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Before approaching a victim, the rescuer must ensure that the scene is safe and then check for response. To do this, tap the victim on the shoulder and shout, “Are you all right?” If the victim is responsive he or she will answer, move, or moan. If the victim remains unresponsive, the lay rescuer should activate the emergency response system. Quotefx is the world's most powerful RFQ Management platform, specifically created for the Electronics Industry. The health care provider should also check for no breathing or no normal breathing (ie, only gasping) while checking for responsiveness; if the healthcare provider finds the victim is unresponsive with no breathing or no normal breathing (ie, only gasping), the rescuer should assume the victim is in cardiac arrest and immediately activate the emergency response system (Class I, LOE C1. These 2. 01. 0 AHA Guidelines for CPR and ECC deemphasize checking for breathing. Professional as well as lay rescuers may be unable to accurately determine the presence or absence of adequate or normal breathing in unresponsive victims. SCA and may be confused with adequate breathing. Occasional gasps do not necessarily result in adequate ventilation. The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class I, LOE C). CPR training, both formal classroom training and “just in time” training such as that given through a dispatch center, should emphasize how to recognize occasional gasps and should instruct rescuers to provide CPR even when the unresponsive victim demonstrates occasional gasps (Class I, LOE B). These 2. 01. 0 AHA Guidelines for CPR and ECC also deemphasize the pulse check as a mechanism to identify cardiac arrest. Studies have shown that both laypersons and healthcare providers have difficulty detecting a pulse. 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Healthcare providers may take too long to check for a pulse. There is no evidence, however, that checking for breathing, coughing, or movement is superior for detection of circulation. Because delays in chest compressions should be minimized, the healthcare provider should take no more than 1. Class IIa, LOE C4. Technique: Chest Compressions (Box 4)To maximize the effectiveness of chest compressions, place the victim on a firm surface when possible, in a supine position with the rescuer kneeling beside the victim's chest (eg, out- of- hospital) or standing beside the bed (eg, in- hospital). Because hospital beds are typically not firm and some of the force intended to compress the chest results in mattress displacement rather than chest compression, we have traditionally recommended the use of a backboard despite insufficient evidence for or against the use of backboards during CPR. If a backboard is used, care should be taken to avoid delays in initiation of CPR, to minimize interruptions in CPR, and to avoid line/tube displacement. Air- filled mattresses should be deflated when performing CPR. The rescuer should place the heel of one hand on the center (middle) of the victim's chest (which is the lower half of the sternum) and the heel of the other hand on top of the first so that the hands are overlapped and parallel (Class IIa, LOE B6. Correct performance of chest compressions requires several essential skills. The adult sternum should be depressed at least 2 inches (5 cm) (Class IIa, LOE B7. Class IIb, LOE C7. Allow the chest to completely recoil after each compression (Class IIa, LOE B7. In human studies of CPR in out- of- hospital. Incomplete recoil during BLS CPR is associated with higher intrathoracic pressures and significantly decreased hemodynamics, including decreased coronary perfusion, cardiac index, myocardial blood flow, and cerebral perfusion. Importantly, the incidence of incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real- time feedback. Manikin studies suggest that lifting the heel of the hand slightly, but completely, off the chest can improve chest recoil. The total number of chest compressions delivered to the victim is a function of the chest compression rate and the proportion of time that chest compressions are delivered without interruption. The compression rate refers to the speed of compressions, not the actual number of compressions delivered per minute. The actual number of chest compressions delivered per minute is determined by the rate of chest compressions and the number and duration of interruptions to open the airway, deliver rescue breaths, and allow AED analysis. The number of chest compressions delivered per minute is an important determinant of return of spontaneous circulation (ROSC) and neurologically intact survival. One study of in- hospital cardiac arrest patients. ROSC. Extrapolation of data from an out- of- hospital observational study. It is therefore reasonable for lay rescuers and healthcare providers to perform chest compressions for adults at a rate of at least 1. Class IIa, LOE B). The term “duty cycle” refers to the time spent compressing the chest as a proportion of the time between the start of 1 cycle of compression and the start of the next. Coronary blood flow is determined partly by the duty cycle (reduced coronary perfusion is associated with a duty cycle of > 5. Although duty cycles ranging between 2. Class IIb, LOE C7. In 2. 00. 5 3 human observational studies. The preponderance of efficacy data. Data are now accumulating regarding the effectiveness of these interventions in “the real world.”2,9. Therefore, despite some data to the contrary,1. Class IIa, LOE B9. Additional evidence of the importance of minimizing interruptions in chest compressions comes from nonrandomized studies suggesting that survival from out- of- hospital cardiac arrest may be improved by the initial EMS provider delivery of continuous chest compressions without initial assisted ventilations,9. EMS providers using a higher compression- to- ventilation ratio (5. Notably, in each of these studies, the airway was opened, oxygen insufflations were provided, and assisted ventilation was recommended at some point during the EMS resuscitation. Other EMS systems have noted significant improvement in survival from out- of- hospital arrest with use of compressions- plus- ventilations with emphases on improved quality of compressions and minimization of hands- off time. At this time there is insufficient evidence to support the removal of ventilations from CPR provided by EMS professionals. Rescuer fatigue may lead to inadequate compression rates or depth. Significant fatigue and shallow compressions are common after 1 minute of CPR, although rescuers may not recognize that fatigue is present for . Consider switching compressors during any intervention associated with appropriate interruptions in chest compressions (eg, when an AED is delivering a shock). Every effort should be made to accomplish this switch in < 5 seconds. If the 2 rescuers are positioned on either side of the patient, 1 rescuer will be ready and waiting to relieve the “working compressor” every 2 minutes. Interruptions of chest compressions to palpate for a spontaneous pulse or to otherwise check for return of spontaneous circulation (ROSC) can compromise vital organ perfusion. Accordingly lay rescuers should not interrupt chest compressions to palpate pulses or check for ROSC (Class IIa, LOE C). In addition lay rescuers should continue CPR until an AED arrives, the victim wakes up, or EMS personnel take over CPR (Class IIa, LOE B). Healthcare providers should interrupt chest compressions as infrequently as possible and try to limit interruptions to no longer than 1. Class IIa, LOE C). Because of difficulties with pulse assessments, interruptions in chest compressions for a pulse check should be minimized during the resuscitation, even to determine if ROSC has occurred. Because of the difficulty in providing effective chest compressions while moving the patient during CPR, the resuscitation should generally be conducted where the patient is found (Class IIa, LOE C). This may not be possible if the environment is dangerous. Compression- Ventilation Ratio (Box 4)A compression- ventilation ratio of 3. Class IIb, LOE B8. This 3. 0: 2 ratio in adults is based on a consensus among experts and on published case series. Further studies are needed to define the best method for coordinating chest compressions and ventilations during CPR and to define the best compression- ventilation ratio in terms of survival and neurologic outcome in patients with or without an advanced airway in place. Once an advanced airway is in place, 2 rescuers no longer need to pause chest compressions for ventilations. Instead, the compressing rescuer should give continuous chest compressions at a rate of at least 1. Class IIa, LOE B). The rescuer delivering ventilation can provide a breath every 6 to 8 seconds (which yields 8 to 1. Hands- Only CPROnly about 2. CPR. 2. 9,4. 8–5. Hands- Only (compression- only) bystander CPR substantially improves survival following adult out- of- hospital cardiac arrests compared with no bystander CPR. Observational studies of adults with cardiac arrest treated by lay rescuers showed similar survival rates among victims receiving Hands- Only CPR versus conventional CPR with rescue breaths. 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