INTRODUCTION:

CPR involves chest compressions at a rate of at least 100 per minute in an effort to
create artificial circulation by manually pumping blood through the heart. In addition
the rescuer may provide breaths by either exhaling into their mouth or utilizing a
device that pushes air into the lungs. The process of externally providing ventilation
is termed artificial respiration. Current recommendations place emphasis on high
quality chest compressions over artificial respirations and a method involving only
chest compressions is recommended for untrained rescuers.
CPR alone is unlikely to restart the heart; its main purpose is to restore partial flow
of oxygenated blood to the brain and heart. It may delay tissue death and extend the
brief window of opportunity for a successful resuscitation without permanent brain
damage. An administering of an electric shock to the heart, termed defibrillation, is
usually needed to restore a viable or "perfusing" heart rhythm. Defibrillation is only
effective for certain heart rhythms, namely ventricular fibrillation or pulseless
ventricular tachycardia, rather than asystolic or pulseless electrical activity. CPR
may however induce a shockable rhythm. CPR is generally continued until the
person regains return of spontaneous circulation (ROSC) or is declared dead.
DEFINITION:
Cardiopulmonary resuscitation, commonly called CPR, combines rescue breathing
(one person breathing into another person) and chest compression in a lifesaving
procedure performed when a person has stopped breathing or a person's heart has
stopped beating.

PURPOSE:
When performed quickly enough, CPR can save lives in such emergencies as loss
of consciousness, heart attacks or heart "arrests," electric shock, drowning,
excessive bleeding, drug overdose, and other conditions in which there is no
breathing or no pulse. The purpose of CPR is to bring oxygen to the victim's lungs
and to keep blood circulating so oxygen gets to every part of the body. When a
person is deprived of oxygen, permanent brain damage can begin in as little as four
minutes and death can follow only minutes later.
MECHANISM OF CPR (ITS WORKING):
The air we breathe in travels to our lungs where oxygen is picked up by our blood
and then pumped by the heart to our tissue and organs. When a person experiences
cardiac arrest - whether due to heart failure in adults and the elderly or an injury
such as near drowning, electrocution or severe trauma in a child - the heart goes
from a normal beat to an arrhythmic pattern called ventricular fibrillation, and
eventually ceases to beat altogether. This prevents oxygen from circulating
throughout the body, rapidly killing cells and tissue. In essence, Cardio (heart)
Pulmonary (lung) Resuscitation (revive, revitalize) serves as an artificial heartbeat
and an artificial respirator. CPR may not save the victim even when performed
properly, but if started within 4 minutes of cardiac arrest and defibrillation is provided
within 10 minutes, a person has a 40% chance of survival.
The circulatory system
Invented in 1960, CPR is a simple but effective procedure that allows almost anyone
to sustain life in the first critical minutes of cardiac arrest. CPR provides oxygenated
blood to the brain and the heart long enough to keep vital organs alive until
emergency equipment arrives.
To make learning CPR easier, a system was devised that makes remembering it as
simple as A-B-C:
• Airway
• Breathing
• Circulation

AIRWAY:

"A" is for AIRWAY. If the victim is unconscious and is unresponsive, you need to
make sure that his airway is clear of any obstructions. The breaths may be faint and
shallow - look, listen and feel for any signs of breathing. If you determine that the
victim is not breathing, then something may be blocking his air passage. The tongue
is the most common airway obstruction in an unconscious person.
With the victim lying flat on his back, place your hand on his forehead and your other
hand under the tip of the chin (Figure 1). Gently tilt the victim's head backward. In
this position the weight of the tongue will force it to shift away from the back of the
throat, opening the airway (Figure 2).
 Chin lift
Jaw thrust
The jaw thrust is a technique used on patients with a suspected spinal injury and is
used on a supine patient. The practitioner uses their thumbs to physically push the
posterior (back) aspects of the mandible upwards - only possible on a patient with a
GCS < 8 (although patients with a GCS higher than this should also be maintaining
their own patent airway). When the mandible is displaced forward, it pulls the tongue
forward and prevents it from occluding (blocking) the entrance to the trachea,
helping to ensure a patent (secure) airway.

Jaw thrust

BREATHING
"B" is for BREATHING. With the victim's airway clear of any obstructions, gently
support his chin so as to keep it lifted up and the head tilted back. Pinch his nose
with your fingertips to prevent air from escaping once you begin to ventilate and
place your mouth over the victim's, creating a tight seal (Figure 1).
As you assist the person in breathing, keep an eye on his chest. Try not to over-
inflate the victim's lungs as this may force air into the stomach, causing him to vomit.
If this happens, turn the person's head to the side and sweep any obstructions out of
the mouth before proceeding.
Give two full breaths. Between each breath allow the victim's lungs to relax - place
your ear near his mouth and listen for air to escape and watch the chest fall as the
victim exhales (Figure 2).
 1. Give two breaths 2. Let victim exhale

CIRCULATION

"C" is for CIRCULATION. In order to determine if the victim's heart is beating, place
two fingertips on his carotid artery, located in the depression between the windpipe
and the neck muscles (Figure 1), and apply slight pressure for several seconds.

1. Carotid artery

DESCRIPTION OF CPR PROCEDURE:

There are three physical symptoms that indicate a need for CPR to be performed
immediately and for emergency medical support to be called: unconsciousness, not
breathing, and no pulse detected.
[CPR in basic life support. Figure A: The victim should be flat on his back and
his mouth should be checked for debris. Figure B: If the victim is
unconscious, open airway, lift neck, and tilt head back. Figure C: If victim is
not breathing, begin artificial breathing with four quick full breaths. Figure D:
Check for carotid pulse. Figure E: If pulse is absent, begin artificial circulation
by depressing sternum. Figure F: Mouth-to-mouth resuscitation of an infant.]

Unconsciousness
Unconsciousness is when the victim seems to be asleep but has lost all awareness
and is not able to respond to questions or to touch or gentle shaking. A sleeping
person will usually respond to a loud noise, shouting, or gentle shaking. An
unconscious person will not respond to noise or shaking. When unconscious, a
person can not cough or clear the throat, which can block the windpipe and cause
suffocation and death. People with a major illness or injury or who have had recent
surgery are at risk for losing consciousness. If the person has fainted, which is brief
unconsciousness, the cause may be dehydration (lack of body fluids), low blood
pressure, or low blood sugar. This is a temporary condition. If the victim is known to
have diabetes, a bit of fruit juice may revive the person once they have regained
consciousness.
Just before a person loses consciousness, symptoms may include:
• lack of response to voice or touch
• disorientation or stupor
• light-headedness
• headache
• sleepiness
Not breathing
Not breathing, which is also called apnea, is the lack of spontaneous breathing. It
requires immediate medical attention. The victim may become limp and lifeless,
have a seizure, or turn blue. Prolonged apnea is called respiratory arrest. In
children, this can lead quickly to cardiac arrest in which the heart stops beating. In
adults, cardiac arrest usually happens first and then respiratory arrest. The common
causes of apnea in adults are obstructive sleep apnea (something blocks the airway
during sleep), choking, drug overdose, near-drowning, head injury, heart
irregularities (arrhythmia, fibrillation) or cardiac arrest, nervous system disorders, or
metabolic disorders. In children the causes may be different, such as prematurity,
bronchial disturbances or pneumonia, airway blockage or choking on a foreign
object, holding the breath, seizures, meningitis, regurgitating food, or asthma
attacks.

No pulse detected
If the rescuer is unable to detect a pulse or has difficulty in feeling a pulse it can be
an indication of the use of improper technique by the rescuer, or shock or cardiac
arrest in the victim. If a sudden, severe decrease occurs in pulse quality (such as
pulse weakness) or pulse rate (how many beats in a minute) when other symptoms
are also present, life-threatening shock is suspected. The rescuer may need to
explain to a doctor or medical professional where on the victim's body the pulse was
measured, if the pulse is weak or absent altogether, and what other symptoms are
present.
Medical help and CPR are needed immediately if any of these symptoms is found.
Time is critical. A local emergency number should be called immediately. If more
than one person is available to help, one can call 911 or a local emergency medical
service, while the other person begins CPR. Ideally, someone CPR certified
performs the procedure. Local medical personnel, a hospital, or the American Heart
Association teaches special accredited CPR courses. If a critically ill patient or post-
operative patient is being cared for at home, it is a good idea for a family member to
take a CPR course to be better prepared to help in case of an emergency.
The steps usually followed in CPR are as follows:
• If the victim appears to be unconscious with either no breathing or no pulse,
the person should be shaken or tapped gently to check for any movement.
The victim is spoken to loudly, asking if he or she is OK. If there is no
response, emergency help must be called and CPR begun immediately.
• The victim is placed on his or her back on a level surface such as the ground
or the floor. The victim's back should be in a straight line with the head and
neck supported slightly by a rolled up cloth, small towel, or piece of clothing
under the neck. A pillow should not be used to support the head. The victim's
clothing should be loosened to expose the chest.
• The rescuer kneels next to the victim, tilts the victim's head back, lifts the jaw
forward, and moves the tongue forward or to the side, making sure it does not
block the opening to the windpipe. The victim's mouth must be kept open at
all times, reopening as necessary.
• The rescuer listens close to the victim's mouth for any sign of breathing, and
watches the chest for movement. If the victim is found to be breathing, and
has perhaps fainted, he or she can be placed in the recovery position until
medical assistance arrives. This is done by straightening the victim's legs and
pulling the closest arm out away from the body with the elbow at a right angle
or 3 o'clock position, and the other arm across the chest. The far leg should
 be pulled up over the victim's body with the hip and knee bent. This allows
the victim's body to be rolled onto its side. The head should be tilted back
slightly to keep the windpipe open. The head should not be propped up.
• If the victim is not breathing, rescue breathing begins, closing the victim's
nostrils between a thumb and index finger, and covering the victim's mouth
with the rescuer's mouth. Two slow breaths, about two seconds each, are
breathed into the victim's mouth with a pause in between. This is repeated
until the chest begins to rise. The victim's head should be repositioned as
often as necessary during the procedure. The mouth must remain open and
the tongue kept away from the windpipe.
• When the chest begins to rise, or the victim begins to breathe on his or her
own, the rescuer looks for signs of circulation, such as coughing or
movement. If a healthcare professional has arrived by this time, the pulse will
be checked before resuming resuscitation.
• If chest compressions are needed to restart breathing, the rescuer will place
the heel of a hand above the lowest part of the victim's ribcage where it
meets the middle-abdomen. The other hand will be placed over the heel of
the first hand, with fingers interlocked. Keeping the elbows straight, the
rescuer will lean his or her shoulders over the hands and press down firmly
about 15 times. It is best to develop an up-and-down rhythm, keeping the
hands firmly on the victim's chest.
• After the compressions, the rescuer will give the victim two long breaths. The
sequence of 15 compressions and two breaths will be repeated until there are
signs of spontaneous breathing and circulation or until professional medical
help arrives.

METHODS OF CPR:
In 2010, the American Heart Association and International Liaison Committee on
Resuscitation updated their CPR guidelines. The importance of high quality CPR
(sufficient rate and depth without excessively ventilating) was emphasized. The
order of interventions was changed for all age groups except newborns from airway,
breathing, chest compressions (ABC) to chest compressions, airway, breathing
(CAB). An exception to this recommendation is for those who are believed to be in a
respiratory arrest (drowning, etc.).
Standard
A universal compression to ventilation ratio of 30:2 is recommended for adult and in
children and infant if only a single rescuer is present. If at least 2 rescuers are
present a ratio of 15:2 is preferred in children and infants. In newborns a rate of 3:1
is recommended unless a cardiac cause is known in which case a 15:2 ratio is
reasonable. If an advanced airway such as an endotracheal tube or laryngeal mask
airway is in placed delivery of respirations should occur without pauses in
compressions at a rate of 8-10 per minute. The recommended order of interventions
is chest compressions, airway, breathing or CAB in most situations. With a
compression rate of at least 100 per minute in all groups. Recommended
compression depth in adults and children is about 5 cm (2 inches) and in infants it is
4 cm (1.5 inches. As of 2010 the Resuscitation Council (UK) still recommends ABC
for children. As it can be difficult to determine the presence or absence of a pulse
the pulse check has been removed for lay providers and should not be performed
for more than 10 seconds by health care providers. In adults rescuers should use
two hands for the chest compressions, while in children they should us one, and
with infants two fingers (index and middle fingers).
Compression only
Compression only (hands-only) CPR is a technique that involves chest
compressions without artificial respiration. It is recommended as the method of
choice for the untrained rescuer or those who are not proficient as it is easier to
perform and instructions are easier to give over the phone. In adults with out-of-
hospital cardiac arrest compression only CPR by the lay public has a higher success
rate than standard CPR. The exceptions are cases of drownings, drug overdose,
and arrest in children. Children who receive compression only CPR having the same
outcomes as those who received no CPR. The method of delivering chest
compressions remains the same, as does the rate (at least 100 per minute). It is
hoped that the use of compression only delivery will increase the chances of the lay
public delivering CPR.
Interposed abdominal compression
Interposed abdominal compressions may be beneficial in the in hospital
environment. There is however no evidence of benefit pre hospital or in children.
Internal cardiac massage
Internal cardiac massage is the process of cardiac massage carried out through a
surgical incision into the chest cavity. This distinguishes the process from
conventional, external cardiac massage, which is carried out by compression near
the sternum during cardiopulmonary resuscitation.

PRECAUTIONS:
There are certain important precautions for rescuers to remember in order to protect
the victim and get the best result from CPR. These include:
• Do not leave the victim alone.
• Do not give chest compressions if the victim has a pulse. Chest compression
when there is normal circulation could cause the heart to stop beating.
• Do not give the victim anything to eat or drink.
• Avoid moving the victim's head or neck if spinal injury is a possibility. The
person should be left as found if breathing freely. To check for breathing
when spinal injury is suspected, the rescuer should only listen for breath by
the victim's mouth and watch the chest for movement.
• Do not slap the victim's face, or throw water on the face, to try and revive the
person.
• Do not place a pillow under the victim's head.
The description above is not a substitute for CPR training and is not intended to be
followed as a procedure.
NORMAL RESULTS:
Successful CPR will restore breathing and circulation in the victim. Medical attention
is required immediately even if successful CPR has been performed and the victim
is breathing freely.
PREVENTION :
Loss of consciousness is an emergency that is potentially life threatening. To avoid
loss of consciousness and protect themselves from emergency situations, people at
risk can follow these general guidelines:
• People with known conditions or diseases, such as diabetes or epilepsy,
should wear a medical alert tag or bracelet.
• People with diabetes should avoid situations that will lower their blood sugar
level.
• People who feel weak, become dizzy or light-headed, or have ever fainted,
should avoid standing in one place too long without moving.
• People who feel faint, can lie down or sit with their head lowered between
their knees.
• Risk factors that contribute to heart disease should be reduced or eliminated.
People can reduce risks if they stop smoking, lower blood pressure and
cholesterol, lose weight, and reduce stress.
• Illegal recreational drugs should be avoided.
• Seeing a doctor regularly and being aware of any disease conditions or risk
factors can help prevent or complicate illness, as can seeking and following
the doctor's advice about diet and exercise.
• Using seat belts and driving carefully can help avoid accidental injury.
• People with poor eyesight or those who have difficulty walking because of
disability, injury, or recovery from illness, can use a cane or other assistance
device to help them avoid falls and injury.