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Basic life support (BLS) is the level of medical care which is used for patients with life-threatening illnesses

or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by laypersons who have received BLS training. BLS is generally used in the pre-hospital setting, and can be provided without medical equipment. Many countries have guidelines on how to provide basic life support (BLS) which are formulated by professional medical bodies in those countries. The guidelines outline algorithms for the management of a number of conditions, such as Cardiac arrest, choking and drowning. BLS generally does not include the use of drugs or invasive skills, and can be contrasted with the provision of Advanced Life Support (ALS). Most laypersons can master BLS skills after attending a short course. Firefighters and police officers are often required to be BLS certified. BLS is also immensely useful for many other professions, such as daycare providers, teachers and security personnel. CPR provided in the field increases the time available for higher medical responders to arrive and provide ALS care. An important advance in providing BLS is the availability of theautomated external defibrillator or AED. This improves survival outcomes in cardiac arrest cases. Basic life support consists of a number of life-saving techniques focused on the medicine "ABC"s of pre-hospital emergency care:  Airway: the protection and maintenance of a clear passageway for gases (principally oxygen and carbon dioxide) to pass between the lungs and the atmosphere.  Breathing: inflation and deflation of the lungs (respiration) via the airway  Circulation: providing an adequate blood supply to tissue, especially critical organs, so as to deliver oxygen to all cells and remove metabolic waste, via the perfusion of blood throughout the body. Healthy people maintain the ABCs by themselves. In an emergency situation, due to illness (medical emergency) or trauma, BLS helps the patient ensure his or her own ABCs, or assists in maintaining for the patient who is unable to do so. For airways, this will include manually opening the patients airway (Head tilt/Chin lift or jaw thrust) or possible insertion of oral (Oropharyngeal airway) or nasal (Nasopharyngeal airway) adjuncts, to keep the airway unblocked (patent). For breathing, this may include artificial respiration, often assisted by emergency oxygen. For circulation, this may include bleeding control or Cardiopulmonary Resuscitation (CPR) techniques to manually stimulate the heart and assist its pumping action. Basic Life Support Atmospheric air that is essential for life contains approximately 21% oxygen. When you breathe in (inhale) only a quarter of the air is taken by the blood in the lungs. The air you breath out (exhale) contains approximately 16% oxygen. Enough to support life! Seconds after being deprived of oxygen, the heart is at risk of developing irregular beats or stopping. Within four to six minutes, the brain is subject to irreversible damage. Basic life support is maintenance of the ABCs (airway, breathing, and circulation) without auxiliary equipment. The primary importance is placed on establishing and maintaining an adequate open airway. Airway obstruction alone may be the emergency: a shipmate begins choking on a piece of food. Restore breathing to reverse respiratory arrest (stopped breathing) commonly caused by electric shock, drowning, head injuries, and allergic reactions. Restore circulation to keep blood circulating and carrying oxygen to the heart, lungs, brain, and body. This course is not a substitute for formal training in basic life support. Airway Obstruction Airway obstruction, also known as choking, occurs when the airway (route for passage of air into and out of the lungs) becomes blocked. The restoration of breathing takes precedence over all other measures.. The reason for this is simple: If a casualty cannot breathe, he or she cannot live. Individuals who are choking may stop breathing and become unconscious. The universally recognized distress signal (Fig. 2-1) for choking is the casualty clutching at his or her throat with one or both hands. The most common causes of airway obstruction are swallowing large pieces of improperly chewed food, drinking alcohol before or during meals, and laughing while eating. The tongue is the most common cause of obstruction in the casualty who is unconscious. A foreign body can cause a partial or complete airway obstruction. Partial Airway Obstruction If the casualty can cough forcefully, and is able to speak, there is good air exchange. Encourage him or her to continue coughing in an attempt to dislodge the object. Do not interfere with the casualty's efforts to remove the obstruction. First aid for a partial airway obstruction is limited to encouragement and observation. When good air exchange progresses to poor air exchange,

demonstrated by a weak or ineffective cough, a high-pitched noise when inhaling, and a bluish discoloration (cyanosis) of the skin (around the finger nails and lips), treat as a complete airway obstruction. Complete Airway Obstruction A complete airway obstruction presents with a completely blocked airway, and an inability to speak, cough, or breathe. If the casualty is conscious, he or she may display the universal distress signal. Ask "Are YOU choking?" If the casualty is choking, do the following: 1. Shout "Help"-Ask the casualty if you can help. 2. Request medical assistance - Say "Airway is obstructed" (blocked), call (Local emergency number or medical personnel).

Figure 2-1 Universal Distress Signal

Figure 2-2 Abdominal Thrust 3. Abdominal thrusts (Heimlich Maneuver) a. Stand behind the casualty. b. Place your arms around the (Fig. 2-2) casualties waist. c. With your fist, place the thumb side against the middle of the abdomen, above the navel and below the tip (xiphoid process) of the (sternum) breastbone. d. Grasp your fist with your other hand. e. Keeping your elbows out, press your fist (Fig. 2-3) into the abdomen with a quick upward thrust. f. Repeat until the obstruction is clear or the casualty becomes unconscious. If the casualty becomes unconscious, do the following:

If the casualty is found unconscious, do the following: 1. Check unresponsiveness - Tap or gently shake the casualty, shout, "Are you OK?" 2. Shout, "Help" - If there is no response from casualty. 3. Position casualty - Kneel midway between his or her hips and shoulders facing casualty. Straighten legs, and move arm closest to you above casualty's head. Place your hand on the casualty's shoulder and one on the hip. Roll casualty toward you as a unit, move your hand from the shoulder to support the back of the head and neck. Place the casualty's arm nearest you alongside his or her body.

Figure 2-3 Abdominal Thrust

Figure 2-4 Head Tilt-Chin Lift 4. Finger sweep - Place the casualty on his or her back, open casualty's mouth and grasp the tongue and lower jaw between your thumb and fingers, lift jaw with your index finger into the mouth along inside of cheek to base of tongue. Use "hooking" motion to dislodge object for removal. 5. Open airway (Head-tilt/Chin-lift) -Place your hand on the casualty's forehead. Place the fingers of your other hand under the (Fig. 2-4) bony part of the chin. Avoid putting pressure under the chin, it may cause an obstruction of the airway. Tilt the head and lift the jaw, avoid closing the casualty's mouth. Place your ear over the casualty's mouth and nose. Look at the chest, listen and feel for breathing, 3 to 5 seconds. If not breathing, say, "Not Breathing." (jaw-thrust maneuver) - If you suspect the casualty may have an injury to the head, neck, or back, you must minimize movement of the casualty when opening the airway. Kneeling at the top of the casualty's head, place your elbows on the surface. Place your fingers behind the angle of the jaw or hook your fingers under the jaw, bring (Fig. 2-5) jaw forward. Separate the lips with your thumbs to allow breathing through the mouth. Note that the head is not tilted and the neck is not extended.

Figure 2-5 Jaw Thrust 6. Give breaths - Pinch nose, open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth. Give 2 full breaths, each lasting 1 to 1 1/2 seconds. Pause between each breath. If unsuccessful, perform abdominal thrusts. 7. Perform abdominal thrusts a. Straddle the casualty's thighs. b. Place the heel of your hand against the middle of the abdomen, above the navel and below the tip of the breastbone. c. Place your other hand directly on top of the first (Fingers should point towards the casualty's head). d. Press abdomen 6 to 10 times (Fig. 2-6) with quick upward thrusts. 8. Continue steps 4 to 7 -Until successful, you are exhausted, you are relieved by another trained individual, or by medical personnel.

Figure 2-6 Abdominal Thrust Reclining 4. Open airway (Head-tilt/Chin-lift or Jaw-thrust) - Place your hand on the casualty's forehead. Place the fingers of your other hand under the bony part of the chin. Avoid putting pressure under the chin, it may cause an obstruction of the airway. Tilt the head and lift the jaw, avoid closing casualty's mouth. Place your ear over the casualty's mouth and nose. Look at the chest, listen, and feel for breathing, 3 to 5 seconds. If not breathing, say, "Not Breathing." 5. Give breaths - Pinch nose, open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth. Give 2 full breaths, each lasting 1 to 1 1/2 seconds. Pause between each breath. If unsuccessful, reposition head, and give 2 full breaths. 6. Request medical assistance - Say "Airway is obstructed" (blocked), call local emergency number or medical personnel. 7. Perform abdominal thrusts a. Straddle the casualty's thighs. b. Place the heel of your hand against the middle of the abdomen, above the navel and below the tip of the breastbone. c. Place your other hand directly on top of the first (fingers should point towards the casualty's head). d. Press abdomen 6 to 10 times with quick upward thrusts. 8. Finger sweep - Place the casualty on his or her back, open the casualty's mouth and grasp the tongue and lower jaw between your thumb and fingers, lift jaw, insert your index finger into the mouth along the inside of cheek to base of tongue. Use "hooking" motion to dislodge object for removal. 9. Give breaths - Pinch nose, open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth. Give 2 full breaths, each lasting 1 to 1 1/2 seconds. Pause between each breath. 10. Continue steps 7 to 9 - Until successful, you are exhausted, you are relieved by another trained individual, or by medical personnel. Chest Thrusts The chest thrust is the preferred method, in place of the abdominal thrust, for individuals who are overweight or pregnant. Manual pressure to the abdominal area in these individuals can be ineffective or cause serious damage. If the casualty is overweight or pregnant, do the following: 1. Conscious - Standing or Sitting. a. Stand behind the casualty. b. Place your arms under the casualty's armpits and around the chest. c. With your fist, place the thumb side against the middle of the breastbone. d. Grasp your fist with your other hand. e. Press your fist against the chest with a sharp, backward thrust until the obstruction is clear or casualty becomes unconscious. 2. Unconscious - Lying. a. Kneel, facing the casualty's chest.

b. With the middle and index fingers of the hand nearest the casualty's legs, locate the lower edge of the rib cage on the side closest to you. c. Slide your fingers up the rib cage to the notch at t d. Place your middle finger on the notch, and your index finger next to it. e. Place the heel of your hand on the breastbone next to the index finger. f. Place the heel of your hand, used to locate the notch, on top of the heel of your other hand. g. Keep your fingers off the casualty's chest. h. Position your shoulders over your hands, with elbows locked and arms straight. i. Give 6 to 10 quick and distinct downward thrusts, each should compress the chest 1 1/2 to 2 inches. j. Finger sweep. k. Open the airway and give 2 full breaths. Repeat the last three steps until the obstruction is clear, you are exhausted, you are relieved by another trained individual, or by medical personnel. Self Abdominal Thrusts If you are alone and choking, try not to panic, you can perform an abdominal thrust (Fig. 2-7) on yourself by doing the following: 1. With the fist of your hand, place the thumb side against the middle of your abdomen, above the navel and below the tip of the breastbone. Grasp your fist with your other hand and give a quick upward thrust. 2. You also can lean forward and press your abdomen over the back of a chair (with rounded edge), a railing, or a sink.

lasting 1 to 1 1/2 seconds. Pause between each breath. Look for the chest to rise, listen, and feel for breathing. 6. Check pulse - While maintaining an open airway, locate the Adam's apple with your middle and index fingers. Slide your fingers down into the groove (Fig. 2-9), on the side closest to you. Feel for a carotid pulse for 5 to 10 seconds. If you feel a pulse, say, "No breathing, but there is a pulse." Quickly examine the casualty for signs of bleeding.

Figure 2-8 Mouth-to-Mouth Ventilation

Figure 2-7 Self-Help for Airway Obstruction If the casualty is not breathing, do the following: Rescue Breathing Rescue breathing is the process of breathing air into the lungs of a casualty who has stopped breathing (respiratory arrest), also known as artificial respiration. The common causes are air-way obstruction, drowning, electric shock, drug overdose, and chest or lung (trauma) injury. Never give rescue breathing to a person who is breathing normally. 1. Check unresponsiveness - Tap or gently shake the casualty, shout, "Are you OK?" 2. Shout, "Help" - If there is no response from casualty. 3. Position casualty - Kneel midway between his or her hips and shoulders facing the casualty. Straighten legs and move arm closest to you above casualty's head. Place your hand on the casualty's shoulder and one on the hip. Roll casualty toward you as a unit, move your hand from the shoulder to support the back of the head and neck. Place the casualty's arm nearest you alongside his/her body. 4. Open airway (Head-tilt/Chin lift or Jaw thrust) - Place your hand on the casualty's forehead. Place the fingers of your other hand under the bony part of the chin. Avoid putting pressure under the chin, it may cause an obstruction of the airway. Tilt the head and lift the jaw, avoid closing the casualty's mouth. Place your ear over the casualty's mouth and nose. Look at the chest, listen, and feel for breathing, 3 to 5 seconds. If not breathing, say, "Not breathing." 5. Give breaths - Pinch nose, open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth (Fig. 2-8). Give 2 full breaths, each

Figure 2-9 Check Carotid Pulse 7. Request medical assistance - Say "No breathing, has a pulse," call (Local emergency number or medical personnel). 8. Rescue breathing (mouth-to-mouth) Maintain an open airway with headtilt/chin-lift or jaw-thrust maneuver, pinch nose. Open your mouth, take a deep breath, and make an air-tight seal around the casualty's mouth. Give 1 breath every 5 seconds, each lasting 1 to 1 1/2 seconds. Count aloud "one onethousand, two one-thousand, three one-thousand, four one-thousand," take a breath, and then give a breath. Look at the chest, listen, and feel for breathing. Continue for 1 minute/12 breaths. 9. Recheck pulse - While maintaining an open airway, locate and feel the carotid pulse for 5 seconds. If you feel a pulse, say, "Has pulse." Look at the chest, listen, and feel for breathing 3 to 5 seconds. If the casualty is not breathing, say, "No breathing." 10. Continue sequence - Maintain an open airway, give 1 breath every 5 seconds, recheck pulse every minute. If pulse is absent, begin CPR. If pulse is present but breathing is absent, continue rescue breathing. If the casualty begins to breathe, maintain an open airway, until medical assistance arrives. Special Situations 1. Air in the stomach (Gastric Distention) - During rescue breathing and CPR, air may enter the stomach in addition to the lungs. To avoid this, keep the casualty's head tilted back, breathe only enough to make the chest rise, and do not give breaths too fast. Do not attempt to expel stomach contents by pressing on the abdomen. 2. Mouth-to-nose breathing - Used when the casualty has mouth or jaw injuries, is bleeding from the mouth, or your mouth is too small to make an air-tight seal. Maintain head tilt with your hand on the forehead, use your other hand to seal the casualty's mouth and lift the chin. Take a deep breath and seal your mouth around the casualty's nose and slowly breathe into the casualty's nose using the procedures for mouth-to-mouth breathing. 3. Mouth-to-stoma breathing - Used when the casualty has had surgery to remove part of the windpipe. They breathe through an opening in the front of the neck, called a stoma. Cover the casualty's mouth with your hand, take a deep breath, and seal your mouth over the stoma and slowly breathe using the procedures for mouth-to-mouth breathing. Do not tilt the head back. (In some situations a person may breathe through the stoma as well as his or her nose and mouth. If the casualty's chest does not rise, you should cover his or her mouth and nose and continue breathing through the stoma).

4. Mouth-to-mask breathing - Used when rescue breathing is required in a contaminated environment, such as after a chemical or biological attack. A resuscitation tube is used to deliver uncontaminated air to the casualty. This resuscitation tube has an adapter at one end that attaches to your mask and a molded rubber mouthpiece at the other end for the mouth of the casualty. 5. Dentures - Leave dentures in place, they provide support to the mouth and cheeks during rescue breathing. If they become loose and block the airway or make it difficult to give breaths, remove them. Circulation Circulation is the movement of blood through the heart and blood vessels. The circulatory system consists of the heart, which pumps the blood, and the blood vessels, which carry the blood throughout the body. Cardiac arrest is the failure of the heart to produce a useful blood flow or the heart has completely stopped beating. The signs of cardiac arrest include unconsciousness, the absence of a pulse, and the absence of breathing. If the casualty is to survive, immediate action must be taken to restore breathing and circulation. Cardiopulmonary Resuscitation (CPR) is an emergency procedure for the casualty who is not breathing and whose heart has stopped beating (cardiac arrest). The procedure involves a combination of chest compressions and rescue breathing. The casualty must be lying face up on a firm surface. Do not assume that a cardiac arrest has occurred simply because the casualty appears to be unconscious. This course is not a substitute for formal training in cardiopulmonary resuscitation (CPR).

Figure 2-11 Xiphoid Process Chest Compressions a. Kneel, facing the casualty's chest. b. With your middle and index fingers (Fig. 2-11) of the hand nearest the casualty's legs, locate the lower edge of the rib cage on the side closest to you. c. Slide your fingers up the rib cage to the notch at the end of the breastbone. d. Place your middle finger on the notch, and your index finger next to it. e. Place the heel of your other hand on the breastbone next to your index finger. f. Place the heel of the hand used to locate the notch on top of the heel of your other hand. g. Keep your fingers (Fig 2-12) off the casualty's chest.

Figure 2-12 Interlocking fingers to help keep fingers off the chest wall h. Position shoulders over your hands, with elbows locked and arms straight. i. Give 15 compressions, each should compress the chest 1 1/2 to 2 inches at a rate of 80 to 100 compressions per minute. Count aloud, "One and two and three," until you reach 15. After each 15 compressions, deliver 2 full breaths. Compressions should be smooth, rhythmic, and uninterrupted. j. Continue 4 complete cycles of 15 compressions and 2 breaths. Check for a carotid pulse and breathing for 5 seconds. Continue CPR - If the casualty has no pulse, give 2 full breaths and continue CPR. Check for a pulse every few minutes. If the pulse is present but breathing is

absent, continue rescue breathing. If the casualty begins to breathe, maintain an open airway until medical assistance arrives. Continue CPR until successful, you are exhausted, you are relieved by another trained in CPR, by medical personnel, or the casualty is pronounced dead. Do not interrupt CPR for more than 7 seconds except for special circumstances. CPR with Entry of Second Person When a second person who is trained in administering CPR arrives at the scene, do the following: 1. The second person shall identify himself or herself as being trained in CPR and that they are willing to help. ("I know CPR. Can I help?") 2. The second person should call the local emergency number or medical personnel for assistance if it has not already been done. 3. The person doing CPR will indicate when he or she is tired; and should stop CPR after the next 2 full breaths. 4. The second person should kneel next to the casualty opposite the first person, tilt the casualty's head back, and check for a carotid pulse for 5 seconds. 5. If there is no pulse, the second rescuer should give 2 full breaths and continue CPR. 6. The first person will monitor the effectiveness of CPR by looking for the chest to rise during rescue breathing and feeling for a carotid pulse (artificial pulse) during chest compressions. CPR for Children and Infants If the casualty is an infant (0-1 year old) or child (1-8 years old), do the following: 1. Check unresponsiveness - Infant: Tap or shake shoulder only. Child: Tap or gently shake the shoulder, shout, "Are you OK?" 2. Shout, "Help" - If there is no response from infant or child. 3. Position casualty - Turn casualty on back as a unit, supporting, the head and neck. Place casualty on a firm surface. 4. Open airway (Head-tilt/Chin-lift or jaw thrust) - Place your hand on the casualty's forehead. Place the fingers of your other hand under the bony part of the chin. Avoid putting pressure under the chin, it may cause an obstruction of the airway. Tilt the head and lift the jaw, avoid closing the casualty's mouth. Infant: Do not overextend the head and neck. Place your ear over the casualty's mouth and nose. Look at the chest, listen, and feel for breathing, 3 to 5 seconds. 5. Give breaths - Open your mouth, take a breath, and make an air-tight seal around the casualty's mouth and nose. Give 2 breaths (puffs for infants), each lasting 1 to 1 1/2 seconds. Pause between each breath. Look for the chest to rise, listen, and feel for breathing. 6. Check pulse - While maintaining an open airway, locate the carotid pulse (Infants: Locate the brachial pulse (Fig. 2-13) on the inside of the upper arm, between the elbow and shoulder). Feel for a pulse for 5 to 10 seconds. Quickly examine the casualty for signs of bleeding. 7. Request medical assistance - If someone responded to your call for help, send them to call the local emergency number or medical personnel. 8. Chest compressions (infant) a. Face infant's chest. b. Place your middle and index fingers on the breastbone at the nipple line. c. Give 5 compressions, each should compress the chest 1/2 to 1 inch at a rate of at least 100 compressions per minute. After each 5th compression, deliver 1 breath. Compressions should be smooth, rhythmic, and uninterrupted. d. Continue for 10 complete cycles of 5 compressions and 1 breath. Check for a brachial pulse for 5 seconds. 9. Chest compressions (children) a. Face child's chest. b. With your middle and index fingers of the hand nearest the child's legs, locate the lower edge of the rib cage on the side closest to you. c. Slide your fingers up the rib cage to the notch at end of the breastbone.

Figure 2-13 Check Infant's Pulse d. Place your middle finger on the notch, and your index finger next to it. e. While looking at the position of your index finger, lift that hand and place your heel (on breastbone at nipple line) next to where your index finger was. f. Keep your fingers off the child's chest. g. Position your shoulder over your hand, with elbow locked and your arm straight. h. Give 5 compressions, each should compress the chest 1 to 1 1/2 inches at a rate of 80 to 100 compressions per minute. After each 5th compression, deliver 1 breath. Compressions should be smooth, rhythmic, and uninterrupted. i. Continue for 10 complete cycles of 3 compressions and 1 breath. Check for a carotid pulse for 5 seconds. 10. Continue CPR - If the infant or child has no pulse, give 1 breath and continue CPR. Check for a pulse every few minutes. If the pulse is present but breathing is absent, continue rescue breathing (Infant: 20 breaths/min; Child: 15 breaths/min.) If the infant or child begins to breathe, maintain an open airway, until medical assistance arrives. Continue CPR until successful, you are exhausted, you are relieved by another trained in CPR or medical personnel, or the infant or child is pronounced dead. This course is not a substitute for formal training in cardiopulmonary resuscitation (CPR).

INTRODUCTION 1. Define cardiopulmonary arrest and list the three phases. Cardiopulmonary arrest is defined as the abrupt, unexpected cessation of spontaneous and effective ventilation and systemic perfusion (circulation). Cardiopulmonary resuscitation (CPR) provides artificial ventilation and circulation until advanced life support can be provided and spontaneous circulation and ventilation can be restored. CPR is divided into three support stages:

Prolonged life support. Return to Table of Contents RISK FACTORS 1. Which animals are at risk to suffer cardiopulmonary arrest and what are the predisposing factors? Cardiopulmonary arrest is usually the result of a cardiac dysrhythmia. This arrest may be the result of primary cardiac disease or diseases which affect other organs. In animals, arrest most frequently occurs with diseases of the respiratory system (pneumonia, laryngeal paralysis, neoplasia, thoracic effusions, and aspiration pneumonitis), as a result of severe multisystem disease, trauma, and following cardiac dysrhythmias. Predisposing causes of cardiopulmonary arrest include the following: 1) cellular hypoxia; 2) vagal stimulation; 3) acid-base and electrolyte abnormalities; 4) anesthetic agents; 5) trauma; 6) systemic and metabolic diseases. WARNING SIGNS AND DIAGNOSIS OF CARDIOPULMONARY ARREST 1. What are the warning signs of cardiopulmonary arrest? Changes in the respiratory rate, depth, or pattern; a weak or irregular pulse; bradycardia; hypotension; unexplained changes in the depth of anesthesia; cyanosis; and hypothermia.

y y y

Basic life support Advanced life support

2. How is cardiopulmonary arrest diagnosed? The classical description of arrest includes the following: 1) absence of ventilation and cyanosis ("respiratory arrest"); 2) absence of a palpable pulse (pulse will disappear when systolic pressure < 60 mm Hg); 3) absence of heart sounds (heart sounds will disappear when systolic pressure < 50 mm Hg); 4) dilatation of the pupils. PHASES OF CARDIOPULMONARY RESUSCITATION AND GOALS 1. What is involved with each of the phases of cardiopulmonary resuscitation? Basic Life Support: A -- Establishment of an Airway. B -- Breathing support. C -- Circulation support. Advanced Life Support: D -- Diagnosis and Drugs. E -- Electrocardiography. F -- Fibrillation control. Prolonged Life Support: G -- Gauging a patient's response. H -- Hopeful measures for the brain I -- Intensive care. In order to optimize CPR, one should ASSESS prior to initiating basic, advanced, and prolonged life support. Eg. Assessment Airway support; assessment breathing support; assessment circulation support, etc. 2. Should you keep accurate records for each cardiopulmonary arrest animal? Yes! Although you won't likely be recording every action during the arrest, it is important to record this information. BASIC_LIFE_SUPPORT 1. How important is basic life support? Basic life support is the most important phase of cardiopulmonary resuscitation. This requires practice by your staff. It is easy to develop "simulated" arrests using "stuffed" toy animals in which you can practice the ABC's of CPR. Through these practice sessions the staff can all be trained to rapidly respond to this serious emergency. 2. How do we establish an airway? The first step is the establishment of the unresponsiveness and assessment of the airway. Quickly check the airway for foreign materials (bones, blood clots, fractured mandible, vomitus). Position the animal in a ventral recumbency in preparation for intubation with an endotracheal tube. Accurately place the endotracheal tube. 3. How do we breathe for the animal? First, assess that the animal is apneic and requires assisted ventilation. Once you have seen there is no movement to the chest wall, begin to ventilate the animal with two long breaths (1.5 - 2.0 seconds each). If the animal does not begin to breathe within 5 to 7 seconds, begin to ventilate at a rate of 12 - 20 times per minute. Use of accupuncture to stimulate respirations has been reported. Placing a needle in acupuncture point Jen Chung (GV26) may reverse respiratory arrest under clinical conditions. The technique involves using a small (22 - 28 gauge, 1 1.5 inch) needle in the nasal philtrum at the ventral limit of the nares. The needle is twirled strongly and moved up and down while monitoring for improvement in respiration. This is a simple technique and can be employed quickly. 4. How is circulation supported during CPR? Assessment is necessary to determine the pulselessness of the animal prior to initiating external cardiac compression. Currently there are two theories to explain the mechanism of forward blood flow during CPR: 1) Cardiac pump theory and 2) thoracic pump theory. The cardiac pump theory is likely most important in the smaller animals (< 7 Kg) and the thoracic pump most important in larger animals (> 7 Kg). It is believed that both the cardiac and thoracic pump are interactive and each contributes to the pressure gradients responsible for blood flow during CPR. 5. What is the "cardiac pump theory"? The original hypothesis, suggests that blood flow to the periphery during external cardiac compression of the heart results from direct compression of the heart between the sternum and vertebrae (dorsal recumbency) or between the right and left thoracic wall (lateral recumbency) of the dog and cat. According to this concept, thoracic compression ("artificial systole") is similar to internal cardiac massage, and will result in blood being squeezed from both ventricles into the pulmonary arteries and aorta as the pulmonary and aortic valves open. Retrograde flow of blood is prevented by closure of the left and right atrioventricular valves. During the relaxation phase of thoracic compression

("artificial diastole"), the ventricles recoil to their original shape and fill by a suction effect, while elevated arterial pressure closes the aortic and pulmonic valves. 6. What is the "thoracic pump theory"? As pressure is applied to the animal's thorax, it has been noted there is a correlation between the rise in intrathoracic pressure during compression and the apparent magnitude of carotid artery blood flow and pressure. For brain blood flow to occur during resuscitation, a carotid arterial-to-jugular pressure gradient must be present during chest compression. Experimental studies in large dogs have shown that thoracic compression during CPR results in an essentially equal rise in central venous, right atrial, pulmonary artery, aortic, esophageal, and lateral pleural space pressures with no transcardiac gradient being developed. Aortic pressure is efficiently transmitted to the carotid arteries, but retrograde transmission of intrathoracic venous pressure into the jugular veins is prevented by valves at the thoracic inlet and possibly by venous collapse. Thus, during "artificial systole" a peripheral arterial venous pressure gradient appears, and blood flow occurs consequent to this gradient. In such a system, there is no pressure gradient across the heart and thus the heart acts mearly as a passive conduit. Cineangiographic studies in large dogs confirm these observations by demonstrating partial right atrioventricular valve closure, collapse of the venae cavae, and opening of the pulmonary, left atrioventricular and aortic valves during thoracic compression. When thoracic compression is released ("artificial diastole"), intrathoracic pressures fall toward zero, and venous flow to the right heart and lungs occur. During "diastole", a modest gradient also develops between the intrathoracic aorta and the right atrium providing coronary (myocardial) perfusion. In small dogs receiving vigorous chest compressions, intrathoracic vascular pressures are much higher than recorded pleural pressures. In these animals, the rise in vascular pressures likely is a result of compression of the heart during chest compression and is likely not a result of rising intrathoracic pressure. 7. What are the determinants of vital organ perfusion during CPR? Cerebral blood flow (cerebral perfusion pressure) is dependent on the gradient between the carotid artery and the intracranial pressure during systole (thoracic compression). Myocardial blood flow (myocardial perfusion pressure) is dependent on the gradient between the aorta and right atrium during diastole (release phase of thoracic compression). During conventional CPR, cerebral and myocardial flow are less than 5% of prearrest values. Below the diaphagm, renal and hepatic blood flow during CPR is 1% to 5% of prearrest values. 8. What are the determinants of improved vital organ perfusion during CPR? Force, rate, and duration of chest compression during CPR will determine the effectiveness of organ perfusion during CPR. Irrespective of the mechanism of forward blood flow during CPR, increasing theforce of chest compressions increases arterial pressures. At pressures >400 newtons (about 40 Kg), bone and tissue trauma are more likely. Increasing the rate of chest compressions will significantly increase the arterial pressure. GENERAL GUIDELINES FOR CPR IN ANIMALS 1. What is the optimal position for maximizing blood flow? A lateral recumbency (with the sternum parallel to the table top) is used for animals < 7 Kg and, ideally, a dorsal recumbency for animals > 7 Kg. As we all know, it is extremely difficult to maintain a dog in dorsal recumbency without special "V"-shaped troughs or other techniques. However, the doral recumbency will provide maximal changes in intrathoracic pressure and thus forward blood flow. When no peripheral pulse is felt during CPR, consider changing the animal's position and your technique. 2. What is the optimal compression/relaxation ratio for administering external cardiac compression? Studies have shown the best ratio of cardiac compression to ventilation is 1:1 (simultaneous compression-ventilation) in animals. This means you will breathe for the animal each time you compress the thoracic wall. 3. At what rate should you compress and ventilate when two persons are available to do CPR? In animals weighing less than 7 Kg the recommended rate of ventilation and compression is 120 times per minute. In animals weighing > 7 Kg, the rate of compression and ventilation is 80 - 100 times each minute. 4. What is "interposed abdominal compression"? To improve venous return and to decrease arterial run-off during external thoracic compression, have one person press upon the cranial abdomen between each compression of the chest. In humans, this has shown to improve hospital discharge rates as much as 33%. No comparable studies are yet available in animals. 5. What if there is only one person available to do CPR?

One person CPR in animals is very ineffective. The ratio of ventilation to chest compression is 15:2. Give 15 chest compressions and then 2 long ventilations. Use a rate of 120 chest compressions per minute when the animal weighs less than 7 Kg and 80 - 100 times per minute when the animal weighs > 7 Kg. 6. Is ventilation really necessary during CPR? For more than 30 years, emergency ventilation has been considered an essential component of basic life support CPR. It would seem logical that ventilation has the potential to improve the success of resuscitation from cardiac arrest by improving tissue oxygenation and acidosis, but this benefit has only recently been studied. When blood flow stops, ventilation does not affect tissue conditions. Ventilation does affect oxygenation, CO2, and pH of arterial and venous blood and may affect intracellular environment in the presence of low rates of blood flow. Ventilation may be unnecessary during the first few minutes of CPR, but under conditions of prolonged untreated cardiac arrest, it affects return of spontaneous circulation and is important for survival. Chest compression alone and spontaneous gasping provides some pulmonary ventilation and gas exchange. However, blood oxygenation can be improved with supplemental oxygen. A recent report in experimentally induced cardiopulmonary resuscitation in swine has shown an excellent resuscitation rate through providing only cardiac compression. In fact, the researchers were unable to detect a difference in hemodynamics, 48-hour survival , or neurological outcome when CPR was applied with or without ventilatory support. With this in mind, if inadequate numbers of professional staff are available, apply only cardiac compressions if cardiopulmonary arrest is present. 7. When should I open the chest and do CPR? Chest compressions raise the venous (right atrial) pressure peaks almost as high as arterial pressure peaks and increase intracranial pressure, thus causing low cerebral and myocardial perfusion pressures. Open chest CPR does not raise atrial pressures, provides better cerebral and coronary perfusion pressures and flows than external CPR in animals. When applied promptly in operating room arrests, open chest CPR, which was introduced in the 1880's until 1960 yielded good clinical results in people. The switch from external to open-chest CPR has not yet improved outcome in human patients, probably because its initiation was too late. There are no comparable studies available for clinicallyemployed open chest CPR in animals. Currently, open-chest CPR should be restricted to the operating room and in selected instances of penetrating thoracic injury. 8. How can one monitor the effectiveness of my external thoracic compressions? Traditionally, the presence of a pulse during thoracic compression has been the hallmark of effective compression. More recently, while monitoring peripheral pulses using quantitative Doppler techniques have shown the pulse generated during compression was in fact from venous flow and not arterial. In veterinary medicine, monitoring the pulse will be the most commonly employed monitoring for effectiveness. Using pulse oximetry can provide information on hemoglobin saturation. During CPR you should see an improvement of oximetry values and mucous membrane color. End-tidal carbon dioxide monitoring has proven to be the most effective means for measuring the effectiveness of CPR. This device fits in-line with the endotracheal tube and will measure carbon dioxide levels. With effective CPR you should see anincreased end-tidal CO2. 9. What can you do if there is no pulse, change in oximetry or end-tidal CO2? As mentioned above, consider changing the position of the animal, the force or the rate of thoracic compression. 10. How can you train your staff in CPR? Periodic training sessions in basic life support should be conducted in each veterinary practice. This is not a time-consuming activity and the benefits are tremendous when your "team" can respond quickly and efficiently. An effective means to provide training is to develop an inexpensive "CPR Animal". These teaching aids were developed by simply taking some old corregated anesthetic tubing ("trachea"), an anesthetic Y-piece ("tracheal bifercation"), two anesthetic rebreathing bags ("lungs"), and then "implanting" them in the chest of a commercially available stuffed animal purchased at any retail outlet. These devices can then be used to practice CPR techniques with your staff. One can place foreign materials in the "mouth", can practice "Gen Chung" manuveurs, palpate for pulses, see the thorax expand with each breath, and feel the expanding "lungs" as you apply chest compression. Someone in your practice can manufacture this model and practice sessions can be called at any time to simulate the sudden, unexpected occurrence of an arrest.

Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. In 2010, the American Heart Association updated its guidelines to recommend that everyone untrained bystanders and medical personnel alike begin CPR with chest compressions. It's far better to do something than to do nothing at all if you're fearful that your knowledge or abilities aren't 100 percent complete. Remember, the difference between your doing something and doing nothing could be someone's life. Here's advice from the American Heart Association:

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Untrained. If you're not trained in CPR, then provide hands-only CPR. That means uninterrupted chest compressions of about 100 a minute until paramedics arrive (described in more detail below). You don't need to try rescue breathing. Trained, and ready to go. If you're well trained and confident in your ability, begin with chest compressions instead of first checking the airway and doing rescue breathing. Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. Trained, but rusty. If you've previously received CPR training but you're not confident in your abilities, then just do chest compressions at a rate of about 100 a minute. (Details described below.) The above advice applies to adults, children and infants needing CPR, but not newborns. CPR can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm. When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. A person may die within eight to 10 minutes. To learn CPR properly, take an accredited first-aid training course, including CPR and how to use an automatic external defibrillator (AED). Before you begin Before starting CPR, check: Is the person conscious or unconscious? If the person appears unconscious, tap or shake his or her shoulder and ask loudly, "Are you OK?" If the person doesn't respond and two people are available, one should call 911 or the local emergency number and one should begin CPR. If you are alone and have immediate access to a telephone, call 911 before beginning CPR unless you think the person has become unresponsive because of suffocation (such as from drowning). In this special case, begin CPR for one minute and then call 911 or the local emergency number. If an AED is immediately available, deliver one shock if instructed by the device, then begin CPR. Remember to spell C-A-B In 2010, the American Heart Association changed its long-held acronym of ABC to CAB circulation, airway, breathing to help people remember the order to perform the steps of CPR. This change emphasizes the importance of chest compressions to help keep blood flowing through the heart and to the brain. Circulation: Restore blood circulation with chest compressions 1. Put the person on his or her back on a firm surface. 2. Kneel next to the person's neck and shoulders. 3. Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands. 4. Use your upper body weight (not just your arms) as you push straight down on (compress) the chest at least 2 inches (approximately 5 centimeters). Push hard at a rate of about 100 compressions a minute. 5. If you haven't been trained in CPR, continue chest compressions until there are signs of movement or until emergency medical personnel take over. If you have been trained in CPR, go on to checking the airway and rescue breathing. Airway: Clear the airway 1. If you're trained in CPR and you've performed 30 chest compressions, open the person's airway using the head-tilt, chin-lift maneuver. Put your palm on the person's forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to open the airway. 2. Check for normal breathing, taking no more than five or 10 seconds. Look for chest motion, listen for normal breath sounds, and feel for the person's breath on your cheek and ear. Gasping is not considered to be normal breathing. If the person isn't breathing normally and you are trained in CPR, begin mouth-to-mouth breathing. If you believe the

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person is unconscious from a heart attack and you haven't been trained in emergency procedures, skip mouth-to-mouth rescue breathing and continue chest compressions. Breathing: Breathe for the person Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or can't be opened. 1. With the airway open (using the head-tilt, chin-lift maneuver), pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal. 2. Prepare to give two rescue breaths. Give the first rescue breath lasting one second and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver and then give the second breath. Thirty chest compressions followed by two rescue breaths is considered one cycle. 3. Resume chest compressions to restore circulation. 4. If the person has not begun moving after five cycles (about two minutes) and an automatic external defibrillator (AED) is available, apply it and follow the prompts. Administer one shock, then resume CPR starting with chest compressions for two more minutes before administering a second shock. If you're not trained to use an AED, a 911 operator may be able to guide you in its use. Use pediatric pads, if available, for children ages 1 through 8. Do not use an AED for babies younger than age 1. If an AED isn't available, go to step 5 below. 5. Continue CPR until there are signs of movement or emergency medical personnel take over. To perform CPR on a child The procedure for giving CPR to a child age 1 through 8 is essentially the same as that for an adult. The differences are as follows:

3.

4. 5. 6.

slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath. If the baby's chest still doesn't rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid for a choking baby. Give two breaths after every 30 chest compressions. Perform CPR for about two minutes before calling for help unless someone else can make the call while you attend to the baby. Continue CPR until you see signs of life or until medical personnel arrive.

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If you're alone, perform five cycles of compressions and breaths on the child this should take about two minutes before calling 911 or your local emergency number or using an AED. Use only one hand to perform heart compressions. Breathe more gently. Use the same compression-breath rate as is used for adults: 30 compressions followed by two breaths. This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and breaths. After five cycles (about two minutes) of CPR, if there is no response and an AED is available, apply it and follow the prompts. Use pediatric pads if available. If pediatric pads aren't available, use adult pads. Continue until the child moves or help arrives. To perform CPR on a baby Most cardiac arrests in babies occur from lack of oxygen, such as from drowning or choking. If you know the baby has an airway obstruction, perform first aid for choking. If you don't know why the baby isn't breathing, perform CPR. To begin, examine the situation. Stroke the baby and watch for a response, such as movement, but don't shake the baby. If there's no response, follow the CAB procedures below and time the call for help as follows: If you're the only rescuer and CPR is needed, do CPR for two minutes five cycles before calling 911 or your local emergency number. about

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If another person is available, have that person call for help immediately while you attend to the baby. Circulation: Restore blood circulation 1. Place the baby on his or her back on a firm, flat surface, such as a table. The floor or ground also will do. 2. Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest. 3. Gently compress the chest about 1.5 inches (about 4 cm). 4. Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of 100 compressions a minute. Airway: Clear the airway 1. After 30 compressions, gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand. 2. In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear. Breathing: Breathe for the infant 1. Cover the baby's mouth and nose with your mouth. 2. Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to

Cardio Pulmonary Resuscitation A particularly important aspect of CPR is that the rescuer's hands are positioned correctly in relation to the casualty's heart. For the rescuer to locate the correct position for the hands, two fingers should be placed over the casualty's xiphoid process, the small 'bump' at the base of the sternum. A hand is then placed centrally on the chest, above the two fingers. This position should then approximate the location of the heart. The second hand is placed over the first, and the fingers entwined for stability, or alternatively, the second hand grips the wrist of the first hand. The chest is compressed 4 5cm. Hand position for a child is on a point centrally located on the lower 1/2 of the sternum. Compressions are performed at a depth of 2 3cm using the heel of one hand only, the pressure is modified so as not to cause damage to the ribcage. An infant's heart is located by placing two fingers centrally on the lower 1/2 of the sternum. Compressions are then performed by pressing with the fingers 1 2cm deep, the pressure is modified to reflect the fragility of the child's chest. The pulse is detected by placing a finger directly over the left nipple. CPR can be performed by a single rescuer, or by two rescuers. As two-person CPR requires a degree of synchronized technique, it is usually more effective for first aid providers to perform individual CPR, and change operators after ten minutes or so. Procedure for CPR (Philippine National Red Cross) 1. Check for ABC. 2. Do Primary and Secondary Survey. 3. "Hey, hey, hey are you okay? (tap/shake shoulder)" 4. If unresponsive, give aid and get help (doctor/physician). 5. Position victim in flat area, lying if necessary. 6. Open airway (head-tilt/chin-lift). 7. Place ears above victim s mouth, look, listen, and feel for breathing. (3-5 sec) 1001, 1002, 1003, 1004, 1005. 8. If breathless, give 2 long full breaths: (1 breath = 1 1 sec) 9. Feel carotid pulse (5-10 sec) 1001, 1002, 1003 1010 Still breathless and without pulse. 10. Locate sternum. 11. Place hands centrally over heart (2 fingers from sternum), fingers entwined. 12. Lean over casualty, arms straight, elbows locked. 13. Commence 15 compressions, with even pressure until resistance is felt. 14. Compressions rate of 60-80 per minute, children and infants 80-100 per minute. 15. Continue cycles (back to #6) and recheck pulse every 2 minutes

Procedure for two-person CPR (Philippine National Red Cross) (A) One rescuer positions close to the casualty's head and delivers breaths. (B) The other positions on the opposite side of the body beside the chest and performs compressions. 1. (A) Check for ABC. 2. (B) Do Primary and Secondary Survey. 3. (A) "Hey, hey, hey are you okay? (tap/shake shoulder)" 4. (A) If unresponsive, give aid and get help (doctor/physician). 5. (A & B) Position victim in flat area, lying if necessary. 6. (A) Open airway (head-tilt/chin-lift). 7. (A) Place ears above victim s mouth, look, listen, and feel for breathing. (3-5 sec) 1001, 1002, 1003, 1004, 1005. 8. (A) If breathless, give 2 long full breath: (1 breath = 1 1 sec) 9. (A) Feel carotid pulse (5-10 sec) 1001, 1002, 1003 1010 10. Still breathless and without pulse. 11. (B) Locate sternum. 12. (B) Place hands centrally over heart (2 fingers from sternum), fingers entwined. 13. (B) Lean over casualty, arms straight, elbows locked. 14. (B) Commence 5 compressions, with even pressure until resistance is felt. 15. Compressions rate of 60-80 per minute, children and infants 80-100 per minute. 16. Continue cycles (back to #6) and recheck pulse every 2 minutes

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