First Aid Emergency

first aid emergency

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Contents Articles First aid

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Cardiopulmonary resuscitation

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Artificial respiration

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References Article Sources and Contributors

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Image Sources, Licenses and Contributors

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Article Licenses License

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First aid

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First aid First aid is the provision of initial care for an illness or injury. It is usually performed by a lay person to a sick or injured casualty until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care past the first aid intervention. It generally consists of a series of simple and in some cases, potentially life-saving techniques that an individual can be trained to perform with minimal equipment. While first aid can also be performed on animals, the term generally refers to care of human patients.

History First Aid symbol

The instances of recorded first aid were provided by religious knights, such as the Knights Hospitaller, formed in the 11th century, providing care to pilgrims and knights, and training other knights in how to treat common battlefield injuries.[1] The practice of first aid fell largely in to disuse during the High Middle Ages, and organized societies were not seen again until in 1859 Henry Dunant organized local villagers to help victims of the Battle of Solferino, including the provision of first aid. Four years later, four nations met in Geneva and formed the organization which has grown into the Red Cross, with a key stated aim of "aid to sick and wounded soldiers in the field".[1] This was followed by the formation of St. John Ambulance in 1877, based on the principles of the Knights Hospitaller, to teach first aid, and numerous other organization joined them, with the term first aid first coined in 1878 as civilian ambulance services spread as a combination of 'first treatment' and 'national aid'[1] in large railway centres and mining districts as well as with police forces. First aid training began to spread through the empire through organisations such as St John, often starting, as in the UK, with high risk activities such as ports and railways.[2] Many developments in first aid and many other medical techniques have been driven by wars, such as in the case of the American Civil War, which prompted Clara Barton to organize the American Red Cross.[3] Today, there are several groups that promote first aid, such as the military and the Scouting movement. New techniques and equipment have helped make today’s first aid simple and effective.

Aims The key aims of first aid can be summarised in three key points:[4] • Preserve life - the overriding aim of all medical care, including first aid, is to save lives • Prevent further harm - also sometimes called prevent the condition from worsening, this covers both external factors, such as moving a patient away from any cause of harm, and applying first aid techniques to prevent worsening of the condition, such as applying pressure to stop a bleed becoming dangerous. • Promote recovery - first aid also involves trying to start the recovery process from the illness or injury, and in some cases might involve completing a treatment, such as in the case of applying a plaster to a small wound. First aid training also involves the prevention of initial injury and responder safety, and the treatment phases.

First aid

Key skills Certain skills are considered essential to the provision of first aid and are taught ubiquitously. Particularly, the "ABC"s of first aid, which focus on critical life-saving intervention, must be rendered before treatment of less serious injuries. ABC stands for Airway, Breathing, and Circulation. The same mnemonic is used by all emergency health professionals. Attention must first be brought to the airway In case of tongue fallen backwards, blocking the airway, it is necessary to to ensure it is clear. Obstruction (choking) is hyperextend the head and pull up the chin, so that the tongue lifts and clears the a life-threatening emergency. Following airway. evaluation of the airway, a first aid attendant would determine adequacy of breathing and provide rescue breathing if necessary. Assessment of circulation is now not usually carried out for patients who are not breathing, with first aiders now trained to go straight to chest compressions (and thus providing artificial circulation) but pulse checks may be done on less serious patients. Some organizations add a fourth step of "D" for Deadly bleeding or Defibrillation, while others consider this as part of the Circulation step. Variations on techniques to evaluate and maintain the ABCs depend on the skill level of the first aider. Once the ABCs are secured, first aiders can begin additional treatments, as required. Some organizations teach the same order of priority using the "3Bs": Breathing, Bleeding, and Bones (or "4Bs": Breathing, Bleeding, Brain, and Bones). While the ABCs and 3Bs are taught to be performed sequentially, certain conditions may require the consideration of two steps simultaneously. This includes the provision of both → artificial respiration and → chest compressions to someone who is not breathing and has no pulse, and the consideration of cervical spine injuries when ensuring an open airway.

Preserving life In order to stay alive, all persons need to have an open airway - a clear passage where air can move in through the mouth or nose through the pharynx and down in to the lungs, without obstruction. Conscious people will maintain their own airway automatically, but those who are unconscious (with a GCS of less than 8) may be unable to maintain a patent airway, as the part of the brain which automatically controls breathing in normal situations may not be functioning. If the patient was breathing, a first aider would normally then place them in the recovery position, with the patient leant over on their side, which also has the effect of clearing the tongue from the pharynx. It also avoids a common cause of death in unconscious patients, which is choking on regurgitated stomach contents. The airway can also become blocked through a foreign object becoming lodged in the pharynx or larynx, commonly called choking. The first aider will be taught to deal with this through a combination of ‘back slaps’ and ‘abdominal thrusts’. Once the airway has been opened, the first aider would assess to see if the patient is breathing. If there is no breathing, or the patient is not breathing normally, such as agonal breathing, the first aider would undertake what is probably the most recognized first aid procedure - Cardiopulmonary resuscitation or CPR, which involves breathing for the patient, and manually massaging the heart to promote blood flow around the body.

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Promoting recovery The first aider is also likely to be trained in dealing with injuries such as cuts, grazes or bone fracture. They may be able to deal with the situation in its entirety (a small adhesive bandage on a paper cut), or may be required to maintain the condition of something like a broken bone, until the next stage of definitive care (usually an ambulance) arrives.

Training Much of first aid is common sense. Basic principles, such as knowing to use an adhesive bandage or applying direct pressure on a bleed, are often acquired passively through life experiences. However, to provide effective, life-saving first aid interventions requires instruction and practical training. This is especially true where it relates to potentially fatal illnesses and injuries, such as those that require → cardiopulmonary resuscitation (CPR); these procedures may be invasive, and carry a risk of further injury to the patient and the provider. As with any training, it is more useful if it occurs before an actual emergency, and in many countries, emergency ambulance dispatchers may give basic first aid instructions over the phone while the ambulance is on the way. Training is generally provided by attending a course, typically leading to certification. Due to regular changes in procedures and protocols, based on updated clinical knowledge, and to maintain skill, attendance First aid scenario training in progress at regular refresher courses or re-certification is often necessary. First aid training is often available through community organizations such as the Red Cross and St. John Ambulance, or through commercial providers, who will train people for a fee. This commercial training is most common for training of employees to perform first aid in their workplace. Many community organizations also provide a commercial service, which complements their community programmes.

Australia In Australia, Nationally recognized First Aid certificates may only be issued by Registered training organisations who are accredited on the National Training Information System (NTIS). Most First Aid certificates are issued at one of 3 levels: • Level 1 (or “Basic First Aid”, or “Basic Life Support”): is a 1-day course covering primarily life-threatening emergencies: CPR, bleeding, choking and other life-threatening medical emergencies. • Level 2 (“Senior First Aid”) is a 2 day course that covers all the aspects of training in Level 1, as well as specialized training for treatment of burns, bites, stings, electric shock and poisons. Level 2 reaccreditation is a 1 day course which must be taken every 3 years, but CPR reaccrediation may be required more frequently (typically yearly). • Level 3 (“Occupational First Aid”) is a 4-day course covering advanced first aid, use of oxygen and automated external defibrillators and documentation. It is suitable for workplace First Aiders and those who manage First Aid facilities. Other courses outside these levels are commonly taught, including CPR-only courses, Advanced Resuscitation, Remote Area or Wilderness First Aid, Administering Medications (such as salbutamol or the Epi-Pen) and specialized courses for parents, school teachers, community first responders or hazardous workplace first aiders. CPR Re-accredidation courses are sometimes required yearly, regardless of the length of the overall certification.

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Canada In Canada, first aid certificates are awarded by one of several national organizations including the Red Cross, the Lifesaving Society and St. John Ambulance. Or they can also be issued by sub-national organizations. The terms "Emergency First Aid" and "Standard First Aid" are generic and based on a Health Canada (a federal department of the Government of Canada) review and approval of a training organization's curriculum / syllabus (training content), standards and other factors. Workplace safety regulations and standards for first aid vary by province depending on occupation. However, as some occupations are governed by federal, not provincial, workplace safety regulations, such as the transportation industry (marine, aviation, rail), trainees need to confirm with their employer as to exactly what specific training and certification standards comply with the applicable regulatory agencies, federal or provincial. • Emergency First Aid: is an 8-hour course covering primarily life-threatening emergencies: CPR, bleeding, choking and other life-threatening medical emergencies. • Standard First Aid: is a 16-hour course that covers the same material as Emergency First Aid and will include training for some, but not all, of the following: breaks; burns; poisons, bites and stings; eye injuries; head and neck injuries; chest injuries; wound care; emergency child birth; and multiple casualty management. • Medical First Responder (BTLS - known by different names among different Canadian organizations): is a 40 hour course. It requires Standard First Aid certification as a prerequisite. Candidates are trained in the use of oxygen, automated external defibrillators, airway management, and the use of additional emergency equipment. CPR CPR certification in Canada is broken into several levels. Depending on the level, the lay person will learn the basic one-person CPR and choking procedures for adults, and perhaps children, and infants. Higher-level designations also require two-person CPR to be learned. Depending on provincial laws, trainees may also learn the basics of automated external defibrillation (AED).[5] • Level A is the lowest level of CPR training. Trainees learn how to perform the standard one-rescuer CPR and choking procedures on adults. • Level B requires the same procedures as Level A, but trainees learn to perform these maneuvers on children and infants in addition to adults. • Level C requires the same maneuvers as Level B, and trainees are also taught how to perform two-person CPR. • Level HCP (Health Care Professional) was introduced in Canada in response to new guidelines set by the International Liaison Committee on Resuscitation.[6] In addition to the techniques taught in Level C, → artificial resuscitation, AED use (to certification standards), and bag-valve-mask use is taught. Anyone with CPR-HCP certification is considered AED certified.

Ireland In Ireland, the workplace qualification is the Occupational First Aid Certificate. The Health and Safety Authority issue the standards for first aid at work and hold a register of qualified instructors, examiners and organisations that can provide the course. A FETAC Level 5 certificate is awarded after passing a three day course and is valid for two years from date of issue. Occupational First Aiders are more qualified than Cardiac First Responders (Cardiac First Response and training on the AED is now part of the OFA course) but less qualified than Emergency First Responders but strangely Occupational First Aid is the only one of the three not certified by PHECC. Organisations offering the certificate include, Ireland's largest first aid organisation, the Order of Malta Ambulance Corps, the St John Ambulance Brigade, and the Irish Red Cross. The Irish Red Cross also provides a Practical First Aid Course aimed at the general public dealing primarily with family members getting injured. Many other (purely commercially run) organisations offer training.

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The Netherlands In the The Netherlands first aid training and certification for lay persons are provided mostly by specialised (commercial) first aid training companies or voluteers of the "Dutch Red Cross" and the foundations "Het Oranje Kruis" and "LPEV". They offer a variety of levels in first aid training, from basic CPR to First Responder. Medical first aid must be provided by certified ambulance crews, physicians and in hospitals. :)

United Kingdom In the U.K., there are two main types of first aid courses offered. An “Emergency First Aid at Work” course typically lasts one day, and covers the basics, focusing on critical interventions for conditions such as cardiac arrest and severe bleeding, and is usually not formally assessed. A “First Aid at Work” course is usually a three-day course (two days for a re-qualification) that covers the full spectrum of first aid, and is formally assessed by recognized Health and Safety Executive assessors. Certificates for the “First Aid at Work” course are issued by the training organization and are valid for a period of three years from the date the delegate passes the course. Other courses offered by training organizations such as St. John Ambulance, St Andrew’s First Aid or the British Red Cross include Baby & Child Courses, manual handling, people moving, and courses geared towards more advanced life support, such as defibrillation and administration of medical gases such as oxygen & entonox. The British Forces use First Aid ranging from levels 1-3, to assist the medical staff on their Ship, Squadron, Section, Base or any other purpose required. They are trained in both Military and Civilian First Aid and often utilise their knowledge in aid stricken regions around the world. First Aid is vital on board HM Ships because of the number of people in a small area and the space given to perform their task, it is also vital for the Army and Royal Marines to know basic first aid to help the survival rate of the soldiers when in combat.

Specific disciplines There are several types of first aid (and first aider) which require specific additional training. These are usually undertaken to fulfill the demands of the work or activity undertaken. • Aquatic/Marine first aid - Usually practiced by professionals such as lifeguards, professional mariners or in diver rescue, and covers the specific problems which may be faced after water-based rescue and/or delayed MedEvac. • Battlefield first aid - This takes in to account the specific needs of treating wounded combatants and non-combatants during armed conflict. • Hyperbaric first aid - Which may be practiced by SCUBA diving professionals, who need to treat conditions such as the bends. • Oxygen first aid - Providing oxygen to casualties who suffer from conditions resulting in hypoxia. • Wilderness first aid is the provision of first aid under conditions where the arrival of emergency responders or the evacuation of an injured person may be delayed due to constraints of terrain, weather, and available persons or equipment. It may be necessary to care for an injured person for several hours or days.

Symbols Although commonly associated with first aid, the symbol of a red cross is an official protective symbol of the Red Cross. According to the Geneva Conventions and other international laws, the use of this and similar symbols is reserved for official agencies of the International Red Cross and Red Crescent, and as a protective emblem for medical personnel and facilities in combat situations. Use by any other person or organization is illegal, and may lead to prosecution. The internationally accepted symbol for first aid is the white cross on a green background shown at the start of the page.

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Some organizations may make use of the Star of Life, although this is usually reserved for use by ambulance services, or may use symbols such as the Maltese Cross, like the Order of Malta Ambulance Corps and St John Ambulance. Other symbols may also be used.

Symbol of the Red Cross

ISO First Aid Symbol

Maltese or Amalfi Cross

Star of life

Conditions that often require first aid Also see medical emergency. • Altitude sickness, which can begin in susceptible people at altitudes as low as 5,000 feet, can cause potentially fatal swelling of the brain or lungs.[7] • Anaphylaxis, a life-threatening condition in which the airway can become constricted and the patient may go into shock. The reaction can be caused by a systemic allergic reaction to allergens such as insect bites or peanuts. Anaphylaxis is initially treated with injection of epinephrine. • Battlefield first aid - This protocol refers to treating shrapnel, gunshot wounds, burns, bone fractures, etc. as seen either in the ‘traditional’ battlefield setting or in an area subject to damage by large scale weaponry, such as a bomb blast or other terrorist activity. • Bone fracture, a break in a bone initially treated by stabilizing the fracture with a splint. • Burns, which can result in damage to tissues and loss of body fluids through the burn site. • Choking, blockage of the airway which can quickly result in death due to lack of oxygen if the patient’s trachea is not cleared, for example by the Heimlich Maneuver. • Childbirth. • Cramps in muscles due to lactic acid build up caused either by inadequate oxygenation of muscle or lack of water or salt. • Diving disorders, drowning or asphyxiation.[8] • Gender-specific conditions, such as dysmenorrhea and testicular torsion. • Heart attack, or inadequate blood flow to the blood vessels supplying the heart muscle. • Heat stroke, also known as sunstroke or hyperthermia, which tends to occur during heavy exercise in high humidity, or with inadequate water, though it may occur spontaneously in some chronically ill persons. Sunstroke, especially when the victim has been unconscious, often causes major damage to body systems such as brain, kidney, liver, gastric tract. Unconsciousness for more than two hours usually leads to permanent disability. Emergency treatment involves rapid cooling of the patient. • Heat syncope, another stage in the same process as heat stroke, occurs under similar conditions as heat stroke and is not distinguished from the latter by some authorities. • Heavy bleeding, treated by applying pressure (manually and later with a pressure bandage) to the wound site and elevating the limb if possible. • Hyperglycemia (diabetic coma) and Hypoglycemia (insulin shock). • Hypothermia, or Exposure, occurs when a person’s core body temperature falls below 33.7°C (92.6°F). First aid for a mildly hypothermic patient includes rewarming, but rewarming a severely hypothermic person could result

First aid

• • • •

• • • •

in a fatal arrhythmia, an irregular heart rhythm. Insect and animal bites and stings. Joint dislocation. Poisoning, which can occur by injection, inhalation, absorption, or ingestion. Seizures, or a malfunction in the electrical activity in the brain. Three types of seizures include a grand mal (which usually features convulsions as well as temporary respiratory abnormalities, change in skin complexion, etc) and petit mal (which usually features twitching, rapid blinking, and/or fidgeting as well as altered consciousness and temporary respiratory abnormalities). Muscle strains and Sprains, a temporary dislocation of a joint that immediately reduces automatically but may result in ligament damage. Stroke, a temporary loss of blood supply to the brain. Toothache, which can result in severe pain and loss of the tooth but is rarely life threatening, unless over time the infection spreads into the bone of the jaw and starts osteomyelitis. Wounds and bleeding, including lacerations, incisions and abrasions, Gastrointestinal bleeding, avulsions and Sucking chest wounds, treated with an occlusive dressing to let air out but not in.

External links • First Aid Guide at the Mayo Clinic [9] • First Aid References at the U.S.A. Center for Disease Control [10] • First Aid at BBC Health [11]

References [1] First Aid: From Witchdoctors & Religious Knights to Modern Doctors (http:/ / www. medicinenet. com/ script/ main/ art. asp?articlekey=52749), retrieved December 10, 2006. [2] Industrial Revolution: St. John Ambulance (http:/ / www. sja. org. uk/ history/ victorian_britain. asp), retrieved December 10, 2006. [3] American Red Cross -- Museum (http:/ / www. redcross. org/ museum/ registry/ profile. asp?id=33), retrieved December 10, 2006. [4] " Accidents and first aid (http:/ / www. nhsdirect. nhs. uk/ articles/ article. aspx?articleId=450)". NHS Direct. . Retrieved 2008-10-04. [5] Lifesaving Society of Canada (16 January 2007). " Communiqué - CPR Training for Alberta Health Care Providers (http:/ / www. lifesaving. org/ download/ Health Regions HCP Letter. pdf)" (pdf). Press release. . Retrieved 25 August 2009. "Together, all five members of the ECC agreed upon the new Canadian levels for CPR and the content and skills required for each level." [6] "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation (United States: Lippincott Williams & Wilkins) 112 (24 Supplement). doi: 10.1161/CIRCULATIONAHA.105.166552 (http:/ / dx. doi. org/ 10. 1161/ CIRCULATIONAHA. 105. 166552). ISSN 0009-7322 (http:/ / worldcat. org/ issn/ 0009-7322). [7] Cymerman, A; Rock, PB. Medical Problems in High Mountain Environments. A Handbook for Medical Officers (http:/ / archive. rubicon-foundation. org/ 7976). USARIEM-TN94-2. US Army Research Inst. of Environmental Medicine Thermal and Mountain Medicine Division Technical Report. . Retrieved 2009-03-05. [8] Longphre, John M.; Petar J. DeNoble; Richard E. Moon; Richard D. Vann; John J. Freiberger (2007). " First aid normobaric oxygen for the treatment of recreational diving injuries. (http:/ / archive. rubicon-foundation. org/ 5514)". Undersea and Hyperbaric Medicine 34 (1): 43–49. ISSN 1066-2936 (http:/ / worldcat. org/ issn/ 1066-2936). OCLC 26915585 (http:/ / worldcat. org/ oclc/ 26915585). PMID 17393938 (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 17393938). . Retrieved 2009-03-05. [9] http:/ / www. mayoclinic. com/ health/ FirstAidIndex/ FirstAidIndex [10] http:/ / www. cdc. gov/ nasd/ menu/ topic/ firstaid. html [11] http:/ / www. bbc. co. uk/ health/ first_aid/ index. shtml

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Cardiopulmonary resuscitation Cardiopulmonary resuscitation (CPR) is an emergency medical procedure for a victim of cardiac arrest or, in some circumstances, respiratory arrest.[1] CPR is performed in hospitals, or in the community by laypersons or by emergency response professionals.[2] CPR involves physical interventions to create artificial circulation through rhythmic pressing on the patient's chest to manually pump blood through the heart, called chest compressions, and usually also involves the rescuer exhaling into the patient (or using a device to simulate this) to inflate the lungs and pass oxygen in to the blood, called → artificial respiration.[1] [3] Some protocols now downplay the importance of the artificial respirations, and focus on the chest compressions only.[4] [5] CPR is unlikely to restart the heart; its main purpose is to maintain a flow of oxygenated blood to the brain and the heart, thereby delaying tissue death and extending the brief window of opportunity for a successful resuscitation without permanent brain damage. Advanced CPR being performed on a mannequin used for life support and defibrillation, the administration of an electric shock to training the heart, is usually needed for the heart to restart, and this only works for patients in certain heart rhythms, namely ventricular fibrillation or ventricular tachycardia, rather than the 'flat line' asystolic patient although CPR can help bring a patient in to a shockable rhythm. CPR is generally continued, usually in the presence of advanced life support (such as from a medical team or paramedics), until the patient regains a heart beat (called "return of spontaneous circulation" or "ROSC") or is declared dead.

History In the 19th century, Doctor H. R. Silvester described a method (The Silvester Method) of artificial respiration in which the patient is laid on their back, and their arms are raised above their head to aid inhalation and then pressed against their chest to aid exhalation.[6] The procedure is repeated sixteen times per minute. This type of artificial respiration is occasionally seen in films made in the early part of the 20th century. A second technique, called the Holger Neilson technique, described in the first edition of the Boy Scout Handbook in the United States in 1911, described a form of artificial respiration where the person was laid on their front, with their head to the side, resting on the palms of both hands. Upward pressure applied at the patient’s elbows raised the upper body while pressure on their back forced air into the lungs, essentially the Silvester Method with the patient flipped over. This form is seen well into the 1950s (it is used in an episode of Lassie

Sign showing old Silvester and Holger-Nielson methods of resuscitation

Cardiopulmonary resuscitation during the Jeff Miller era), and was often used, sometimes for comedic effect, in theatrical cartoons of the time (see Tom and Jerry's "The Cat and the Mermouse"). This method would continue to be shown, for historical purposes, side-by-side with modern CPR in the Boy Scout Handbook until its ninth edition in 1979. The technique was later banned from first-aid manuals in the UK. However, it was not until the middle of the 20th century that the wider medical community started to recognize and promote artificial respiration combined with chest compressions as a key part of resuscitation following cardiac arrest. The combination was first seen in a 1962 training video called "The Pulse of Life" created by James Jude, Guy Knickerbocker and Peter Safar. Jude and Knickerbocker, along with William Kouwenhoven and Jospeh S. Redding had recently discovered the method of external chest compressions, whereas Safar had worked with Redding and James Elam to prove the effectiveness of artificial respiration. It was at Johns Hopkins University where the technique of CPR was originally developed. The first effort at testing the technique was performed on a dog by Redding, Safar and JW Perason. Soon afterwards, the techique was used to save the life of a child. [7] Their combined findings were presented at annual Maryland Medical Society meeting on September 16, 1960 in Ocean City, and gained rapid and widespread acceptance over the following decade, helped by the video and speaking tour they undertook. Peter Safar wrote the book ABC of resuscitation in 1957. In the U.S., it was first promoted as a technique for the public to learn in the 1970s. [8] → Artificial respiration was combined with chest compressions based on the assumption that active ventilation is necessary to keep circulating blood oxygenated, and the combination was accepted without comparing its effectiveness with chest compressions alone. However, research over the past decade has shown that assumption to be in error, resulting in the AHA's acknowledgment of the effectiveness of chest compressions alone (see Cardiocerebral resuscitation below).[4]

Use in cardiac arrest The medical term for the condition in which a person's heart has stopped is cardiac arrest (also referred to as cardiorespiratory arrest).[9] CPR is used on patients in cardiac arrest in order to oxygenate the blood and maintain a cardiac output to keep vital organs alive. Blood circulation and oxygenation are absolute requirements in transporting oxygen to the tissues. The brain may sustain damage after blood flow has been stopped for about four minutes and irreversible CPR training: CPR is being administrated while a damage after about seven minutes.[10] [11] [12] [13] [14] If blood flow second rescuer prepares for defibrillation. ceases for one to two hours, the cells of the body die unless they get an adequately gradual bloodflow, (provided by cooling and gradual warming, rarely, in nature [such as in a cold stream of water] or by an advanced medical team). Because of that CPR is generally only effective if performed within seven minutes of the stoppage of blood flow.[15] The heart also rapidly loses the ability to maintain a normal rhythm. Low body temperatures as sometimes seen in near-drownings prolong the time the brain survives. Following cardiac arrest, effective CPR enables enough oxygen to reach the brain to delay brain death, and allows the heart to remain responsive to defibrillation attempts. If the patient still has a pulse, but is not breathing, this is called respiratory arrest and → artificial respiration is more appropriate. However, since people often have difficulty detecting a pulse, CPR may be used in both cases, especially when taught as first aid.

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Guidelines In 2005, new CPR guidelines[16] [17] were published by the International Liaison Committee on Resuscitation (ILCOR), agreed at the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science.[18] [19] The primary goal of these changes was to simplify CPR for lay rescuers and healthcare providers alike, to maximize the potential for early resuscitation. The important changes for 2005 were:[20] • A universal compression-ventilation ratio (30:2) recommended for all single rescuers of infant (less than one year old), child (1 year old to puberty), and adult (puberty and above) victims (excluding newborns).[21] The primary difference between the age groups is that with adults the rescuer uses two hands for the chest compressions, while with children it is only one, and with infants only two fingers (index and middle fingers).[22] While this simplification has been introduced, it has not been universally accepted, and especially amongst healthcare professionals, protocols may still vary.[23] • The removal of the emphasis on lay rescuers assessing for pulse or signs of circulation for an unresponsive adult victim, instead taking the absence of normal breathing as the key indicator for commencing CPR. • The removal of the protocol in which lay rescuers provide rescue breathing without chest compressions for an adult victim, with all cases such as these being subject to CPR. Research[16] has shown that lay personnel cannot accurately detect a pulse in about 40% of cases and cannot accurately discern the absence of pulse in about 10%. The pulse check step has been removed from the CPR procedure completely for lay persons and de-emphasized for healthcare professionals.

Alternative methods Compression only (cardiocerebral) resuscitation The traditional International Liaison Committee on Resuscitation approach described above has been challenged in recent years by advocates for compression-only CPR, also known as cardiocerebral resuscitation (CCR). This technique is simply chest compressions without → artificial respiration. The respiration component of CPR has been a topic of major controversy over the past decade. The CCR method has been championed by the University of Arizona's Sarver Heart Center, and a study by the university,[24] claimed a 300% greater success rate over standard CPR.[25] The exceptions were in the case of drowning or drug overdose. In March 2007, a Japanese study in the medical journal The Lancet presented strong evidence that compressing the chest, not mouth-to-mouth (MTM) ventilation, is the key to helping someone recover from cardiac arrest.[26] An editorial by Gordon Ewy MD (a proponent of CCR) in the same issue of The Lancet called for an interim revision of the ILCOR Guidelines based on the results of the Japanese study, but the next scheduled revision of the Guidelines was not until 2010. However, on March 30, 2008, the American Heart Association broke away from the ILCOR position and stated that compression-only CPR works as well as, and sometimes better than, traditional CPR.[27] The method of delivering chest compressions remains the same, as does the rate (100 per minute), but the rescuer delivers only the compression element which, the University of Arizona claims, keeps the bloodflow moving without the interruption caused by MTM respiration. It has been claimed that the use of compression only delivery increases the chances of lay person delivering CPR.[28]

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Rhythmic abdominal compressions Rhythmic abdominal compression-CPR works by forcing blood from the blood vessels around the abdominal organs, an area known to contain about 25 percent of the body's total blood volume. This blood is then redirected to other sites, including the circulation around the heart. Findings published in the September 2007 issue of the American Journal of Emergency Medicine using pigs found that 60 percent more blood was pumped to the heart using rhythmic abdominal compression-CPR than with standard chest compression-CPR, using the same amount of effort. There was no evidence that rhythmic abdominal compressions damaged the abdominal organs and the risk of rib fracture was avoided. Avoiding mouth-to-mouth breathing and chest compressions eliminates the risk of rib fractures and transfer of infection.[29]

Self-CPR hoax A form of "self-CPR" termed "Cough CPR" was the subject of a hoax chain e-mail entitled "How to Survive a Heart Attack When Alone" which wrongly cited "ViaHealth Rochester General Hospital" as the source of the technique. Rochester General Hospital has denied any connection with the technique.[30] [31] Rapid coughing has been used in hospitals for brief periods of cardiac arrhythmia on monitored patients. One researcher has recommended that it be taught broadly to the public.[32] [33] However, “cough CPR” cannot be used outside the hospital because the first symptom of cardiac arrest is unconsciousness[34] in which case coughing is impossible, although myocardial infarction (heart attack) may occur to give rise to the cardiac arrest, so a patient may not be immediately unconscious. Further, the vast majority of people suffering chest pain from a heart attack will not be in cardiac arrest and CPR is not needed. In these cases attempting “cough CPR” will increase the workload on the heart and may be harmful. When coughing is used on trained and monitored patients in hospitals, it has only been shown to be effective for 90 seconds.[35] The American Heart Association (AHA) and other resuscitation bodies[35] do not endorse "Cough CPR", which it terms a misnomer as it is not a form of resuscitation. The AHA does recognize a limited legitimate use of the coughing technique: "This coughing technique to maintain blood flow during brief arrhythmias has been useful in the hospital, particularly during cardiac catheterization. In such cases the patients ECG is monitored continuously, and a physician is present."[36]

Internal cardiac massage Internal cardiac massage is the process of cardiac massage carried out through a surgical incision into the chest cavity.[37] This distinguishes the process from conventional, external cardiac massage, which is carried out by compression near the sternum during cardiopulmonary resuscitation.

Prevalence and effectiveness Chance of receiving CPR Various studies suggest that in out-of-home cardiac arrest, bystanders, lay persons or family members attempt CPR in between 14%[38] and 45%[39] of the time, with a median of 32%. This indicates that around 1/3 of out-of-home arrests have a CPR attempt made on them. However, the effectiveness of this CPR is variable, and the studies suggest only around half of bystander CPR is performed correctly.[40] [41] There is a clear correlation between age and the chance of CPR being commenced, with younger people being far more likely to have CPR attempted on them prior to the arrival of emergency medical services.[38] [42] It was also found that CPR was more commonly given by a bystander in public than when an arrest occurred in the patient's home, although health care professionals are responsible for more than half of out-of-hospital resuscitation

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Cardiopulmonary resuscitation attempts.[39] This is supported by further research, which suggests that people with no connection to the victim are more likely to perform CPR than a member of their family.[43] This is likely because of the shock experienced by finding a family member in need of CPR; it is easier to remain calm - and think clearly - when the person in need of CPR is a complete stranger, as in this case one will not be as frightened. There is also a correlation between the cause of arrest and the likelihood of bystander CPR being initiated. Lay persons are most likely to give CPR to younger cardiac arrest victims in a public place when it has a medical cause; victims in arrest from trauma, exsanguination or intoxication are less likely to receive CPR.[43] Finally, it has been claimed that there is a higher chance of CPR being performed if the bystander is told to only perform the chest compression element of the resuscitation.[28]

Chance of receiving CPR in time CPR is only likely to be effective if commenced within 6 minutes after the blood flow stops,[44] because permanent brain cell damage occurs when fresh blood infuses the cells after that time, since the cells of the brain become dormant in as little as 4–6 minutes in an oxygen deprived environment and the cells are unable to survive the reintroduction of oxygen in a traditional resuscitation. Research using cardioplegic blood infusion resulted in a 79.4% survival rate with cardiac arrest intervals of 72±43 minutes, traditional methods achieve a 15% survival rate in this scenario, by comparison. New research is currently needed to determine what role CPR, electroshock, and new advanced gradual resuscitation techniques will have with this new knowledge[45] A notable exception is cardiac arrest occurring in conjunction with exposure to very cold temperatures. Hypothermia seems to protect the victim by slowing down metabolic and physiologic processes, greatly decreasing the tissues' need for oxygen.[46] There are cases where CPR, defibrillation, and advanced warming techniques have revived victims after substantial periods of hypothermia.[47]

Chance of surviving Used alone, CPR will result in few complete recoveries, and those that do survive often develop serious complications. Estimates vary, but many organizations stress that CPR does not "bring anyone back," it simply preserves the body for defibrillation and advanced life support.[48] However, in the case of "non-shockable" rhythms such as Pulseless Electrical Activity (PEA), defibrillation is not indicated, and the importance of CPR rises. On average, only 5%-10% of people who receive CPR survive.[49] The purpose of CPR is not to "start" the heart, but rather to circulate oxygenated blood, and keep the brain alive until advanced care (especially defibrillation) can be initiated. As many of these patients may have a pulse that is impalpable by the layperson rescuer, the current consensus is to perform CPR on a patient that is not breathing. Studies have shown the importance of immediate CPR followed by defibrillation within 3–5 minutes of sudden VF cardiac arrest improve survival. In cities such as Seattle where CPR training is widespread and defibrillation by EMS personnel follows quickly, the survival rate is about 30 percent. In cities such as New York City, without those advantages, the survival rate is only 1-2 percent.[50] In most cases, there is a higher proportion of patients who achieve a Return of Spontaneous Circulation (ROSC), where their heart starts to beat on its own again, than ultimately survive to be discharged from hospital (see table below). This is due to medical staff either being ultimately unable to address the cause of the arrhythmia or cardiac arrest, or in some instances due to other co-morbidities, due to the patient being gravely ill in more than one way.

12

Cardiopulmonary resuscitation

13

Type of Arrest

ROSC Survival

Source

Witnessed In-Hospital Cardiac Arrest

48%

22%

[51]

Unwitnessed In-Hospital Cardiac Arrest

21%

1%

[51]

Bystander Cardiocerebral Resuscitation

40%

6%

[52]

Bystander Cardiopulmonary Resuscitation 40%

4%

[52]

No Bystander CPR (Ambulance CPR)

15%

2%

[52]

Defibrillation within 3–5 minutes

74%

30%

[48] [50]

ROSC = Return of spontaneous circulation

Therapeutic Hypothermia In some cases, doctors may choose to induce hypothermia after return of spontaneous circulation (ROSC). This procedure is called therapeutic hypothermia. The first study conducted in Europe focused on people who were resuscitated 5–15 minutes after collapse. Patients participating in this study experienced spontaneous return of circulation (ROSC) after an average of 105 minutes. Subjects were then cooled over a 24 hour period, with a target temperature of 32-34°C (89.6-93.2°F). 55% of the 137 patients in the hypothermia group experienced favorable outcomes, compared with only 39% in the group that received standard care following resuscitation.[53] Death rates in the hypothermia group were 14% lower, meaning that for every 7 patients treated one life was saved.[53] Notably, complications between the two groups did not differ substantially. This data was supported by another similarly run study that took place simultaneously in Australia. In this study 49% of the patients treated with hypothermia following cardiac arrest experienced good outcomes, compared to only 26% of those who received standard care.[54]

Chest compression adjuncts Several different devices have become available in order to help facilitate rescuers in getting the chest compressions completed correctly. These devices can be split in to three broad groups - timing devices, those that assist the rescuer to achieve the correct technique, especially depth and speed of compressions, and those which take over the process completely. Timing devices They can feature a metronome (an item carried by many ambulance crews) in order to assist the rescuer in getting the correct rate. The CPR trainer cited here [55] has timed indicators for pressing on the chest, breathing and changing operators. Manual assist devices Studies have shown that audible and visual prompting can improve the quality of CPR and prevent the decrease of compression rate and depth that naturally occurs with fatigue,[56] [57] [58] [59] [60] [61] and to address this potential improvement, a number of devices have been developed to help improve CPR technique. These items can be devices to placed on top of the chest, with the rescuers hands going over the device, and a display or audio feedback giving information on depth, force or rate,[62] or in a wearable format such as a glove.[63] Several published evaluations show that these devices can improve the performance of chest compressions.[64] [65] As well as use during actual CPR on a cardiac arrest victim, which relies on the rescuer carrying the device with them, these devices can also be used as part of training programmes to improve basic skills in performing correct chest compressions..[66]

Cardiopulmonary resuscitation Certain defibrillation pads are capable of performing similar function, in that they may display rate and depth of compressions. Additionally, a certain algorithm may allow them to monitor electrical activity even during CPR.[67] . Automatic devices There are also some devices available which take over the chest compressions for the rescuer. These devices use techniques such as pneumatics to drive a compressing pad on to the chest of the patient. One such device, known as the LUCAS, was developed at the University Hospital of Lund, is powered by the compressed air cylinders or lines available in ambulances or in hospitals, and has undergone numerous clinical trials, showing a marked improvement in coronary perfusion pressure[68] and return of spontaneous circulation.[69] Another system called the AutoPulse is electrically powered and uses a large band around the patients chest which contracts in rhythm in order to deliver chest compressions. This is also backed by clinical studies showing increased successful return of spontaneous circulation.[70] [71]

Place in film and television Portrayed effectiveness CPR is often severely misrepresented in movies and television as being highly effective in resuscitating a person who is not breathing and has no circulation. A 1996 study published in the New England Journal of Medicine showed that CPR success rates in television shows was 75% for immediate circulation, and 67% survival to discharge.[72] [73] This gives members of the public an unrealistic expectation of a successful outcome.[72] When educated on the actual survival rates, the proportion of patients over 60 years of age desiring CPR should they suffer a cardiac arrest drops from 41% to 22%.[74]

Stage CPR Chest compressions are capable of causing significant local blunt trauma, including bruising or fracture of the sternum or ribs. Performing CPR on a healthy person may or may not disrupt normal heart rhythm, but regardless the technique should not be performed on a healthy person because of the risk of trauma. The portrayal of CPR technique on television and film often is purposely incorrect. Actors simulating the performance of CPR may bend their elbows while appearing to compress, to prevent force from reaching the chest of the actor portraying the victim. Other techniques, such as substituting a mannequin torso for the "victim" in some shots, may also be used to avoid harming actors.

Application on animals It is entirely feasible to perform CPR on animals including cats and dogs. The principles and practices are virtually identical to CPR for humans. One is cautioned to only perform CPR on unconscious animals to avoid the risk of being bitten and that animals, depending on species, have a lower bone density than humans causing bones to become weakened after CPR is performed.[75]

See also • • • •

Advanced life support Basic Life Support (BLS) Cardiocerebral Resuscitation (CCR), a similar technique CPR mask

• Face shield • Resusci Anne

14

Cardiopulmonary resuscitation

External links • The Center for Resuscitation Science at the Hospital of the University of Pennsylvania [76] • 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [77] • ERC European Resuscitation Council [78] • Learn CPR - University of Washington [79] • Akuttjournalen.com - The Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine [80] • How Stuff Works - CPR [81]

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Cardiopulmonary resuscitation PMID 12197686 (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 12197686). . Retrieved 2007-06-14. [52] " Resuscitation Council Comment on CPR study (http:/ / www. resus. org. uk/ pages/ compCPRs. htm)". Resuscitation Council UK. April 2007. . Retrieved 2007-06-14. [53] Holzer, Michael. “Mild Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest.” New England Journal of Medicine. (2002) Vol. 346, No. 8. [54] Bernard, Stephen et al. "Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypothermia." N England Journal of Medicine. (2002) Vol. 346, No. 8. [55] http:/ / www. siliconchip. com. au/ cms/ A_108147/ article. html [56] Hightower, D., S.H. Thomas, et al., Decay in quality of closed-chest compressions over time. Ann Emerg Med, 1995. 26(3): p. 300-3. [57] Chiang, W.C., W.J. Chen, et al., Better adherence to the guidelines during cardiopulmonary resuscitation through the provision of audio-prompts. 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Resuscitation 55: 285. doi: 10.1016/S0300-9572(02)00271-X (http:/ / dx. doi. org/ 10. 1016/ S0300-9572(02)00271-X). [69] Rubertsson et al. (2006). "Increased restoration of spontaneous circulation after cardiac arrest with the LUCAS device compared to manual chest compressions". Resuscitation 69. [70] Casner, M; Anderson, D; Isaacs, SM (January-March 2005). " The impact of a new CPR assist device on the rate of return of spontaneous circulation in out-of-hospital cardiac arrest (http:/ / www. ncbi. nlm. nih. gov/ sites/ entrez?cmd=Retrieve& db=pubmed& dopt=AbstractPlus& list_uids=16036830& query_hl=11& itool=pubmed_docsum)". Prehospital Emergency Care 9 (1). . [71] Hallstrom, Al; Rea, Thomas; Sayre, Michael; Christenson, James; Anton, Andy; Mosesso, Vince; Ottingham, Lois; Olsufka, Michele; Pennington, Sarah; White, Lynn; Yahn, Stephen; Husar, James; Morris, Mary; Cob, Leonard. " Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest (http:/ / jama. ama-assn. org/ cgi/ reprint/ jama;295/ 22/ 2620. pdf?ijkey=V96Oxk0wfyGibgF& keytype=finite)" (PDF). Journal of the American Medical Association 295 (22). . [72] Diem, S. J.; Diem, Susan J MD; Lantos, John D MD; Tulsky, James A MD (1996-06-13). " Cardiopulmonary Resuscitation on Television Miracles and Misinformation (http:/ / content. nejm. org/ cgi/ content/ full/ 334/ 24/ 1578)". New England Journal of Medicine 334 (24): 1578–1582. doi: 10.1056/NEJM199606133342406 (http:/ / dx. doi. org/ 10. 1056/ NEJM199606133342406). PMID 8628340 (http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 8628340). . Retrieved 2009-02-01. [73] " CPR statistics (http:/ / content. nejm. org/ cgi/ content/ abstract/ 334/ 24/ 1578)". American Heart Association. . Retrieved 2007-06-13. [74] "Public expectations of survival following cardiopulmonary resuscitation". Academy of Emergency Medicine 7 (1): 48–53. 2000. [75] " CPR for Cats & Dogs (http:/ / depts. washington. edu/ learncpr/ cat_dog. html)". University of Washington School of Medicine. . [76] http:/ / www. med. upenn. edu/ resuscitation/ [77] http:/ / circ. ahajournals. org/ content/ vol112/ 24_suppl/ [78] http:/ / www. erc. edu/ [79] http:/ / depts. washington. edu/ learncpr/ [80] http:/ / www. akuttjournalen. com/ [81] http:/ / health. howstuffworks. com/ cpr. htm

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Artificial respiration

Artificial respiration Artificial respiration is the act of simulating respiration, which provides for the overall exchange of gases in the body by pulmonary ventilation, external respiration and internal respiration.[1] This means providing air for a person who is not breathing or is not making sufficient respiratory effort on their own[2] (although it must be used on a patient with a beating heart or as part of → cardiopulmonary resuscitation in order to achieve the internal respiration). Pulmonary ventilation (and hence external respiration) is achieved through manual insufflation of the lungs either by the rescuer blowing into the patient's lungs, or by using a mechanical device to do so. This method of insufflation has been proved more effective than methods which involve mechanical manipulation of the patients chest or arms, such as the Silvester method.[3] It is also known as Expired Air Resuscitation (EAR), Expired Air Ventilation (EAV), mouth-to-mouth resuscitation, rescue breathing or colloquially the kiss of life. Artificial respiration is a part of most protocols for performing → cardiopulmonary resuscitation (CPR)[4] [5] making it an essential skill for → first aid. In some situations, artificial respiration is also performed separately, for instance in near-drowning and opiate overdoses. The performance of artificial respiration in its own is now limited in most protocols to health professionals, whereas lay first aiders are advised to undertake full CPR in any case where the patient is not breathing sufficiently. Mechanical ventilation involves the use of a mechanical ventilator to move air in and out of the lungs when an individual is unable to breathe on his or her own, for example during surgery with general anesthesia or when an individual is in a coma.

Insufflations Insufflation, also known as 'rescue breaths' or 'ventilations', is the act of mechanically forcing air into a patient's respiratory system. This can be achieved via a number of methods, which will depend on the situation and equipment available. All methods require good airway management to perform, which ensures that the method is effective. These methods include: • Mouth to mouth - This involves the rescuer making a seal between their mouth and the patient's mouth and 'blowing', in order to pass Mouth-to-mouth insufflation air into the patient's body • Mouth to nose - In some instances, the rescuer may need or wish to form a seal with the patient's nose. Typical reasons for this include maxillofacial injuries, performing the procedure in water or the remains of vomit in the mouth • Mouth to mouth and nose - Used on infants (usually up to around 1 year old), as this forms the most effective seal • Mouth to mask – Most organisations recommend the use of some sort of barrier between rescuer and patient to reduce cross infection risk. One popular type is the 'pocket mask'. This may be able to provide higher tidal volumes than a Bag Valve Mask.[6] • Bag valve mask (BVM) - This is a simple device manually operated by the rescuer, which involves squeezing a bag in order to expel air into the patient. • Mechanical resuscitator - An electric unit designed to breathe for the patient

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Artificial respiration

Adjuncts to insufflation Most training organisations recommend that in any of the methods involving mouth to patient, that a protective barrier is used, in order to minimise the possibility of cross infection (in either direction).[7] Barriers available include pocket masks and keyring-sized face shields. These barriers are an example of Personal Protective Equipment to guard the face against splashing, spraying or splattering of blood or other potentially infectious materials. These barriers should provide a one-way filter valve which lets the air A CPR pocket mask, with carrying case from the rescuer deliver to the patient while any substances from the patient (eg. vomit, blood) cannot reach the rescuer. Many adjuncts are single use, though if they are multi use, after use of the adjunct, the mask must be cleaned and autoclaved and the filter replaced. The CPR mask is the preferred method of ventilating a patient when only one rescuer is available. Many feature 18mm inlets to support supplemental oxygen, which increases the oxygen being delivered from the approximate 17% available in the expired air of the rescuer to around 40-50%. Tracheal intubation is often used for short term mechanical ventilation. A tube is inserted through the nose (nasotracheal intubation) or mouth (orotracheal intubation) and advanced into the trachea. In most cases tubes with inflatable cuffs are used for protection against leakage and aspiration. Intubation with a cuffed tube is thought to provide the best protection against aspiration. Tracheal tubes inevitably cause pain and coughing. Therefore, unless a patient is unconscious or anesthetized for other reasons, sedative drugs are usually given to provide tolerance of the tube. Other disadvantages of tracheal intubation include damage to the mucosal lining of the nasopharynx or oropharynx and subglottic stenosis. In an emergency a Cricothyrotomy can be used by health care professionals, where an airway is inserted through a surgical opening in the cricothyroid membrane. This is similar to a tracheostomy but a cricothyrotomy is reserved for emergency access. This is usually only used when there is a complete blockage of the pharynx or there is massive maxillofacial injury, preventing other adjunts being used.[8]

Efficiency of mouth to patient insufflation Normal atmospheric air contains approximately 21% oxygen when created in. After gaseous exchange has taken place in the lungs, with waste products (notably carbon dioxide) moved from the bloodstream to the lungs, the air being exhaled by humans normally contains around 17% oxygen. This means that the human body utilises only around 19% of the oxygen inhaled, leaving over 80% of the oxygen available in the exhalatory breath. [9] This means that there is more than enough residual oxygen to be used in the lungs of the patient, which then crosses the cell membrane to form oxyhemoglobin.

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Artificial respiration

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Oxygen The efficiency of artificial respiration can be greatly increased by the simultaneous use of oxygen therapy. The amount of oxygen available to the patient in mouth to mouth is around 16%. If this is done through a pocket mask with an oxygen flow, this increases to 40% oxygen. If a Bag Valve Mask or mechanical respirator is used with an oxygen supply, this rises to 99% oxygen. The greater the oxygen concentration, the more efficient the gaseous exchange will be in the lungs.

See also • mechanical ventilation for a detailed discussion from the medical perspective. • → cardiopulmonary resuscitation • medical emergency

External links

Typical view of resuscitation in progress with a BVM in use

• Expired Air Resuscitation [10] • Basic first aid advice from the Australian New South Wales ambulance service [11] • Two page pamphlet detailing EAR [12] • UK resuscitation council website - contains information on the latest approved guidelines [13]

References [1] Tortora, Gerard J; Derrickson, Bryan (2006). Principles of Anatomy and Physiology. John Wiley & Sons Inc.. [2] " Artificial Respiration (http:/ / www. britannica. com/ eb/ article-9009713/ artificial-respiration)". Encyclopaedia Britannica. . Retrieved 2007-06-15. [3] " Artificial Respiration (http:/ / www. webcitation. org/ 5kwKiCVG5)". Microsoft Encarta Online Encyclopedia 2007. Archived from the original (http:/ / encarta. msn. com/ encyclopedia_761562617/ Artificial_Respiration. html) on 2009-10-31. . Retrieved 2007-06-15. [4] " Decisions about cardiopulmonary resuscitation model information leafler (http:/ / www. bma. org. uk/ ap. nsf/ Content/ cprleaflet)". British Medical Association. July 2002. . Retrieved 2007-06-15. [5] " Overview of CPR (http:/ / circ. ahajournals. org/ cgi/ content/ full/ 112/ 24_suppl/ IV-12)". American Heart Association. 2005. . Retrieved 2007-06-15. [6] Dworkin, Gerald M (Winter 1987). " Mouth to Mouth rescue breathing and comparisons of personal resuscitation masks (http:/ / www. lifesaving. com/ issues/ articles/ 30mouth_to_mouth. html)". Rescue Squad Quarterly. . Retrieved 2007-06-15. [7] " Emergency Cardiovascular Care Revisions for the professional rescuer (http:/ / www. redcross. org/ services/ hss/ resources/ eccpr. doc)" (DOC). American Red Cross. . Retrieved 2007-06-15. [8] http:/ / emj. bmjjournals. com/ cgi/ content/ full/ 19/ 2/ 109 [9] " Physical Intervention: Life Support (Rescue Breathing) (http:/ / www. doitnow. org/ pages/ 208/ 208-5. html)". . Retrieved December 29 2005. [10] http:/ / www. justincase. com. au/ ear. html [11] http:/ / www. ambulance. nsw. gov. au/ areas/ ambulance/ firstaid/ basic. html [12] http:/ / www. health. qld. gov. au/ phs/ Documents/ shpu/ 12413. pdf [13] http:/ / www. resus. org. uk

Article Sources and Contributors

Article Sources and Contributors First aid  Source: http://en.wikipedia.org/w/index.php?oldid=323881547  Contributors: 16@r, 216.237.32.xxx, 2Wikid, A3RO, ABF, AJR, Acroterion, Agen814, Ajorm, Alansohn, Alastair Rae, Alexf, Amorymeltzer, Andrew Rocks, AndrewHowse, Andrewjuren, Andyjsmith, AnnaFrance, Anonymous101, Antandrus, Anthony Appleyard, Arcadian, Aryeh, Attilio Ridomi, Ayushdgr8st, Badgernet, Betterusername, Bobo192, Bongwarrior, Bradman1981, Brat32, Butterboy, CDrecche, CambridgeBayWeather, Cameron Dewe, Can't sleep, clown will eat me, Cardibling, CardinalDan, Catgut, Cburnett, Cdang, Chicocvenancio, Chriszenios, Cisco teen, Clarka, Cmdrjameson, Colocomp, Colonel oneill, CommonsDelinker, Conversion script, CryptoDerk, Cutler, Cyanide911, D. Recorder, DAMurphy, DJ Clayworth, Danlina, Daveb, Davehi1, Dawn Bard, Dddstone, Deedeedum, Def3kthx, Deleting Unnecessary Words, Deli nk, Delldot, Dep. 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Van De Walker, Reconsider the static, Redmist, Redsox04, Reedy, Regibox, RexNL, Rich Janis, Richardshusr, Rolandg, Rossami, Roy2, RoyBoy, Rrenner, S3000, SBJohnny2, SJP, Saber girl08, Santtus, Scottalter, Sdfisher, Sean William, Shanel, Shanes, Sid 6467, SiobhanHansa, Siu yu1988, Sjakkalle, Sjö, Skittleys, Smack, Smartasswikiguy, Snappled, Sortior, Spiritia, Splarka, Stardotboy, SteinbDJ, Stephenb, Sushant gupta, Sverdrup, THEN WHO WAS PHONE?, TUF-KAT, TaiPing, Tarquin, Tarret, Tbone762, TexMurphy, Tjwood, Tombomp, Treisijs, Twang, Until It Sleeps, Useight, VanBurenen, Versageek, Versus22, W guice, Wayward, Webmaster961, Welsh, Weyes, Wiki alf, WikiLaurent, WikidSmaht, Wikipediarules2221, Wimt, Wpktsfs, X!, Xaosflux, Xyzzyplugh, Yashgaroth, Yerpo, YourEyesOnly, Zanetobin, Zapptastic, Zembrium, Zfr, Ævar Arnfjörð Bjarmason, ‫نیهاشریما‬, 626 anonymous edits Cardiopulmonary resuscitation  Source: http://en.wikipedia.org/w/index.php?oldid=323944481  Contributors: AAAAA, Aaronmz, Adam Schwing, Ahoerstemeier, Akaisuisei, Alansohn, Alex43223, [email protected], Andrewjlockley, Andrewjuren, Arancaytar, Arcadian, Armeria, Aryeh, Attilio Ridomi, Awsomeguy101, Ayudante, Bayerischermann, Bdesham, Beland, Bevo, Billyb, Bingobangobongoboo, Blouis79, Bobblewik, Bobo192, Bogiwogie, Boingo the Clown, Brat32, Brenont, COMPFUNK2, CPRLongIsland, CWY2190, Cahk, Calmer Waters, CapFan, Carabinieri, Caspian, Cburnett, Cdang, Chamal N, Chaser, Chris 73, Chris the speller, Chungahb, Chzz, Coderedkyle, Coemgenus, CompuRuss, Courage Dog, Crohnie, Cyan, DMCer, DS1953, DXRAW, Dammit, Dan100, Dana boomer, Daniel Quinlan, DataMatrix, Davered, Daveswagon, David, Davipo, Davodavy, DennisTheTiger, Dep. Garcia, DerHexer, Dickandharry, Diderot, DimaDorfman, Discospinster, Djm1279, Doudoumi, DrBob, Drange net, Dzordzm, EatMyShortz, Ec5618, Egil, Eilu, Emeraldstone, Emergencyuniversity, Emperorbma, Epbr123, Erich gasboy, Es uomikim, Escape Orbit, Euphoria64, Ex nihil, Fdixon, Finog, Flowanda, Foobaz, Fratrep, Freedomlinux, Freeonlinecpr, Frencheigh, Func, Fuzzform, G1bb0g1bb0, Gaius Cornelius, Gak, Gerriegijsen, Giraffedata, Glenlarson, Godsong122, Graham87, Greentryst, Gschett, GummAY, Gökhan, Hadal, HavocXphere, Heartguy, Hephaestos, Hiimalilboy, Homeontheroad, Hongkongtravelguide, Horsten, Howdy, Hypotyposis, ITasteLikePaint, Icarus, Icarus3, Inform4653, Ioldanach, Iridescent, Ixfd64, J Di, J.delanoy, JLaTondre, JaGa, Jake Wartenberg, James Bedford, JamieJones, Japanese Searobin, Jastewart, Jclemens, Jeeves, Jeffq, JesseW, Jfdwolff, Jiang, Jiddisch, Jimp, Jmatt1122, JoanneB, Job Baggs, John DiMatteo, John24601, Joshuagross, Juansidious, Justanother, Justinfr, Keith26, Kether852, Killing sparrows, Kitch, Kizor, Kjetilniki, KnightRider, Kodster, Kosebamse, Kukini, KurtRaschke, Lady bluej, Lateknightucd, Leon7, Lexi Marie, Lifeguard Emeritus, Lifeguardmedical, Linkspamremover, Lolsimon, Lschneid, Lwg9q, Lylum, M omalley, M7, Manco Capac, Mandarax, Mandsford, Mankapr, MastCell, Master Thief-117, Maximus Rex, Mboverload, Melsaran, Michaelyahoo, Mikael Häggström, Mike.lifeguard, Mikeh0303, Monobeg, Montrealais, MoodyGroove, Moverton, Mr.bonus, Msswiki, Mufka, NCFireman242, Namescases, Natalie Erin, NawlinWiki, Nehrams2020, Nick123, NickBush24, Nikai, Nike787, NoPetrol, NorwegianBlue, Novem Linguae, Nunh-huh, Odie5533, Omicronpersei8, Oneiros, Owain.davies, Owen, Oxymoron83, Patrcikshearin, Patrick, Persian Poet Gal, Petersam, Pethr, Pewen13, Philb, Poccil, Posix memalign, Pzavon, RJaguar3, Radiojon, Rama, Reddi, Redsox04, Reedy, ReelExterminator, Resus2222, RexNL, Reywas92, Rhombus, Rich Farmbrough, Rjwilmsi, Rl, Robert Stephen Spiegel, Roberta F., RoyBoy, Rror, Rubenmajor, Rye1967, Ryester1120, SJP, SU Linguist, SabrinaInCalgary, Safe-Keeper, Salgueiro, Sallyjames, Sandstein, Sango123, Santaduck, Scetoaux, Scottalter, Scottxp, Security, Septegram, Sfahey, Sfcollegeguy, Shai-kun, Shalmanese, Shinyplasticbag, SimonP, Sittingduck123, Skeetinyogrille, Skysmith, Smalljim, Snowolf, Soularmor57, SpaceFlight89, Spencer233416, Spymanut, Steven Walling, Stevenspurrel, Stormbay, Strikepal, Sverdrup, Symplectic Map, SynergyBlades, Tabletop, Taconizer, Taemyr, Tbasherizer, Thatcher, The Anome, The posp, TheEgyptian, TheGerm, Tim Peterson, Tim9123, Tjwood, Trainspotter, Triona, Tucci528, Tygrrr, Tyjvi, Unitycenter, UtherSRG, VNgo, Veinor, VengeancePrime, VigilancePrime, Vivalarey, Voidxor, WRK, Wasted Sapience, Wayfarer, Wayland, Wayneli, Wizzard2k, Wyksztalcioch, Xl5, Ymaziar, Yorick8080, Yunnny, Z10x, Zzuuzz, 540 anonymous edits Artificial respiration  Source: http://en.wikipedia.org/w/index.php?oldid=323128354  Contributors: ABF, Altzinn, Alvin-cs, Arm, Bassaar, Black Kite, Bobo192, Chris the speller, Clicketyclack, DXRAW, Ddxc, DeknMike, Dep. 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Image Sources, Licenses and Contributors Image:Sign first aid.svg  Source: http://en.wikipedia.org/w/index.php?title=File:Sign_first_aid.svg  License: Copyrighted free use  Contributors: Rafal Konieczny Image:Tongue-blocking-airways.png  Source: http://en.wikipedia.org/w/index.php?title=File:Tongue-blocking-airways.png  License: Public Domain  Contributors: User:Spiritia Image:Suicide-prague.jpg  Source: http://en.wikipedia.org/w/index.php?title=File:Suicide-prague.jpg  License: unknown  Contributors: User:Chmee2 Image:Sign_first_aid.svg  Source: http://en.wikipedia.org/w/index.php?title=File:Sign_first_aid.svg  License: Copyrighted free use  Contributors: Rafal Konieczny Image:Flag_of_the_Red_Cross.svg  Source: http://en.wikipedia.org/w/index.php?title=File:Flag_of_the_Red_Cross.svg  License: Public Domain  Contributors: User:Jhs Image:Maltese-Cross-Heraldry.svg  Source: http://en.wikipedia.org/w/index.php?title=File:Maltese-Cross-Heraldry.svg  License: Public Domain  Contributors: User:AnonMoos Image:Star_of_life2.svg  Source: http://en.wikipedia.org/w/index.php?title=File:Star_of_life2.svg  License: Public Domain  Contributors: User:Verdy p Image:CPR training-04.jpg  Source: http://en.wikipedia.org/w/index.php?title=File:CPR_training-04.jpg  License: Creative Commons Attribution-Sharealike 2.0  Contributors: User:Rama Image:Picture of old resus methods.jpg  Source: http://en.wikipedia.org/w/index.php?title=File:Picture_of_old_resus_methods.jpg  License: Public Domain  Contributors: Owain.davies, VMS Mosaic, 1 anonymous edits File:CPR training-03.jpg  Source: http://en.wikipedia.org/w/index.php?title=File:CPR_training-03.jpg  License: Creative Commons Attribution-Sharealike 2.0  Contributors: User:Rama Image:insulfation2.jpg  Source: http://en.wikipedia.org/w/index.php?title=File:Insulfation2.jpg  License: unknown  Contributors: user:Rama Image:CPR mask 2.jpg  Source: http://en.wikipedia.org/w/index.php?title=File:CPR_mask_2.jpg  License: unknown  Contributors: User:Rama Image:CPR-oxygen-defibrillator.jpg  Source: http://en.wikipedia.org/w/index.php?title=File:CPR-oxygen-defibrillator.jpg  License: unknown  Contributors: User:Rama

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License

License Creative Commons Attribution-Share Alike 3.0 Unported http:/ / creativecommons. org/ licenses/ by-sa/ 3. 0/

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