Chapter 1: Emergency Care and Responsibilities PDF

Chapter 1 BEFORE GIVING CARE AND CHECKING AN INJURED OR ILL PERSON LESSON OBJECTIVES: 1. Describe how to recognize an emergency. 2. Describe how to prioritize care for injuries and sudden illnesses. 3. Describe the purpose of Good Samaritan laws. 4. Ident...

Chapter 1 BEFORE GIVING CARE AND CHECKING AN INJURED OR ILL PERSON LESSON OBJECTIVES: 1. Describe how to recognize an emergency. 2. Describe how to prioritize care for injuries and sudden illnesses. 3. Describe the purpose of Good Samaritan laws. 4. Identify the difference between (expressed) consent and implied consent. 5. Identify how to reduce the risk of disease transmission when giving care. 6. Explain how to activate and work with the EMS system. 7. Explain when to move an injured or ill person from a dangerous scene. 8. Explain how to check a conscious person for life-threatening and non-life-threatening conditions. 9. Identify the signals of shock. 10. Describe how to minimize the effects of shock. 11. Demonstrate how to check an unconscious person for life-threatening conditions. INTRODUCTION Medical emergencies can happen every day, in any setting. People are injured in situations like falls or motor-vehicle accidents, or they develop sudden illnesses, such as heart attack or stroke. The statistics are sobering. For example, about 900,000 people in the United States die e ach year from some form of heart disease. More than 300,000 of these deaths are caused by sudden cardiac arrest. Heart disease is the number one cause of death in this country. Given the large number of injuries and sudden illnesses that occur in the United States each year, it is possible that you might have to deal with an emergency situation someday. If you do, you should know who and when to call, what care to give and how to give that care until emergency medical help takes over. This chapter discusses your role in the emergency medical services (EMS) system, the purpose of Good Samaritan laws, how to gain consent from an injured or ill person and how to reduce your risk of disease transmission while giving care. In addition, you will read about the emergency action steps, CHECK—CALL—CARE, which guide you on how to check and give emergency care for an injured or suddenly ill person. You also will read about the effects of incident stress and how to identify the signals of shock and minimize its effects. YOUR ROLE IN THE EMS SYSTEM You play a major role in making the EMS system work effectively. The EMS system is a network of community resources, including police, fi re and medical personnel—and you. The system begins when someone like you recognizes that an emergency exists and decides to take action, such as calling 9-1-1 or the local emergency number for help. The EMS dispatcher or call taker answers the call and uses the information that you give to determine what help is needed. Emergency personnel are dispatched to the scene based on the information given. These personnel then give care at the scene and transport the injured or ill person to the hospital where emergency department staff and other professionals take over. Early arrival of emergency personnel increases a person’s chance of surviving a life-threatening emergency. Calling 9-1-1 or the local emergency number is the most important action that you can take. Your role in the EMS system includes four basic steps: Step 1: Recognize that an emergency exists. Step 2: Decide to act. Step 3: Activate the EMS system. Step 4: Give care until help takes over. STEP 1: RECOGNIZE THAT AN EMERGENCY EXISTS Emergencies can happen to anyone, anywhere. Before you can give help, however, you must be able to recognize an emergency. You may realize that an emergency has occurred only if you become aware of unusual noises, sights, odors and appearances or behaviors. Examples include the following:  Unusual noises o Screaming, moaning, yelling or calls for help o Breaking glass, crashing metal or screeching tires o A change in the sound made by machinery or equipment Sudden, loud noises, such as the sound of collapsing buildings or falling ladders o Unusual silence  Unusual sights o A stopped vehicle on the roadside or a car that has run off of the road o Downed electrical wires o A person lying motionless o Spilled medication or empty container o An overturned pot in the kitchen o Sparks, smoke or fire  Unusual odors o Odors that are stronger than usual o Unrecognizable odors o Inappropriate odors  Unusual appearances or behaviors o Unconsciousness o Confusion, drowsiness or unusual behavior o Trouble breathing o Sudden collapse, slip or fall o Clutching the chest or throat A person doubled over in pain o Slurred, confused or hesitant speech o Sweating for no apparent reason o Uncharacteristic skin color o Inability to move a body part STEP 2: DECIDE TO ACT Once you recognize that an emergency has occurred, you must decide how to help and what to do. There are many ways you can help in an emergency, but in order to help, you must act. Overcoming Barriers to Act Being faced with an emergency may bring out mixed feelings. While wanting to help, you also may feel hesitant or may want to back away from the situation. These feelings are personal and real. Sometimes, even though people recognize that an emergency has occurred, they fail to act. The most common factors that keep people from responding are:  Panic or fear of doing something wrong  Being unsure of the person’s condition and what to do  Assuming someone else will take action  Type of injury or illness  Fear of catching a disease  Fear of being sued  Being unsure of when to call 9-1-1 or the local emergency number PANIC OR FEAR OF DOING SOMETHING WRONG People react differently in emergencies. Some people are afraid of doing the wrong thing and making matters worse. Sometimes people simply panic. Knowing what to do in an emergency can instill confidence that can help you to avoid panic and be able to provide the right care. If you are not sure what to do, call 9-1-1 or the local emergency number and follow the instructions of the EMS dispatcher or call taker. The worst thing to do is nothing. BEING UNSURE OF THE PERSON’S CONDITION AND WHAT TO DO Because most emergencies happen in or near the home, you are more likely to find yourself giving care to a family member or a friend than to someone you do not know. However, you may be faced with an emergency situation involving a stranger, and you might f eel uneasy about helping someone whom you do not know. For example, the person may be much older or much younger than you, be of a different gender or race, have a disabling condition, be of a different status at work or be the victim of a crime. Sometimes, people who have been injured or become suddenly ill may act strangely or be uncooperative. The injury or illness; stress; or other factors, such as the effects of drugs, alcohol or medications, may make people unpleasant or angry. Do not take this behavior personally. If you feel at all threatened by the person’s behavior, leave the immediate area and call 9 -1-1 or the local emergency number for help. ASSUMING SOMEONE ELSE WILL TAKE ACTION If several people are standing around, it might not be easy to tell if anyone is giving care. Always ask if you can help. Just because there is a crowd does not mean someone is caring for the injured or ill person. In fact, you may be the only one on the scene who knows first aid. Although you may feel embarrassed about coming forward in front of other people, this should not stop you from offering help. Someone has to take action in an emergency, and it may have to be you. If others already are giving care, ask if you can help. If bystanders do not appear to be helping, tell them how to help. You can ask them to call 9-1-1 or the local emergency number, meet the ambulance and direct it to your location, keep the area free of onlookers and traffic, send them for blankets or other supplies such as a first aid kit or an automated external defibrillator (AED), or help to give care. THE TYPE OF INJURY OR ILLNESS An injury or illness sometimes may be very unpleasant. Blood, vomit, bad odors, deformed body parts, or torn or burned skin can be very upsetting. You may have to turn away for a moment and take a few deep breaths to get control of your feelings before you can give care. If you still are unable to give care, you can help in other ways, such as volunteering to call 9 -1-1 or the local emergency number. FEAR OF CATCHING A DISEASE Many people worry about the possibility of being infected with a disease while giving care. Although it is possible for diseases to be transmitted in a first aid situation, it is extremely unlikely that you will catch a disease this way. (For more information on disease transmission, see the Disease Transmission section in this chapter.) FEAR OF BEING SUED Sometimes people worry that they might be sued for giving care. In fact, lawsuits against people who give emergency care at a scene of an accident are highly unusual and rarely successful. Good Samaritan Laws The vast majority of states and the District of Columbia have Good Samaritan laws that protect people against claims of negligence when they give emergency care in good faith without accepting anything in return. Good Samaritan laws usually protect citizens who act the same way that a “reasonable and prudent person” would if that person were in the same situation. For example, a reasonable and prudent person would:  Move a person only if the person’s life were in danger.  Ask a conscious person for permission, also called consent, before giving care.  Check the person for life-threatening conditions before giving further care.  Call 9-1-1 or the local emergency number.  Continue to give care until more highly trained personnel take over. Good Samaritan laws were developed to encourage people to help others in emergency situations. They require the “Good Samaritan” to use common sense and a reasonable level of skill and to give only the type of emergency care for which he or she is trained. They assume each person would do his or her best to save a life or prevent further injury. Non-professionals who respond to emergencies, also called “lay responders,” rarely are sued for helping in an emergency. Good Samaritan laws protect the responder from financial responsibility. In cases in which a lay responder’s actions were deliberately negligent or reckless or when the responder abandoned the person after starting care, the courts have ruled Good Samaritan laws do not protect the responder. For more information about your state’s Good Samaritan laws, contact a legal professional or check with your local library. BEING UNSURE WHEN TO CALL 9-1-1 People sometimes are afraid to call 9-1-1 or the local emergency number because they are not sure that the situation is a real emergency and do not want to waste the time of the EMS personnel. Your decision to act in an emergency should be guided by your own val ues and by your knowledge of the risks that may be present. However, even if you decide not to give care, you should at least call 9-1-1 or the local emergency number to get emergency medical help to the scene. STEP 3: ACTIVATE THE EMS SYSTEM Activating the EMS system by calling 9-1-1 or the local emergency number is the most important step you can take in an emergency. Remember, some facilities, such as hotels, office and university buildings, and some stores, require you to dial a 9 or some other number to get an outside line before you dial 9-1-1. Also, a few areas still are without access to a 9-1-1 system and use a local emergency number instead. Becoming familiar with your local system is important because the rapid arrival of emergency medical help greatly increases a person’s chance of surviving a life-threatening emergency. When your call is answered, an emergency call taker (or dispatcher) will ask for your phone number, address, location of the emergency and questions to determine whether you need police, fire or medical assistance. You should not hang up before the call taker does so. Once EMS personnel are on the way, the call taker may stay on the line and continue to talk with you. Many call takers also are trained to give first aid instructions so they can assist you with life-saving techniques until EMS personnel take over. STEP 4: GIVE CARE UNTIL HELP TAKES OVER This manual and the American Red Cross First Aid/ CPR/AED courses provide you with the confidence, knowledge and skills you need to give care to a person in an emergency medical situation. In general, you should give the appropriate care to an ill or injured person until: You see an obvious sign of life, such as  breathing.  Another trained responder or EMS personnel take over.  You are too exhausted to continue.  The scene becomes unsafe. If you are prepared for unforeseen emergencies, you can help to ensure that care begins as soon as possible for yourself, your family and your fellow citizens. If you are trained in first aid, you can give help that can save a life in the first few minutes of an emergency. First aid can be the difference between life and death. Often, it makes the difference between complete recovery and permanent disability. By knowing what to do and acting on that knowledge, you can make a difference. GETTING PERMISSION TO GIVE CARE People have a basic right to decide what can and cannot be done to their bodies. They have the legal right to accept or refuse emergency care. Therefore, before giving care to an injured or ill person, you must obtain the person’s permission. To get permission from a conscious person, you must first tell the person who you are, how much training you have (such as training in first aid, CPR and/or AED), what you think is wrong and what you plan to do. You also must ask if you may give care. When a conscious person who understands your questions and what you plan to do gives you permission to give care, this is called expressed consent. Do not touch or give care to a conscious person who refuses it. If the person refuses care or withdraws consent at any time, step back and call for more advanced medical personnel. Sometimes, adults may not be able to give expressed consent. This includes people who are unconscious or unable to respond, confused, mentally impaired, seriously injured or seriously ill. In these cases, the law assumes that if the person could respond, he or she would agree to care. This is called implied consent. If the conscious person is a child or an infant, permission to give care must be obtained from a parent or guardian when one is available. If the condition is life threatening, permission—or consent—is implied if a parent or guardian is not present. If the parent or guardian is present but does not give consent, do not give care. Instead, call 9-1-1 or the local emergency number. DISEASE TRANSMISSION AND PREVENTION Infectious diseases—those that can spread from one person to another—develop when germs invade the body and cause illness. How Disease Spreads The most common germs are bacteria and viruses. Bacteria can live outside of the body and do not depend on other organisms for life. The number of bacteria that infect humans is small, but some cause serious infections. These can be treated with medications called antibiotics. Viruses depend on other organisms to live. Once in the body, it is hard to stop their progression. Few medications can fight viruses. The body’s immune system is its number one protection against infection. Bacteria and viruses spread from one person to another through direct or indirect contact. Direct contact occurs when germs from the person’s blood or other body fluids pass directly into your body through breaks or cuts in your skin or through the lining of your mouth, nose or eyes. Some diseases, such as the common cold, are transmitted by droplets in the air we breathe. They can be passed on through indirect contact with shared objects like spoons, doorknobs and pencils that have been exposed to the droplets. Fortunately, exposure to these germs usually is not adequate for diseases to be transmitted. Animals, including humans and insects, also can spread some diseases through bites. Contracting a disease from a bite is rare in any situation and uncommon when giving first aid care. Some diseases are spread more easily than others. Some of these, like the fl u, can create discomfort but often are temporary and usually not serious for healthy adults. Other germs can be more serious, such as the Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Human Immunodeficiency Virus (HIV), which causes Acquired Immune Deficiency Syndrome (AIDS) (see HIV and AIDS box in this chapter). Although serious, they are not easily transmitted and are not spread by casual contact, such as shaking hands. The primary way to transmit HBV, HCV or HIV during first aid care is through blood-to-blood contact. Preventing Disease Transmission By following some basic guidelines, you can greatly decrease your risk of getting or transmitting an infectious disease while giving care or cleaning up a blood spill. While Giving Care To prevent disease transmission when giving care, follow what are known as standard precautions:  Avoid contact with blood and other body fluids or objects that may be soiled with blood and other body fluids. Use protective CPR breathing barriers.  Use barriers, such as disposable gloves, between the person’s blood or body fluids and yourself.  Before putting on personal protective equipment (PPE), such as disposable gloves, cover any of your own cuts, scrapes or sores with a bandage.  Do not eat, drink or touch your mouth, nose or eyes when giving care or before you wash your hands after care has been given.  Avoid handling any of your personal items, such as pens or combs, while giving care or before you wash your hands.  Do not touch objects that may be soiled with blood or other body fluids.  Be prepared by having a first aid kit handy and stocked with PPE, such as disposable gloves, CPR breathing barriers, eye protection and other supplies.  Wash your hands thoroughly with soap and warm running water when you have finished giving care, even if you wore disposable gloves. Alcohol-based hand sanitizers allow you to clean your hands when soap and water are not readily available and your hands are not visibly soiled. (Keep alcohol-based hand sanitizers out of reach of children.)  Tell EMS personnel at the scene or your health care provider if you have come into contact with an injured or ill person’s body fluids.  If an exposure occurs in a workplace setting, follow your company’s exposure control plan for reporting incidents and follow-up (post-exposure) evaluation. While Cleaning Up Blood Spills To prevent disease transmission while cleaning up a blood spill:  Clean up the spill immediately or as soon as possible after the spill occurs (Fig. 1 -3).  Use disposable gloves and other PPE when cleaning spills.  Wipe up the spill with paper towels or other absorbent material.  If the spill is mixed with sharp objects, such as broken glass or needles, do not pick these up with your hands. Use tongs, a broom and dustpan or two pieces of cardboard to scoop up the sharp objects.  After the area has been wiped up, flood the area with an appropriate disinfectant, such as a solution of approximately 11⁄2 cups of liquid chlorine bleach to 1 gallon of fresh water (1part bleach per 9 parts water), and allow it to stand for at least 10 minutes.  Dispose of the contaminated material used to clean up the spill in a labeled biohazard container.  Contact your worksite safety representative or your local health department regarding the proper disposal of potentially infectious material. For more information on preventing disease transmission, visit the federal Occupational Safety and Health administration: http://www.osha.gov/SLTC/bloodbornepathogens/ index.html. TAKING ACTION: EMERGENCY ACTION STEPS In any emergency situation, follow the emergency action steps: 1. CHECK the scene and the person. 2. CALL 9-1-1 or the local emergency number. 3. CARE for the person. CHECK Before you can help an injured or ill person, make sure that the scene is safe for you and any bystanders (Fig. 1-4). Look the scene over and try to answer these questions:  Is immediate danger involved?  What happened?  How many people are involved?  Is anyone else available to help?  What is wrong? Is It Safe? Check for anything unsafe, such as spilled chemicals, traffic, fire, escaping steam, downed electrical lines, smoke or extreme weather. Avoid going into confined areas with no ventilation or fresh air, places where there might be poisonous gas, collapsed structures, or places where natural gas, propane or other substances could explode. Such areas should be entered by responders who have special training and equipment, such as respirators and self -contained breathing apparatus. If these or other dangers threaten, stay at a safe distance and call 9-1-1 or the local emergency number immediately. If the scene still is unsafe after you call, do not enter. Dead or injured heroes are no help to anyone! Leave dangerous situations to professionals like firefighters and police. Once they make the scene safe, you can offer to help. Is Immediate Danger Involved? Do not move a seriously injured person unless there is an immediate danger, such as fire, flood or poisonous gas; you have to reach another person who may have a more serious injury or illness; or you need to move the injured person to give proper care and you are able to do so without putting yourself in danger from the fire, flood or poisonous gas. If you must move the person, do it as quickly and carefully as possible. If there is no danger, tell the person not to move. Tell any bystanders not to move the person. What Happened? Look for clues to what caused the emergency and how the person might be injured. Nearby objects, such as a fallen ladder, broken glass or a spilled bottle of medicine, may give you information. Your check of the scene may be the only way to tell what happened. If the injured or ill person is a child, keep in mind that he or she may have been moved by well- meaning adults. Be sure to ask about this when you are checking out what happened. If you find that a child has been moved, ask the adult where the child was and how he or she was found. How Many People Are Involved? Look carefully for more than one person. You might not spot everyone at first. If one person is bleeding or screaming, you might not notice an unconscious person. It also is easy to overlook a small child or an infant. In an emergency with more than one injured or ill person, you may need to prioritize care (in other words, decide who needs help first). Is Anyone Else Available to Help? You already have learned that the presence of bystanders does not mean that a person is receiving help. You may have to ask them to help. Bystanders may be able to tell you what happened or make the call for help while you provide care. If a family member, friend or co -worker is present, he or she may know if the person is ill or has a medical condition. The injured or ill person may be too upset to answer your questions. Anyone who awakens after having been unconscious also may be frightened. Bystanders can help to comfort the person and others at the scene. A child may be especially frightened. Parents or guardians who are present may be able to calm a frightened child. They also can tell you if a child has a medical condition. What Is Wrong? When you reach the person, try to find out what is wrong. Look for signals that may indicate a life- threatening emergency. First, check to see if the injured or ill person is conscious (Fig. 1-5). Sometimes this is obvious. The person may be able to speak to you. He or she may be moaning, crying, making some other noise or moving around. If the person is conscious, reassure him or her and try to find out what happened. If the person is lying on the ground, silent and not moving, he or she may be unconscious. If you are not sure whether someone is unconscious, tap him or her on the shoulder and ask if he or she is OK. Use the person’s name if you know it. Speak loudly. If you are not sure whether an infant is unconscious, check by tapping the infant’s shoulders and shouting or flicking the bottom of the infant’s foot to see if the infant responds. Unconsciousness is a life-threatening emergency. If the person does not respond to you in any way, assume that he or she is unconscious. Make sure that someone calls 9 -1-1 or the local emergency number right away. For purposes of first aid, an adult is defined as someone about age 12 (adolescent) or older; someone between the ages of 1 and 12 is considered to be a child; and an infant is someone younger than 1 year. When using an AED, a child is considered to be someone between the ages of 1 and 8 years or weighing less than 55 pounds. Look for other signals of life-threatening injuries including trouble breathing, the absence of breathing or breathing that is not normal, and/or severe bleeding. While you are checking the person, use your senses of sight, smell and hearing. They will help you to notice anything abnormal. For example, you may notice an unusual smell that could be caused by a poison. You may see a bruise or a twisted arm or leg. You may hear the person say something that explains how he or she was injured. Checking Children and the Elderly Keep in mind that it is often helpful to take a slightly different approach when you check and care for children, infants and elderly people in an emergency situation. For more information on checking and caring for children, infants, the elderly and others with special needs, see Chapter 9. Identifying Life-Threatening Conditions At times you may be unsure if advanced medical personnel are needed. Your first aid training will help you to make this decision. The most important step you can take when giving care to a person who is unconscious or has some other life-threatening condition is to call for emergency medical help. With a life-threatening condition, the survival of a person often depends on both emergency medical help and the care you can give. You will have to use your best judgment— based on the situation, your assessment of the injured or ill person, information gained from this course and other training you may have received—to make the decision to call. When in doubt, and you think a lif e-threatening condition is present, make the call. CALL Calling 9-1-1 or the local emergency number for help often is the most important action you can take to help an injured or ill person (Fig. 1-6). It will send emergency medical help on its way as fast as possible. Make the call quickly and return to the person. If possible, ask someone else to make the call. As a general rule, call 9-1-1 or the local emergency number if the person has any of the following conditions:  Unconsciousness or an altered level of consciousness (LOC), such as drowsiness or confusion  Breathing problems (trouble breathing or no breathing)  Chest pain, discomfort or pressure lasting more than a few minutes that goes away and comes back or that radiates to the shoulder, arm, neck, jaw, stomach or back  Persistent abdominal pain or pressure Severe external bleeding (bleeding that spurts or gushes steadily from a wound)   Vomiting blood or passing blood  Severe (critical) burns  Suspected poisoning  Seizures  Stroke (sudden weakness on one side of the face/ facial droop, sudden weakness on one side of the body, sudden slurred speech or trouble getting words out or a sudden, severe headache)  Suspected or obvious injuries to the head, neck or spine  Painful, swollen, deformed areas (suspected broken bone) or an open fracture Also call 9-1-1 or the local emergency number immediately for any of these situations:  Fire or explosion  Downed electrical wires  Swiftly moving or rapidly rising water  Presence of poisonous gas  Serious motor-vehicle collisions  Injured or ill persons who cannot be moved easily Deciding to Call First or Care First If you are ALONE:  Call First (call 9-1-1 or the local emergency number before giving care) for: o Any adult or child about 12 years of age or older who is unconscious. o A child or an infant who you witnessed suddenly collapse. o An unconscious child or infant known to have heart problems.  Care First (give 2 minutes of care, then call 9-1-1 or the local emergency number) for: o An unconscious child (younger than about 12 years of age) who you did not see collapse. o Any drowning victim. Call First situations are likely to be cardiac emergencies, where time is a critical factor. In Care First situations, the conditions often are related to breathing emergencies. CARE Once you have checked the scene and the person and have made a decision about calling 9 -1- 1 or the local emergency number, you may need to give care until EMS personnel take over. After making the 9-1-1 call, immediately go back to the injured or ill person. Check the person for life- threatening conditions and give the necessary care. To do so, follow these general guidelines:  Do no further harm.  Monitor the person’s breathing and consciousness.  Help the person rest in the most comfortable position.  Keep the person from getting chilled or overheated.  Reassure the person.  Give any specific care as needed. Transporting the Person, Yourself In some cases, you may decide to take the injured or ill person to a medical facility yourself instead of waiting for EMS personnel. NEVER transport a person:  When the trip may aggravate the injury or illness or cause additional injury.  When the person has or may develop a life-threatening condition.  If you are unsure of the nature of the injury or illness. If you decide it is safe to transport the person, ask someone to come with you to keep the person comfortable. Also, be sure you know the quickest route to the nearest medical facility capable of handling emergency care. Pay close attention to the injured or ill person and watch for any changes in his or her condition. Discourage an injured or ill person from driving him- or herself to the hospital. An injury may restrict movement, or the person may become groggy or faint. A sudden onset of pain may be distracting. Any of these conditions can make driving dangerous for the person, passengers, other drivers and pedestrians. Moving an Injured or Ill Person One of the most dangerous threats to a seriously injured or ill person is unnecessary movement. Moving an injured person can cause additional injury and pain and may complicate his or her recovery. Generally, you should not move an injured or ill person while giving care. However, it would be appropriate in the following three situations: 1. When you are faced with immediate danger, such as fire, lack of oxygen, risk of explosion or a collapsing structure. 2. When you have to get to another person who may have a more serious problem. In this case, you may have to move a person with minor injuries to reach someone needing immediate care. 3. When it is necessary to give proper care. For example, if someone needed CPR, he or she might have to be moved from a bed because CPR needs to be performed on a firm, flat surface. If the surface or space is not adequate to give care, the person should be moved. Techniques for Moving an Injured or Ill Person Once you decide to move an injured or ill person, you must quickly decide how to do so. Carefully consider your safety and the safety of the person. Move an injured or ill person only when it is safe for you to do so and there is an immediate life threat. Base your decision on the dangers you are facing, the size and condition of the person, your abilities and physical condition, and whether you have any help. To improve your chances of successfully moving an injured or ill person without injuring yourself or the person:  Use your legs, not your back, when you bend.  Bend at the knees and hips and avoid twisting your body.  Walk forward when possible, taking small steps and looking where you are going.  Avoid twisting or bending anyone with a possible head, neck or spinal injury.  Do not move a person who is too large to move comfortably. You can move a person to safety in many different ways, but no single way is best for every situation. The objective is to move the person without injuring yourself or causing further injury to the person. The following common types of emergency moves can all be done by one or two people and with minimal to no equipment. Types of Non-Emergency Moves Walking Assist The most basic emergency move is the walking assist. Either one or two responders can use this method with a conscious person. To perform a walking assist, place the injured or ill person’s arm across your shoulders and hold it in place with one hand. Support the person with your other hand around the person’s waist. In this way, your body acts as a crutch, supporting the person’s weight while you both walks. A second responder, if present, can support the person in the same way on the other side. Do not use this assist if you suspect that the person has a head, neck or spinal injury. 1. This is for someone who has suffered a minor injury and merely feels weak. He can still walk, but needs help. 2. Bring one arm over your shoulder. 3. Grasp his wrist with the hand now below the arm. 4. Place your free arm around his waist. 5. In this manner, walk slowly to your destination. Allow the victim to set the pace. Two-Person Seat Carry The two-person seat carry requires a second responder. This carry can be used for any person who is conscious and not seriously injured. Put one arm behind the person’s thighs and the other across the person’s back. Interlock your arms with those of a second responder behind the person’s legs and across his or her back. Lift the person in the “seat” formed by the responders’ arms. Responders should coordinate their movement so they walk together. Do not use this assist if you suspect that the person has a head, neck or spinal injury. 1. This is another carry for two rescuers. It will work for an unconscious victim as well as a conscious one. 2. The two rescuers kneel down on either side of the victim. 3. Each rescuer slides one arm under the victim's back, and one under his thighs. 4. The bearers grasp each others wrists and shoulders. 5. They then rise from the ground slowly with the patient supported between them. 6. The two walk slowly to their destination. In all rescues, call emergency care as soon as possible. Types of Emergency Moves Pack-Strap Carry The pack-strap carry can be used with conscious and unconscious persons. Using it with an unconscious person requires a second responder to help position the injured or ill person on your back. To perform the pack-strap carry, have the person stand or have a second responder support the person. Position yourself with your back to the person, back straight, knees bent, so that your shoulders fi t into the person’s armpits. Cross the person’s arms in front of you and grasp the person’s wrists. Lean forward slightly and pull the person up and onto your back. Stand up and walk to safety. Depending on the size of the person, you may be able to hold both of his or her wrists with one hand, leaving your other hand free to help maintain balance, open doors and remove obstructions. Do not use this assist if you suspect that the person has a head, neck or spinal injury. 1. This is for a victim who is too tired to walk, and you have no one else to assist you with the carrying. 2. Kneel in front of the victim with your back to his chest. 3. Grasp his hands over your chest. 4. Slowly stand up, lifting with your legs to avoid straining your back. 5. Carry the victim piggyback to your destination. If the victim is small enough to carry in front of you, this may work easier than heaving them over your back. Place one arm around their back and the other hand under their legs. This carry is used mainly for women and children. Clothes Drag The clothes drag can be used to move a conscious or unconscious person with a suspected head, neck or spinal injury. This move helps keep the person’s head, neck and back stabilized. Grasp the person’s clothing behind the neck, gathering enough to secure a firm grip. Using the clothing, pull the person (headfirst) to safety. During this move, the person’s head is cradled by clothing and the responder’s arms. Be aware that this move is exhausting and may cause back strain for the responder, even when done properly. Blanket Drag The blanket drag can be used to move a person in an emergency situation when equipment is limited. Keep the person between you and the blanket. Gather half of the blanket and place it against the person’s side. Roll the person as a unit toward you. Reach over and place the blanket so that it is positioned under the person, then roll the person onto the blanket. Gather the blanket at the head and move the person. Ankle Drag Use the ankle drag (also known as the foot drag) to move a person who is too large to carry or move in any other way. Firmly grasp the person’s ankles and move backward. The person’s arms should be crossed on his or her chest. Pull the person in a straight line, being careful not to bump the person’s head. Reaching a Person in the Water Do not enter the water unless you are specifically trained to perform in-water rescues. Get help from a trained responder, such as a lifeguard, to get the person out of the water as quickly and safely as possible. You can help a person in trouble in the water from a safe position by using reaching assists, throwing assists or wading assists. When possible, start by talking to the person. Let the person know that help is coming. If noise is a problem or if the person is too far away to hear you, use nonverb al communication. Direct the person what to do, such as grasping a line, ring buoy or other object that fl oats. Ask the person to move toward you, which may be done by using the back fl oat with slight leg movements or small strokes. Some people can reach safety by themselves with the calm and encouraging assistance of someone calling to them. Reaching Assists. Firmly brace yourself on a pool deck, pier or shoreline and reach out to the person with any object that will extend your reach, such as a pole, oar or paddle, tree branch, shirt, belt or towel. If no equipment is available, you can still perform a reaching assist by lying down and extending your arm or leg for the person to grab. Throwing Assists. An effective way to rescue someone beyond your reach is to throw a floating object out to the person with a line attached. Once the person grasps the object, pull the individual to safety. Throwing equipment includes heaving lines, ring buoys, throw bags or any floating object available, such as a picnic jug, small cooler, buoyant cushion, kickboard or extra life jacket. CHECKING A CONSCIOUS PERSON If you determine that an injured or ill person is conscious and has no immediate life -threatening conditions, you can begin to check for other conditions that may need care. Checking a conscious person with no immediate life-threatening conditions involves two basic steps:  Interview the person and bystanders.  Check the person from head to toe. Conducting Interviews Ask the person and bystanders simple questions to learn more about what happened. Keep these interviews brief. Remember to first identify yourself and to get the person’s consent to give care. Begin by asking the person’s name. This will make him or her feel more comfortable. Gather additional information by asking the person the following questions:  What happened?  Do you feel pain or discomfort anywhere?  Do you have any allergies?  Do you have any medical conditions or are you taking any medication? If the person feels pain, ask him or her to describe it and to tell you where it is located. Descriptions often include terms such as burning, crushing, throbbing, aching or sharp pain. Ask when the pain started and what the person was doing when it began. Ask the person to rate his or her pain on a scale of 1 to 10 (1 being mild and 10 being severe). Sometimes an injured or ill person will not be able to give you the information that you need. The person may not speak your language. In some cases, the person may not be able to speak because of a medical condition. Known as a laryngectomee, a person whose larynx (voice box) was surgically removed breathes through a permanent opening, or stoma, in the neck and may not be able to speak. Remember to question family members, friends or bystanders as well. They may be able to give you helpful information or help you to communicate with the person. Children or infants may be frightened. They may be fully aware of you but still unable to answer your questions. In some cases, they may be crying too hard and be unable to stop. Approach slowly and gently, and give the child or infant some time to get used to you. Use the child’s name, if you know it. Get down to or below the child’s eye level. Write down the information you learn during the interviews or, preferably, have so meone else write it down for you. Be sure to give the information to EMS personnel when they arrive. It may help them to determine the type of medical care that the person should receive. Checking from Head to Toe Next you will need to thoroughly check the injured or ill person so that you do not overlook any problems. Visually check from head to toe. When checking a conscious person:  Do not move any areas where there is pain or discomfort, or if you suspect a head, neck or spinal injury.  Check the person’s head by examining the scalp, face, ears, mouth and nose.  Look for cuts, bruises, bumps or depressions. Think of how the body usually looks. If you are unsure if a body part or limb looks injured, check it against the opposite limb or the other side of the body.  Watch for changes in consciousness. Notice if the person is drowsy, confused or is not alert.  Look for changes in the person’s breathing. A healthy person breathes easily, quietly, regularly and without discomfort or pain. Young children and infants generally breathe faster than adults. Breathing that is not normal includes noisy breathing, such as gasping for air; rasping, gurgling or whistling sounds; breathing that is unusually fast or slow; and breathing that is painful.  Notice how the skin looks and feels. Skin can provide clues that a person is injured or ill. Feel the person’s forehead with the back of your hand to determine if the skin feels unusually damp, dry, cool or hot. Note if it is red, pale or ashen.  Look over the body. Ask again about any areas that hurt. Ask the person to move each part of the body that does not hurt. Ask the person to gently move his or her head from side to side. Check the shoulders by asking the person to shrug them. Check the chest and abdomen by asking the person to take a deep breath. Ask the person to move his or her fingers, hands and arms; and then the toes, legs and hips in the same way. Watch the person’s face and listen for signals of discomfort or pain as you check for injuries.  Look for a medical identification (ID) tag, bracelet or necklace on the person’s wrist, neck or ankle. A tag will provide medical information about the person, explain how to care for certain conditions and list whom to call for help. For example, a person with diabetes may have some form of medical ID tag, bracelet or necklace identifying this condition. If a child or an infant becomes extremely upset, conduct a toe-to-head check of the child or infant. This will be less emotionally threatening. Parents or guardians who are present may be able to calm a frightened child. In fact, it often is helpful to check a young child while he or she is seated in his or her parent’s or guardian’s lap. Parents also can tell you if a child has a medical condition. When you have finished checking, determine if the person can move his or her body without any pain. If the person can move without pain and there are no other signals of injury, have him or her attempt to rest in a sitting position or other comfortable position (Fig. 1-16). When the person feels ready, help him or her to stand up. Determine what additional care is needed and whether to call 9-1-1 or the local emergency number. SHOCK When the body is healthy, three conditions are needed to keep the right amount of blood fl owing:  The heart must be working well.  An adequate amount of oxygen-rich blood must be circulating in the body.  The blood vessels must be intact and able to adjust blood flow. Shock is a condition in which the circulatory system f ails to deliver enough oxygen-rich blood to the body’s tissues and vital organs. The body’s organs, such as the brain, heart and lungs, do not function properly without this blood supply. This triggers a series of responses that produce specific signals known as shock. These responses are the body’s attempt to maintain adequate blood flow. When someone is injured or becomes suddenly ill, these normal body functions may be interrupted. In cases of minor injury or illness, this interruption is brief because the body is able to compensate quickly. With more severe injuries or illnesses, however, the body may be unable to adjust. When the body is unable to meet its demand for oxygen because blood fails to circulate adequately, shock occurs. WHAT TO LOOK FOR? The signals that indicate a person may be going into shock include:  Restlessness or irritability.  Altered level of consciousness.  Nausea or vomiting.  Pale, ashen or grayish, cool, moist skin.  Rapid breathing and pulse.  Excessive thirst. Be aware that the early signals of shock may not be present in young children and infants. However, because children are smaller than adults, they have less blood volume and are more susceptible to shock. WHEN TO CALL 9-1-1 In cases where the person is going into shock, call 9-1-1 or the local emergency number immediately. Shock cannot be managed effectively by first aid alone. A person suffering from shock requires emergency medical care as soon as possible. WHAT TO DO UNTIL HELP ARRIVES? Caring for shock involves the following simple steps:  Have the person lie down. This often is the most comfortable position. Helping the person rest in a more comfortable position may lessen any pain. Helping the person to rest comfortably is important because pain can intensify the body’s stress and speed up the progression of shock.  Control any external bleeding.  Since you may not be sure of the person’s condition, leave him or her lying fl at.  Help the person maintain normal body temperature. If the person is cool, try to cover him or her to avoid chilling.  Do not give the person anything to eat or drink, even though he or she is likely to be thirsty. The person’s condition may be severe enough to require surgery, in which case it is better if the stomach is empty.  Reassure the person.  Continue to monitor the person’s breathing and for any changes in the person’s condition. Do not wait for signals of shock to develop before caring for the underlying injury or illness. CHECKING AN UNCONSCIOUS PERSON If you think someone is unconscious, tap him or her on the shoulder and ask if he or she is OK. Use the person’s name if you know it. Speak loudly. If you are not sure whether an infant is unconscious, check by tapping the infant’s shoulder and shouting or by flicking the bottom of the infant’s foot to see if the infant responds. If the person does not respond, call 9-1-1 or the local emergency number and check for other life- threatening conditions. Always check to see if an unconscious person:  Has an open airway and is breathing normally?  Is bleeding severely. Consciousness, effective (normal) breathing and circulation and skin characteristics sometimes are referred to as signs of life. Airway Once you or someone else has called 9-1-1 or the local emergency number, check to see if the person has an open airway and is breathing. An open airway allows air to enter the lungs for the person to breathe. If the airway is blocked, the person cannot breathe. A blocked airway is a life- threatening condition.  When someone is unconscious and lying on his or her back, the tongue may fall to the back of the throat and block the airway. To open an unconscious person’s airway, push down on his or her forehead while pulling up on the bony part of the chin with two or three fingers of your other hand. This procedure, known as the head-tilt/chin-lift technique, moves the tongue away from the back of the throat, allowing air to enter the lungs. o For a child: Place one hand on the forehead and tilt the head slightly past a neutral position (the head and chin are neither flexed downward toward the chest nor extended backward). o For an infant: Place one hand on the forehead and tilt the head to a neutral position while pulling up on the bony part of the chin with two or three fingers of your other hand.  If you suspect that a person has a head, neck or spinal injury, carefully tilt the head and lift the chin just enough to open the airway. Check the person’s neck to see if he or she breathes through an opening. A person whose larynx was removed may breathe partially or entirely through a stoma instead of through the mouth. person may breathe partially or entirely through this opening instead of through the mouth and nose. It is important to recognize this difference in the way a person breathes. This will help you give proper care. Breathing After opening the airway, quickly check an unconscious person for breathing. Position yourself so that you can look to see if the person’s chest clearly rises and falls, listen for escaping air and feel for it against the side of your face. Do this for no more than 10 seconds. If the person needs CPR, chest compressions must not be delayed. Normal breathing is regular, quiet and effortless. A person does not appear to be working hard or struggling when breathing normally. This means that the person is not making noise when breathing, breaths are not fast (although it should be noted that normal breathing rates in children and infants are faster than normal breathing rates in adults) and breathing does not cause discomfort or pain. In an unconscious adult you may detect an irregular, gasping or shal low breath. This is known as an agonal breath. Do not confuse this with normal breathing. Care for the person as if there is no breathing at all. Agonal breaths do not occur frequently in children. If the person is breathing normally, his or her heart is beating and is circulating blood containing oxygen. In this case, maintain an open airway by using the head-tilt/chin-lift technique as you continue to look for other life-threatening conditions. If an adult is not breathing normally, this person most likely needs immediate CPR. If a child or an infant is not breathing, give 2 rescue breaths. Tilt the head back and lift chin up. Pinch the nose shut then make a complete seal over the child’s mouth and blow in for about 1 second to make the chest clearly rise. For an infant, seal your mouth over the infant’s mouth and nose. Give rescue breaths one after the other. If you witness the sudden collapse of a child, assume a cardiac emergency. Do not give 2 rescue breaths. CPR needs to be started immediately, just as with an adult. Sometimes you may need to remove food, liquid or other objects that are blocking the person’s airway. This may prevent the chest from rising when you attempt rescue breaths. You will learn how to recognize an obstructed airway and give care to the person in Chapter 4. Circulation It is important to recognize breathing emergencies in children and infants and to act before the heart stops beating. Adults’ hearts frequently stop beating because of disease. Children’s and infants’ hearts, however, are usually healthy. When a child’s or an infant’s heart stops, it usually is the result of a breathing emergency. If an adult is not breathing or is not breathing normally and if the emergency is not the result of non-fatal drowning or other respiratory cause such as a drug overdose, assume that the problem is a cardiac emergency. Quickly look for severe bleeding by looking over the person’s body from head to toe for signals such as blood-soaked clothing or blood spurting out of awound (Fig. 1-23). Bleeding usually looks worse than it is. A small amount of blood on a slick surface or mixed with water usually looks like a large volume of blood. It is not always easy to recognize severe bleeding.  CHAPTER 2 CARDIAC EMERGENCIES AND CPR LESSON OBJECTIVES - Recognize the signals of a cardiac emergency. - Identify the links in the Cardiac Chain of Survival. - Describe how to care for a heart attack. - List the causes of cardiac arrest. - Explain the role of CPR in cardiac arrest. - Demonstrate how to perform CPR INTRODUCTION Cardiac emergencies are life threatening. Heart attack and cardiac arrest are major causes of illness and death in the United States. Every day in U.S. homes, parks and workplaces someone will have a heart attack or go into cardiac arrest. Recognizing the signals of a heart attack and cardiac arrest, calling 9-1-1 or the local emergency number and giving immediate care in a cardiac emergency saves lives. Performing CPR and using an automated external defibrillator (AED) immediately after a person goes into cardiac arrest can greatly increase his or her chance of survival. In this chapter you will find out what signals to look for if you suspect a person is having a heart attack or has gone into cardiac arrest. This chapter also discusses how to care for a person having a heart attack and how to perform CPR for a person in cardiac arrest. In addition, this chapter covers the important links in the Cardiac Chain of Survival. Although cardiac emergencies occur more commonly in adults, they also occur in infants and children. This chapter discusses the causes of cardiac arrest and how to provide care for all age groups. BACKGROUND The heart is a fascinating organ. It beats more than 3 billion times in an average lifetime. The heart is about the size of a fist and lies between the lungs in the middle of the chest. It pumps blood throughout the body. The ribs, breastbone and spine protect it from injury. The heart is separated into right and left halves. Blood that contains little or no oxygen enters the right side of the heart and is pumped to the lungs. The blood picks up oxygen in the lungs when you breathe. The oxygen-rich blood then goes to the left side of the heart and is pumped from the heart’s blood vessels, called the arteries, to all other parts of the body. The heart and your body’s vital organs need this constant supply of oxygen-rich blood. Cardiovascular disease is an abnormal condition that affects the heart and blood vessels. An estimated 80 million Americans suffer from some form of the disease. It remains the number one killer in the United States and is a major cause of disability. The most common conditions caused by cardiovascular disease include coronary heart disease, also known as coronary artery disease, and stroke, also called a brain attack. Coronary heart disease occurs when the arteries that supply blood to the heart muscle harden and narrow. This process is called atherosclerosis. The damage occurs gradually, as cholesterol and fatty deposits called plaque build-up on the inner artery walls. As this build-up worsens, the arteries become narrower. This reduces the amount of blood that can flow through them and prevents the heart from getting the blood and oxygen it needs. If the heart does not get blood containing oxygen, it will not work properly. Coronary heart disease accounts for about half of the greater than 800,000 adults who die each year from cardiovascular disease. When the heart is working normally, it beats evenly and easily, with a steady rhythm. When damage to the heart causes it to stop working effectively, a person can experience a heart attack or other damage to the heart muscle. A heart attack can cause the heart to beat in an irregular way. This may prevent blood from circulating effectively. When the heart does not work properly, normal breathing can be disrupted or stopped. A heart attack also can cause the heart to stop beating entirely. This condition is called cardiac arrest. The number one cause of heart attack and cardiac arrest in adults is coronary heart disease. Other significant causes of cardiac arrest are non-heart related (e.g., poisoning or drowning). HEART ATTACK When blood flow to the heart muscle is reduced, people experience chest pain. This reduced blood flow usually is caused by coronary heart disease. When the blood and oxygen supply to the heart is reduced, a heart attack may result. What to Look For? A heart attack can be indicated by common signals. Even people who have had a heart attack may not recognize the signals, because each heart attack may not show the same signals. You should be able to recognize the following signals of a heart attack so that you can give prompt and proper care:  Chest pain, discomfort or pressure. The most common signal is persistent pain, discomfort or pressure in the chest that lasts longer than 3 to 5 minutes or goes away and comes back. Unfortunately, it is not always easy to distinguish heart attack pain from the pain of indigestion, muscle spasms or other conditions. This often causes people to delay getting medical care. Brief, stabbing pain or pain that gets worse when you bend or breathe deeply usually is not caused by a heart problem. o The pain associated with a heart attack can range from discomfort to an unbearable crushing sensation in the chest. o The person may describe it as pressure, squeezing, tightness, aching or heaviness in the chest. o Many heart attacks start slowly as mild pain or discomfort. o Often the person feels pain or discomfort in the center of the chest (Fig. 2-3). o The pain or discomfort becomes constant. It usually is not relieved by resting, changing position or taking medicine. o Some individuals may show no signals at all.  Discomfort in other areas of the upper body in addition to the chest. Discomfort, pain or pressure may also be felt in or spread to the shoulder, arm, neck, jaw, stomach or back.  Trouble breathing. Another signal of a heart attack is trouble breathing. The person may be breathing faster than normal because the body tries to get the much-needed oxygen to the heart. The person may have noisy breathing or shortness of breath.  Other signals. The person’s skin may be pale or ashen (gray), especially around the face. Some people suffering from a heart attack may be damp with sweat or may sweat heavily, feel dizzy, become nauseous or vomit. They may become fatigued, lightheaded or lose consciousness. These signals are caused by the stress put on the body when the heart does not work as it should. Some individuals may show no signals at all.  Differences in signals between men and women. Both men and women experience the most common signal for a heart attack: chest pain or discomfort. However, it is important to note that women are somewhat more likely to experience some of the other warning signals, particularly shortness of breath, nausea or vomiting, back or jaw pain and unexplained fatigue or malaise. When they do experience chest pain, women may have a greater tendency to have atypical chest pain: sudden, sharp but short-lived pain outside of the breastbone. When to Call 9-1-1? Remember, the key signal of a heart attack is persistent chest pain or discomfort that lasts more than 3 to 5 minutes or goes away and comes back. If you suspect the person is having a heart attack based on his or her signals, call 9-1-1 or the local emergency number immediately. A person having a heart attack probably will deny that any signal is serious. Do not let this influence you. If you think the person might be having a heart attack, act quickly. What to Do Until Help Arrives? It is important to recognize the signals of a heart attack and to act on those signals. Any heart attack might lead to cardiac arrest, but prompt action may prevent further damage to the heart. A person suffering from a heart attack, and whose heart is still beating, has a far better chance of living than does a person whose heart has stopped. Most people who die of a heart attack die within 2 hours of the first signal. Many could have been saved if people on the scene or the person having the heart attack had been aware of the signals and acted promptly. Many people who have heart attacks delay seeking care. Nearly half of all heart attack victims wait for 2 hours or more before going to the hospital. Often, they do not realize they are having a heart attack. They may say the signals are just muscle soreness, indigestion or heartburn. Early treatment with certain medications—including aspirin—can help minimize damage to the heart after a heart attack. To be most effective, these medications need to be given within 1 hour of the start of heart attack signals. If you suspect that someone might be having a heart attack, you should:  Call 9-1-1 or the local emergency number immediately.  Have the person stop what he or she is doing and rest comfortably (Fig. 2-4).  This will ease the heart’s need for oxygen. Many people experiencing a heart attack find it easier to breathe while sitting.  Loosen any tight or uncomfortable clothing.  Closely watch the person until advanced medical personnel take over. Notice any changes in the person’s appearance or behavior. Monitor the person’s condition.  Be prepared to perform CPR and use an AED, if available, if the person loses consciousness and stops breathing. Ask the person if he or she has a history of heart disease. Some people with heart disease take prescribed medication for chest pain. You can help by getting the medication for the person and assisting him or her  with taking the prescribed medication.  Offer aspirin, if medically appropriate and local protocols allow, and if the patient can swallow and has no known contraindications (see the following section). Be sure that the person has not been told by his or her health care provider to avoid taking aspirin.  Be calm and reassuring. Comforting the person helps to reduce anxiety and eases some of the discomfort.  Talk to bystanders and if possible, the person to get more information.  Do not try to drive the person to the hospital yourself. He or she could quickly get worse on the way. Giving Aspirin to Lessen Heart Attack Damage You may be able to help a conscious person who is showing early signals of a heart attack by offering him or her an appropriate dose of aspirin when the signals first begin. However, you should never delay calling 9-1-1 or the local emergency number to do this. Always call for help as soon as you recognize the signals of a heart attack. Then help the person to be comfortable before you give the aspirin. If the person is able to take medicine by mouth, ask:  Are you allergic to aspirin?  Do you have a stomach ulcer or stomach disease?  Are you taking any blood thinners, such as warfarin (Coumadin™)?  Have you ever been told by a doctor to avoid taking aspirin? If the person answers no to all of these questions, you may offer him or her two chewable (81 mg each) baby aspirins, or one 5-grain (325 mg) adult aspirin tablet with a small amount of water. Do not use coated aspirin products or products meant for multiple uses such as for cold, fever and headache. You also may offer these doses of aspirin if the person regains consciousness while you are giving care and is able to take the aspirin by mouth. Be sure that you offer only aspirin and not Tylenol®, acetaminophen or nonsteroidal anti- inflamatory drugs (NSAIDs), such as ibuprofen, Motrin®, Advil®, naproxen and Aleve®. CARDIAC ARREST Cardiac arrest occurs when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs. The beats, or contractions, of the heart become ineffective if they are weak, irregular or uncoordinated, because at that point the blood no longer flows through the arteries to the rest of the body. When the heart stops beating properly, the body cannot survive. Breathing will soon stop, and the body’s organs will no longer receive the oxygen they need to function. Without oxygen, brain damage can begin in about 4 to 6 minutes, and the damage can become irreversible after about 10 minutes. A person in cardiac arrest is unconscious, not breathing and has no heartbeat. The heart has either stopped beating or is beating weakly and irregularly so that a pulse cannot be detected. Cardiovascular disease is the primary cause of cardiac arrest in adults. Cardiac arrest also results from drowning, choking, drug abuse, severe injury, brain damage and electrocution.  Causes of cardiac arrest in children and infants include airway and breathing problems, traumatic injury, a hard blow to the chest, congenital heart disease and sudden infant death syndrome (SIDS). Cardiac arrest can happen suddenly, without any of the warning signs usually seen in a heart attack. This is known as sudden cardiac arrest or sudden cardiac death and accounts for more than 300,000 deaths annually in the United States. Sudden cardiac arrest is caused by abnormal, chaotic electrical activity of the heart (known as arrhythmias). The most common life- threatening abnormal arrhythmia is ventricular fibrillation (V-fi b). What to Look For? The main signals of cardiac arrest in an adult, a child and an infant are unconsciousness and no breathing. The presence of these signals means that no blood and oxygen are reaching the person’s brain and other vital organs. When to Call 9-1-1 Call 9-1-1 or the local emergency number immediately if you suspect that a person is in cardiac arrest or you witness someone suddenly collapse. What to Do Until Help Arrives Perform CPR until an AED is available and ready to use or advanced medical personnel take over. Early CPR and Defibrillation A person in cardiac arrest needs immediate CPR and defibrillation. The cells of the brain and other important organs continue to live for a short time— until all of the oxygen in the blood is used. Cardio Pulmonary Resuscitation (CPR) A combination of chest compressions and rescue breaths. When the heart is not beating, chest compressions are needed to circulate blood containing oxygen. Given together, rescue breaths and chest compressions help to take over for the heart and lungs. CPR increases the chances of survival for a person in cardiac arrest. In many cases, however, CPR alone cannot correct the underlying heart problem: defibrillation delivered by an AED is needed. This shock disrupts the heart’s electrical activity long enough to allow the heart to spontaneously develop an effective rhythm on its own. Without early CPR and early defibrillation, the chances of survival are greatly reduced. (Using an AED is discussed in detail in Chapter 3.) CPR FOR ADULTS To determine if an unconscious adult needs CPR, follow the emergency action steps (CHECK—CALL— CARE) that you learned in Chapter 1. CHECK the scene and the injured or ill person. CALL 9-1-1 or the local emergency number. CHECK for breathing for no more than 10 seconds. Quickly  CHECK for severe bleeding. (If the person is not breathing) CARE by beginning CPR. For chest compressions to be the most effective, the person should be on his or her back on a firm, flat surface. If the person is on a soft surface like a sofa or bed, quickly move him or her to a firm, flat surface before you begin. To perform CPR on an adult:  Position your body correctly by kneeling beside the person’s upper chest, placing your hands in the correct position, and keeping your arms and elbows as straight as possible so that your shoulders are directly over your hands. Your body position is important when giving chest compressions. Compressing the person’s chest straight down will help you reach the necessary depth. Using the correct body position also will be less tiring for you.  Locate the correct hand position by placing the heel of one hand on the person’s sternum (breastbone) at the center of his or her chest. Place your other hand directly on top of the first hand and try to keep your fingers off of the chest by interlacing them or holding them upward. If you feel the notch at the end of the sternum, move your hands slightly toward the person’s head. If you have arthritis in your hands, you can give compressions by grasping the wrist of the hand positioned on the chest with your other hand. The person’s clothing should not interfere with finding the proper hand position or your ability to give effective compressions. If it does, loosen or remove enough clothing to allow deep compressions in the center of the person’s chest.  Give 30 chest compressions. Push hard, push fast at a rate of at least 100 compressions per minute. Note that the term “100 compressions per minute” refers to the speed of compressions, not the number of compressions given in a minute. As you give compressions, count out loud, “One and two and three and four and five and six and…” up to 30. Push down as you say the number and come up as you say “and.”, This will help you to keep a steady, even rhythm.  Give compressions by pushing the sternum down at least 2 inches. The downward and upward movement should be smooth, not jerky. Push straight down with the weight of your upper body, not with your arm muscles. This way, the weight of your upper body will create the force needed to compress the chest. Do not rock back and forth. Rocking results in less- effective compressions and wastes much needed energy. If your arms and shoulders tire quickly, you are not using the correct body position. After each compression, release the pressure on the chest without removing your hands or changing hand position. Allow the chest to return to its normal position before starting the next compression. Maintain a steady down-and-up rhythm and do not pause between compressions. Spend half of the time pushing down and half of the time coming up. When you press down, the walls of the heart squeeze together, forcing the blood to empty out of the heart. When you come up, you should release all pressure on the chest, but do not take hands off the chest. This allows the heart’s chambers to fill with blood between compressions.  Once you have given 30 compressions, open the airway using the head-tilt/chin-lift technique and give 2 rescue breaths. Each rescue breath should last about 1 second and make the chest clearly rise.  o Open the airway and give rescue breaths, one after the other. o Tilt the head back and lift the chin up. o Pinch the nose shut then make a complete seal over the person’s mouth. o Blow in for about 1 second to make the chest clearly rise. o Continue cycles of chest compressions and rescue breaths. o Each cycle of chest compressions and rescue breaths should take about 24 seconds. Minimize the interruption of chest compressions. If Two Responders Are Available If two responders trained in CPR are at the scene, both should identify themselves as being trained. One should call 9-1-1 or the local emergency number for help while the other performs CPR. If the first responder is tired and needs help:  The first responder should tell the second responder to take over.  The second responder should immediately take over CPR, beginning with chest compressions. When to Stop CPR Once you begin CPR, do not stop except in one of these situations:  You notice an obvious sign of life, such as breathing.  An AED is available and ready to use.  Another trained responder or EMS personnel take over.  You are too exhausted to continue.  The scene becomes unsafe. If at any time you notice that the person is breathing, stop CPR. Keep his or her airway open and continue to monitor the person’s breathing and for any changes in the person’s condition until EMS personnel take over. CARDIAC EMERGENCIES IN CHILDREN AND INFANTS It is rare for a child or an infant to initially suffer a cardiac emergency. Usually, a child or an infant has a respiratory emergency first and then a cardiac emergency develops. Causes of cardiac arrest in children and infants include:  Airway and breathing problems.  Traumatic injury or an accident (e.g., motor-vehicle collision, drowning, electrocution or poisoning).  A hard blow to the chest.  Congenital heart disease.  Sudden infant death syndrome (SIDS).  If you recognize that a child or an infant is not breathing, begin CPR. CPR FOR CHILDREN AND INFANTS Follow the emergency action steps (CHECK— CALL—CARE) to determine if you will need to perform CPR for a child or an infant. The principles of CPR (compressing the chest and giving rescue breaths) are the same for children and infants as for adults. However, the CPR techniques are slightly different since children’s and infants’ bodies are smaller. CPR FOR A CHILD  If during the unconscious check you find that the child is not breathing, place the child face-up on a firm, flat surface. Begin CPR by following these steps:  Locate the proper hand position on the middle of the breastbone as you would for an adult. If you feel the notch at the end of the sternum, move your hands slightly toward the child’s head.  Position your body as you would for an adult, kneeling next to the child’s upper chest, positioning your shoulders over your hands and keeping your arms and elbows as straight as possible.  Give 30 chest compressions. Push hard, push fast to a depth of about 2 inches and at a rate of at least 100 compressions per minute. Lift up, allowing the chest to fully return to its normal position, but keep contact with the chest.  After giving 30 chest compressions, open the airway and give 2 rescue breaths. Each rescue breath should last about 1 second and make the chest clearly rise. Use the head-tilt/chin-lift technique to ensure that the child’s airway is open. Continue cycles of 30 chest compressions and 2 rescue breaths. Do not stop CPR except in one of these situations:  You find an obvious sign of life, such as breathing.  An AED is ready to use.  Another trained responder or EMS personnel take over.  You are too exhausted to continue.  The scene becomes unsafe. If at any time you notice the child begin to breathe, stop CPR, keep the airway open and monitor breathing and for any changes in the child’s condition until EMS personnel take over. CPR FOR AN INFANT If during your check you find that the infant is not breathing, begin CPR by following these steps:  Find the correct location for compressions. Keep one hand on the infant’s forehead to maintain an open airway. Use the pads of two or three fingers of your other hand to give chest compressions on the center of the chest, just below the nipple line (toward the infant’s feet). If you feel the notch at the end of the infant’s sternum, move your fingers slightly toward the infant’s head.  Give 30 chest compressions using the pads of these fingers to compress the chest. Compress the chest about 1½ inches. Push hard, push fast. Your compressions should be smooth, not jerky. Keep a steady rhythm. Do not pause between each compression. When your fingers are coming up, release pressure on the infant’s chest completely but do not let your fingers lose contact with the chest. Compress at a rate of at least 100 compressions per minute.  After giving 30 chest compressions, give 2 rescue breaths, covering the infant’s mouth and nose with your mouth. Each rescue breath should last about 1 second and make the chest clearly rise. Continue cycles of 30 chest compressions and 2 rescue breaths. Do not stop CPR except in one of these situations:  You find an obvious sign of life, such as breathing.  An AED is ready to use.  Another trained responder or EMS personnel take over.  You are too exhausted to continue.  The scene becomes unsafe.  If at any time you notice the infant begin to breathe, stop CPR, keep the airway open and monitor breathing and for any changes in the infant’s condition until EMS personnel take over. IF CHEST DOES NOT RISE WITH RESCUE BREATHS If the chest does not rise with the initial rescue breath, retilt the head before giving the second breath. If the second breath does not make the chest rise, the person may be choking. After each subsequent set of chest compressions and before attempting breaths, look for an object and, if seen, remove it. Continue CPR. Continuous Chest Compressions (Hands-Only CPR) If you are unable or unwilling for any reason to perform full CPR (with rescue breaths), give continuous chest compressions after checking the scene and the person and calling 9-1-1 or the local emergency number. Continue giving chest compressions until EMS personnel take over or you notice an obvious sign of life, such as breathing. Skill Components Adult Child Infant HAND POSITION Two hands in center Two hands in center Two or three fingers of chest of chest in center of chest (on lower half of sternum) (on lower (on lower half half of sternum) of sternum, just below nipple line) CHEST At least 2 inches Until the About 2 inches Until About 1 1/2 inches Until COMPRESSIONS chest clearly rises the chest clearly rises the chest clearly rises RESCUE BREATHS (about 1 second per (about 1 second per (about 1 second per breath) breath) breath) CYCLE 30 chest compressions 30 chest compressions 30 chest compressions and 2 rescue breaths and 2 rescue breaths and 2 rescue breaths RATE 30 chest compressions in 30 chest compressions 30 chest compressions about 18 seconds in about 18 seconds in about 18 seconds (at least 100 (at least 100 (at least 100 compressions per compressions per compressions per minute) minute) minute) PUTTING IT ALL TOGETHER Cardiac emergencies are life threatening. Every day someone will have a heart attack or go into cardiac arrest. These cardiac emergencies usually happen in the home. If you know the signals of a heart attack and cardiac arrest, you will be able to respond immediately. Call 9-1-1 or the local emergency number and give care until help takes over. If the person is in cardiac arrest, perform CPR. Use an AED if one is available. These steps will increase the chances of survival for the person having a cardiac emergency.  CHAPTER 3 BREATHING EMERGENCIES LESSON OBJECTIVES - Recognize the signals of a breathing emergency. - Demonstrate how to care for a person who is choking. INTRODUCTION A breathing emergency is any respiratory problem that can threaten a person’s life. Breathing emergencies happen when air cannot travel freely and easily into the lungs. Respiratory distress, respiratory arrest and choking are examples of breathing emergencies. In a breathing emergency, seconds count so you must react at once. This chapter discusses how to recognize and care for breathing emergencies. BACKGROUND The human body needs a constant supply of oxygen to survive. When you breathe through your mouth and nose, air travels down your throat, through your windpipe and into your lungs. This pathway from the mouth and nose to the lungs is called the airway. As you might imagine, the airway, mouth and nose are smaller in children and infants than they are in adults. As a result, they can be blocked more easily by small objects, blood, fluids or swelling. In a breathing emergency, air must reach the lungs. For any person, regardless of age, it is important to keep the airway open when giving care. Once air reaches the lungs, oxygen in the air is transferred to the blood. The heart pumps the blood throughout the body. The blood flows through the blood vessels, delivering oxygen to the brain, heart and all other parts of the body. In some breathing emergencies the oxygen supply to the body is greatly reduced, whereas in others the oxygen supply is cut off entirely. As a result, the heart soon stops beating and blood no longer moves through the body. Without oxygen, brain cells can begin to die within 4 to 6 minutes. Unless the brain receives oxygen within minutes, permanent brain damage or death will result. It is important to recognize breathing emergencies in children and infants and act before the heart stops beating. Frequently, an adult’s heart stops working (known as cardiac arrest) because of heart disease. However, children and infants usually have healthy hearts. When the heart stops in a child or infant, it usually is the result of a breathing emergency. No matter what the age of the person, trouble breathing can be the first signal of a more serious emergency, such as a heart problem. Recognizing the signals of breathing problems and giving care often are the keys to preventing these problems from becoming more serious emergencies. If the injured or ill person is conscious, he or she may be able to indicate what is wrong by speaking or gesturing to you and may be able to answer questions. However, if you are unable to communicate with a person, it can be difficult to determine what is wrong. Therefore, it is important to recognize the signals of breathing emergencies, know when to call 9-1-1 or the local emergency number and know what to do until help arrives and takes over. RESPIRATORY DISTRESS AND RESPIRATORY ARREST Respiratory distress and respiratory arrest are types of breathing emergencies. Respiratory distress is a condition in which breathing becomes difficult. It is the most common breathing emergency. Respiratory distress can lead to respiratory arrest, which occurs when breathing has stopped. Normal breathing is regular, quiet and effortless. A person does not appear to be working hard or struggling when breathing normally. This means that the person is not making noise when breathing, breaths are not fast and breathing does not cause discomfort or pain. However, it should be noted that normal breathing rates in children and infants are faster than normal breathing rates in adults. Infants have periodic breathing, so changes in breathing patterns are normal for infants. You usually can identify a breathing problem by watching and listening to the person’s breathing and by asking the person how he or she feels. CAUSES OF RESPIRATORY DISTRESS AND RESPIRATORY ARREST Respiratory distress and respiratory arrest can be caused by: Choking (a partially or completely obstructed airway). Illness. Chronic conditions (long-lasting or frequently recurring), such as asthma. Electrocution. Irregular heartbeat. Heart attack. Injury to the head or brain stem, chest, lungs or abdomen. Allergic reactions. Drug overdose (especially alcohol, narcotic painkillers, barbiturates, anesthetics and other depressants). Poisoning. Emotional distress. Drowning. ASTHMA Asthma is the inflammation of the air passages that results in a temporary narrowing of the airways that carry oxygen to the lungs. An asthma attack happens when a trigger, such as exercise, cold air, allergens or other irritants, causes the airway to swell and narrow. This makes breathing difficult. The Centers for Disease Control and Prevention (CDC) estimate that in 2005, nearly 22.2 million Americans were affected by asthma. Asthma is more common in children and young adults than in older adults, but its frequency and severity is increasing in all age groups in the United States. Asthma is the third-ranking cause of hospitalization among those younger than 15 years. You often can tell when a person is having an asthma attack by the hoarse whistling sound that he or she makes while exhaling. This sound, known as wheezing, occurs because air becomes trapped in the lungs. Trouble breathing, shortness of breath, tightness in the chest and coughing after exercise are other signals of an asthma attack. Usually, people diagnosed with asthma prevent and control their attacks with medication. These medications reduce swelling and mucus production in the airways. They also relax the muscle bands that tighten around the airways, making breathing easier. CHRONIC OBSTRUCTIVE PULMONARY DISEASE Chronic obstructive pulmonary disease (COPD) is a long-term lung disease encompassing both chronic bronchitis and emphysema. COPD causes a person to have trouble breathing because of damage to the lungs. In a person with COPD, the airways become partly blocked and the air sacs in the lungs lose their ability to fill with air. This makes it hard to breathe in and out. There is no cure for COPD, and it worsens over time. The most common cause of COPD is cigarette smoking, but breathing in other types of lung irritants, pollution, dust or chemicals over a long period also can cause COPD. It usually is diagnosed when a person is middle aged or older. It is the fourth-ranking cause of death in the United States and a major cause of illness. Common signals of COPD include: Coughing up a large volume of mucus. Tendency to tire easily. Loss of appetite. Bent posture with shoulders raised and lips pursed to make breathing easier. A fast pulse. Round, barrel-shaped chest. Confusion (caused by lack of oxygen to the brain). EMPHYSEMA Emphysema is a type of COPD. Emphysema is a disease that involves damage to the air sacs in the lungs. It is a chronic (long-lasting or frequently recurring) disease that worsens over time. The most common signal of emphysema is shortness of breath. Exhaling is extremely difficult. In advanced cases, the affected person may feel restless, confused and weak, and even may go into respiratory or cardiac arrest. BRONCHITIS Bronchitis is an inflammation of the main air passages to the lungs. It can be acute (short- lasting) or chronic. Chronic bronchitis is a type of COPD. To be diagnosed with chronic bronchitis, a person must have a cough with mucus on most days of the month for at least 3 months. Acute bronchitis is not a type of COPD; it develops after a person has had a viral respiratory infection. It first affects the nose, sinuses and throat and then spreads to the lungs. Those most at risk for acute bronchitis include children, infants, the elderly, people with heart or lung disease and smokers. Signals of both types of bronchitis include: Chest discomfort. Cough that produces mucus. Fatigue. Fever (usually low). Shortness of breath that worsens with activity.  Wheezing. Additional signals of chronic bronchitis include: Ankle, feet and leg swelling. Blue lips. Frequent respiratory infections, such as colds or the flu. HYPERVENTILATION Hyperventilation occurs when a person’s breathing is faster and more shallow than normal. When this happens, the body does not take in enough oxygen to meet its demands. People who are hyperventilating feel as if they cannot get enough air. Often, they are afraid and anxious or seem confused. They may say that they feel dizzy or that their fingers and toes feel numb and tingly. Hyperventilation often results from fear or anxiety and usually occurs in people who are tense and nervous. However, it also can be caused by head injuries, severe bleeding or illnesses, such as high fever, heart failure, lung disease and diabetic emergencies. Asthma and exercise also can trigger hyperventilation. Hyperventilation is the body’s way of compensating when there is a lack of enough oxygen. The result is a decrease in carbon dioxide, which alters the acidity of the blood. ALLERGIC REACTIONS An allergic reaction is the response of the immune system to a foreign substance that enters the body. Common allergens include bee or insect venom, antibiotics, pollen, animal dander, sulfa and some foods such as nuts, peanuts, shellfish, strawberries and coconut oils. Allergic reactions can cause breathing problems. At first the reaction may appear to be just a rash and a feeling of tightness in the chest and throat, but this condition can become life threatening. The person’s face, neck and tongue may swell, closing the airway. A severe allergic reaction can cause a condition called anaphylaxis, also known as anaphylactic shock. During anaphylaxis, air passages swell and restrict a person’s breathing. Anaphylaxis can be brought on when a person with an allergy comes into contact with allergens via insect stings, food, certain medications or other substances. Signals of anaphylaxis include a rash, tightness in the chest and throat, and swelling of the face, neck and tongue. The person also may feel dizzy or confused. Anaphylaxis is a life-threatening emergency. Some people know that they are allergic to certain substances or to insect stings. They may have learned to avoid these things and may carry medication to reverse the allergic reaction. People who have severe allergic reactions may wear a medical identification (ID) tag, bracelet or necklace. CROUP Croup is a harsh, repetitive cough that most commonly affects children younger than 5 years. The airway constricts, limiting the passage of air, which causes the child to produce an unusual- sounding cough that can range from a high-pitched wheeze to a barking cough. Croup mostly occurs during the evening and nighttime. Most children with croup can be cared for at home using mist treatment or cool air. However, in some cases, a child with croup can progress quickly from respiratory distress to respiratory arrest. EPIGLOTTITIS Epiglottitis is a far less common infection than croup that causes severe swelling of the epiglottis. The epiglottis is a piece of cartilage at the back of the tongue. When it swells, it can block the windpipe and lead to severe breathing problems. Epiglottitis usually is caused by infection with Hemophilus influenzae bacteria. The signals of epiglottitis may be similar to croup, but it is a more serious illness and can result in death if the airway is blocked completely. In the past, epiglottitis was a common illness in children between 2 and 6 years of age. However, epiglottitis in children has dropped dramatically in the United States since the 1980s when children began routinely receiving the H. influenzae type B (Hib) vaccine. For children and adults, epiglottitis begins with a high fever and sore throat. A person with epiglottitis may need to sit up and lean forward, perhaps with the chin thrust out in order to breathe. Other signals include drooling, difficulty swallowing, voice changes, chills, shaking and fever. Seek medical care immediately for a person who may have epiglottitis. This condition is a medical emergency. WHAT TO LOOK FOR? Although breathing problems have many causes, you do not need to know the exact cause of a breathing emergency to care for it. You do need to be able to recognize when a person is having trouble breathing or is not breathing at all. Signals of breathing emergencies include: Trouble breathing or no breathing. Slow or rapid breathing. Unusually deep or shallow breathing. Gasping for breath. Wheezing, gurgling or making high-pitched noises. Unusually moist or cool skin. Flushed, pale, ashen or bluish skin. Shortness of breath. Dizziness or light-headedness. Pain in the chest or tingling in the hands, feet or lips. Apprehensive or fearful feelings. WHEN TO CALL 9-1-1? If a person is not breathing or if breathing is too fast, too slow, noisy or painful, call 9-1-1 or the local emergency number immediately. WHAT TO DO UNTIL HELP ARRIVES? If an adult, child or infant is having trouble breathing: Help the person rest in a comfortable position. Usually, sitting is more comfortable than  lying down because breathing is easier in that position If the person is conscious, check for other conditions. Remember that a person having breathing problems may find it hard to talk. If the person cannot talk, ask him or her to nod or to shake his or her head to answer yes-or-no questions. Try to reassure the person to reduce anxiety. This may make breathing easier. If bystanders are present and the person with trouble breathing is having difficulty answering your questions, ask them what they know about the person’s condition. If the person is hyperventilating and you are sure whether it is caused by emotion, such as excitement or fear, tell the person to relax and breathe slowly. A person who is hyperventilating from emotion may resume normal breathing if he or she is reassured and calmed down. If the person’s breathing still does not slow down, the person could have a serious problem. If an adult is unconscious and not breathing, the cause is most likely a cardiac emergency. Immediately begin CPR starting with chest compressions. If an adult is not breathing because of a respiratory cause, such as drowning, or drug overdose, give 2 rescue breaths after checking for breathing and before quickly scanning for severe bleeding and beginning CPR. Remember, a nonbreathing person’s greatest need is for oxygen. If breathing stops or is restricted long enough, a person will become unconscious, the heart will stop beating and body systems will quickly fail. If a child or an infant is unconscious and not breathing, give 2 rescue breaths after checking for breathing and before quickly scanning for severe bleeding and beginning CPR. CHOKING Choking is a common breathing emergency. It occurs when the person’s airway is partially or completely blocked. If a conscious person is choking, his or her airway has been blocked by a foreign object, such as a piece of food or a small toy; by swelling in the mouth or throat; or by fluids, such as vomit or blood. With a partially blocked airway, the person usually can breathe with some trouble. A person with a partially blocked airway may be able to get enough air in and out of the lungs to cough or to make wheezing sounds. The person also may get enough air to speak. A person whose airway is completely blocked cannot cough, speak, cry or breathe at all. Causes of Choking in