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Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary resuscitation (CPR) is an attempt to revive the heart and pulmonary functions of a patient. Due to accidents, or illness the breathing or heartbeats may be hampered. The brain can stand low oxygen for not more than 4-8 minutes. After this, brain damage sets in & this is irreversible. Isolated cases of full neurological recovery are documented when the body has been in cold water. The children have more of respiratory causes leading to gasping & needing CPR. While elders are more prone to cardiac ischemia & infarcts which deranges the heart & respiration functions.

Every individual should know about CPR as early treatment guarantees improved neurological outcome & survival. The CPR involves few steps, which should be carried out tactfully and in order. These steps are the ABC of CPR.

  • The responsiveness of the person who has collapsed should be evaluated. You should shake the body and ask whether "he or she" is ok?
  • Shout for help immediately.
  • Turn the patient over by rolling him over in one piece. While doing this, the patients head & neck should be supported and place him in supine position.
  • A = Airway patency should be achieved and maintained. The cessation of respiration is usually due to ensure airway patency; the person's head should be tilted back by placing the left palm on the forehead. This should be followed by "chin lift". In the latter, the rescuer should place his / her right hand just over the angle of the mandible and lift it. The soft tissue should not be compressed. This pulls the tongue forward & relieves the obstruction.
  • B = Breathing should be looked for. The breathing is present if there is chest rise & fall one can also feel for the exhaled air on the rescuer's cheeks or hear the sound of expiration. If it is present, just maintain the "head till & chin lift". But if it is absent you have to give "mouth to mouth ventilation". The exhaled air has at least 14-18 % oxygen & can be used for the hypoxic victim. The rescuer should take a deep breath & exhale into the victim's mouth. There should be an airtight seal made by the rescuer's mouth over that of the victim. In case of a small child, the nose & mouth should be covered. In this era of AIDS & HIV, refrain from mouth-to-mouth breathing for strangers. In them one can use some barrier in between like a univalvular mask or handkerchief. While breathing in, look for the chest rise. 2 rescue breaths should be given. If there is no chest rise, reposition the head & try again. If still no chest rise, suspect a foreign body & check the mouth. Remove if visible. No blind sweeps are allowed. If there is chest rise, continue for a minute & check for pulse.
  • C= Circulation - The presence of an adequate circulation could be gauged by the palpation of the pulse. In older children & adults, the carotids are palpated. They are just lateral to the cricothyroids in the neck. In children < 1 year, brachials are felt. Palpation is done in the medial aspect at the middle of the upper arm. If the pulses are felt, just continue rescue breaths at the frequency of one per 3 seconds. If pulse is absent, start external cardiac massage. In infants, 3 fingers are placed below the internipple line on the sternum. The upper end finger is lifted & the compressions are given with the remaining 2 fingers. The ratio should be 5 compressions: 1 breath. The depth should be 1/2 inch. Continue till help comes or pulse returns. In older children, place heel of left palm over lower one third of sternum & give 1/2 - 1 inch deep compressions in the ratio of 5 compressions: 1 breath. Do not bend at elbow or rock. In adults, the site of compression is same. But the heels of both hands are used; right over the left. Do not double-cross. The depth of compressions is 1 - 1½ inches & ratio of compressions to rescue breaths is 15:2.

Start rescue breaths in water itself in case of a drowned victim. If above steps are followed promptly, many a life would be saved with almost complete neurological recovery. Once the patient's breathing and heartbeats are reestablished, but the victim is still unconscious, it is vital to reposition him or her in the recovery position. To do this, follow the underlying steps:

  • Kneel beside the patient, about 9 inches away at the level of the chest. Turn the head towards you and tilt it back keeping the jaw forward in the open airway position.
  • Place the victim's nearest arm by the side. Place the hand of this upper limb below the buttocks with the palm facing upwards. Bring the other forearm over the front of the chest. Hold the other far leg and bring it to cross the near leg.
  • Protecting the victim's head with one hand, grasp the buttocks with the other hand and pull the victim towards you. The knees of the victim would support him in this lateral position.
  • The uppermost arm of the victim should be placed in a comfortable position to support the upper body.
  • Bend the upper leg at the knee so as to support the body of the victim.
  • The other hand should be gradually removed from under the body and placed on the side. It should lie parallel to the body.

The advantage of this position is that it maintains the patency of the airways. The tongue remains forward. The victim's vomitus will drain freely and the risk of aspiration is abolished. But fractures of the neck bones, long bones and the like if present can prevent the patient to be put in this position. When the space is small, the victim cannot be put in the recovery position.