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On this page, we will attempt an explanation of the mechanics of CPR. Our goal is to put the steps in a logical order and to keep the explanation simple enough to hold the interest of our reader (that's you.)
Before you go any further, we would suggest that you first read "CPR 'The Simple View'." It explains a number of concepts, that will lend some clarity and purpose to the procedures explained here.
CPR must first be divided into two categories of "in-depth-ness." There is the kind of CPR that is taught to everyday people (Civilian CPR) and there is the kind that is taught to those in the medical profession (Professional CPR,) the latter being more in-depth and demanding a stricter adherence to performance standards. Within each of those categories, there are procedures that are appropriate for the "Adult" (age 8+ years,) the "Child" (age 1 - 8 years,) and the "Infant" (less than 1 year of age.)
In order to do justice to the information, and there is a "mountain" of it to cover, we'll need to discuss each category separately.
Civilian CPR - Adult
When a you see a person laying on the ground, we can almost guarantee that your initial reaction will not be, "Oh my God, that person is dead, and needs CPR." A more realistic response would be, "Why is that person laying on the ground?" And that is actually a much better place from which to start, because it keeps open the possibility that this person may indeed just be sleeping. It is a perfect "lead-in" to the first step in any CPR event. That is to establish unresponsiveness. And so, you should tap the victim on the shoulders and shout, "Hey, hey, are you okay?" If the person does not respond, you need to immediately activate the Emergency Medical Services (EMS) System. This means that, if necessary, you should leave the patient, go to the nearest phone, and call 9-1-1. Hopefully, someone else will be standing around, and you can send them to make the telephone call for you. Be sure to instill in them a sense of importance by asking them to come back and let you know that the call has been made ("You! Go call an ambulance for an unresponsive adult. Then come back and let me know that the call was made.")
Once the EMS system has been activated (or you've sent this "helper" on his way to the nearest phone,) you should first position the patient on his/her back, then check the ABC's of CPR.
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A - Airway This means positioning the patient's head so that it is hyperextended, by tilting the head and lifting the chin. If there is a chance that the patient has a neck injury, then the rescuer should guard against further injury by modifying the procedure. Instead of a head tilt with a chin lift, the rescuer should perform a modified jaw thrust, where the jaw is displaced anteriorly (in this case - upwardly) without moving the neck.
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B - Breathing The rescuer should check to see if the patient is breathing. This is done by the Look, Listen, and Feel method. Look at the chest to determine if it is moving. Listen for the sound of air moving in and/or out of the nose and mouth. Feel for the movement of air from the nose and/or mouth. If this adult patient is not breathing, then the rescuer should ventilate the patient (mouth-to-mouth or mouth-to-mask) about 12 times a minute, or once every 5 seconds. If the patient is breathing, the rescuer should roll the patient into the recovery position. Once in the recovery position, monitor the patient's breathing to be certain that is is adequate. (see below)
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C - Circulation The rescuer should check for signs of circulation (breathing, coughing, eyelid flutter, movement, and if trained to do so, the presence of a pulse.)
Our assumption at this point will be that we have a patient that is not exhibiting any "signs of circulation." Position the patient on his/her back. Applying an Automatic External Defibrillator (AED,) if available, might be appropriate, if the rescuer is properly trained and if the rescuer is certain that the patient is without a pulse (merely checking for the other "signs of circulation" would not be enough.) In lieu of the AED, the rescuer should initiate the CPR process by first assuring patient's head is in a position of hyperextension. Ventilate the patient twice (as explained in the "Simple CPR" section,) if the ventilations do not seem to be "going in," reposition the head and try again (as explained in the "Obstructed Airway" section for Unconscious Adults.) Once you have successfully ventilated the patient, position your hands (one on top of the other) over that portion of the patient's chest where you would expect to find the heart (generally, between the nipples on the chest of a man, or an equivalent position on the chest of a woman.) You are going to push the breastbone down toward the patient's back and "squeeze the heart between the breastbone and backbone. To do this the breastbone must be displaced approximately 1½ to 2 inches toward the backbone. From this point the rescuer will do a combination of ventilations and compressions (Two [2] ventilations after fifteen [15] compressions) for about a minute (or four [4] cycles of ventilations and compressions,) at a rate of about 100 times per minute. Don't be surprised if you hear/feel some 'snapping or crunching' when you do that first compression. The likelihood is that you are disconnecting the ribs from the cartilage that connects them to the sternum (or maybe you just busting some ribs.) If you hear or feel any 'uncomfortable' sensations as described above, just be certain that you are in the right location, and continue with CPR.
After about one minute of CPR, the rescuer should check for return of "signs of life" (including breathing.) If none, continue CPR. If the patient exhibits some signs of life, make sure that the patient is breathing at an appropriate rate (about 12 times per minute or once every 5 seconds for an adult patient.) If the patient is not breathing or is breathing inadequately, then the rescuer should perform rescue breathing to assure that the patient is ventilated once every 5 seconds.
If the patient is breathing adequately, he/she must be placed in the recovery position.
Civilian CPR - Child
When dealing with a child (age 1 - 8) the approach to the patient is the same. The rescuer must first establish unresponsiveness, then activate the EMS system. The use of an AED on children has not been approved, and is most likely not the "first choice" therapeutic action for this child. The ABC's of CPR are the same for this child as they were for the adult. The rate of ventilation for a child is a little faster at fifteen (15) time a minute (once every four [4] seconds,) and the compression to ventilation ratio during CPR is five (5) compression to one (1) ventilation at a rate that is approximately 100 times a minute. The anterior chest wall (breastbone) must be displaced 1 - 1½ inches in order to "squeeze" squeeze the heart between it and the spinal column (backbone.) Because this "child" is smaller than the adult, the rescuer will use only one hand to compress the chest. The heal of that hand should be placed on the sternum, generally between the nipples, or where the rescuer would expect to "find" the heart.
The recovery position would also be used for this patient, in the event that he/she was breathing adequately, but had not yet regained consciousness.
Civilian CPR - Baby
When dealing with a baby (under 1 year of age) the "assessment skills" of the rescuer need to be very sharp. This patient is unable to answer any questions, and may not appear as sick, or distressed as patients that are over a year old, even when involved in a "full-blown" emergency. And so, the "approach" to this patient will be one of intense observation, looking for signs of life. Don't forget to activate the EMS system, but, if you are alone (unlike the adult) do not leave the patient to do so until after one minute of unsuccessful resuscitation effort. The ventilation rate for this baby is even faster yet, at about 20 times a minute or once every 3 seconds, and the compression to ventilation ratio is the same as the child at 5 to 1, at a rate of about 100 times per minute (120 if the baby is a "newborn.") The chest of the infant should be displaced ½ - 1 inch using two fingers placed on the baby's sternum approximately one finger width below an imaginary line drawn between the nipples. Babies are probably the most intimidating of all patients. Baby CPR is by far the most frightening of all the CPR procedures. But, take heart, the "universe" for this patient group is patients under 1 year of age and that represents a small segment of our society and hence, minimizes the probability that you will actually encounter a patient in this age group. If you do encounter a "baby" patient, and can't remember what to do, just remember the concepts offered in "The Simple View," and that should help refresh your memory regarding the Baby CPR.
If you are going to read through the "Professional" section, have at it. If not, however, there is a "final note" at the bottom of this page that you should have a look at.
Professional CPR - Adult, Child, & Infant
CPR is CPR. Whether "Professional" or "Civilian," the patient's heart is still beating in the same place, and breathing is still a process of "sucking" air into the lungs. If your patient has lost one or both of those abilities, you need to replace the missing function(s.)
As a "professional" provider you are expected to be able to:
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Locate and palpate pulses (to affirm the absence or presence of "signs of circulation.")
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Locate the proper compression site by following the inferior border of the rib cage, from its closest lateral (ipsilateral) aspect, medially, to the intersection of the contralateral border (a point directly above the xiphoid process and on the patient's center line,) and selecting a compression site approximately "two-fingers width" superior to that point.
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Properly evaluate the head position (hyperextension or, in the case of the baby, neutral) by visualizing an imaginary line perpendicular to the patient's spine drawn through the patient's earlobe and intersecting either the patient's chin (hyperextension) or the patient's nose (neutral.) For a graphic representation of this look here.
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Be able to more closely approximate the proper depth of compression, rate of compression and ventilation
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Be able to perform two rescuer CPR.
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Be able to use a barrier device, or Bag-Valve-Mask (BVM) for ventilating this patient.
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And, you are expected to do so, without any extraordinary show of emotion or confusion, while exercising professionalism and courtesy, in an environment that is very likely to be highly "charged," and possibly "volatile."
And so, all of the forgoing procedure, regarding each of the three classes of patients, is appropriate for you the "Professional." In order to achieve the necessary standards of professionalism and perform the procedures within acceptable limits, it is imperative that you practice regularly with manikins, guided by instructors. All of the concepts of CPR apply to two rescuer CPR, regarding when to ventilate or compress, where to ventilate or compress, and how fast (or hard) to ventilate or compress, all we've done is to add a "dance" that the CPR partners perform as each becomes fatigued (to change "places"), and that "dance" needs to be practiced until it can be performed flawlessly. The skill required to manipulate a bag-valve-mask is one that can only be taught by "hands-on" methods. The confidence to perform under pressure, and under close scrutiny, can only be achieved by repetitive sessions, continued until the skills become second nature. And, the ability to locate pulses and compression sites is one that requires demonstration and repetition. I would not insult your intelligence here by trying to "teach" the skills that you can more than adequately learn from your training officers and fellow rescuers.
Just a final note. When performing CPR in colder environments, it is imperative that all bulky/heavy clothing be removed in order to properly visualize/palpate the proper compression site. Not only will this "padding" hamper your efforts to locate the proper site, it will also act as cushioning between your hands and the patient's sternum, rendering the compressions less effective. In some circumstances, it may be necessary to remove all clothing to accurately locate the proper compression site (use your discretion to protect the patient's right to modesty, but remember that this person is DEAD, and 'protected modesty' will not bring them back.) Removing all clothing would certainly be appropriate (in all cases) if the application of an AED were being considered.
