CPR Certification

Compression Depth for Children

At least one third the depth of the chest. Approximately 2 inches (5 cm).

Attaching AED Pads

- Choose adults pads (not child pads or a child system) for victims 8 years of age and older. - Peel the backing away from the AED pads. - Attach the adhesive AED pad to the victim's bare chest: Place one AED pad on the victim's upper-right chest (directly below the collarbone). Place the other pad to the left side of the nipple with the top edge of the pad a few inches below the armpit.

Compression to Breaths in the Presence of an Advanced Airway

- Compression of at least 100/min without pauses for breaths - 1 breath every 6 to 8 seconds (8 to 10 breaths per minute) (same for adults, children, and infants)

Rescue Breathing

- Give each breath in 1 second (every 3 to 5 seconds for children and infants; every 5 to 6 seconds for adults). - Each breath should result in visible chest rise. - Check the pulse about every 2 minutes.

Adult Chain of Survival

1. Immediate recognition of cardiac arrest and activation of the emergency response system 2. Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions 3. Rapid defibrillation 4. Effective advanced life support 5. Integrated post-cardiac arrest care

Step 1: Assessment and Scene Safety

1. Make sure the scene is safe. 2. Tap the victim's shoulder and shout, "Are you all right? 3. Check to see if the victim is breathing. If a victim is not breathing or not breathing normally (ie, only gasping), you must activate the emergency response system.

Locating the Femoral Artery Pulse (Children)

1. Place 2 fingers in the inner thigh, midway between the hipbone and the pubic bone and just below the crease where the leg meets the abdomen. 2. Feel for a pulse for at least 5 but no more than 10 seconds. If you do not definitely feel a pulse, begin CPR, starting with chest compressions (CAB sequence).

Compression Depth (For Infants)

Approximately 1 1/2 inches (4 cm)

Compression Depth (For Children)

Approximately 2 inches (5 cm)

Compression Rate

At least 100/min

Compression Depth for Infants

At least one third the chest depth, approximately 1 1/2 inches (4 cm)

Chest Recoil

At the end of each compression, make sure you allow the chest to recoil (re-expand completely. Chest recoil allows blood to flow into the heart and is necessary for chest compressions to create blood flow. Incomplete chest recoil is harmful because it reduces the blood flow created by chest compressions. Chest compression and chest recoil/relaxation times should be approximately equal.

Bag-Mask Device

Bag-mask devices consist of a bag attached to a face mask. They may also include a 1-way valve. Bag-mask devices are the most common method that healthcare providers use to give positive-pressure ventilation during CPR. The bag-mask ventilation technique requires instruction and is not recommended by a lone rescuer during CPR.

Location of Pulse Check in Infants

Brachial Artery

CPR

Cardiopulmonary Resuscitation

Main Parts of BLS

Chest Compressions Airway Breathing Defibrillation

Foreign-Body Airway Obstruction

Choking

Rescue Breathing for Infants and Children

Give 1 breath every 3 to 5 seconds (about 12 to 20 breaths per minute).

Effective Breaths

Make the chest rise and avoid excessive ventilation

Interruptions in Compressions

Minimize interruptions to <10 seconds

If you can't create an airtight seal over an infant's mouth and nose, what technique should you use?

Mouth-to-Mouth

What is the preferred technique for giving mouth breaths for infants?

Mouth-to-mouth-and-nose

Carotid Pulse

On the neck

Switching Duties In 2-Rescuer CPR

Rescuers should switch duties every 5 cycles or about 2 minutes, taking <5 seconds to switch.

Compression Rate and Ratio for Lone Rescuer

The lone rescuer should use the universal compression-ventilation ratio of 30 compressions to 2 breaths when giving CPR to victims of all ages. The term universal represents an attempt to develop a consistent ratio for lone rescuers.

When should you use a jaw thrust?

When you suspect a head or neck injury, as it may reduce neck and spine movement.

Examples of Advanced Airways

- Laryngeal mask airway - Supraglottic - Endotracheal tube

Child Age

1 year of age to puberty

Locating the Brachial Pulse (Infants)

1. Place 2 or 3 fingers on the inside of the upper arm, between the infant's elbow and shoulder. 2. Press the index and middle fingers gently on the inside of the upper arm for at least 5 but no more than 10 seconds when attempting to feel the pulse.

Initial BLS Steps for Adults

1. Assess the victim for a response and look for normal or abnormal breathing. If there is no response and no breathing or no normal breathing (ie, only gasping), shout for help. 2. If you are alone, activate the emergency response system and get an AED (or defibrillator) if available and return to the victim. 3. Check the victim's pulse (take at least 5 but no more than 10 seconds). 4. If you do not definitely feel a pulse within 10 seconds, peform 5 cycles of compressions and breaths (30:2) ratio, starting with compressions (C-A-B sequence).

Adult Mouth-to-Mouth Breathing

1. Hold the victim's airway open with a head tilt-chin lift. 2. Pinch the nose closed with your thumb and index finger (using the hand on the forehead). 3. Take a regular (not deep) breath and seal your lips around the victim's mouth, creating an airtight seal. 4. Give 1 breath (blow for about 1 second). Watch for the chest to rise as you give the breath. 5. If the chest does not rise, repeat the head tilt-chin lift. 6. Give a second breath (blow for about 1 second). Watch for the chest to rise. 7. If you are unable to ventilate the victim after 2 attempts, promptly return to chest compressions.

Steps to Perform Jaw Thrust

1. Place one hand on each side of the victim's head, resting your elbows on the surface on which the victim is lying. 2. Place your fingers under the angles of the victim's lower jaw and lift with both hands, displacing the jaw forward. 3. If the lips close, push the lower lip with your thumb to open the lips.

Steps for Operating an AED

1. Power on the AED (the AED will then guide you through the next steps). 2. Attach AED pads to the victim's bare chest 3. "Clear" the victim and analyze the rhythm 4. If the AED advises a shock, it will tell you to clear the victim. 5. If no shock is needed, and after any shock deliver, immediately resume CPR, starting with chest compressions. 6. After 5 cycles or 2 minutes of CPR, the AED will prompt you to repeat steps 3 and 4. If no shock advised, immediately restart CPR beginning with chest compressions.

Pediatric Chain of Survival

1. Prevention of arrest 2. Early high-quality bystander CPR 3. Rapid activation of the EMS (or other emergency response) system 4. Effective advanced life support (including rapid stabilization and transport to definitive care and rehabilitation) 5. Integrated post-cardiac arrest care

Compression-Ventilation Ratio for 2-Rescuer CPR in Children From 1 Year of Age to Puberty

15:2

Compression-Ventilation Rate and Ratio for 2 Rescuer in Infants

15:2 (same as children)

Technique of Delivery Chest Compressions for Infants

2 fingers for single rescuer and 2 thumb-encircling hands technique for 2 rescuers

When should rescuers give breaths without chest compressions?

When an adult, child, or infant has a pulse but is not breathing effectively.

Compression to Ventilation Ratio

30:2

Compression Depth (For Adults)

At least 2 inches (5 cm)

Two rescuers are generally needed to perform what?

A jaw thrust and provide breaths with a bag-mask device.

Cardiac Arrest

A sudden, sometimes temporary, cessation of function of the heart.

Automated External Defibrillator (AED)

AEDs are computerized devices that can identify cardiac rhythms that need a shock, and they can then deliver the shock.

Apnea

Absence of respirations.

Agonal Gasps

Agonal gasps are not normal breathing. Agonal gasps may be present in the first minutes after sudden cardiac arrest. A person who gasps usually looks like he is drawing air in very quickly. The mouth may be open and the jaw, head, or neck may move with gasps. Gasps may appear forceful or weak, and some time may pass between gasps because they usually happen at a slow rate. The gasp may sound like a snort, snore, or groan. Gasping is not normal breathing. It is a sign of cardiac arrest in someone who doesn't respond. If a victim is not breathing or there is no normal breathing (ie, only agonal gasps), you must activate the emergency response system, check the pulse, and start CPR.

What should you do after each chest compression?

Allow complete chest recoil

AHA

American Heart Association

AED

Automated External Defibrillator

BLS Sequence of Steps (CAB)

Chest Compressions Airway Breathing

Rescuer's Exhaled Air (Mouth-to-Mouth)

Contains 17% oxygen and 4% carbon dioxide

Transdermal Medication Patches with AED

Do not place AED pads directly on top of a medication path (eg, a path of nitroglycerin, nicotine, pain medication, hormone replacement therapy, or antihypertensive medication). The medication patch may block the transfer of energy from the AED pad to the heart and may cause small burns to the skin. If it won't delay shock delivery, remove the patch and wipe the area clean before attaching the AED pad.

ECC

Emergency Cardiovascular Care

Two Methods for Opening Airway

Head Tilt-Chin Lift Jaw Thrust

Opening the Airway for Breaths: Jaw Thrust

If the victim has a head or neck injury and you suspect a spine injury, 2 rescuers may use another method to open the airway: a jaw thrust. Two people perform a jaw thrust while holding the neck and giving bag-mask ventilation. If the jaw thrust does not open the airway, use a head tilt-chin lift.

Pulse Check

If the victim is unresponsive and not breathing or only gasping, healthcare providers may take up to 10 seconds to attempt to feel for a pulse (brachial in an infant and carotid or femoral in a child). If within 10 seconds you don't feel a pulse or are not sure if you feel a pulse, begin chest compressions.

Step 2: Activate the Emergency Response System and Get an AED

If you are alone and find an unresponsive victim not breathing, shout for help. If no one responds, activate the emergency response system, get an AED (or defibrillator) if available, and then return to the victim to check a pulse and begin CPR (CAB sequence).

If you do not definitely feel a pulse within 10 seconds, what should you do?

If you do not definitely feel a pulse within 10 seconds, peform 5 cycles of compressions and breaths (30:2) ratio, starting with compressions (C-A-B sequence).

Implanted Defibrillators and Pacemakers with AED

If you identify an implanted defibrillator/pacemaker: - If possible, avoid placing the AED pad directly over the implanted device. - Follow the normal steps for operating an AED. Occasionally the analysis and shock cycles of implanted defibrillators and AEDs will conflict. If the implanted defibrillator is delivering shocks to the victim (the victim's muscles contract in a manner like that observed after an AED shock), allow 30 to 60 seconds for the implanted defibrillator to complete the treatment cycle before delivering a shock from the AED.

Compression Depth in Infants

In infants, the recommended compression depth is at least one third of the anterior-posterior depth of the infant's chest, or approximately 1 1/2 inches (4 cm). This is different from compression depth for both adults (at least 2 inches) and children (at least one third the depth of the chest, approximately 2 inches [5 cm]).

Infant Age

Infants to 1 year of age (12 months)

Brachial Pulse

Inside the elbow or close to the biceps

Femoral Pulse

On the groin

Location of AED Pad Placement

Place one AED pad on the victim's upper-right chest (directly below the collarbone). Place the other pad to the left side of the nipple with the top edge of the pad a few inches below the armpit.

Where should your hands be placed during chest compressions?

Put the heel of one hand on the center of the victim's chest on the lower half of the breastbone. Put the heel of your other hand on top of the first hand.

Adult Mouth-to-Barrier Device Breathing

Standard precautions include barrier devices, such as a face mask or a bag-mask device, when giving breaths. Rescuers should replace face shields with mouth-to-mask or bag-mask devices at the first opportunity. Mask usually have a 1-way valve that diverts exhaled air, blood, or bodily fluids away from the rescuer.

If the jaw thrust does not work?

Switch to a head tilt-chin lift maneuver.

Checking the Victim's Pulse

Take at least 5 but no more than 10 seconds

Step 4: Begin Cycles of 30 Chest Compressions and 2 Breaths (CPR)

The lone rescuer should use the compression-ventilation ratio of 30 compressions to 2 breaths when giving CPR to victims of any age. When you give compressions, it is important to push the chest hard and fast, at a rate of at least 100 compressions per minute, allow the chest to recoil completely after each compression, and minimize interruptions in compressions. Begin with chest compressions.

Feeling a Child's Pulse

You may try to feel the child's carotid or femoral pulse.

Within 30 seconds after the AED arrives at the victim's side, what should you do?

You should ideally be able to perform the first 2 steps within 30 seconds to reduce the time to shock delivery.

Things to Avoid With Head Tilt-Chin Lift

- Do not press deeply into the soft tissue under the chin because this might block the airway. - Do not use the thumb to lift the chin. - Do not close the victim's mouth completely.

Mild Airway Obstruction

- Good air exchange - Can cough forcefully - May wheeze between coughs

When to Activate the Emergency Response for Children

- If you did not witness the arrest and are alone, provide 2 minutes of CPR before leaving the child to activate the emergency response system and get the AED (or defibrillator). - If the arrest is sudden and witnessed, leave the child to activate the emergency response system and get the AED (or defibrillator), and then return to child.

When to Activate the Emergency Response for Infants

- If you did not witness the arrest and are alone, provide 2 minutes of CPR before leaving the infant to activate the emergency response system and get the AED (or defibrillator). - If the arrest is sudden and witnessed, leave the infant to activate the emergency response system and get the AED (or defibrillator), and then return to the infant. (same as children)

Mouth-to-Mouth (for Infants)

- Maintain a head tilt-chin lift to keep the airway open. - Pinch the victim's nose tightly with thumb and forefinger. - Make a mouth-to-mouth seal. - Provide 2 mouth-to-mouth breaths. Make sure the chest rises with each breath. - If the chest doesn't rise, repeat the head tilt-chin lift to reopen the airway. It may be necessary to move the infant's head through a range of positions to provide optimal airway patency and effective rescue breaths. When the airway is open, give 2 breaths that make the chest rise.

Mouth-to-Mouth-and-Nose (for Infants)

- Maintain head tilt-chin lift to keep airway open - Place your mouth over the infant's mouth and nose to create an airtight seal - Blow into the infant's nose and mouth (pausing to inhale between breaths) to make the chest rise with each breath - If the chest does not rise, repeat the head tilt-chin lift to reopen the airway and try to give a breath that makes the chest rise. It may be necessary to move the infant's head through a range of positions to provide optimal airway patency and effective rescue breaths. When the airway is open, give 2 breaths that make the chest rise. You may need to try a couple of times.

Severe Airway Obstruction

- Poor or no air exchange - Weak, ineffective cough or no cough at all - High-pitched noise while inhaling or no noise at all - Increased respiratory difficulty - Possible cyanosis (turning blue) - Unable to speak - Clutching the neck with the thumb and fingers, making the universal choking sign

High-Quality CPR

- Start compressions within 10 seconds of recognition of cardiac arrest. - Push hard, push fast: Compress at a rate of at least 100/min with a depth of at least 2 inches (5 cm) for adults, approximately 2 inchest (5 cm) for children, and approximately 1 1/2 inches (4 cm) for infants. - Allow complete chest recoil after each compression. - Minimize interruptions in compressions (try to limit interruptions to <10 seconds). - Give effective breaths that make the chest rise. - Avoid excessive ventilation.

Hairy Chest with AED

1. If the pads stick to the hair instead of the skin, press down firmly on each pad. 2. If the AED continues to prompt you to "check pads" or "check electrodes" quickly pull on the pads. This will remove a large amount of hair and should allow the pads to stick to the skin. 3. If a large amount of hair still remains where you will put the pads, shave the area with the razor in the AED carrying case. 4. Put on a new set of pads. Follow the AED voice prompts.

2 Thumb-Encircling Hands Chest Compression Technique (For Infants)

1. Place both thumbs side by side in the center of the infant's chest on the lower half of the breastbone. The thumbs may overlap in very small infants. 2. Encircle the infant's chest and support the infant's back with the fingers of both hands. 3. With your hands encircling the chest, use both thumbs to depress the breastbone approximately one third the depth of the infant's chest (approximately 1 1/2 inches [4 cm]). 4. Deliver compressions in a smooth fashion at a rate of at least 100/min. 5. After each compression, completely release the pressure on the breastbone and allow the chest to recoil completely. 6. After every 15 compressions, pause briefly for the second rescuer to open the airway with a head tilt-chin lift and give 2 breaths. The chest should rise with each breath. 7. Continue compressions and breaths in a ration of 15:2 (for 2 rescuers), switching roles every 2 minutes to avoid rescuer fatigue.

Opening the Airway: Head Tilt-Chin Lift

1. Place one hand on the victim's forehead and push with your palm to tilt the head back. 2. Place the fingers of the other hand under the bony part of the lower jaw near the chin. 3. Lift the jaw to bring the chin forward.

2 Finger Chest Compression Technique (For Infants)

1. Place the infant on a firm, flat surface. 2. Place 2 fingers in the center of the infant's chest just below the nipple line. Do not press on the bottom of the breastbone. 3. Push hard and fast. To give chest compressions, press the infant's breastbone down at least one third the depth of the chest (approximately 1 1/2 inches [4 cm]). Deliver compressions in a smooth fashion at a rate of at least 100/min. 4. At the end of each compression, make sure you allow the chest to recoil (reexpand) completely. Chest recoil allows blood to flow into the heart and is necessary to create blood flow during chest compressions. Incomplete chest compressions will reduce the blood flow created by chest compressions. Chest compression and chest recoil/relaxation times should be approximately equal. 5. Minimize interruptions in chest compressions.

Chest Compression Technique (For Adult)

1. Position yourself at the victim's side. 2. Make sure the victim is lying faceup on a firm, flat surface. If they are lying facedown, carefully roll them faceup. If you suspect a head or neck injury, try to keep the head, neck, and torso in a line when rolling the victim to a faceup position. 3. Put the heel of one hand on the center of the victim's chest on the lower half of the breastbone. 4. Put the heel of your other hand on top of the first hand. 5. Straighten your arms and position your shoulders directly over your hands. 6. Push hard and fast. - Press down at least 2 inches (5 cm) with each compression (this requires hard work). For each chest compression, make sure you push straight down on the victim's breastbone. - Deliver compressions in a smooth fashion of a rate of at least 100/min. 7. At the end of each compression, make sure you allow the chest to recoil (re-expand completely. Chest recoil allows blood to flow into the heart and is necessary for chest compressions to create blood flow. Incomplete chest recoil is harmful because it reduces the blood flow created by chest compressions. Chest compression and chest recoil/relaxation times should be approximately equal. 8. Minimize interruptions.

Giving Mouth-to-Mask Breaths

1. Position yourself at the victim's side. 2. Place the mask on the victim's face, using the bridge of the nose as a guide for correct position. 3. Seal the mask against the face: - Using the hand that is closer to the top of the victim's head, place your index finger and thumb along the edge of the mask. - Place the thumb of your second hand along the bottom edge of the mask. 4. Place the remaining fingers of your second hand along the bony margin of the jaw and lift the jaw. Perform a head tilt-chin lift to open the airway. 5. While you lift the jaw, press firmly and completely around the outside edge of the mask to seal the mask against the face. 6. Deliver air over 1 second to make the victim's chest rise.

Using the Bag-Mask During 2-Rescuer CPR

1. Position yourself directly above the victim's head. 2. Place the mask on the victim's face, using the bridge of the nose as a guide for correct position. 3. Use the E-C clamp technique to hold the mask in place while you lift the jaw to hold the airway open: - Perform a head tilt. - Place the mask on the face with the narrow portion at the bridge of the nose. - Use the thumb and index finger of one hand to make a "C" on the side of the mask, pressing the edges of the mask to the face. - Use the remaining fingers to lift the angles of the jaw (3 fingers form an "E"), open the airway, and press the face to the mask. 4. Squeeze the bag to give breaths (1 second each) while watching for chest rise. Deliver all breaths over 1 second whether or not you use supplementary oxygen.

Abdominal Thrusts With Victim Standing or Sitting

1. Stand or kneel behind the victim and wrap your arms around the victim's waist. 2. Make a fist with one hand. 3. Place the thumb side of your fist against the victim's abdomen, in the midline, slightly above the navel and well below the breastbone. 4. Grasp your fist with your other hand and press your fist into the victim's abdomen with a quick, forceful upward thrust. 5. Repeat thrusts until the object is expelled from the airway or the victim becomes unresponsive. 6. Give each new thrust with a separate, distinct movement to relieve the obstruction.

Mild Airway Obstruction Rescuer Actions

As long as good air exchange continues, encourage the victim to continue spontaneous coughing and breathing efforts. Do not interfere with the victim's own attempts to expel the foreign body, but stay with the victim and monitor his or her condition. If mild airway obstruction persists, activate the emergency response system.

Severe Airway Obstruction Rescuer Actions

Ask the victim if he or she is choking. If the victim nods yes and cannot talk, severe airway obstruction is present and you must try to relieve the obstruction.

AED for Infants

For infants, a manual defibrillator is preferred to an AED for defibrillation. If a manual defibrillator is not available, an AED equipped with a pediatric dose attenuator is preferred. If neither is available, you may use an AED without a pediatric dose attenuator.

Giving Adult Mouth-to-Mask Breaths

For mouth-to-mask breaths, you use a mask with or without a 1-way valve. The 1-way valve allows the rescuer's breath to enter the victim's mouth and nose and diverts the victim's exhaled air away from the rescuer. Some masks have an oxygen inlet that allows you to administer supplementary oxygen.

Rescue Breathing for Adults

Give 1 breath every 5 to 6 seconds (about 10 to 12 breaths per minute).

Step 3: Pulse Check

Healthcare providers should take no more than 10 seconds to check for a pulse. To perform a pulse check in the adult, palpate a carotid pulse. 1. Locate the trachea, using 2 or 3 fingers. 2. Slide these 2 or 3 fingers into the groove between the trachea and the muscles at the side of the neck, where you can feel the carotid pulse. 3. Feel for a pulse for at least 5 but no more than 10 seconds. If you do not definitely feel a pulse, begin CPR, starting with chest compressions (CAB sequence).

If a manual defibrillator is not available for an infant, what should be used?

If a manual defibrillator is not available, an AED equipped with a pediatric dose attenuator is preferred. If neither is available, you may use an AED without a pediatric dose attenuator.

Duties of Rescuer 2 (In 2-Rescuer CPR)

Location: At the victim's head Maintain an open airway using either - Head tilt-chin lift - Jaw thrust Give breaths, watching for chest rise and avoiding excessive ventilation. Encourage the first rescuer to perform compressions that are deep enough and and to allow complete chest recoil between compressions. Switch duties with the first rescuer every 5 cycles or about 2 minutes, taking <5 seconds to switch.

Duties of Rescuer 1 (In 2-Rescuer CPR)

Location: At the victim's side Perform chest compressions. - Compress the chest at least 2 inches (5 cm) - Compress at a rate of at least 100/min - Allow the chest to recoil completely after each compression - Minimize interruptions in compressions (try to limit any interruptions to <10 seconds.) - Use a compression-to-breaths ratio 30:2 - Count compressions aloud Switch duties with the second rescuer every 5 cycles or about 2 minutes, taking <5 seconds to switch.

Compression Technique for Children

May use 1- or 2- handed chest compressions for very small children.

Radial Pulse

On the wrist

Pregnant and Obese Victims of Foreign-Body Airway Obstruction

Perform chest thrusts instead of abdominal thrusts.

Infants and children who develop cardiac arrest often have what?

Respiratory failure or shock that reduces the oxygen content in the blood even before the onset of arrest. As a result, for most infants and children in cardiac arrest, chest compressions alone are not as effective for delivering oxygen to the heart and brain as the combination of compressions plus breaths. For this reason it is very important to give both compressions and breaths for infants and children during CPR.

ROSC

Return of Spontaneous Circulation. (A defibrillator delivers an electric shock to stop the quivering of the heart fibers. This allows the muscle fibers of the heart to "reset" so that they can begin to contract at the same time. Once an organized rhythm occurs, the heart muscle may begin to contract effectively and begin to generate a pulse, called ROSC)

Respiratory Arrest

The absence of respirations (apnea). During both respiratory arrest and inadequate ventilation, the victim has cardiac output (blood flow to the body), detectable as a palpable central pulse. The heart rate may be slow, and cardiac arrest may develop if rescue breathing is not provided.

Relieving Choking in a Responsive Victim 1 Year of Age or Older

Use abdominal thrusts (Heimlich maneuver) to relieve choking in a responsive victim 1 year of age or older.

Implanted Defibrillators and Pacemakers

Victims with a high risk for sudden cardiac arrest may have implanted defibrillators/pace-makers that automatically deliver shocks directly to the heart. You can immediately identify these devices because they create a hard lump beneath the skin of the upper chest or abdomen. The lump is half the size of a deck of cards, with an overlying scar. If you place an AED pad directly over an implanted medical device, the device may block delivery of the shock to the heart.

Water with AED

Water is a good conductor of electricity. Do not use an AED in water. If the victim is in water, pull them out of the water. If the victim is lying in water or the chest is covered with water, the water may conduct the shock electricity across the skin of the victim's chest. This prevents the delivery of an adequate shock dose to the heart. If water is covering the victim's chest, quickly wipe the chest before attaching the AED pads. If the victim is lying on snow or in a small puddle, you may use the AED.

2 Rescuers Using the Bag-Mask

When 3 or more rescuers are present, 2 rescuers can provide more effective bag-mask ventilation than 1 rescuer. When 2 rescuers use the bag-mask system, one rescuer open the airway with a head tilt-chin lift (or jaw thrust) and holds the mask to the face while the other rescuer squeezes the bag. All professional rescuers should learn both the 1- and 2-rescuer bag-mask ventilation techniques.

Giving Breaths with an Advanced Airway

When an advanced airway is in place during 2-rescuer CPR, do not stop compressions to give breaths. Give 1 breath every 6 to 8 seconds (8 to 10 breaths per minute), without attempting to deliver breaths between compressions. There should be no pause in chest compressions for delivery of breaths.

Defibrillation

When ventricular fibrillation is present, the heart muscle fibers quiver and do not contract together to pump blood. A defibrillator delivers an electric shock to stop the quivering of the heart fibers. This allows the muscle fibers of the heart to "reset" so that they can begin to contract at the same time. Once an organized rhythm occurs, the heart muscle may begin to contract effectively and begin to generate a pulse (called return of spontaneous circulation, or ROSC).

When do you start chest compressions?

Within 10 seconds of cardiac arrest.