Cardiopulmonary Resuscitation (CPR)

Definition

Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation for a person who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest).

Purpose

CPR is performed to restore and maintain breathing and circulation and to provide oxygen and blood flow to the heart, brain, and other vital organs. CPR should be performed if a person is unconscious and not breathing. Respiratory and cardiac arrest can be caused by allergic reactions, an ineffective heartbeat, asphyxiation, breathing passages that are blocked, choking, drowning, drug reactions or overdoses, electric shock, exposure to cold, severe shock, or trauma. CPR can be performed by trained bystanders or healthcare professionals on infants, children, and adults. It should always be performed by the person on the scene who is most experienced in CPR.

Precautions

CPR should never be performed on a healthy person because it can cause serious injury to a beating heart by interfering with normal heartbeats.

Description

CPR is part of the emergency cardiac care system designed to save lives. Many deaths can be prevented by prompt recognition of the problem and notification of the emergency medical system (EMS), followed by early CPR, defibrillation (which delivers a brief electric shock to the heart in attempt to get the heart to beat normally), and advanced cardiac life support measures.

CPR must be performed within four to six minutes after cessation of breathing so as to prevent brain damage or death. It is a two-part procedure that involves rescue breathing and external chest compressions. To provide oxygen to a person's lungs, the rescuer administers mouth-to-mouth breaths, then helps circulate blood through the heart to vital organs by external chest compressions. Mouth-to-mouth breathing and external chest compression should be performed together, but if the rescuer is not strong enough to do both, the external chest compressions should be done. This is more effective than no resuscitation attempt, as is CPR that is performed "poorly."

When performed by a bystander, CPR is designed to support and maintain breathing and circulation until emergency medical personnel arrive and take over. When performed by healthcare personnel, it is used in conjunction with other basic and advanced life support measures.

According to the American Heart Association, early CPR and defibrillation combined with early advanced emergency care can increase survival rates for people with a type of abnormal heart beat called ventricular fibrillation by as much as 40%. CPR by bystanders may prolong life during deadly ventricular fibrillation, giving emergency medical service personnel time to arrive.

However, many CPR attempts are not ultimately successful in restoring a person to a good quality of life. Often, there is brain damage even if the heart starts beating again. CPR is therefore not generally recommended for the chronically or terminally ill or frail elderly. For these people, it represents a traumatic and not a peaceful end of life.

Each year, CPR helps save thousands of lives in the United States. More than five million Americans annually receive training in CPR through American Heart Association and American Red Cross courses. In addition to courses taught by instructors, the American Heart Association also has an interactive video called Learning System, which is available at more than 500 healthcare institutions. Both organizations teach CPR the same way, but use different terms. These organizations recommend that family members or other people who live with people who are at risk for respiratory or cardiac arrest be trained in CPR. A hand-held device called a CPR Prompt is available to walk people trained in CPR through the procedure, using American Heart Association guidelines. CPR has been practiced for more than 40 years.

Performing CPR

The basic procedure for CPR is the same for all people, with a few modifications for infants and children to account for their smaller size.

PERFORMING CPR ON AN ADULT. The first step is to call the emergency medical system for help by telephoning 911; then to begin CPR, following these steps:

• The rescuer opens a person's airway by placing the head face up, with the forehead tilted back and the chin lifted. The rescuer checks again for breathing (three to five seconds), then begins rescue breathing (mouth-to-mouth artificial respiration), pinching the nostrils shut while holding the chin in the other hand. The rescuer's mouth is placed against the unconscious person's mouth with the lips making a tight seal, then gently exhales for about one to one and a half seconds. The rescuer breaks away for a moment and then repeats. The person's head is repositioned after each mouth-to-mouth breath.
• After two breaths, the rescuer checks the unconscious person's pulse by moving the hand that was under the person's chin to the artery in the neck (carotid artery). If the unconscious person has a heartbeat, the rescuer continues rescue breathing until help arrives or the person begins breathing without assistance. If the unconscious person is breathing, the rescuer turns the person onto his or her side.
• If there is no heartbeat, the rescuer performs chest compressions. The rescuer kneels next to the unconscious person, placing the heel of one hand in the spot on the lower chest where the two halves of the rib cage come together. The rescuer puts one hand on top of the other on the person's chest and interlocks the fingers. The arms are straightened, the rescuer's shoulders are positioned directly above the hands on the unconscious person's chest. The hands are pressed down, using only the palms, so that the person's breastbone sinks in about 1 1/2-2 inches. The rescuer releases pressure without removing the hands, then repeats about 15 times per 10-15 second intervals.
• The rescuer tilts the unconscious person's head and returns to rescue breathing for one or two quick breaths. Then breathing and chest compressions are alternated for one minute before checking for a pulse. If the rescuer finds signs of a heartbeat and breathing, CPR is stopped. If the unconscious person is breathing but has no pulse, the chest compressions are continued. If the unconscious person has a pulse but is not breathing, rescue breathing is continued.
• For children over the age of eight, the rescuer performs CPR exactly as for an adult.

PERFORMING CPR ON AN INFANT OR CHILD UNDER THE AGE OF EIGHT. The procedures outlined above are followed with these differences:

• The rescuer administers CPR for one minute, then calls for help.
• The rescuer makes a seal around the child's mouth or infant's nose and mouth to give gentle breaths. The rescuer delivers 20 rescue breaths per minute, taking 1 1/2-2 seconds for each breath.
• Chest compressions are given with only one hand for a child and with two or three fingers for an infant. The breastbone is depressed only 1-1 1/2 inch for a child and 1/2-1 inch for an infant, the rescuer gives at least 100 chest compressions per minute.

New developments in CPR

Some new ways of performing CPR have been tried. Active compression-decompression resuscitation, abdominal compression done in between chest compressions, and chest compression using a pneumatic vest have all been tested but none are currently recommended for routine use.

The active compression-decompression device was developed to improve blood flow from the heart, but clinical studies have found no significant difference in survival between standard and active compression-decompression CPR. Interposed abdominal counterpulsation, which requires two or more rescuers, one compressing the chest and the other compressing the abdomen, was developed to improve pressure and therefore blood flow. It has been shown in a small study to improve survival but more data is needed. A pneumatic vest, which circles the chest of an unconscious person and compresses it, increases pressure within the chest during external chest compression. The vest has been shown to improve survival in a preliminary study but more data is necessary for a full assessment.

Preparation

If a person suddenly becomes unconscious, a rescuer should call out for help from other bystanders, and then determine if the unconscious person is responsive by gently shaking the shoulder and shouting a question. Upon receiving no answer, the rescuer should call the emergency medical system. The rescuer should check to see whether the unconscious person is breathing by kneeling near the person's shoulders, looking at the person's chest, and placing a cheek next to the unconscious person's mouth. The rescuer should look for signs of breathing in the chest and abdomen, and listen and feel for signs of breathing through the person's lips. If no signs of breathing are present after three to five seconds, CPR should be started.

Aftercare

Emergency medical care is always necessary after successful CPR. Once a person's breathing and heartbeat have been restored, the rescuer should make the person comfortable and stay there until emergency medical personnel arrive. The rescuer can continue to reassure the person that help is coming and talk positively until professionals arrive and take over.

Risks

CPR can cause injury to a person's ribs, liver, lungs, and heart. However, these risks must be accepted if CPR is necessary to save the person's life.

Normal results

In many cases, successful CPR results in restoration of consciousness and life. Barring other injuries, a revived person usually returns to normal functions within a few hours of being revived.

Abnormal results

These include injuries incurred during CPR and lack of success with CPR. Possible sites for injuries include a person's ribs, liver, lungs, and heart. Partially successful CPR may result in brain damage. Unsuccessful CPR results in death.

KEY TERMS

Cardiac arrest— Temporary or permanent cessation of the heartbeat.

Cardiopulmonary— Relating to the heart and the lungs.

Defibrillation— A procedure to stop the type of irregular heart beat called ventricular fibrillation, usually by using electric shock.

Resuscitation— Bringing a person back to life after an apparent death or in cases of impending death.

Ventricular fibrillation— An irregular heartbeat where the heart beats very fast but ineffectively. Ventricular fibrillation is fatal if not quickly corrected.

Resources

BOOKS

Alton, Thygerson. First Aid and CPR. 4th ed. Sudbury, Massachusetts: Jones & Bartlett Pub, 2001.

Knoop, Kevin J., and Lawrence B. Stack. Atlas of Emergency Medicine. 2nd ed. New York: McGraw Hill, 2001.

National Safety Council. First Aid and CPR for Infants and Children. 4th ed. Sudbury, Massachusetts: Jones & Bartlett Pub, 2001.

PERIODICALS

Davies, N., and D. Gould. "Updating cardiopulmonary resuscitation skills: a study to examine the efficacy of self-instruction on nurses' competence." Journal of Clinical Nursing 9 (2000): 400-410.

Eftestol T., K. Sunde, S. O. Aase, J. H. Husoy, and P. A. Steen. "'Probability of successful defibrillation' as a monitor during CPR in out-of-hospital cardiac arrested patients." Resuscitation 48 (2001): 245-254.

Kern, K. B., H. R. Halperin, and J. Field. "New guidelines for cardiopulmonary resuscitation and emergency cardiac care: changes in the management of cardiac arrest." Journal of the American Medical Association 285 (2001): 1267-1269.

Meyer W., and F. Balck. "Resuscitation decision index: a new approach to decision-making in prehospital CPR." Resuscitation 48 (2001): 255-263.

ORGANIZATIONS

American College of Emergency Physicians. P.O. Box 619911, Dallas, TX 75261-9911. (800) 798-1822 or (972) 550-0911. Fax: (972) 580-2816. 〈http://www.acep.org/〉. [email protected].

American College of Osteopathic Emergency Physicians. 142 E. Ontario Street, Suite 550, Chicago, IL 60611. (312) 587-3709 or (800) 521-3709. Fax: (312) 587-9951. 〈http://www.acoep.org〉.

American Heart Association, National Center. 7272 Greenville Avenue, Dallas, TX 75231. (877) 242-4277. 〈http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/heim.html〉.

Heimlich Institute. PO Box 8858, Cincinnati, OH 45208. 〈http://www.heimlichinstitute.org/index.htm〉. [email protected].

National Safe Kids Campaign. 1301 Pennsylvania Avenue, Suite 1000, Washington, DC 20004-1707. 〈http://pedsccm.wustl.edu/All-Net/english/neurpage/protect/drown.htm〉.

OTHER

American Heart Association. 〈http://www.cpr-ecc.org/〉 and 〈http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/cprs.html〉.

Columbia Presbyterian Medical Center. 〈http://cpmcnet.columbia.edu/texts/guide/hmg13_0001.html〉.

Learn CPR. 〈http://www.learn-cpr.com〉.

National Registry of Cardiopulmonary Resuscitation. 〈http://www.nrcpr.org/〉.

University of Washington School of Medicine. 〈http://depts.washington.edu/learncpr/〉.

Cardiopulmonary resuscitation

Definition

Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation on a person who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest).

Purpose

CPR is performed to restore and maintain breathing and circulation and to provide oxygen and blood flow to the heart, brain, and other vital organs. It should be performed if a person is unconscious and not breathing. Respiratory and cardiac arrest can be caused by allergic reactions, an ineffective heartbeat, a heart attack , asphyxiation, breathing passages that are blocked, choking, drowning, drug reactions or overdoses, electric shock, exposure to cold, severe shock, or trauma. CPR can be performed on infants, children, and adults by trained bystanders or healthcare professionals. It should always be performed by the person on the scene who is most experienced in CPR.

Precautions

CPR should never be performed on a healthy person, since it can cause serious injury to a beating heart.

Description

CPR is part of the emergency cardiac care system designed to save lives. Many deaths can be prevented by prompt recognition of the medical situation and notification of the emergency medical system (EMS). This should be followed by early CPR, defibrillation (which delivers a brief electric shock to the heart in an attempt to get the heart to beat normally), and advanced cardiac life support measures.

CPR must be performed within four to six minutes of the time that breathing stopped in order to prevent brain damage or death . It is a two-part procedure that involves rescue breathing and external chest compressions. To provide oxygen to the person's lungs, the rescuer administers mouth-to-mouth breaths, then helps circulate the blood through the heart to vital organs by external chest compressions. Mouth-to-mouth breathing and external chest compression should be performed together, but if the rescuer is not strong enough to do both, the external chest compressions should be done alone. Some bystanders are reluctant to initiate CPR because of the possible transmission of infectious disease during mouth-to-mouth breathing or their inexperience with CPR. External chest compressions alone have been found to have similar results when compared to mouth-to-mouth breathing and external chest compressions combined. External chest compressions, as well as CPR that is performed inexpertly, are more effective than no resuscitation attempt.

When performed by a bystander, CPR is designed to support and maintain breathing and circulation until emergency medical personnel arrive and take over. When performed by healthcare personnel, it is used in conjunction with other basic and advanced life support measures.

According to the American Heart Association, early CPR and defibrillation combined with early advanced emergency care can increase survival rates for people with a type of abnormal heart beat called ventricular fibrillation by as much as 40%. CPR by bystanders may prolong life during deadly ventricular fibrillation, giving emergency medical service personnel time to arrive.

It must be appreciated, however, that most CPR attempts are not ultimately successful in restoring the victim to a good quality of life. Often, there is brain damage even if the heart starts beating again. CPR is therefore not generally recommended for the chronically or terminally ill or frail elderly. For these people, it is traumatic and not a peaceful end of life.

CPR has been practiced for more than 40 years. Each year, it helps save thousands of lives in the United States. More than five million Americans receive training in CPR through the American Heart Association and the American Red Cross courses annually. In addition to courses taught by instructors, the American Heart Association also has an interactive video called Learning System, which is available at more than 500 healthcare institutions. Both organizations teach CPR the same way, but use different terms. They recommend that family members or other people who live with patients at risk of respiratory or cardiac arrest be trained in CPR. A hand-held device called CPR Prompt is available to walk people trained in CPR through the procedure, using American Heart Association guidelines.

In 2000, focus groups from the American Heart Association and the American Red Cross joined forces with international councils in order to create a consistent, single description of resuscitation guidelines. These guidelines have been released and many changes in CPR have been instituted. These changes replace the recommendations from their publications in 1992.

Performing CPR

The basic procedure for CPR is the same for adults, infants, and children, with a few modifications for infants and children to account for their smaller size.

PERFORMING CPR ON AN ADULT In most cases, the first step is to call the emergency medical system for help by telephoning 911. There are exceptions to calling for help first. The new concept of “phone fast” is being recommended for trauma victims, water submersion victims, and medication/drug overdoses. CPR should be started immediately on these types of victims because the rate of survival increases with early rescue efforts. To start CPR, use the following steps:

• The rescuer opens the person's airway by placing the head face up, with the forehead tilted back and the chin lifted. The rescuer checks again for breathing (three to five seconds), then begins rescue breathing (mouth-to-mouth artificial respiration). He pinches the person's nostrils shut while holding the chin in the other hand. The rescuer places his mouth against the person's mouth with the lips making a tight seal, then gently exhales for about one to one and a half seconds. The rescuer breaks away for an instant and then repeats. The person's head is repositioned after each mouth-to-mouth breath.
• After two breaths, the rescuer checks for indications of blood circulation (regular respiratory inhalations, vomiting, or any attempt to move). If the rescuer is a health care professional, the person's pulse is checked by moving the hand that was under the person's chin to the artery in the neck (carotid artery). If the person shows no signs of circulating blood, the rescuer continues rescue breathing until help arrives or the person begins breathing spontaneously. If the person is breathing, the rescuer turns the person onto his or her side.
• If there is no heartbeat, the rescuer performs chest compressions. The rescuer kneels next to the person, placing the heel of one hand in the spot on the lower chest where the two halves of the rib cage come together. The rescuer puts his other hand on top of the one on the chest and interlocks the fingers. He straightens his arms, leans forward to position the shoulders directly above the hands on the person's chest, and presses down, using only the palms, so that the person's breastbone sinks in about 1–2 in (4–5 cm). The rescuer releases without removing the hands, then repeats about 15 times in 10–15 seconds.
• The rescuer tilts the person's head and returns to rescue breathing for one or two quick breaths. Then he alternates breathing and chest presses for one minute, and checks for any signs of blood circulation. If the rescuer finds signs of a heartbeat and breathing, CPR is stopped. If the person is breathing but has no pulse, the chest presses are continued; if the person has a pulse but is not breathing, rescue breathing is continued. The number of chest presses has recently increased to 15 chest presses to two breaths for single or double rescuer CPR. The recommended number of chest presses is at least 100 a minute. The rationale for this increase relates to establishing adequate heart and brain circulation.
• For children over the age of eight, the rescuer performs CPR the same as on an adult.

PERFORMING CPR ON AN INFANT OR CHILD UNDER THE AGE OF EIGHT The procedures outlined above are followed with these differences:

• The rescuer administers CPR for one minute, then calls for help.
• The rescuer makes a seal around the infant/child's mouth (and nose with infants) to give gentle breaths. The rescuer delivers 20 rescue breaths per minute, taking 1–2 seconds for each breath.
• Chest compressions are given with only one hand for a child and with two or three fingers for an infant. The breastbone is depressed only 1–1.5 in (2.5–3.75cm) for a child and 0.5–1 in (1–2.5 cm) for an infant. The rescuer gives at least 100 chest compressions per minute.

New developments in CPR

The use of the automated external defibrillator (AED) has saved many lives and is now considered part of the CPR chain of survival. The AED is a machine that is attached to the unresponsive victim, analyzes the heart rhythm and has the ability to shock the victim with electricity. The AED has two pads that have to be placed on the victim's right upper chest wall and the left lower chest wall. Most cardiac arrest victims have a heart rhythm called ventricular fibrillation and the only way to correct this deadly heartbeat is with electricity. Some airports, airplanes, and shopping malls have automated external defibrillators onsite with user-friendly instructions and survival rates in these places have increased significantly.

Preparation

If a person suddenly becomes unconscious, the rescuer should call out for help from other bystanders, and then determine if the person is responsive by shaking him or her gently on the shoulder and asking, loudly, if they are OK. Upon receiving no answer, the rescuer should call the emergency medical system with the exception of the “phone fast” victims. The rescuer should check to see whether the person is breathing by kneeling near the person's shoulders, looking at the person's chest, and placing his cheek next to the person's mouth. The rescuer should look for signs of breathing in the chest and abdomen, and listen and feel for signs of breathing through the person's lips. If no signs of breathing are present after three to five seconds, CPR should be started.

Aftercare

Emergency medical care is always necessary after successful CPR. Once the person's breathing and heartbeat have been restored, the rescuer should make him or her comfortable and stay there until emergency medical personnel arrive. The rescuer can continue to reassure the person that help is coming and talk positively until the professionals arrive and take over.

Complications

CPR can cause injury to the person's ribs, liver, lungs, and heart. But these risks must be accepted if CPR is necessary to save the person's life. As health care professionals, many complications will be apparent in the acute care setting. Medical and nursing management of these complications will be addressed by prioritizing the most traumatic or deadly first.

KEY TERMS

Automated external defibrillator (AED) —A device that analyzes a person's heartbeat and can automatically deliver an electric shock if needed.

Cardiopulmonary —Relating to the heart and the lungs.

Defibrillation —A procedure to stop the type of irregular heart beat called ventricular fibrillation, usually by using electric shock.

Resuscitation —Bringing a person back to life after an apparent death.

Ventricular fibrillation —An irregular heartbeat where the heart beats very fast but ineffectively. Ventricular fibrillation is fatal if not quickly corrected.

Caregiver concerns

CPR and basic life support are important skills to have for anyone in the health care field. Recognition of the need to initiate CPR and the activation of proper resuscitation can save many lives. The international, universal mnemonic used to prompt health care professionals with the basics of CPR quickly is ABCD. This mnemonic stands for:

• Airway: Is the person's airway open?
• Breathing: Is the person breathing?
• Circulation: Does the person have a pulse (health care professional)? Does the person have any signs of blood circulation (layperson)?
• Defibrillation: Where is the defibrillator (AED)?

Legally, health care professionals coming to a person's aid in an emergency situation are covered under the federal Good Samaritan Law. Protection under this law requires that the situation be an emergency, that no monetary compensation for the treatment be provided, and that the care provided has to be done “in good faith.” In most states, health care professionals have no mandatory obligation to help in an emergency situation, but this law is in place to protect those who do from liability.

Patient education

All health care professionals should emphasize the importance of laypeople in their communities being trained in CPR. Classes are offered through the American Heart Association and the American Red Cross. Many hospitals and local health departments have classes available for the public.

Training

CPR training is recommended every two years, and most health care institutions require their workers to obtain certification in Basic Cardiac Life Support (BCLS), which covers CPR. Studies have been done on the differences between video aided/practice training and lecture training. Video and practice training has been found to be the most effective.

Resources

BOOKS

DeBakey, Michael E., and Antonio M. Gotto, Jr. “The Healthy Heart and How it Works.” In The New Living Heart, Holbrook, MA: Adams Media Corporation, 1997, pp. 267–82.

PERIODICALS

American Heart Association. “Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 3: Adult Basic Life Support.”Circulation 102 (August 22, 2000): 22–59.

Brown, Sylvia M. “Good Samaritan Laws: Protection and Limits.” RN 62 (November 1999) 65–67.

Hallstrom, Alfred, et al. “Cardiopulmonary Resuscitation by Chest Compression Alone or with Mouth-to-Mouth Ventilation.” New England Journal of Medicine 342 (May 25, 2000): 1546–1553.

Hull, Bob. “Response in a Heartbeat.” American School & University 73 (October 2000): 40–41.

Lori Beck

Cardiopulmonary Resuscitation (CPR)

Definition

Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation on a person who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest).

Purpose

CPR is performed to restore and maintain breathing and circulation and to provide oxygen and blood flow to the heart, brain, and other vital organs. It should be performed if a person is unconscious and not breathing. Respiratory and cardiac arrest can be caused by allergic reactions, an ineffective heartbeat, a heart attack, asphyxiation, breathing passages that are blocked, choking, drowning, drug reactions or overdoses, electric shock, exposure to cold, severe shock, or trauma. CPR can be performed on infants, children, and adults by trained bystanders or healthcare professionals. It should always be performed by the person on the scene who is most experienced in CPR.

Precautions

CPR should never be performed on a healthy person, since it can cause serious injury to a beating heart.

Description

CPR is part of the emergency cardiac care system designed to save lives. Many deaths can be prevented by prompt recognition of the medical situation and notification of the emergency medical system (EMS). This should be followed by early CPR, defibrillation (which delivers a brief electric shock to the heart in an attempt to get the heart to beat normally), and advanced cardiac life support measures.

CPR must be performed within four to six minutes of the time that breathing stopped in order to prevent brain damage or death. It is a two-part procedure that involves rescue breathing and external chest compressions. To provide oxygen to the person's lungs, the rescuer administers mouth-to-mouth breaths, then helps circulate the blood through the heart to vital organs by external chest compressions. Mouth-to-mouth breathing and external chest compression should be performed together, but if the rescuer is not strong enough to do both, the external chest compressions should be done alone. Some bystanders are reluctant to initiate CPR because of the possible transmission of infectious disease during mouth-to-mouth breathing or their inexperience with CPR. External chest compressions alone have been found to have similar results when compared to mouth-to-mouth breathing and external chest compressions combined. External chest compressions, as well as CPR that is performed inexpertly, are more effective than no resuscitation attempt.

When performed by a bystander, CPR is designed to support and maintain breathing and circulation until emergency medical personnel arrive and take over. When performed by healthcare personnel, it is used in conjunction with other basic and advanced life support measures.

According to the American Heart Association, early CPR and defibrillation combined with early advanced emergency care can increase survival rates for people with a type of abnormal heart beat called ventricular fibrillation by as much as 40%. CPR by bystanders may prolong life during deadly ventricular fibrillation, giving emergency medical service personnel time to arrive.

It must be appreciated, however, that most CPR attempts are not ultimately successful in restoring the victim to a good quality of life. Often, there is brain damage even if the heart starts beating again. CPR is therefore not generally recommended for the chronically or terminally ill or frail elderly. For these people, it is traumatic and not a peaceful end of life.

CPR has been practiced for more than 40 years. Each year, it helps save thousands of lives in the United States. More than five million Americans receive training in CPR through the American Heart Association and the American Red Cross courses annually. In addition to courses taught by instructors, the American Heart Association also has an interactive video called Learning System, which is available at more than 500 healthcare institutions. Both organizations teach CPR the same way, but use different terms. They recommend that family members or other people who live with patients at risk of respiratory or cardiac arrest be trained in CPR. A hand-held device called CPR Prompt is available to walk people trained in CPR through the procedure, using American Heart Association guidelines.

In 2000, focus groups from the American Heart Association and the American Red Cross joined forces with international councils in order to create a consistent, single description of resuscitation guidelines. These guidelines have been released and many changes in CPR have been instituted. These changes replace the recommendations from their publications in 1992.

Performing CPR

The basic procedure for CPR is the same for adults, infants, and children, with a few modifications for infants and children to account for their smaller size.

PERFORMING CPR ON AN ADULT. In most cases, the first step is to call the emergency medical system for help by telephoning 911. There are exceptions to calling for help first. The new concept of "phone fast" is being recommended for trauma victims, water submersion victims, and medication/drug overdoses. CPR should be started immediately on these types of victims because the rate of survival increases with early rescue efforts. To start CPR, use the following steps:

• The rescuer opens the person's airway by placing the head face up, with the forehead tilted back and the chin lifted. The rescuer checks again for breathing (three to five seconds), then begins rescue breathing (mouth-to-mouth artificial respiration). He pinches the person's nostrils shut while holding the chin in the other hand. The rescuer places his mouth against the person's mouth with the lips making a tight seal, then gently exhales for about one to one and a half seconds. The rescuer breaks away for an instant and then repeats. The person's head is repositioned after each mouth-to-mouth breath.
• After two breaths, the rescuer checks for indications of blood circulation (regular respiratory inhalations, vomiting, or any attempt to move). If the rescuer is a health care professional, the person's pulse is checked by moving the hand that was under the person's chin to the artery in the neck (carotid artery). If the person shows no signs of circulating blood, the rescuer continues rescue breathing until help arrives or the person begins breathing spontaneously. If the person is breathing, the rescuer turns the person onto his or her side.
• If there is no heartbeat, the rescuer performs chest compressions. The rescuer kneels next to the person, placing the heel of one hand in the spot on the lower chest where the two halves of the rib cage come together. The rescuer puts his other hand on top of the one on the chest and interlocks the fingers. He straightens his arms, leans forward to position the shoulders directly above the hands on the person's chest, and presses down, using only the palms, so that the person's breastbone sinks in about 1 1/2-2 in (4-5 cm). The rescuer releases without removing the hands, then repeats about 15 times in 10-15 seconds.
• The rescuer tilts the person's head and returns to rescue breathing for one or two quick breaths. Then he alternates breathing and heart presses for one minute, and checks for any signs of blood circulation. If the rescuer finds signs of a heartbeat and breathing, CPR is stopped. If the person is breathing but has no pulse, the heart presses are continued; if the person has a pulse but is not breathing, rescue breathing is continued. The number of heart presses has recently increased to 15 heart presses to two breaths for single or double rescuer CPR. The recommended number of heart presses is at least 100 a minute. The rationale for this increase relates to establishing adequate heart and brain circulation.
• For children over the age of eight, the rescuer performs CPR the same as on an adult.

PERFORMING CPR ON AN INFANT OR CHILD UNDER THE AGE OF EIGHT. The procedures outlined above are followed with these differences:

• The rescuer administers CPR for one minute, then calls for help.
• The rescuer makes a seal around the infant/child's mouth (and nose with infants) to give gentle breaths. The rescuer delivers 20 rescue breaths per minute, taking 1 1/2-2 seconds for each breath.
• Chest compressions are given with only one hand for a child and with two or three fingers for an infant. The breastbone is depressed only 1-1.5 in (2.5-3.75 cm) for a child and 0.5-1 in (1-2.5 cm) for an infant. The rescuer gives at least 100 chest compressions per minute.

New developments in CPR

The use of the automated external defibrillator (AED) has saved many lives and is now considered part of the CPR chain of survival. The AED is a machine that is attached to the unresponsive victim, analyzes the heart rhythm and has the ability to shock the victim with electricity. The AED has two pads that have to be placed on the victim's right upper chest wall and the left lower chest wall. Most cardiac arrest victims have a heart rhythm called ventricular fibrillation and the only way to correct this deadly heartbeat is with electricity. Some airports, airplanes, and shopping malls have automated external defibrillators onsite with user-friendly instructions and survival rates in these places have increased significantly.

Preparation

If a person suddenly becomes unconscious, the rescuer should call out for help from other bystanders, and then determine if the person is responsive by shaking him or her gently on the shoulder and asking, loudly, if they are OK. Upon receiving no answer, the rescuer should call the emergency medical system with the exception of the "phone fast" victims. The rescuer should check to see whether the person is breathing by kneeling near the person's shoulders, looking at the person's chest, and placing his cheek next to the person's mouth. The rescuer should look for signs of breathing in the chest and abdomen, and listen and feel for signs of breathing through the person's lips. If no signs of breathing are present after three to five seconds, CPR should be started.

Aftercare

Emergency medical care is always necessary after successful CPR. Once the person's breathing and heartbeat have been restored, the rescuer should make him or her comfortable and stay there until emergency medical personnel arrive. The rescuer can continue to reassure the person that help is coming and talk positively until the professionals arrive and take over.

Complications

CPR can cause injury to the person's ribs, liver, lungs, and heart. But these risks must be accepted if CPR is necessary to save the person's life. As health care professionals, many complications will be apparent in the acute care setting. Medical and nursing management of these complications will be addressed by prioritizing the most traumatic or deadly first.

Health care team roles

CPR and basic life support are important skills to have for anyone in the health care field. Recognition of the need to initiate CPR and the activation of proper resuscitation can save many lives. The international, universal mnemonic used to prompt health care professionals with the basics of CPR quickly is ABCD. This mnemonic stands for:

• Airway: Is the person's airway open?
• Breathing: Is the person breathing?
• Circulation: Does the person have a pulse (health care professional)? Does the person have any signs of blood circulation (layperson)?
• Defibrillation: Where is the defibrillator (AED)?

Legally, health care professionals coming to a person's aid in an emergency situation are covered under the federal Good Samaritan Law. Protection under this law requires that the situation be an emergency, that no monetary compensation for the treatment be provided, and that the care provided has to be done "in good faith." In most states, health care professionals have no mandatory obligation to help in an emergency situation, but this law is in place to protect those who do from liability.

Patient education

All health care professionals should emphasize the importance of laypeople in their communities being trained in CPR. Classes are offered through the American Heart Association and the American Red Cross. Many hospitals and local health departments have classes available for the public.

Training

CPR training is recommended every two years, and most health care institutions require their workers to obtain certification in Basic Cardiac Life Support (BCLS), which covers CPR. Studies have been done on the differences between video aided/practice training and lecture training. Video and practice training has been found to be the most effective.

KEY TERMS

Automated external defibrillator (AED)— A device that analyzes a person's heartbeat and can automatically deliver an electric shock if needed.

Cardiopulmonary— Relating to the heart and the lungs.

Defibrillation— A procedure to stop the type of irregular heart beat called ventricular fibrillation, usually by using electric shock.

Resuscitation— Bringing a person back to life after an apparent death.

Ventricular fibrillation— An irregular heartbeat where the heart beats very fast but ineffectively. Ventricular fibrillation is fatal if not quickly corrected.

Resources

BOOKS

DeBakey, Michael E., and Antonio M. Gotto, Jr. "The Healthy Heart and How it Works." In The New Living Heart, Holbrook, MA: Adams Media Corporation, 1997, pp. 267-82.

PERIODICALS

American Heart Association. "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 3: Adult Basic Life Support." Circulation 102 (August 22, 2000): 22-59.

Brown, Sylvia M. "Good Samaritan Laws: Protection and Limits." RN 62 (November 1999) 65-67.

Hallstrom, Alfred, et. al. "Cardiopulmonary Resuscitation by Chest Compression Alone or with Mouth-to-Mouth Ventilation." New England Journal of Medicine 342 (May 25, 2000): 1546-1553.

Hull, Bob. "Response in a Heartbeat." American School & University 73 (October, 2000): 40-41.

Cardiopulmonary Resuscitation

Definition
Purpose
Description
Precautions
Normal results
Prevention

Definition

Cardiopulmonary resuscitation, commonly called CPR, combines rescue breathing (one person breathing into another person) and chest compression in a lifesaving procedure performed when a person has stopped breathing or a person’s heart has stopped beating.

Purpose

When performed quickly enough, CPR can save lives in such emergencies as loss of consciousness, heart attacks or heart “arrests,” electric shock, drowning, excessive bleeding, drug overdose, and other conditions in which there is no breathing or no pulse. The purpose of CPR is to bring oxygen to the victim’s lungs and to keep blood circulating so oxygen gets to every part of the body. When a person is deprived of oxygen, permanent brain damage can begin in as little as four minutes and death can follow only minutes later.

Description

There are three physical symptoms that indicate a need for CPR to be performed immediately and for emergency medical support to be called: unconsciousness, not breathing, and no pulse detected.

Unconsciousness

Unconsciousness is when the victim seems to be asleep but has lost all awareness and is not able to respond to questions, touch, or gentle shaking. A sleeping person will usually respond to a loud noise, shouting, or gentle shaking. An unconscious person will not respond to noise or shaking. When unconscious, a person can not cough or clear the throat, which may allow the windpipe to become blocked, causing suffocation and death. People with a major illness or injury or who have had recent surgery are at risk for losing consciousness. If a person has fainted, which is brief unconsciousness, the cause may be dehydration (lack of body fluids), low blood pressure, or low blood sugar. This is a temporary condition. If the victim is known to have diabetes, a bit of fruit juice may revive the person once they have regained consciousness.

Just before a person loses consciousness, symptoms may include:

• lack of response to voice or touch
• disorientation or stupor
• light-headedness
• headache
• sleepiness

Not breathing

Not breathing, which is also called apnea, is the lack of spontaneous breathing. It requires immediate medical attention. The victim may become limp and lifeless, have a seizure, or turn blue. Prolonged apnea is called respiratory arrest. In children, this can lead quickly to cardiac arrest in which the heart stops beating. In adults, cardiac arrest usually happens first and

KEY TERMS

Apnea— A period of no breathing, sometimes sudden, sometimes prolonged.

Arrest— A sudden stopping of the function of a body organ, such as no breathing (respiratory arrest) or no beating of the heart (cardiac arrest).

Cardiopulmonary— Involving both heart and lungs.

Circulation— The passage of blood and delivery of oxygen through the veins and arteries of the body.

Respiratory— Referring to breathing in and breathing out, and the function of the lungs.

Resuscitation— Reviving an unconscious person or restoring breathing.

Shock— A sudden reducing of function in major body systems such as circulation and respiration.

then respiratory arrest. In adults, the common causes of apnea are obstructive sleep apnea (something blocks the airway during sleep), choking, drug overdose, near-drowning, head injury, heart irregularities (arrhythmia, fibrillation) or cardiac arrest, nervous system disorders, or metabolic disorders. In children the causes may be different, such as prematurity, bronchial disturbances or pneumonia, airway blockage or choking on a foreign object, holding the breath, seizures, meningitis, regurgitating food, or asthma attacks.

No pulse detected

If the rescuer is unable to detect a pulse or has difficulty feeling a pulse, it can be an indication of the use of improper technique by the rescuer, or it may be due to shock or cardiac arrest in the victim. If a sudden, severe decrease occurs in pulse quality (such as pulse weakness) or pulse rate (how many beats in a minute) when other symptoms are also present, life-threatening shock is suspected. The rescuer may need to explain to a doctor or medical professional where on the victim’s body the pulse was measured, whether or not the pulse is weak or absent, and what other symptoms are present.

Medical help and CPR are needed immediately if any of these symptoms are found. Time is critical. A local emergency number should be called immediately. If more than one person is available to help, one person can call 911 or a local emergency medical service, while the other person begins CPR. If needed, the emergency dispatcher (the person who picks up emergency 911 calls) can give step-by-step CPR instructions over the telephone. Local medical personnel, staff at hospitals and fire departments, and members of the American Heart Association teach CPR courses. If a critically ill patient or postoperative patient is being cared for at home, it is a good idea for a family member to take a CPR course to be better prepared to help in the event of an emergency.

The steps usually followed in adult CPR by a layperson are as follows:

1. If the victim appears to be unconscious with either no breathing or no pulse, the person should be shaken or tapped gently to check for any movement. The victim should be spoken to loudly, asking if he or she is OK. If there is no response, the rescuer should leave to call 911 immediately, send someone to call for help, or call from a cell phone. If the rescuer is alone, they should call 911 before beginning CPR. If an automated external defibrillator (AED) is found close by, the rescuer should bring the AED back with them to the victim’s side.
2. The victim should be placed on his or her back on a level surface such as the ground or the floor. The rescuer should kneel next to the victim and tilt the victim’s head back. The rescuer should then put their ear to the victim’s open mouth and look for chest movement, listen for air flowing through the mouth or nose, and feel for air on his or her cheek. If there is no breathing, they should pinch the victim’s nose, make a seal over the victim’s mouth with theirs, and give the victim a breath big enough to make the chest rise. The rescuer should use a CPR mask if there is one available. The rescuer should let the chest fall, then repeat the rescue breath once more. If the chest does not rise, the victim’s head should be repositioned to help ensure the tongue is kept away from the windpipe, then the rescuer should try again to give a breath.
3. If the victim is found to be breathing and has perhaps fainted, he or she can be placed in the recovery position until medical assistance arrives. This is done by straightening the victim’s legs and pulling the closest arm out away from the body with the elbow at a right angle (or three o’clock position), and the other arm across the chest. The far leg should be pulled up over the victim’s body with the hip and knee bent. This allows the victim’s body to be rolled onto its side. The head should be tilted back slightly to keep the windpipe open. The head should not be propped up.
4. If the victim is not breathing, the rescuer should begin chest compressions. Chest compressions are needed to restore circulation (the victim has no pulse). The rescuer should push down one and a half to two inches on the chest, placing the heel of one hand in the middle of the chest, putting the other hand on top of the first, and interlacing the fingers. When performing compressions, the rescuer should keep the elbows straight, center his or her shoulders over the victim, develop an up-and-down rhythm, and keep their hands firmly on the victim’s chest. Compressions should be done on the center of the chest midway between the nipples. Compressions should be hard and fast, at a rate of 100 times per minute. The rescuer should perform 30 compressions at this rate, then give 2 breaths and the again, 30 compressions (this ratio is the same whether it is performed by one or by two people at the scene). The rescuer should allow the chest to completely recoil before the next compression. The sequence of 30 compressions and two breaths should continue to be repeated until professional medical help arrives. Note: If an AED is immediately available, deliver one shock if advised by the device, then begin CPR. If an AED is not available initially, but later becomes available and the person is still unresponsive, stop doing CPR and quickly follow the directions for using the AED.

Precautions

There are certain important precautions for rescuers to remember in order to protect the victim and get the best result from CPR. These include:

• Do not leave the victim alone.
• Do not give the victim anything to eat or drink.
• Avoid moving the victim’s head or neck if spinal injury is a possibility. The person should be left as found if breathing freely. To check for breathing when spinal injury is suspected, the rescuer should only listen for breath by the victim’s mouth and watch the chest for movement.
• Do not slap the victim’s face, or throw water on the face to try and revive the person.
• Do not place a pillow under the victim’s head.

The description above is not a substitute for CPR training and is not intended to be followed as a procedure.

Normal results

Successful CPR will restore breathing and circulation in the victim. Medical attention is required immediately even if successful CPR has been performed and the victim is breathing freely.

Prevention

Loss of consciousness is an emergency that is potentially life threatening. To avoid loss of consciousness and protect themselves from emergency situations, people at risk can follow these general guidelines:

• People with such conditions as diabetes or epilepsy should wear a medical alert tag or bracelet.
• People with diabetes should avoid situations that will lower their blood sugar level.
• People who feel weak, become dizzy or light-headed, or have ever fainted, should avoid standing in one place too long without moving.
• People who feel faint can lie down or sit with their heads lowered between their knees.
• Risk factors that contribute to heart disease should be reduced or eliminated. People can reduce risks if they stop smoking, lower blood pressure and cholesterol, lose excess weight, and reduce stress.
• Illegal recreational drugs should be avoided.
• Seeing a doctor regularly and being aware of any disease conditions or risk factors can help prevent or complicate illness, as can seeking and following the doctor’s advice about diet and exercise.
• Using seat belts and driving carefully can help avoid accidental injury.
• People with poor eyesight or those who have difficulty walking because of disability, injury, or recovery from illness, can use a cane or other assistive device to help them avoid falls and injury.

Resources

BOOKS

Ornato, Joseph P. and Mary Ann Peberdy. Cardiopulmonary Resuscitation, 1st ed. Totowa, NJ: Humana Press, 2004.

Ribes, Ramon and Sergio Mejia Viana. Cardiovascular English, 1st ed. New York: Springer, 2008.

OTHER

American Heart Association. Emergency Cardiovascular Care [cited February 2008]. http://www.americanheart.org/presenter.jhtml?identifier=3011764.

ORGANIZATIONS

American CPR Training, 444 Sante Fe Drive #127, Encinitas, CA, 92024-5134, (760) 944-1048, http://www.cprtraining-classes.com.

American Heart Association, National Center, 7272 Greenville Avenue, Dallas, TX, 75231, (800) 242-8721, http://www.americanheart.org.

L Lee Culvert, Ph.D.

Laura Jean Cataldo, R.N., Ed.D.

Cardiopulmonary resuscitation

Definition

Cardiopulmonary resuscitation, commonly called CPR, combines rescue breathing (one person breathing into another person) and chest compression in a lifesaving procedure performed when a person has stopped breathing or a person's heart has stopped beating.

Purpose

When performed quickly enough, CPR can save lives in such emergencies as loss of consciousness, heart attacks or heart "arrests," electric shock, drowning, excessive bleeding, drug overdose, and other conditions in which there is no breathing or no pulse. The purpose of CPR is to bring oxygen to the victim's lungs and to keep blood circulating so oxygen gets to every part of the body. When a person is deprived of oxygen, permanent brain damage can begin in as little as four minutes and death can follow only minutes later.

Description

There are three physical symptoms that indicate a need for CPR to be performed immediately and for emergency medical support to be called: unconsciousness, not breathing, and no pulse detected.

Unconsciousness

Unconsciousness is when the victim seems to be asleep but has lost all awareness and is not able to respond to questions or to touch or gentle shaking. A sleeping person will usually respond to a loud noise, shouting, or gentle shaking. An unconscious person will not respond to noise or shaking. When unconscious, a person can not cough or clear the throat, which can block the windpipe and cause suffocation and death. People with a major illness or injury or who have had recent surgery are at risk for losing consciousness. If the person has fainted, which is brief unconsciousness, the cause may be dehydration (lack of body fluids), low blood pressure, or low blood sugar. This is a temporary condition. If the victim is known to have diabetes, a bit of fruit juice may revive the person once they have regained consciousness.

Just before a person loses consciousness, symptoms may include:

• lack of response to voice or touch
• disorientation or stupor
• light-headedness
• headache
• sleepiness

Not breathing

Not breathing, which is also called apnea, is the lack of spontaneous breathing. It requires immediate medical attention. The victim may become limp and lifeless, have a seizure, or turn blue. Prolonged apnea is called respiratory arrest. In children, this can lead quickly to cardiac arrest in which the heart stops beating. In adults, cardiac arrest usually happens first and then respiratory arrest. The common causes of apnea in adults are obstructive sleep apnea (something blocks the airway during sleep), choking, drug overdose, near-drowning, head injury, heart irregularities (arrhythmia, fibrillation) or cardiac arrest, nervous system disorders, or metabolic disorders. In children the causes may be different, such as prematurity, bronchial disturbances or pneumonia, airway blockage or choking on a foreign object, holding the breath, seizures, meningitis, regurgitating food, or asthma attacks.

No pulse detected

If the rescuer is unable to detect a pulse or has difficulty in feeling a pulse it can be an indication of the use of improper technique by the rescuer, or shock or cardiac arrest in the victim. If a sudden, severe decrease occurs in pulse quality (such as pulse weakness) or pulse rate (how many beats in a minute) when other symptoms are also present, life-threatening shock is suspected. The rescuer may need to explain to a doctor or medical professional where on the victim's body the pulse was measured, if the pulse is weak or absent altogether, and what other symptoms are present.

Medical help and CPR are needed immediately if any of these symptoms is found. Time is critical. A local emergency number should be called immediately. If more than one person is available to help, one can call 911 or a local emergency medical service, while the other person begins CPR. Ideally, someone CPR certified performs the procedure. Local medical personnel, a hospital, or the American Heart Association teaches special accredited CPR courses. If a critically ill patient or post-operative patient is being cared for at home, it is a good idea for a family member to take a CPR course to be better prepared to help in case of an emergency.

The steps usually followed in CPR are as follows:

• If the victim appears to be unconscious with either no breathing or no pulse, the person should be shaken or tapped gently to check for any movement. The victim is spoken to loudly, asking if he or she is OK. If there is no response, emergency help must be called and CPR begun immediately.
• The victim is placed on his or her back on a level surface such as the ground or the floor. The victim's back should be in a straight line with the head and neck supported slightly by a rolled up cloth, small towel, or piece of clothing under the neck. A pillow should not be used to support the head. The victim's clothing should be loosened to expose the chest.
• The rescuer kneels next to the victim, tilts the victim's head back, lifts the jaw forward, and moves the tongue forward or to the side, making sure it does not block the opening to the windpipe. The victim's mouth must be kept open at all times, reopening as necessary.
• The rescuer listens close to the victim's mouth for any sign of breathing, and watches the chest for movement. If the victim is found to be breathing, and has perhaps fainted, he or she can be placed in the recovery position until medical assistance arrives. This is done by straightening the victim's legs and pulling the closest arm out away from the body with the elbow at a right angle or 3 o'clock position, and the other arm across the chest. The far leg should be pulled up over the victim's body with the hip and knee bent. This allows the victim's body to be rolled onto its side. The head should be tilted back slightly to keep the windpipe open. The head should not be propped up.
• If the victim is not breathing, rescue breathing begins, closing the victim's nostrils between a thumb and index finger, and covering the victim's mouth with the rescuer's mouth. Two slow breaths, about two seconds each, are breathed into the victim's mouth with a pause in between. This is repeated until the chest begins to rise. The victim's head should be repositioned as often as necessary during the procedure. The mouth must remain open and the tongue kept away from the windpipe.
• When the chest begins to rise, or the victim begins to breathe on his or her own, the rescuer looks for signs of circulation, such as coughing or movement. If a healthcare professional has arrived by this time, the pulse will be checked before resuming resuscitation.
• If chest compressions are needed to restart breathing, the rescuer will place the heel of a hand above the lowest part of the victim's ribcage where it meets the middle-abdomen. The other hand will be placed over the heel of the first hand, with fingers interlocked. Keeping the elbows straight, the rescuer will lean his or her shoulders over the hands and press down firmly about 15 times. It is best to develop an up-and-down rhythm, keeping the hands firmly on the victim's chest.
• After the compressions, the rescuer will give the victim two long breaths. The sequence of 15 compressions and two breaths will be repeated until there are signs of spontaneous breathing and circulation or until professional medical help arrives.

Precautions

There are certain important precautions for rescuers to remember in order to protect the victim and get the best result from CPR. These include:

• Do not leave the victim alone.
• Do not give chest compressions if the victim has a pulse. Chest compression when there is normal circulation could cause the heart to stop beating.
• Do not give the victim anything to eat or drink.
• Avoid moving the victim's head or neck if spinal injury is a possibility. The person should be left as found if breathing freely. To check for breathing when spinal injury is suspected, the rescuer should only listen for breath by the victim's mouth and watch the chest for movement.
• Do not slap the victim's face, or throw water on the face, to try and revive the person.
• Do not place a pillow under the victim's head.

The description above is not a substitute for CPR training and is not intended to be followed as a procedure.

Normal results

Successful CPR will restore breathing and circulation in the victim. Medical attention is required immediately even if successful CPR has been performed and the victim is breathing freely.

Prevention

Loss of consciousness is an emergency that is potentially life threatening. To avoid loss of consciousness and protect themselves from emergency situations, people at risk can follow these general guidelines:

• People with known conditions or diseases, such as diabetes or epilepsy, should wear a medical alert tag or bracelet.
• People with diabetes should avoid situations that will lower their blood sugar level.
• People who feel weak, become dizzy or light-headed, or have ever fainted, should avoid standing in one place too long without moving.
• People who feel faint, can lie down or sit with their head lowered between their knees.
• Risk factors that contribute to heart disease should be reduced or eliminated. People can reduce risks if they stop smoking, lower blood pressure and cholesterol, lose weight, and reduce stress.
• Illegal recreational drugs should be avoided.
• Seeing a doctor regularly and being aware of any disease conditions or risk factors can help prevent or complicate illness, as can seeking and following the doctor's advice about diet and exercise.
• Using seat belts and driving carefully can help avoid accidental injury.
• People with poor eyesight or those who have difficulty walking because of disability, injury, or recovery from illness, can use a cane or other assistance device to help them avoid falls and injury.

Resources

organizations

American CPR Training. <http://www.cpr-training-classes.com>.

American Heart Association, National Center. 7272 Greenville Avenue, Dallas, TX 75231. <http://www.americanheart.org>.

other

Emergency Cardiovascular Care. [cited April 2003]. <http://www.cpr-ecc.org>.

Severson, Todd. "Cardiopulmonary Resuscitation." Medline Plus. April 2003 [cited April 2003]. <http://www.nlm.nih.gov/medlineplus>.

L. Lee Culvert