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Essential First Aid

Cardio-Pulmonary Resuscitation
Cardio-pulmonary resuscitation (CPR) is expired air resuscitation (EAR) used in conjunction with external cardiac compressions (ECC). It is the singularly most effective form of active resuscitation available, and is used universally by trained first aid providers and medical personnel. The technique is used to assist in resuscitation of casualties in cardiac arrest.

While expired air resuscitation is the method by which oxygen is provided to the casualty, external cardiac compressions, when applied correctly, duplicate the heart's mechanical function of pumping the oxygenated blood around the body. This combination of techniques is the basis of CPR. Effective CPR can sustain a casualty until more expert definitive medical treatment is available.  It is vital that CPR is initiated immediately on contact with the casualty.

A particularly important aspect of CPR is that the rescuer's hands are positioned correctly in relation to the casualty's heart.  There are two common methods used to locate the correct position of the heart; the Xiphoid Location , and the Calliper Method.

Xiphoid Location

Place two fingers of one hand over the casualty's xiphoid process, the small 'bump' at the base of the sternum. The other hand is then placed with the palm of the hand in the centre of the sternum, above the two fingers.  This position on the lower part of the sternum approximates the location of the heart.

Calliper Method

The middle finger of one hand is placed on the `sternal notch', the depression above the sternum below the throat. The middle finger of the other hand is placed at the base of the xiphoid process. Both hands are then moved together so that the thumbs meet in the middle of the sternum. The lower hand is then positioned palm down across the lower part of the sternum, close to the thumb of the upper hand. This approximates the location of the heart.

For adults and older children place one hand in position, the second hand is positioned over the first and the fingers entwined for stability. An alternative is for the second hand to grip the wrist of the first. The chest is then compressed approximately 1/3 the depth of the chest with pressure exerted through the heel of the bottom hand.

CPR can be performed by a single rescuer for all age groups, or by two rescuers for adults and older children. As two-person CPR requires a degree of synchronised technique, it is usually more effective for first aid providers to perform individual CPR, and change operators after five minutes or so.

INDICATIONS FOR CPR:

unconsciousness
usually no respirations, although there may be brief irregular, 'gasping' breaths
no pulse

PROCEDURE FOR ADULT AND OLDER CHILD ONE-PERSON CPR:

check for DANGER
check for response, gently shake and shout
call for help
roll casualty away from you
check and clear airway
look, listen and feel for breathing
If not breathing place casualty on back on a firm flat surface
open airway
give two effective breaths
assess the rise and fall of the chest
check for carotid (neck) pulse (5 - 10 seconds)
kneel beside casualty's chest
locate correct hand position
place hands centrally over heart, fingers entwined
lean over casualty, arms straight, elbows locked
commence 15 compressions, with even pressure approximately 1/3 the depth of the chest
compressions - rate of 100 per minute
give two effective breaths
relocate correct hand position
15 compressions
continue cycles and recheck pulse around every 1 minute

PROCEDURE FOR YOUNG CHILD AND INFANT CPR:

begin immediately
check for DANGER
check for response, gently squeeze the shoulder and shout
roll casualty away from you
check and clear airway
look, listen and feel for breathing
If not breathing place casualty on back on a firm flat surface
open airway
initial two effective breaths or puffs
check for carotid pulse (5 - 10 seconds)
5 compressions
1 breath or puff delivered on completion of the fifth compression
continue cycles and recheck pulse about every 1 minute 

PROCEDURE FOR TWO-PERSON CPR:

check for DANGER
check for response, gently shake and shout
call for help
roll casualty away from you
check and clear airway
look, listen and feel for breathing
If not breathing place casualty on back on a firm flat surface
one rescuer positions close to the casualty's head and delivers breaths
the other positions on the opposite side of the body beside the chest and performs compressions
open airway
initial two effective breaths
check for carotid pulse (5 - 10 seconds)
5 compressions
1 breath delivered on completion of the fifth compression
As air is forced under pressure into the casualty, and pressure is exerted by compressions, the risk of causing the casualty to vomit is very real. Rescuers must be alert at all times to avoid the airway becoming soiled by vomitus. Upon detection of vomitus in the casualty's mouth, roll him/her into the stable side position, clear the airway, and when clear, roll casualty back and resume CPR.

CPR is to be continued once begun until either the casualty is revived, the rescuer is relieved by expert medical aid, or until the rescuer is too exhausted to continue. Should the casualty regain his/her pulse and breathing, put him/her into the stable side position and observe closely, as often the casualty lapses back into cardiac arrest. If pulse only returns, continue with EAR.

RESUSCITATION SUMMARY CHART:

Expired Air Resuscitation
On normal inspiration, a person breathes in approximately 21% oxygen. The body uses between 4 — 4.5% of this amount for its normal functions. Therefore, on expiration a person breathes out approximately 16% oxygen. To breathe into another person as a means of supplementing their oxygen supply is not only feasible, but in cases of a non-breathing casualty, essential. Immediate supplementary breathing is necessary, as the brain suffers irreversible tissue damage if deprived of oxygen for longer than about three minutes. Rapid and effective resuscitation saves lives!

EXPIRED AIR RESUSCITATION (EAR) is the method by which a rescuer breathes for a casualty who is in respiratory arrest. The common term is 'mouth-to-mouth resuscitation'. It is a most effective method for sustaining life, as a rescuer breathes out sufficient oxygen to supply a casualty with the necessary requirement. There are five methods for delivering EAR:

MOUTH-TO-MOUTH where the rescuer seals the casualty's mouth with his or her mouth and breathes into the airway through the mouth.

MOUTH-TO-NOSE is used where the casualty has sustained facial injuries that preclude using the mouth. The rescuer closes the casualty's mouth, seals the nose with his or her mouth, breathes gently, then releases the casualty's jaw to allow exhalation.

MOUTH-TO-NOSE-AND-MOUTH is the preferred method when resuscitating a child, as the rescuer's mouth can cover and seal the child's nose and mouth.

MOUTH-TO-STOMA is used for resuscitating a casualty fitted with a stoma from a pipe-like device fitted into the throat with an opening in the neck. These devices are often encountered because the casualty is in a high-risk group, usually because of previous respiratory and/or cardiac problems. The rescuer breathes through the stoma directly into the airway — a most effective method.

EAR is necessary for casualties in complete respiratory arrest. Certain conditions cause the loss of respiratory effort, and the first aid provider should be aware of the potential for resuscitation. Choking, heroin overdose, near drowning, certain bites and stings, as well as respiratory conditions such as asthma and emphysema can cause respiratory arrest necessitating rapid and effective EAR to sustain life.

Breaths need to be effective, which is evidenced by the rise and fall of the chest with each breath from the rescuer.  Make up to five attempts to achieve the initial two effective breaths.

When considering which resuscitation technique to use, the age of the casualty must be taken into account.  The classifications are:

Infant - Newborn to 1 year
Young Child - 1 to 8 years
Older Child - 9 to 14 years
Adult - 15 years and older
Additional consideration must be given to the physical size of the child.  Often a young child may be as well developed as an older child.

INDICATIONS FOR EAR:

unconscious collapse
cyanosis (blue)
absent respirations, or breathing rate less than 4—5 per minute

PROCEDURE FOR EAR:

check for DANGER
call help
roll casualty away from you
check airway
open airway
look, listen and feel for breathing
if breathing effectively, remain in stable side position
if not breathing, roll onto back
ensure airway is open (head tilt or jaw lift)
give two effective breaths - jaw support (pistol grip).  Make up to five attempts to achieve two effective breaths
assess the rise and fall of the chest (if suspected obstruction — reassess airway)
check pulse
IF PULSE PRESENT, commence EAR for adults and older children by giving one effective breath every 4 seconds (15 breaths per minute)
for younger children and infants, give one effective breath every three (3) seconds (20 breaths per minute)
reassess pulse about every one minute
constantly reassess airway, be alert for vomitus

Breaths must be effective.  An effective breath is one where there is visible rise and fall of the chest during EAR.  Five attempts may be used to deliver the two effective breaths.

Full breaths are used for an adult and older child. When breathing into a young child ensure that you modify the force of the breaths. If delivered too forcefully, the air will be directed into the stomach, which may cause the child to vomit.

The method to be employed for infants is 'frog breathing' or 'puffing', where the rescuer fills his or her mouth with air and 'puffs' it into the infant's mouth. There will be adequate pressure and volume to satisfy the lung's requirements, but not enough to impact on the stomach.

EAR is continued until the casualty begins breathing spontaneously, until the rescuer is relieved by medical aid, or until the casualty deteriorates into full cardiac arrest at which point the rescuer delivers cardio-pulmonary resuscitation (CPR).