1. CPR/AED

2. Chain of Survival
The chain of survival are five steps to help increase the chances of an injured person of surviving a cardiac arrest.

3. Chain of Survival – step one
After determining that there is an injury needing advanced care; if unconscious tap and shout.
Call 911
Questions you will need to answer:
Nature of the emergency?
Where are you?
How many are hurt?
Ages of who is/are hurt
Who are you?
Has treatment started?
Only hang up when instructed to do so by operator.

4. Chain of Survival – step two
Begin CPR
Most adult cardiac arrests (CA) victims heart is in ventricular fibrillation (VF) - Abnormal chaotic heart rhythm that prevents the heart from pumping blood.
CPR will not usually stop VF but plays an important part in pushing oxygenated blood to the brain and heart and prolonging VF so that an AED will be useful.
CPR can double or triple the victims survival rate
For every passing minute without CPR; rate of surviving drops 7-10%.
With CPR there is only a 3-4% drop each minute

5. Chain of Survival – step three
Use an AED
The use of the AED will stun the fibrillating heart, if the heart is still viable the normal pacemakers in the heart will begin firing and start a normal rhythm.
If used within 5 min; chances of survival is 49-75%.
Using an AED is simple.

6. Chain of Survival – step four
Advanced Care – EMS
Response time is 7-8 minutes – CPR is extremely important.

7. Chain of Survival – step five
Integrated post-cardiac arrest care.

8. How to recognize major emergencies

9. Heart Attack Myocardial infarction
Coronary heart disease is the leading cause of death in our nation.
During MI - part of heart muscle is starting to die.
Caused by a blockage of an artery (coronary) due to buildup of cholesterol deposits or a blood clot.
Victims are usually awake and can talk but feels severe pain
Most critical time is within the first 30 minutes after Sx begin.

10. Heart Attack Most common symptoms
Pain or pressure in the center of the chest – which last more than 3-5 minutes.
Pain might feel pressure, fullness, squeezing, or heaviness
Pain might spread to shoulder, neck, lower jaw and down arm (usually the right).
Pain lasts 3-5 minutes. Sometimes will stutter, stop momentarily but then begin again.
Other Sx – lightheadedness, fainting, sweating without fever, nausea, shortness of breath
Most victims will downplay symptoms, you must take action!!!
Call 911, get the nearest AED, and have the person rest in a position that is comfortable where they can breathe easily.
Put them in an area that you can get them to the floor easily and paramedics can get in.

11. Cardiac Arrest
When the heart stops beating. Usually caused by VF, which begins where the heart muscle is injured.
Without blood flow and no pulse the person becomes unconscious and stops breathing and collapses.
VF and cardiac arrest may be the only symptom of a heart attack.
AED is only thing that will stop a VF

12. Stroke
Its is a rapid onset of neurological problems like weakness, paralysis in one or more limbs, difficulty speaking, visual problems, intense dizziness, facial weakness, altered consciousness, and severe headache.
Two causes
blood vessel to brain is blocked by a blood clot
blood vessel to brain breaks
#3 cause of death and #1 cause of serious disability among Americans

13. Stroke Most signs overlooked; three major signs to observe
facial droop
arm weakness – most obvious when victim attempts to extend arms with eyes closed – one or both may not move very well
speech difficulties – slurring of words and sentences
Call 911 immediately if see signs of stroke
Provide CPR if needed

14. Foreign body obstruction
Usually caused by food, but can be caused by many objects
Major signs
Universal choking signal
poor ineffective coughs
inability to speak
high pitched sounds while inhaling
increased difficulty breathing
Blue lips or skin (cyanosis)
Loss of consciousness and responsiveness
Heimlich maneuver in conscious victim
CPR in unconscious victim

15. CPR - adult

16. Step one Make sure area is safe
Check unresponsiveness – tap and shout – “Are you alright”
If no response – call 911 or send someone directly to call
Grab AED if one present or send someone to get one.

17. Step two If possible place victim supine and on a hard surface.
If victim is prone – roll over
Try protecting the neck as much as possible if you suspect neck injury

18. Begin CAB’s C = Circulation
If not breathing or see abnormal breathing begin chest compressions
Agnal breathing – gasps that occur at the beginning of CA – not efficient – act as they are not breathing
Check for pulse or signs of circulation (at least 5sec nomore than 10sec) just go straight to CPR
Place one palm on the chest between the nipple line
Interlock your other hand on top of the hand on the chest
Bring your shoulder over the top
Make sure you have a wide base (knees spread just outside your shoulders)
Press down 2 inches at a rate of at least 100 compressions per minute – hard and fast
Make sure chest recoils completely
Complete 30 compressions and then give two breaths.
Do not stop unless and AED is available, victim moves, or you substituted out (if two rescuers are available – switch every five cycles of 30:2 – approx two minutes) – reduces fatigue

19. A = Airway B = Breathing Head tilt and Chin lift
If you do not detect normal breathing – give two breaths lasting 1 second each (may use barrier)
Watch chest rise, allow exhalation before next breath.
If breaths do not go in – reposition head and try again.
Practice

21. Practice
Practice compressions 30 times twice – alternate with partner – no breaths
60 sec test – just compressions – try to get compressions – allows to learn rhythm. Perform 1-2 times or as needed
Two minute test – performing 30:2 (includes breath) - should complete five cycles in that time.

22. Very important to limit interruptions of chest compressions.
During the beginning stages of CA – chest compressions are more important than breaths. Oxygen level will stay high for the first few minutes but blood is not moving to due to the heart not pumping.
Breathing becomes as important as the length of CPR continues
Very important to limit interruptions of chest compressions.
Be mindful not to give to many breaths, too much breath or too forceful – may cause gastric filling and the resultant complications, and/or cause diminished blood flow and reduce survival.

23. Vomiting/other breathing
If someone does throw up – do not panic.
Roll victim towards you. Use your body to hold them.
Clean out the mouth – roll back and continue.
Mouth to nose
Use when it is impossible to use the mouth due to injury.
Face shields and masks – may be used -
Very little chance of transfer of bodily fluids if perform mouth to mouth without mask.
Using shield or mask can slow down the CPR process
“Chest compression only” CPR is more beneficial than no CPR at all.

24. Recovery position
If victim begins breathing and having a pulse then turn victim to their side with lower arm in front.
No position is perfect- just make sure they are stable, near a true lateral position, and there is no pressure on the chest to impair breathing

25. Potential neck injury If two or more responders
One stabilizes the neck – they will be in charge if victim needs to be moved
Place hands on the sides of the head and neck, using your hands to cup around the neck.
Place pressure on head with forearms near the ears
Elbows should be on the ground, wrists in ulnar deviation so that they come in contact with the head.
This will limit the amount of movement that will occur if you have to move your body, for example moving so that CPR can be administered or when EMS puts on a neck brace.
If movement is necessary then move body as one.

26. CPR – Child and infant

27. Child CPR (ages 1-Puberty) Child AED (ages 1-8yrs)
Similarities with single rescuer Adult CPR
Location on chest for compressions is the same – nipple line
Ratio of compressions to breaths the same – 30:2
Differences with Adult CPR
In the chain of survival-If arrest is unwittnessed you will perform CPR first for two minutes performing five cycles of 30:2 – then call 911 (if you are alone)
Reason is that most child and infant cardiac arrests are due from asphyxiation, so they will benefit more from the CPR.
The depth you use for compression is 2 inches or 1/3 depth of the chest. Use one or two hands – which ever is more comfortable.
Compression/respiration ratio 15-2

28. Infant CPR Similarities with single rescuer adult CPR
30:2 ratio of compressions to breaths
Similarities with Child
Perform CPR first in the Chain of Survival, for the same reasons.
If small enough you may carry to phone with you after completing the five cycles – use speaker phone
Depth of compressions 1/3 depth of the chest or 1 1/2 inches or 4 cm
Differences with CPR
Check responsiveness by thumping or slapping the foot
Check pulse in the upper arm / brachial artery
If no pulse or if the pulse is present but below 60bpm you initiate compression
You will perform chest compressions one finger below nipple line
You will only puff air in
If unsure if it is a child or not, if it can fit on your arm, then treat as an infant
2-rescuer – thumb-encircle chest; compression/resp ratio 15-2

29. Remember… Do Not tilt an infants head too far or it will actually occlude the airway. For infant mouth to mouth respiration you cover the mouth and nose with your mouth.

30. Foreign Body Airway Obstruction (FBAO)
Heimlich Maneuver

31. Choking Universal sign of choking – hand around throat Ask questions
Are you choking? Can you speak? May I help you? – Very important.
If they say no leave them alone until they pass out – then it is assumed they want help.
If a person can speak or can cough - do not help

32. Abdominal thrusts Practice
Place yourself behind victim scissor you legs
Front leg between victims legs
Slightly bend knees
Place hands on navel
place hands on chest if woman is pregnant or victim is severely overweight
Pull in and up
continue until object is out or they pass out
Use chest thrusts if you are unable to circumvent the abdomen
If pass out lower them carefully to the floor begin CPR
Only difference with CPR is you check mouth for object before breaths.
Finger sweep only if you see object.
Practice

33. Infant FBAO Infant – Finger sweep if see object Practice
Conscious – place infant on forearm with babies mouth between fingers – back blows to upper back
Unconscious –
after back blows - five compressions –
look for object
give breath
repeat cycle – back blows, compressions, look and breaths
Finger sweep if see object
Practice

34. Automated External Defibrillator
AED

35. What is an AED?
Automated external defibrillator – is an computerized defibrillator
it can analyze heart rhythm
recognize shockable rhythm
advise the operator whether the rhythm should be shocked
very easy to use
AED’s computer chips analyze the rate, size and wave shape of human cardiac rhythm.
will not shock a properly functioning heart
will not shock a heart that has stopped – VF is not present

36. Universal steps of AED use
Place AED parallel to patients left ear
Power on the AED first
Some automatically turn on when opened
Attach the AED to the patients chest with electrode pads
Remove clothing – to bear chest
Be kind to females
Dry patient or shave chest in area of electrode placement if needed
Place one pad above right nipple and one to the side and below the left nipple. (CPR is continued up to the point when the AED says analyzing rhythm stand clear)
Analyze rhythm
Make sure everyone is clear (must say “stand clear of the victim”). No contact
Push analyze (in necessary) some machine analyze automatically.
Charge AED if shock is required (some machine charge automatically)

37. Begin CPR for five cycles then analyze again
Shock if indicated – (after checking everyone is clear again) Press the shock button.
Begin CPR for five cycles then analyze again
If shock is advisable again you clear everyone and shock
If shock is not advisable – continue with CPR
If victim has pulse and is breathing put into recovery position.
DO NOT take off pads or turn off AED until prompted by EMS

38. Special Considerations
Water
Must remove victim from water or wet surface
Dry before attaching pads
Metal surfaces
Is victim lying on metal surface? – if so move victim
The metal surface may cause the shock form the AED to hit you.
Children
Children 8 and older use as soon as possible
Children 1-8 – CPR for two minutes before using AED
Transdermal medications
Remove patch and wipe clean before attaching AED pads
Implanted pacemakers and defibrillators
Do not place an AED electrode directly over implanted device.
Move at least one inch to the side of device
Practice

39. How CPR Works Effective CPR provides 1/4 to 1/3 normal blood flow
Rescue breaths contain 16% oxygen (21%)

40. Start CPR Immediately Better chance of survival
Brain damage starts in 4-6 minutes
Brain damage is certain after 10 minutes without CPR

41. Do Not Move the Victim Until CPR is Given and Qualified Help Arrives…
unless the scene dictates otherwise
threat of fire or explosion
victim must be on a hard surface
Place victim level or head slightly lower than body

42. Even With Successful CPR, Most Won’t Survive Without ACLS
ACLS (Advanced Cardiac Life Support)
ACLS includes defibrillation, oxygen, drug therapy

43. Survey The Scene, then: RAP
R - Responsiveness
Tap shoulder and shout “Are you ok?”

44. RAP A - Activate EMS ( if unresponsive)
YOU - call 911 – come back and let me know what they said (another can stay by the phone)
You may have to make the call

45. RAP P - Position on back All body parts rolled over at the same time
Always be aware of head and spinal cord injuries
Support neck and spinal column

46. When Can I Stop CPR? Victim revives Trained help arrives
Too exhausted to continue
Unsafe scene
Physician directed (do not resuscitate orders)
Cardiac arrest of longer than 30 minutes
(controversial)

47. Checking for CPR Effectiveness
Does chest rise and fall with rescue breaths?
Have a second rescuer check pulse while you give compressions

48. Why CPR May Fail Delay in starting
Improper procedures (ex. Forget to pinch nose)
No ACLS follow-up and delay in defibrillation
Only 15% who receive CPR live to go home
Improper techniques
Terminal disease or unmanageable disease (massive heart attack)

49. Injuries Related to CPR
Rib fractures
Laceration related to the tip of the sternum
Liver, lung, spleen

50. Complications of CPR Vomiting Aspiration Place victim on left side
Wipe vomit from mouth with fingers wrapped in a cloth
Reposition and resume CPR

51. Stomach Distension Air in the stomach
Creates pressure against the lungs
Prevention of Stomach Distension
Don’t blow too hard
Slow rescue breathing
Re-tilt the head to make sure the airway is open
Use mouth to nose method

52. Mouth to Mouth Barrier Devices
Masks
Shields

53. If You Are Afraid to Perform CPR
Call EMS
Open the airway
Give chest compressions

54. First Aid

55. Medical emergencies Breathing difficulties Anaphylaxisis Seizures
Asthma problems are increasing
Most have medicines
May need assist victim is administrating
If symptoms continue to get worse call 911
Anaphylaxisis
Severe reaction to allergen
Victim may have epinephrine injector
May need to administer
Call 911 if medicine is not administered
Seizures
General rules – 1) Prevent injury 2) ensure open airway 3) maintain open airway after seizure is completed – place in recovery position
Never try to restrain victim, place anything in the mouth.

56. Injury emergencies Bleeding Direct pressure best way
If bleeding continues add more gauze or cloth; do not remove gauze or cloth
Use elastic bandage to apply pressure to gauze and hold it in place.
The use of tourniquets should be avoided unless in extreme matters
The efficacy of elevation and pressure points is inconclusive; if used, use only in conjunction with direct pressure and when there is no apparent fracture or other underlying injury.

57. Wounds and abrasions Irrigate wounds until free of any foreign matter.
Small wounds and abrasions should be cleaned thoroughly then have triple antibiotic ointment placed on it and covered.
Larger wounds need to also be cleaned then covered and taken to doctor for possible stitches

58. Burns Thermal burns Electrical burns
Cool burn with cold water until pain ceases
Do not cool for more than 10 min. Can lead to further damage
Burn blisters cover with loose gauze, but keep intact – breaking them can lead to infection
Electrical burns
Make sure electrical current is shut off before trying to help victim.
CPR and defibrillation may be needed as well as burn treatment
All electrocution injuries should be checked out by a physician

59. Spine stabilization Suspect possible spinal injury if… Car accident
Injured from fall greater than their height
Complains of neck pain, tingling, or extremity weakness
Is not fully alert
Appears to be intoxicated
Appears frail or is >65 yrs old
Has sustained a head injury
- Manually stabilize the neck until help arrives.

60. Musculoskeletal trauma – sprains, strains, contusions, fractures
For sprains, strains, contusions – apply ice for 20.
Sprains elevate and place compression bandage
R.I.C.E. – rest, ice, compression, elevation
If victim has aversion to cold – place wet cloth between ice and skin
Young kids and elderly especially susceptible
Contusion you want to stretch the injury as well as ice
If you are unsure of the injury suspect fracture – do not move or straighten injury. Place ice on area and splint in position, send to ER.
If suspect dislocation – splint as is and send to ER.

61. Dental injuries Avulsed tooth
Hold onto by the crown not the root (part embedded into gum
Rinse off with water (do not scrub)
Either place back into socket or place in glass of milk and see a dentist immediately
Clean bleeding wound with saline solution or tap water
Use cotton to apply pressure to stop bleeding

62. Environmental injuries
Snakebite
Do not suck wound, it will only exasperate the problem
In case of Coral snake – wrap a bandage around the extremity of the bite – it will help slow the poison – then get to medical facility immediately.
Coral snake bites and sucks
Other snake bites, wash area with soap and water, try not to move extremity very much and get to medical facility.
Cold injuries
Hypothermia
Immediately begin re-warming – remove wet clothes and wrap body surface with anything at hand; get to medical facility immediately
If far from medical facility you begin active warming – placing near heat source, placing in warm (not hot) water.
Frostbite
Remove wet clothing, usually occurs on extremities, do not re-warm if there is any chance it could freeze again or you are close to a medical facility.
Use luke-warm water if you are far from medical facility

63. Heat Injuries
Heat cramps – muscle cramping, usually due to extreme loss of fluids
Get to cooler area
Replace fluids
Ice and stretch area
Heat exhaustion
Dizziness, could have flushed skin or cool and clammy, disoriented, nausea, headache
Get victim to cool area immediately
Place ice on side of neck (carotid artery), arm pits, and groin area
Watch for shock; could lead into heat stroke
Heat Stroke – medical emergency – call 911 immediately
Extreme disorientation, possible unconsciousness, very little sweating, internal temperature of >105.
Cool down by any means

64. Drowning
Get victim out of water as soon as possible
Begin CPR immediately
If you are alone – finish five cycles of CPR before calling 911

65. Poisons Poison control center – 1-800-222-1222 Chemical Burns
Brush off any powder and remove all contaminated clothing
Alki or acid exposure – rinse with copious amounts of water.
Ingested poisons
Do not ingest any medication; milk, activated charcoal, syrup of ipecac unless instructed by poison control

66. Shock
Develops when there is not enough blood flowing to the cells of the body
Causes in adults;
loss of blood
heart attack,
allergic reaction
Symptoms
feel cold and shiver,
feel weak, faint, or dizzy,
restless,
vomit,
feel thirsty
Treatment
Call 911
Put victim on their back
If not leg injury or pain raise legs 12 inches
Cover victim with blanket
If bleeding is visible – use direct pressure