Chapter 3: Cardia Emergencies
CPR
or cardiopulmonary resuscitation, is a skill that is used when a person is in cardiac arrest to keep oxygenated blood moving to the brain and other vital organs until advanced medical help arrives (Figure 3-5). CPR involves giving sets of 30 chest compressions followed by sets of 2 rescue breaths. When you give compressions, you press down on the person's chest. This squeezes (compresses) the heart between the breastbone (sternum) and spine, moving blood out of the heart and to the brain and other vital organs. After each compression, you must let the chest return to its normal position. This allows blood to flow back into the heart. The rescue breaths you give after each set of 30 compressions deliver a fresh supply of oxygen into the person's lungs. When you give CPR, you help to keep oxygenated blood moving throughout the body, which can buy the person some time until advanced medical help arrives. Although full CPR (compressions and rescue breaths) is preferred, if you are unable or unwilling for any reason to give full CPR, you can give compression-only CPR instead. In compression-only CPR, you give continuous chest compressions, with no rescue breaths. After checking the scene and the person and calling 9-1-1 or the designated emergency number, give chest compressions without stopping until another trained responder or EMS personnel take over or you notice an obvious sign of life.
When the heart stops beating properly, the body cannot survive for long
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 8 to 10 minutes (Figure 3-4). Death occurs within a matter of minutes if the person does not receive immediate care.
First Aid Care for a Heart Attack
Call 911 Have the person stop what he or she is doing and having them rest in a comfortable position to reduce the heart's need for oxygen. Many people having a heart attack find it easier to breathe while sitting. Loosen any tight or uncomfortable clothing. Reassure the person to lower anxiety. If the person has a history of heart disease and takes a prescribed medication to relieve chest pain (e.g., nitroglycerin), offer to locate the medication and help the person to take it. If the person is responsive, able to chew and swallow, and allowed to have aspirin, you may offer two low-dose (81-mg) aspirin tablets or one 5-grain (325-mg) regular-strength aspirin tablet (Box 3-1). Closely monitor the person's condition until EMS personnel arrive and take over. Notice any changes in the person's appearance or behavior. ■If you are trained in giving CPR and using an automated external defibrillator (AED), be prepared to give CPR and use an AED if the person becomes unresponsive.
First Aid Care for Cardiac Arrest
Cardiac Chain or Survival: Recognition of cardiac arrest and activation of the emergency medical services (EMS) system. Early CPR Early Defibrillation Early advanced life support Integrated post-cardiac arrest care
Cardiac Arrest
Cardiac arrest is not the same as a heart attack. Remember, a heart attack occurs when blood flow to part of the heart muscle is blocked, causing part of the heart muscle to die. Cardiac arrest, on the other hand, occurs when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs. A network of special cells in the heart muscle conducts electrical impulses that coordinate contraction, causing the heart to beat rhythmically. In cardiac arrest, the electrical impulses become abnormal and chaotic. This causes the heart to lose the ability to beat rhythmically, or to stop beating altogether (Figure 3-3)
Using an AED
Different types of AEDs are available, but all are similar to operate and use visual displays, voice prompts or both to guide the responder. If your place of employment has an AED on site, know where it is located, how to operate it and how to maintain it (Box 3-3). Also take note of the location of AEDs in public places that you frequent, such as shopping centers, airports, recreation centers and sports arenas. When a person is in cardiac arrest, use an AED as soon as possible. Skill Sheet 3-4 describes how to use an AED step by step. Environmental and person-specific considerations for safe and effective AED use are given in Box 3-4.
Giving CPR to a Child
Giving CPR to a child is very similar to giving CPR to an adult. However, in a child, you open the airway by tilting the head to a slightly past-neutral position, rather than to a past-neutral position (see Table 3-1). Rather than compressing the chest to a depth of at least 2 inches as you would for an adult, you compress the chest to a depth of about 2 inches for a child. Also, for a small child, you may only need to give compressions with one hand, instead of two.
Giving CPR to an Adult
Position your hands. Place the heel of one hand in the center of the person's chest on the person's breastbone (sternum). If you feel the notch at the end of the breastbone, move your hand slightly toward the person's head. Place your other hand on top of your first hand and interlace your fingers or hold them up so that your fingers are not on the person's chest. If you have arthritis in your hands, you can grasp the wrist of the hand positioned on the chest with your other hand instead. 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 a set of 30 compressions. Position your body so that your shoulders are directly over your hands. This will let you push on the chest using a straight up-and-down motion, which moves the most blood with each push and is also less tiring. Keeping your arms straight, push down at least 2 inches, and then let the chest completely return to its normal position. Push hard and push fast! You want to go at a rate of 100-120 compressions per minute. As you give compressions, count out loud up to 30. Maintain a smooth, steady down-and-up rhythm and do not pause between compressions. Give a set of 2 rescue breaths. Once you have given 30 compressions, give 2 rescue breaths. First, open the airway using the head-tilt/chin-lift maneuver. Place one of your hands on the person's forehead and two fingers of your other hand on the bony part of the person's chin. Tilt the person's head back and lift the chin. For an adult, tilt the head to a past-neutral position (see Table 3-1). If possible, use a CPR breathing barrier when you are giving rescue breaths, but do not delay rescue breaths to find a breathing barrier or learn how to use it. Pinch the person's nose shut. Take a normal breath, make a complete seal over the person's mouth with your mouth, and blow into the person's mouth to give the first rescue breath. Take another breath, make a seal, and give the second rescue breath. Each rescue breath should last about 1 second and make the person's chest rise. After you finish giving 2 rescue breaths, return to giving compressions as quickly as possible. The process of giving 2 rescue breaths and getting back to compressions should take less than 10 seconds. Never give more than 2 rescue breaths per set. Table 3-2 describes how to troubleshoot special situations when giving rescue breaths. Once you begin CPR, continue giving sets of 30 chest compressions and 2 rescue breaths until: ■You notice an obvious sign of life, such as movement. (If the person shows an obvious sign of life, stop CPR, place the person in the recovery position and continue to monitor the person's condition until EMS personnel take over.) ■An AED is ready to use and no other trained responders are available to assist you with the AED.
Pediatric Cardiac Chain of Survival
Prevention Early CPR Activation of EMS Early advanced life support Integrated post-cardiac arrest care
Signs and Symptoms of a Heart Attack
Signs and symptoms of a heart attack vary from person to person, and can be different in women than they are in men. Even people who have had a heart attack before may not experience the same signs and symptoms if they have a second heart attack. A person who is having a heart attack may show any of the following signs and symptoms: ■Chest pain, which can range from mild to unbearable. The person may complain of pressure, squeezing, tightness, aching or heaviness in the chest. The pain or discomfort is persistent, lasting longer than 3 to 5 minutes, or going away and then coming back. It is not relieved by resting, changing position or taking medication. It may be difficult to distinguish the pain of a heart attack from the pain of indigestion, heartburn or a muscle spasm. ■Discomfort or pain that spreads to one or both arms, the back, the shoulder, the neck, the jaw or the upper part of the stomach ■Dizziness or light-headedness ■Trouble breathing, including noisy breathing, shortness of breath or breathing that is faster than normal ■Nausea or vomiting ■Pale, ashen (gray) or slightly bluish skin, especially around the face and fingers ■Sweating ■A feeling of anxiety or impending doom ■Extreme fatigue (tiredness) ■Unresponsiveness
Giving CPR to an Infant
The general principles of giving CPR to an infant are the same as they are for children and adults. However, because the infant's body is smaller, you will position your hands differently to deliver compressions. Place the pads of two fingers on the center of the infant's chest, just below the nipple line. If you feel the notch at the end of the infant's breastbone, move your fingers slightly toward the infant's head. Place your other hand on the infant's forehead. Give compressions by using the pads of your fingers to compress the chest about 1½ inches. When you give rescue breaths, open the airway by tilting the head to a neutral position (see Table 3-1). Instead of pinching the nose shut and covering the mouth with your mouth, cover the infant's nose and mouth with your mouth to form a seal.
Using an AED on a child or infant
The procedure for using an AED on a child or infant is the same as the procedure for using an AED on an adult. Some AEDs come with pediatric AED pads that are smaller and designed specifically to analyze a child's heart rhythm and deliver a lower level of energy. These pads should be used on children up to 8 years of age or weighing less than 55 pounds. Other AEDs have a key or switch that configures the AED for use on a child up to 8 years of age or weighing less than 55 pounds. If pediatric AED pads are not available or the AED does not have a pediatric setting, it is safe to use adult AED pads and adult levels of energy on a child or infant. (Note that the opposite is not true—you should not use pediatric AED pads or the pediatric setting on an adult because the shock delivered will not be sufficient if the person is older than 8 years or weighs more than 55 pounds.)Just as when you are using an AED on an adult, apply the AED pads to the child's bare, dry chest, placing one pad on the upper right chest and the other pad on the lower left side of the chest below the armpit. If you cannot position the pads this way without them touching (as in the case of an infant or a small child), position one pad in the middle of the chest and the other pad on the back between the shoulder blades (Figure 3-8). Then follow the standard procedure for using an AED.
Signs and Symptoms of Cardiac Arrest
When a person experiences cardiac arrest, you may see the person suddenly collapse. When you check the person, you will find that the person is not responsive and not breathing, or only gasping. (In an unresponsive person, isolated or infrequent gasping in the absence of normal breathing may be agonal breaths, which can occur even after the heart has stopped beating. Agonal breaths are not breathing and are a sign of cardiac arrest.) The person has no heartbeat. Cardiac arrest can happen suddenly and without any warning signs. When this occurs, the person is said to have experienced sudden cardiac arrest. People who have a history of cardiovascular disease or a congenital heart disorder are at higher risk for sudden cardiac arrest. However, sudden cardiac arrest can happen in people who appear healthy and have no known heart disease or other risk factors for the condition. A person who experiences sudden cardiac arrest is at very high risk for dying and needs immediate care.
AED
While CPR can help to prevent brain damage and death by keeping oxygenated blood moving throughout the body, an AED can correct the underlying problem for some people who go into sudden cardiac arrest. Two abnormal heart rhythms in particular, ventricular fibrillation(V-fib) and ventricular tachycardia (V-tach), can lead to sudden cardiac arrest. In V-fib, the heart muscle simply quivers (fibrillates) weakly instead of contracting strongly. In V-tach, the heart muscle contracts too fast (tachy- means "fast"). Both abnormal rhythms impair the heart's ability to pump and circulate blood throughout the body and are life threatening. However, in many cases, V-fib and V-tach can be corrected by an electrical shock delivered by an AED. This shock disrupts the heart's electrical activity long enough to allow the heart to spontaneously develop an effective rhythm on its own. Starting CPR immediately and using an AED as soon as possible gives the person the best chance for surviving cardiac arrest (Figure 3-6). Automated External Defibrillator
Aspirin for a Heart Attack
You may be able to help a person who is showing early signs and symptoms of a heart attack by offering the person an appropriate dose of aspirin. Aspirin can help to prevent blood clotting and is most effective when given soon after the onset of signs and symptoms of a heart attack. However, you should never delay calling 9-1-1 or the designated emergency number to find or offer aspirin. If the person answers "no" to each of these questions, you may offer the person two low-dose (81-mg) aspirin tablets or one 5-grain (325-mg) regular-strength aspirin tablet. Have the person chew the aspirin completely. Chewing the aspirin speeds its absorption into the bloodstream. Before offering aspirin, make sure the person is responsive, able to chew and swallow, and allowed to have aspirin. Ask the person: ■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 healthcare provider to avoid taking aspirin? Do not offer the person an aspirin-containing combination product meant to relieve multiple conditions, or another type of pain medication, such as acetaminophen (Tylenol®), ibuprofen (Motrin®, Advil®) or naproxen (Aleve®). These medications do not work the same way aspirin does and are not beneficial for a person who is experiencing a heart attack.
Women
mat experience the "classic" signs and symptoms but they are often milder and may be accompanied by more general signs and symptoms such as: Shortness of breath Nausea, vomiting or diarrhea Fatigue Dizziness Sweating Back or jaw pain
Using an AED on an Adult
o use an AED, first turn the device on. Remove or cut away clothing and undergarments to expose the person's chest. If the person's chest is wet, dry it using a towel or gauze pad. Dry skin helps the AED pads to stick properly. Do not use an alcohol wipe to dry the skin because alcohol is flammable. Next, apply the AED pads. Peel the backing off the pads as directed, one at a time, to expose the adhesive. Place one pad on the upper right side of the person's chest and the other pad on the lower left side of the person's chest below the armpit, pressing firmly to adhere (Figure 3-7). Plug the connector cable into the AED (if necessary) and follow the device's directions. Most AEDs will begin to analyze the heart rhythm automatically, but some may require you to push an "analyze" button to start this process. No one should touch the person while the AED is analyzing the heart rhythm because this could result in a faulty reading. Next, the AED will tell you to push the "shock" button if a shock is advised. Again, avoid touching the person, because anyone who is touching the person while the device is delivering a shock is at risk for receiving a shock as well. After a shock is delivered (or if the AED determines that no shock is necessary), immediately resume CPR, starting with compressions. The AED will continue to check the heart rhythm every 2 minutes. Listen for prompts from the AED and continue giving CPR and using the AED until you notice an obvious sign of life or EMS personnel arrive. If you notice an obvious sign of life, stop CPR but leave the AED turned on and the pads in place on the person's chest, and continue to follow the AED's prompts.
Heart Attack
occurs when blood flow to part of the heart muscle is blocked (as a result of coronary artery disease). Because the cells in the affected area of the heart muscle are not receiving the oxygen and nutrients they need, they die, causing permanent damage to the heart muscle (Figure 3-1). Seeking advanced medical care as soon as you recognize the signs and symptoms of a heart attack can minimize the damage to the heart and may save the person's life.
Men
often, but no always experience the "classic" signs and symptoms of a heart attack: chest pain: pressure, squeezing, tightness, aching or heaviness that last longer than 3-5 minuntes or goes away and comes back. Radiating pain: to arms, shoulder or neck. Secondary signs and symptoms: may include dizziness, loss of consciousness, sweating, nausea or shortness of breath.
