In the mid-1950s, a medical study found that a staggeringly high number of Americans were dying prematurely from heart disease. Just as concerning, it was determined that one of every three deaths was directly related to sudden cardiac arrest. The discussion quickly became centered on how to improve the outcome of these sudden and often unpredictable events. In an attempt to improve the chance of surviving, the medical community began researching a US Army technique that used mouth-to-mouth resuscitation and cardiac massage on pulseless victims. After determining its effectiveness in combating sudden cardiac arrest, a CPR program was developed and taught to emergency room physicians. Over time, the life-saving technique became even more effective and was taught to all healthcare professionals.

By the late 1950s and early 60s, a civilian cardio-pulmonary resuscitation program had been developed to combat the high incidence of heart disease and sudden cardiac arrest in America. In 1963, a CPR committee was formed to start a “life-saving” campaign that would teach cardiopulmonary resuscitation (CPR) to citizens who had no medical background.
For the first time in US history, Americans were being asked to become directly involved in the “life-or-death” medical treatment of their fellow citizens. By the early 1970s, hundreds of thousands of Americans across the nation had been taught CPR. Though survival rates began to increase, still to this day, only one in five American adults know how to appropriately and/or effectively perform cardiopulmonary resuscitation.

According to a 2015 report, there are 326,000 cases of out-of-hospital sudden cardiac arrests each year. With this high a number, many Americans will likely witness someone needing bystander assistance in order to survive.

Heart disease encompasses a wide variety of conditions and ailments that can lead to a person's premature death. However, victims of sudden cardiac arrest normally suffer from either a massive "sudden death" heart attack caused by blockage of a coronary artery or a lethal electrical disturbance in the heart called dysrhythmia. Regardless of the cause of the sudden cardiac arrest, the initial treatment remains the same.

High-Quality, “Fast-n-Hard” Cardiopulmonary Resuscitation

The human body is strong, and many vital functions and natural fail-safes work non-stop to maintain life. However, without a continuous supply of oxygen being delivered to the body by a properly functioning heart and lungs, the vital organs will quickly begin to shut down. When this cascading event begins, irreversible brain damage and multi-system organ failure follow within four to six minutes.

The Chain of Survival

• 1. Early recognition that an emergency requiring assistance is occurring.
  (The sooner help (911) is called, the sooner EMS will arrive and take over the care of the victim, thus doubling their chance of survival.)
• 2. Early "fast-n-hard" cardiopulmonary resuscitation
  (When bystander CPR is initiated quickly, it helps keep the vital organs sufficiently oxygenated until an AED or EMS personnel can arrive to assist.)
• 3. Early defibrillation with AED/defibrillator.
  (In the first few minutes of most cardiac arrest situations, an electrical shock delivered by an AED/defibrillator may return the victim's heart to a "more normal" rhythm.)
• 4. Early advanced life support by EMS/fire dept.
  (EMS personnel have the advanced knowledge and equipment to perform life-saving interventions while transporting the victim to a hospital.)

Once a victim is found to be breathless, rapid recognition and accurate CPR intervention can double a victim’s chance of survival and reduce the risk of permanent brain injury.

Although “fast-n-hard” CPR by itself is unlikely to restart a victim’s heart, it is highly effective in maintaining some flow of oxygenated blood to the body’s organs and tissues until an AED can be used or definitive medical care initiated. High-quality cardiopulmonary resuscitation delays tissue death and extends the brief window of opportunity for successful resuscitation. This helps prevent the victim from suffering permanent brain damage, especially when it is initiated within a few minutes of the victim’s collapse. (There are always exceptions to the rule, and we’ll discuss them later in the manual).

One of the most important steps in saving a victim of sudden cardiac arrest is rapid recognition followed by citizen involvement. The new (2015) “fast-n-hard” CPR guidelines provide paramedics with the needed time to reach the victim and initiate advanced resuscitation measures. In order for a victim to have the best chance of survival, someone nearby must realize that a life-threatening event is occurring and quickly call for professional help (911). But it doesn’t stop there; if emergency care isn’t rendered within the first few minutes of a sudden cardiac arrest, the victim will most likely not recover.

After receiving a 911 call, it can take an ambulance 15 minutes or more to arrive at the victim’s side due to many uncontrollable events. Therefore, rapid notification of the emergency response system (911) and being prepared to deliver effective CPR are crucial “links” in the chain of survival. In most cases, the entire chain is required to successfully resuscitate a victim of sudden cardiac arrest.

Although the reasons for the cardiac arrest aren’t always the same, the response to the event is.

The best way to prevent the progression to irreversible brain death is for bystanders to:

• Recognize an emergency exists that requires CPR.
• Call for help and request bystanders to locate an AED and bring it to you.
• Perform high-quality CPR while awaiting an AED/defibrillator or the EMS unit to arrive.

Note: Once the medical emergency is recognized and help has been called, you must make a conscious decision of how you can best help the victim. Initiating the call for help is a great first step, but it is not going to be enough to save a victim’s life, in most cases. Facing a medical emergency that may mean life or death is scary, but do not be afraid that your intervention will worsen the victim’s condition if not conducted exactly as you were taught. At this point, intervention can only help. Remember, if only one link of the chain is weak or missing, the chances of survival decrease.

The Common Signs and Symptoms of a Heart Attack

Most, but not all, adult victims of a heart attack (myocardial infarction) will have common signs and symptoms associated with the heart’s inability to function (pump) properly: chest or upper body pain/discomfort, shortness of breath, a feeling of impending doom, or nausea and vomiting, depending on the degree of heart muscle damage and the area of the heart affected. However, about one-third of all heart attack victims report they did not experience any chest pain. In fact. chest pain is often initially mistaken as indigestion by the victim. A tell-tale sign of a true heart attack is when a chest pain victim appears very ill with cool, pale, sweaty skin without a logical explanation (e.g., flu with fever, exertion from a marathon, etc.).

If a person is suspected of experiencing a heart attack, it is imperative to call 911 as quickly as possible. If the victim reaches the hospital quickly, the damage caused by the heart attack may be reversed in some situations.

Let’s Review the Common Signs and Symptoms of a Heart Attack:

• Chest discomfort/pain - Heart attacks can involve discomfort or pain in the center of the chest (or anywhere in the upper chest) that can last for more than a few minutes or that may go away and return. Some victims describe the pain as uncomfortable pressure, squeezing, fullness, or crushing pain. Victims often mistake the pain for indigestion or gas, and it is common for victims to have another explanation for the pain and deny the likelihood of a heart attack.
• Upper body discomfort/pain - This includes pain or discomfort in one or both arms, shoulders, back, neck, jaw, and/or stomach. The pain may be intense and move from its point of origin to another body region. This is known as pain radiation. To get a good idea of the intensity of the victim’s pain, ask them to rate the pain on a scale from 1 to 10. Pain that changes when the victim breathes or moves may not be a heart attack but should still be treated as if it is.
• Shortness/Loss of breath - This can occur with or without chest discomfort due to the heart’s inability to pump oxygenated blood effectively during a heart attack.
• Other Signs & Symptoms - These may include cold sweats, nausea, vomiting, and/or dizziness. If a victim is truly experiencing a cardiac event, the signs and symptoms of decreased blood flow will be evident. A victim who presents with cool, clammy, and sweaty skin with nausea/vomiting is likely experiencing a true heart attack. Victims also often complain of feeling as if “they are going to die.”

All adults who experience chest pain of any type that lasts longer than 10 minutes should be treated as if they are having a heart attack until it is proven otherwise at the hospital.

Good Samaritan Laws and Consent to Render Aid

Another problem often faced by victims of cardiac arrest is the general public's apprehension of "getting involved" as many Americans are reluctant to administer CPR on a stranger out of a fear of being sued. Every state is different, but all 50 states have some form of law enacted to protect a person from being sued or held liable if they attempt to save a person's life when acting in good faith and without any expectation of pay. The laws are intended to reduce frivolous lawsuits, prevent unnecessary fears of being sued, and protect volunteer rescuers from being prosecuted for unintentional injury and/or wrongful death after helping someone in a potentially life-threatening emergency.

Good Samaritan laws vary, but for the most part, the following criteria applies:

• Any medical assistance such as first-aid, performance of a life-saving intervention like CPR, or clearing of an obstructed airway cannot be conducted in exchange for any type of monetary or material gain for the rescuer.
• If rendering first-aid care of any type to a victim, you are not permitted to leave them alone unless:
  • - It is necessary to call for help (911).
  • - Another rescuer with equal or higher qualifications takes over the care of the victim.
  • - Continuing care becomes dangerous/unsafe for the rescuer.
  • - The victim refuses your first-aid care.

A voluntary responder is not legally liable for the death, disfigurement, or disability of any victim they attempt to assist as long as the responder acted rationally, in good faith, and in accordance with their level of training.

Consent to Render Medical Care

Informed Consent

To help a conscious victim over 18 years of age in an emergency you must have that individual’s verbal/written permission to do so, when at all possible. This is known as informed consent and is the highest degree of legal consent. To receive permission from a conscious and alert victim, ask them if it is okay to help. If the victim refuses your help, you can’t legally touch them; doing so can initiate battery charges against you. However, you can still help the victim partially by calling 911. If the victim becomes unconscious at any time, you may render care even if the victim denied your help while conscious. This is known as implied consent.

Implied Consent

Implied consent gives the rescuer (paid or volunteer) the legal right to render first-aid and/or CPR under the premise that a responsible, competent adult would give permission to render care or perform life-saving interventions if they were able to give the rescuer verbal consent.

Implied consent exists if the responder has a reasonable belief that an adult or child is:

• Unconscious/unresponsive
• Pulseless/breathless
• Delusional/confused
• Intoxicated after ingesting alcohol/drugs
• Deemed mentally unfit to make decisions regarding their own safety

Parental Consent

If the victim is under 18 years of age and is in the presence of a parent or legal guardian, you must ask the parent/legal guardian for permission to treat the minor victim to legally render care to the minor. If the parent or legal guardian is unavailable or not immediately reachable, the rescuer should care for the child based on the implied consent just as the parent or legal guardian would in making decisions for the child.

Terms we need to know concerning consent:
Assault – The act of causing fear, apprehension, or intentional harm to another person
Battery – The unlawful touching of another person without their consent

Without a victim’s consent, you may be committing a crime that’s punishable by law.
(Never force care on a competent adult who is refusing medical care)

Universal Precautions and Personal Protective Equipment

Another issue that first-responders face when attempting to help a victim of sudden cardiac arrest is the fear of catching a communicable disease while conducting CPR/first aid. The truth is the chance of disease transmission while rendering emergency care to a victim is nearly zero, as long as the first responder uses due care and utilizes the proper universal precaution measures for the situation.

The term universal precautions refers to the practice of avoiding any contact with an individual’s blood and/or bodily fluids to prevent the spread of communicable disease. This is best accomplished by using the appropriate barrier device, such as latex exam gloves and one-way valve CPR masks for mouth-to-mouth rescue breathing. Universal precautions should be initiated in any environment where the rescuer can be exposed to any body fluids. It is now recommended that all first-responders or other healthcare workers wear appropriate exam gloves for all contact with an injured/ill person with or without body fluids present.

It is a rescuer’s responsibility to protect themself first and foremost. With the following safety and universal precaution guidelines, the chance of disease transmission while caring for an ill/injured person becomes nearly impossible.

It is highly recommended that first-responders take the proper universal precautions and treat everyone they assist as if they have a communicable disease, whether they do or not!

Universal precautions include the following:

• Always use the appropriate protective equipment for the situation (e.g., gloves, goggles, breathing barriers).
• Always remove contaminated material from the area once EMS takes over the care of the victim. (Place gloves and bloody items such as bandages in a hazardous material bag or container box while wearing the proper PPE.)
• Always wash your hands and any possible exposed skin with an alcohol-based hand sanitizer or soap and warm water. (Always wash your hands after rendering care, even when gloves were worn.)

• Clean all surfaces and contaminated objects of your personal equipment. (Use a bleach solution of one-quarter cup of bleach to one gallon of water, or a commercial cleaning agent for the purpose)

Proper removal of contaminated gloves:

1. Grab the palm of one gloved hand with the finger and thumb of the other gloved hand.
2. Carefully pull the glove away from your palm while also pulling forward to remove the glove inside out.
3. Wad up the removed glove in the other still-gloved hand.
4. Slide your now ungloved index finger inside the wrist area of the remaining gloved hand.
5. Carefully pull the glove away from your palm while also pulling forward to remove the glove inside out similarly to the first glove.
6. Discard the gloves in a hazmat container.

Other means of universal precautions include eye shields and goggles, gowns, and personal respirators or HEPA masks

The Basics of:

High-Quality Cardio-Pulmonary Resuscitation

The following actions provide a solid foundation for successful CPR administration

Emergency Action Steps:

Check the victim’s level of consciousness as soon as it is safe to do so!
Make sure the scene is safe for you to enter before proceeding. Simply put, you cannot help anyone if you become a victim yourself! Check the scene for possible hazards such as any signs of violence (past or ongoing), fire, and/or downed electrical lines (any wires on the ground should be considered dangerous until proven otherwise). Also, if you smell anything strange, it could be a poisonous gas, carbon dioxide, or other toxic substance. If ANY potential danger/hazard exists, the rescuer must back out of the situation, call for additional assistance, retreat to a safe distance from the scene, and wait for the proper authority to intervene.

The excitement, adrenaline, and desire to help can entice us to rush in to a bad situation when it isn’t safe to do so. It is HIGHLY recommended to take a deep breath while “taking in” your surroundings before approaching the victim. At this point, you don’t know what caused the victim’s potential collapse and rushing in without checking it out first may leave you in the same predicament! Once it is declared by the proper authority on scene, (i.e., law enforcement, fire dept., utility company, etc.) that approaching the victim is safe, approach the victim from upwind if possible. Once you are kneeling beside the unresponsive victim, check them by tapping their shoulder and loudly ask them, “Are you okay?”

When assessing the level of consciousness of an infant or small child, you should tap and/or tickle the bottom of their feet. It's appropriate to make irritating noises that would adequately wake up a sleeping infant or arouse an infant with a slightly decreased level of consciousness.

Note: More details concerning infant resuscitation will be discussed in the Infant CPR section of the manual.

Phone 911 or alert EMS by the quickest means possible!
If you are alone with an adult who is found pulseless/breathless, you should immediately call for help from the scene before initiating care to the victim. This will make finding you and the victim easier. Although an adult can withstand longer periods of breathlessness than a child or elderly person, the key priority is to initiate CPR including rescue-breathing as quickly as possible.

If you are alone with an unresponsive or pulseless child, and you must leave them to call 911 or alert help, it is appropriate to perform two minutes (five cycles) of CPR on a child before stopping to call for assistance. If you have a cellular phone, it is recommended to call for help as soon as it is confirmed the victim needs emergency medical care.

If you are alone with an unresponsive or pulseless infant, you should perform two minutes (five cycles) of CPR before calling 911 for help. With cellular phone technology, it is recommended to call as soon as an arrest is realized and place the phone on speaker so you can be hands-free to assist the victim. This is appropriate as long as calling initially doesn’t interfere with initiating care quickly. Remember seconds count and the goal is rapid CPR, defibrillation, and advanced medical care. Therefore, it is crucial to get help on the way and initiate CPR as quickly as possible.

If a bystander is nearby, eliciting their assistance would be beneficial. Having them call 911 or locating an AED could be life-saving. Remember, everyone can be a potential life-saver if given the chance. Have a commanding voice, but do not appear as if you are screaming at the person or panicking. Be courteous and commanding so the people involved are willing to help. Make sure only one person receives and carries out your request. If you don’t, you are likely to have several people calling 911 all at once, essentially flooding the phone lines at the emergency operations center and causing mass confusion. It is also possible that if you do not single out a person to call for help, no one at all will call, assuming that someone else has taken care of it.

React to the cardiac arrest by delivering high-quality,“hard-n-fast” chest compressions!

Recent studies have prompted a major change in the recommended procedure for CPR. It is now believed that the blood of a sudden cardiac arrest victim contains enough oxygen to adequately oxygenate the vital organs and tissues of the body for several minutes. Meaning that it may be best to circulate the oxygen that is already contained in the victim’s blood to the vital organs and tissues before initiating rescue breathing. The belief is that a non-trained rescuer wouldn’t be able to deliver adequate rescue breaths to a victim of sudden cardiac arrest quickly enough to justify the time it would take to open the airway and adequately deliver a rescue breath.

Remember; the body only uses a small percentage of the oxygen we breathe at once. Therefore, the blood and lungs contain oxygen for several minutes following cardiac arrest. It is now (as of 2015) appropriate to deliver 30 chest compressions before delivering 2 rescue breaths for an adult victim of sudden cardiac arrest. This is the case with witnessed or unwitnessed arrests when an AED is not readily available.

• C - Circulation/Compressions
• A - Airway
• B - Breathing
• D - Defibrillation

This CPR course covers Adult / Child / Infant CPR, AED, Choking, and Foreign Body Airway Obstruction (FBAO)

The age breakdown is different per organization, but the common age breakdowns are as follows:

Layperson Rescuer
Adult: eight-years-old to adult
Child: one-year-old to eight-years-old
Infant: one-month to one-year-old
Newborn: less than one-month-old

Note: Determining the age of a victim can be a task in itself. Use your best judgment when estimating an unresponsive person’s age.

Due to recent research (2015), it is appropriate to deliver high-quality, “fast-n-hard” chest compressions of varying depth for adults, children, and infants at a rate of at least 100 to 120 compressions per minute. See chart below:

Age	Compression Rate	Compression Depth	Compression / Ventilations
Adult 8+ Years Old	100 to 120 per min.	2 - 2.4 in. (4-5 cm)	30 Comp. / 2 Vent (6-8 Breaths per Minute)
Child 1 Year to 8 Years Old	100 to 120 per min.	Up to 2 in. (1/3 Chest Diameter)	30 Comp. / 2 Vent (6-8 Breaths per Minute)
Infant Up to 1 Year Old	100 to 120 per min.	About 1.5 in. (3 cm)	30 Comp. / 2 Vent (6-8 Breaths per Minute)

As of 2015, to maximize simplicity in cardiopulmonary resuscitation programs across the board, it is now reasonable to apply the new recommended adult compression rate of 100 to 120 per minute at 30 compressions to 2 rescue breaths ratio for adults, children, and infants.

Congratulations!

You have completed the 'Introduction to CPR' section of your training. If you are comfortable with this material, please proceed to 'Adult CPR.' If you are unclear on any of the topics or procedures discussed, please review them before proceeding to the next section.