continue CPR until EMS arrives or infant shows signs oflife.
1
23
1
23
Perform these steps quickly — in a minute or less Emergency Action Steps
• Assess Infant. Suspect severe blockage if infant suddenly becomes very quiet.
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Section 7 — Legal and Emotional Aspects
CPR Pro for the Professional Rescuer Legal and Emotional Aspects38
Legal Aspects of ProvidingBasic Life SupportGood Samaritan Laws — These are laws to prevent
someone who has voluntarily helped another in need
from being sued for ‘wrongdoing.’ You are generally
protected from liability as long as you act reasonably
and in “good faith” without payment or reward, and
you do not provide care beyond your skill level.
Abandonment — If you decide to help in an emer-
gency, you must not leave the patient until someone
with equal or more training takes over.
Consent — Consent is permission. A responsive
adult must agree to receive emergency medical care.
“Expressed consent” means the patient gives his or
her permission to receive care. To get consent, firstidentify yourself. Then tell the patient your level of
training and ask if it’s okay to help. “Implied consent”
means that permission to provide care to an unre-
sponsive patient is assumed. This is based on the
idea that a reasonable person would give permission
to receive lifesaving care if able. Consent for children
must be gained from a parent or legal guardian. When
life-threatening situations exist and the parent or
guardian is not available, care should be given based
on implied consent. When suffering from a distur-
bance in normal mental functioning, like Alzheimer’s
disease, a patient may not understand your request
for consent. Consent must be gained from a family
member or legal guardian.
Duty to Act — This is a requirement to act toward
others and the public with the watchfulness, atten-
tion, caution and prudence that a reasonable person
in the same circumstances would use. If a person’s
actions do not meet this standard, then the acts may
be considered negligent, and any damages resulting
may be claimed in a lawsuit for negligence. If you are
a state-licensed healthcare provider, first responder,
or other professional rescuer expected to give emer-
gency medical care, including CPR, you almost cer-
tainly have a duty to act. However, BLS performed
voluntarily on a stranger in need while off-duty is gen-
erally considered a “Good Samaritan Act.”
Starting CPR — Start CPR for all patients in cardiac
arrest unless signs of irreversible death are present,
including rigor mortis (limbs of corpse stiff and impossi-
ble to move), dependent lividity (settling of blood in
lower portions of body, causing a purplish red discol-
oration), or conditions are present that are incompatible
with life (decomposition, decapitation, massive head
injury, etc.). Do not start CPR if it puts you in danger of
injury, or the patient has a valid DNR order. In a mass
casualty incident with limited resources, patients requir-ing rescue breathing or CPR are considered dead and
attempts to resuscitate them should not be started.
Stopping CPR — Do not stop CPR until a healthcare
provider or other professional rescuer with equal or
more training takes over, you are exhausted, the scene
becomes too dangerous to continue, or the patient
shows signs of life. You can also stop if the physician
in charge of the patient decides to order the resuscita-
tion effort stopped (follow local protocol, standard
operating procedures, and/or medical direction).
Except when death is obvious, irreversible brain dam-
age or brain death cannot be reliably assessed or
predicted. Rescuers should never make an impulsive
decision about the present or future quality of life of a
cardiac arrest patient, because such decisions may
be incorrect.
Advanced Directives and Living Wills — These are
documents authorized by state law that allow a per-
son to appoint someone as his or her representative to
make decisions on resuscitation and continued life-
support in a situation where a person has lost deci-
sion-making capacity (for example, if in a coma).
These documents may also be referred to as “a
durable power of attorney.” Advanced directives are
statements about what the patient wants done or not
done when the patient can’t speak on his or her own
behalf. Laws about advanced directives are different in
each state. You should be aware of the laws in your
state.
Do Not Resuscitate (DNR) or Do Not Attempt
Resuscitation (DNAR) Orders — The DNR/DNAR
order is a kind of advanced directive. This is a specif-
ic request not to have CPR performed. In the United
States, a doctor’s order is required to withhold CPR.
Therefore, unless the patient has a DNR order, EMS
providers and hospital staff should attempt resuscita-
tion. Patients who are not likely to benefit from CPR
and may have a DNR order include those with termi-
nal conditions from which they are unlikely to recover.
Outside the hospital, healthcare providers, first
responders, and other professional rescuers should
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Legal and Emotional Aspects CPR Pro for the Professional Rescuer
begin CPR if there is a reasonable doubt about the
validity of a DNAR order or advanced directive, if the
patient may have changed his or her mind, or the
patient’s best interests are in question.
Emotional Aspects ofProviding Basic Life SupportRescuers trained in CPR are often unwilling to per-
form it — both in and outside the hospital setting.
There are a variety of reasons given, including fear of
disease, fear of hurting the patient, fear of performing
the skills incorrectly, and fear of liability. It is important
to remember that the risk of getting disease while giv-
ing CPR is extremely low and observing universal pre-
cautions for patients of all ages will make it lower.
Fears associated with CPR skill performance can be
reduced through regular participation in quality train-
ing that focuses on simple, practical skills and confi-
dence building.22 Still, when resuscitation is attempt-
ed, doctors, nurses, EMS providers and bystanders
can experience a wide range of negative reactions
and emotional stress.
Failed resuscitation attempts often leave rescuers —
especially those who perform resuscitation infre-
quently — feeling guilt when CPR was not “done
right.” This distress is normal and usually temporary.
Although CPR should be “done right” and at a high
quality, it is helpful to remember that a person in car-
diac arrest is already dead (without breathing or a
pulse). It is not possible to make the patient worse.
You can only help.23
Traumatic stress reactions are a normal, human
response to a traumatic event and are usually tempo-
rary. Symptoms begin within minutes of the traumatic
event and should disappear within hours or a couple
of days.
During Incident
• Anxiety/worry
• Trembling/shaking
• Sweating
• Fast breathing
• Pounding heartbeat, shock, anger
• Excitement, intense fear
• Nausea
Following Incident
• Thinking about event repeatedly
• Worry about self or loved ones
• Guilt for not having done more
• Tense muscles, diarrhea/constipation,
nausea/vomiting, headaches, fatigue
• Easily startled
• Lack of interest in usual activities
• Sadness, feeling detached
• Sleep problems/nightmares
• Problems concentrating
• Hyperactive/depressed
During the incident, remain calm and act sensibly.
Accept your own limitations as a rescuer. Following
the incident, remind yourself that stress reactions are
normal and will pass. Get back into a normal routine
as soon as possible. Be kind to yourself. Allow your-
self time to deal with memories of the incident.
Accept every person’s right to his or her own feelings.
Keep what happened in a realistic perspective. Be
sure to exercise, eat, drink, and rest. Have a connec-
tion to professional resources for continued care if
necessary.
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End Notes
CPR Pro for the Professional Rescuer End Notes40
End Notes1 U.S. Department of Labor; Occupational Safety & Health
Administration Regulations (Standards — 29 CFR)
Bloodborne pathogens — 1910.1030; Available:
http://www.osha.gov/ [23–Mar–05].
2 Division of Healthcare Quality Promotion, National Center
for Infectious Diseases Centers for Disease Control and
Prevention; Standard Precautions; January 1996;
Available: http://www.cdc.gov/ncidod/dhqp/
gl_isolation_standard.html [26–Aug–08].
3 Mejicano GC, Maki DG; Infections acquired during
cardiopulmonary resuscitation: estimating the risk and
defining strategies for prevention; Ann Intern Med; 1998
Nov 15;129(10):813–28.
4 Hand Hygiene in Healthcare Settings; Division of
Healthcare Quality Promotion, National Center forInfectious Diseases Centers for Disease Control and
Prevention; Available: http://www.cdc.gov/handhygiene/
[26–Aug–08].
5 Preventing Heart Disease and Stroke Addressing the
Nation’s Leading Killers; National Center for Chronic
Disease Prevention and Health Promotion; Available:
http://www.cdc.gov/dhdsp/library/toolkit/index.htm
[26–Aug–08].
6 National Institute of Neurological Disorders and Stroke;
National Institutes of Health; Available:
http://www.ninds.nih.gov/disorders/stroke/stroke.htm
[26–Oct–05].
7 Liferidge AT, Brice JH, Overby BA, Evenson KR; Ability of
laypersons to use the Cincinnati Prehospital Stroke
Scale; Prehosp Emerg Care; 2004 Oct–Dec;8(4):384–7.
8 Learn To Recognize A Stroke; ©2005 American Heart
Association, Inc; Available:
http://www.strokeassociation.org/ [13–Jun–05].
9 The Merck Manual; Section 16; Cardiovascular
Disorders; Ch. 202; Coronary Artery Disease; Available:
http://www.merck.com/mmpe/sec07/ch073/ch073a.html
[26–Aug–08].
10 Diseases and Conditions Index; National Heart Lung and
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