Hypothermia

         Hypothermia is defined as a core, or internal, body temperature of less than 95°F (35°C). The tragic tales of people falling into icy lakes are poignant examples of hypothermia. Anyone exposed to cold temperatures, whether for work or recreation, may be at risk of becoming too cold.
Hypothermia has been a military problem ever since Hannibal lost nearly half of his troops while crossing the Pyrenees Alps in 218 B.C. and has continued to plague military campaigns through both world wars and the Korean War.
Today, with the popularity of an expanding number of winter sports and increasing at-risk populations, hypothermia has slowly become a civilian, urban problem.

Hypothermia Causes

Normal body temperature is the reflection of a delicate balance between heat production and heat loss. Many of the chemical reactions necessary for human survival can occur only in specific temperature ranges. The human brain has a number of ways to maintain vital temperature. When these mechanisms are overwhelmed, heat loss happens faster than heat production resulting in hypothermia.
Sometimes the body’s temperature control can be altered by disease. In this case, core body temperature can decrease in almost any environment. This condition is called secondary hypothermia.

• The body loses heat in several ways.
  • 55-65% is lost to the environment via radiation.
  • Conduction only accounts for 2-3% in dry conditions, but this figure can increase to 50% if the victim is immersed in cold water.
  • Convection accounts for 10%, while 2-9% is lost to heating inspired air.
  • 20-27% is lost as a result of evaporation from the skin and lungs.
  • Children cool quicker than adults because they have more surface area compared to body mass.
• The body also has a variety of methods to increase heat production. But at a certain low level, the body cannot continue heat production, and core body temperature drops quickly. From 98.6°F to 89.6°F, the body begins to shiver, blood vessels contract, and hormones generate heat.
  • Shivering can double heat generation. However, this can only last a few hours. Eventually fatigue sets in, and the body exhausts its fuel stores.
  • Blood vessels contract or narrow in your arms and legs, which allows warm blood to remain internal and somewhat protected from the cold temperatures to which the skin is subjected.
  • Hormones and other small proteins are released in order to speed up the basal metabolic rate, essentially eating stored fuels in the hopes of producing heat as a byproduct.
• From 89.6°F to 75.2°F, shivering stops, and basic metabolism progressively slows down. At a body temperature lower than 75.2°F, almost every mechanism for heat conservation becomes inactive. Core body temperature continues to plummet. In primary hypothermia, the body is unable to generate heat fast enough to compensate for ongoing heat losses. This primarily is a disease of exposure.
  • In general, in cold, dry environments, hypothermia occurs over a period of hours.
  • In cold water, core temperature can drop to dangerous levels in a matter of minutes.
  • The elderly, because of their impaired ability to produce and retain heat, may become hypothermic over a period of days while living in indoor, regulated conditions that other people would find comfortable.
  • The homeless, alcoholics, and mentally ill are prone to hypothermia because they are unable to find adequate shelter or are unable to recognize when it is time to come in from the cold.
• In secondary hypothermia, something goes wrong with the body’s heat-balancing mechanisms. People with such diseases as stroke, spinal cord injury, low blood sugar, and a variety of skin disorders can become hypothermic in only mildly cool air.

Hypothermia Symptoms

Although the distinctions among mild, moderate, and severe hypothermia are not often clear, a somewhat constant sequence of events occurs as core body temperatures continue to decline.

• At temperatures below 95°F (35°C), shivering is seen. Heart rate, breathing rate, and blood pressure increase.
• As the temperature drops further, pulse, breathing rate, and blood pressure all decrease. You may experience some clumsiness, apathy, confusion, and slurred speech.
• As core temperature drops lower than 89.9°F (32.2°C), shivering stops and oxygen consumption begins to drop. The victim may be in a stupor. The heart rhythm may become irregular.
• At temperatures below 82.4°F (28°C), reflexes are lost and cardiac output continues to fall. The risk of dangerously irregular heart rhythms increases, and brain activity is seriously slowed. The pupils are dilated, and the victim appears comatose or dead.

When to Seek Medical Care

You may treat minor cold exposure at home with blankets and home care techniques. Call a doctor to ask about danger signs that might warrant immediate transportation to a medical facility.
Any person who is at risk for hypothermia and is suspected to have sustained a cold exposure should be brought to a hospital’s Emergency Department. Look for these danger signs of cold exposure:

• Intense shivering, stiffness, and numbness in the arms and legs, stumbling and clumsiness, sleepiness, confusion, and amnesia.
• The adage that "a person is not dead until warm and dead" means that victims may appear dead because of cold exposure, but many of these people have made complete recoveries when rewarmed. All such victims in this situation need rapid transport to a hospital so that resuscitation attempts may be made.

Exams and Tests

In severe cases of hypothermia, diagnosis and treatment will occur at the same time.

• The doctor will take a history from either the victim, if possible, or from whoever is present. Some vital information includes the length of exposure, the circumstances of recovery, and any past medical problems that may have influenced this episode.
• Symptoms vary, so the final diagnosis depends on the core body temperature. It is never taken by mouth. The temperature may be measured rectally, by a tube placed in the esophagus, or by an instrument inserted in an ear canal. Temperature will be measured continuously.
• A long list of blood tests will be performed because hypothermia can affect almost every organ system in the body. X-rays, especially of the chest, may be ordered, and many ECGs will be done to look at the electrical activity of the heart.

Hypothermia Treatment

Self-Care at Home

• The first priority is to perform a careful check for breathing and a pulse and initiate cardiopulmonary resuscitation (CPR) as necessary.
  • If the person is unconscious, having severe breathing difficulty, or is pulseless, call 911 for an ambulance.
  • Because the victim’s heartbeat may be very weak and slow, the pulse check should ideally be continued for at least 1 minute before beginning CPR. Rough handling of these victims may cause deadly heart rhythms.
• The second priority is rewarming.
  • Remove all wet clothes and move the person inside.
  • The victim should be given warm fluids if he or she is able to drink, but do not give the person caffeine or alcohol.
  • Cover the person’s body with blankets and aluminum-coated foils, and place the victim in a sleeping bag. Avoid actively heating the victim with outside sources of heat such as radiators or hot water baths. This may only decrease the amount of shivering and slow the rate of core temperature increase.
  • Strenuous muscle exertion should be avoided.
• Some cold exposure, such as cold hands and feet, may be treated with home care techniques.

Medical Treatment

• The doctor will first assess for immediate life threats, which are primarily the lack of breathing or a pulse. If the victim is not breathing, he or she will have a tube placed to help them breathe. If the victim does not have a pulse, chest compressions will be started.
• If the person is not responding, he or she will receive a dosage of the vitamin thiamine and have a blood sugar level checked to make sure it is not low. In this way, doctors make sure these are not the reasons why the person is unconscious.
• If the heart appears on the cardiac monitor to be beating ineffectively (a condition known as ventricular fibrillation), electricity may be applied to the chest using 2 paddles in an attempt to defibrillate the heart. This procedure may be tried up to 3 times at first, and then occasionally as the person’s temperature begins to climb.
• A tube may be placed through the nose into the stomach, and a catheter inserted into the bladder to monitor urine output. An IV line will be started, and warmed fluids will be given to treat the dehydration commonly seen in people with hypothermia.
• During this time, the process of rewarming is begun. There are 3 categories of rewarming:
• Passive external rewarming (PER): This method is ideal for mild hypothermia. In order to be effective, the person must be able to generate enough heat to maintain a good rate of spontaneous rewarming. The victim is placed in a suitably warm environment and covered with insulation. Core temperature is expected to increase a few degrees per hour with this method. At a core temperature below 86°F (30°C), spontaneous shivering is lost. The person has no ability to increase his or her own temperature, and PER is ineffective.
• Active external rewarming (AER) is a controversial technique in which heat is applied to the skin. Although common sense would suggest that this would be an effective method of rewarming, it has complications. When applied to the entire body, the warmth causes the brain to dilate the blood vessels in the arms and legs from their highly narrowed state. This action can bring cold blood that was previously trapped in the arms and legs back to the core of the body and actually lower its temperature. This same blood also carries with it a large amount of toxins, including acids, which flood the core and cause a dangerous acidosis. For these reasons and others, if AER is employed, it is directed over the trunk of the body only.
• Active core rewarming (ACR) is the most effective way to rapidly increase core temperature. It avoids many of the dangers associated with external rewarming. ACR is used when the person’s heart is unstable, when body temperature is below 89.9°F (32.2°C), and when the person is rewarming too slowly or not at all or in cases of secondary hypothermia. ACR may be performed in a variety of ways.
  • Airway: Warmed, humidified air is given either through the breathing tube or a closely fitted oxygen mask.
  • Peritoneal dialysis: Warmed fluid is placed into the abdomen through an incision and later removed. This cycle is repeated every 20-30 minutes. The major benefit here is that the liver may be quickly rewarmed and thus able to clear the body of toxins.
  • Heated irrigation: Tubes may be placed between the ribs, and heated water applied over the lungs and heart. Its effects are questionable.
  • Diathermy: This is a new method in which ultrasound and low-frequency microwave radiation is employed to deliver heat to deeper tissues.
  • Extracorporeal: Employing one of a variety of methods, blood is circulated from the person’s body through a warmer and then back into the bloodstream. This is the most rapid means currently available.

Follow-up

People who experience accidental hypothermia with body temperatures in the range of 95-89.9°F (35-32.2°C) and are otherwise healthy usually rewarm easily and can be safely sent home.
Those whose core temperatures are below 89.9°F (32.2°C) are admitted to the hospital. Underlying medical disorders are investigated and cardiac monitoring performed.

Prevention

Prepare well before embarking on any cold weather activities.

• Make sure you are conditioned physically with adequate nutrition and rest.
• Travel with a partner.
• Wear multiple layers of clothing, loosely fitted. Cover the head, wrists, neck, hands, and feet and try to remain dry.
• In an emergency, drink cold water rather than ice or snow.
• Be wary of wind and wet weather because they increase the rate of heat loss.
• Keep the homes of the elderly heated to at least 70°F (21.1°C), especially the sleeping area.

Outlook

People with accidental hypothermia in the range of 95-89.9°F (35-32.2°C) and who are otherwise healthy usually rewarm easily and can be safely sent home. Those with lower core body temperatures are usually admitted to the hospital.
People with uncomplicated hypothermia do better as a group than do people with hypothermia and another associated disease. In fact, outcome depends more on the underlying disease process than the person’s initial temperature or the rewarming method employed.
Age is not always a risk factor, although elderly people tend to have more associated medical problems. People with mild to moderate hypothermia usually have a complete recovery.
People with poor outcomes usually have had cardiac arrest, a very low or no blood pressure, and the need to have breathing assisted with a tube—all before arriving at the hospital.

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Anesthesia

Anesthesia controls pain during surgery or other medical procedures. It includes using medicines, and sometimes close monitoring, to keep you comfortable. It can also help control breathing, blood pressure, blood flow, and heart rate and rhythm, when needed.

 An anesthesiologist or a nurse anesthetist takes charge of your comfort and safety during surgery. This topic focuses on anesthesia care that you get from these specialists.
Anesthesia may be used to:

• Relax you.
• Block pain.
• Make you sleepy or forgetful.
• Make you unconscious for your surgery.

Other medicines also may be used to relax your muscles during surgery.

What are the types of anesthesia?

• Local anesthesia numbs a small part of the body. You get a shot of local anesthetic directly into the surgical area to block pain. It is used only for minor procedures. You may stay awake during the procedure, or you may get medicine to help you relax or sleep.
• Regional anesthesia blocks pain to a larger part of your body. Anesthetic is injected around major nerves or the spinal cord. You may get medicine to help you relax or sleep. Major types of regional anesthesia include:
  • Peripheral nerve blocks. A nerve block is a shot of anesthetic near a specific nerve or group of nerves. It blocks pain in the part of the body supplied by the nerve. Nerve blocks are most often used for procedures on the hands, arms, feet, legs, or face.
   
  
  
  • Epidural and spinal anesthesia. This is a shot of anesthetic near the spinal cord and the nerves that connect to it. It blocks pain from an entire region of the body, such as the belly, hips, or legs.
• General anesthesia affects the brain as well as the entire body. You may get it through a vein (intravenously), or you may breathe it in. With general anesthesia, you are completely unaware and do not feel pain during the surgery. General anesthesia also often causes you to forget the surgery and the time right after it.

What determines the type of anesthesia used?

The type of anesthesia used depends on several things:

• Your past and current health. The doctor or nurse will consider other surgeries you have had and any health problems you have, such as heart disease, lung disease, or diabetes. You also will be asked whether you or any family members have had an allergic reaction to any anesthetics or medicines.
• The reason for your surgery and the type of surgery.
• The results of tests, such as blood tests or an electrocardiogram (EKG, ECG).

Your doctor or nurse may prefer one type of anesthesia over another for your surgery. In some cases, your doctor or nurse may let you choose which type to have. Sometimes, such as in an emergency, you do not get to choose.

What are the potential risks and complications of anesthesia?

Major side effects and other problems of anesthesia are not common, especially in people who are in good health overall. But all anesthesia has some risk. Your specific risks depend on the type of anesthesia you get, your health, and how you respond to the medicines used.
Some health problems increase your chances of problems from anesthesia. Your doctor or nurse will identify any health problems you have that could affect your care.
Your doctor or nurse will closely watch your vital signs, such as your blood pressure and heart rate, during anesthesia and surgery, so most side effects and problems can be avoided.

Preparing for Anesthesia

Being well-prepared for anesthesia may help you remain calm and relaxed. If you take the time to learn about your procedure and the anesthesia, you will be better able to understand the information and instructions you are given. Knowing what to expect can help decrease tension and anxiety.
Usually, your surgeon's office, clinic, or hospital will contact you in advance to give you information about what to do the evening before and the day of the procedure. Your surgeon will also provide information about what will happen when you arrive at the clinic or hospital, during the procedure, and afterward.

Food and drink restrictions

As part of the preparation for your procedure, you are not allowed to eat or drink anything for a certain time period before anesthesia. The following times are averages. In some cases, such as in those people with gastroesophageal reflux disease (GERD), the restrictions must be started earlier for safety.

• Do not eat for 6 hours before anesthesia.
• You may drink clear liquids only (water, filtered apple juice, black coffee or tea, and clear carbonated beverages such as Seven-Up) up to 2 hours before your surgery. You should having nothing else to eat or drink for at least 6 hours before anesthesia.

Food and fluids are restricted to reduce the risk of aspiration by reducing the contents of your stomach. Aspiration occurs when an object or liquid is inhaled into the respiratory tract when a person regurgitates contents into the throat. Aspiration during anesthesia is very uncommon, but it can cause severe complications.

Medicine restrictions

If you take any medicines on a regular basis, such as diabetes medicines or heart medicines, ask your surgeon whether you should take your medicines on the day before or the day of your procedure. Some medicines may interact with the anesthetics and other medicines used for anesthesia.

Informed consent

Before any nonemergency surgery or procedure, most surgery centers and hospitals have a surgery consent for you to sign. This is called an informed consent because your surgeon will explain why your surgery is needed, what it will involve, its risks and expected outcome, and how long it will take you to recover. After discussing this information, you may be asked to sign the informed consent. It needs to be signed before you receive any medicines that could affect your state of mind.
Your anesthesia specialist will discuss the anesthesia care for your surgery so that you will understand what is involved, and you can then give your informed consent. You will be able to ask questions and express any concerns.
If the person undergoing anesthesia is a child or is mentally incompetent to sign a consent form, the consent may be signed by a responsible family member or guardian.

Mental relaxation techniques

Many people experience anxiety before medical procedures, especially surgery. Mental relaxation techniques can help reduce anxiety. If you will be awake during the procedure, you also can use these techniques to relax while it is being done. They can also be used to help reduce pain and anxiety following your procedure.
Some mental relaxation techniques that may be useful include:

• Optimistic self-recitation, in which you focus on and recite thoughts that are optimistic and positive.
• Guided imagery (visualization), a method of using your imagination to help you relax and release tension by concentrating on a pleasant experience or restful scene.
• Meditation, to help focus your attention on feeling calm and relaxed. You may want to focus on a single image, a sound, or your own breathing.
• Distraction techniques, such as listening to music through headphones.

Medicine given before anesthesia

You may be given a medicine before anesthesia. Medicines may be given by mouth or by injection immediately before anesthesia.
Medicine is given before anesthesia for many reasons, including:

• Relieve anxiety. The medicines most commonly given to relieve anxiety are benzodiazepines such as midazolam (Versed), diazepam (Valium), and lorazepam (Ativan).
• Relieve or prevent pain. Medicines to relieve pain (analgesics) may be given to people who are in pain before the procedure begins as well as to reduce pain during the procedure.
• Reduce secretions. Certain medicines (anticholinergic agents) may be used to reduce secretions in the mouth and respiratory tract.
• Reduce the volume and acidity of fluids in the stomach to help reduce the risk of aspiration. Aspiration occurs when an object or liquid is inhaled into the respiratory tract. In some cases, medicines are given to reduce or neutralize stomach acidity in order to lower the risk of injury if stomach juices are regurgitated into the throat or inhaled into the airway.
• Reduce nausea and vomiting. People who are at risk for nausea and vomiting either during the procedure or during recovery may receive medicines called antiemetics.
• Control body functions. Medicines may be given that help control the body's automatic responses to the pain and stress of surgery. Other medicines may be given to help maintain heartbeat or blood pressure at a stable and regular level.

Other preparation

For many procedures, medicines are given through a vein (intravenously, IV). An IV is usually inserted into a vein in the hand or lower arm. When the IV is in place, medicines or fluids can be given quickly into your bloodstream. Children and some adults may find insertion of the IV painful and stressful. In these cases, the IV may be inserted after they have been sedated or after an inhaled anesthetic has been given through a mask.
Some of the instruments used to monitor your breathing, blood pressure, and heart function may be placed on your body while you are being prepared for your surgery.

Helping children prepare for anesthesia

Children do better when receiving anesthesia if they know what to expect. You can help relieve your child's anxiety or fears by being calm and explaining what will happen at the clinic or hospital. Explain to your child that he or she will be in unfamiliar surroundings but that many doctors and nurses will be there to help.
It is best to be honest and explain that there may be some discomfort or pain after the procedure, but reassure your child that you will be close by. Bringing familiar items such as books or toys may help comfort and distract your child.

What happens when you are recovering from anesthesia?

    Recovery from anesthesia occurs as the effects of the anesthetic medicines wear off and your body functions begin to return. Immediately after surgery, you will be taken to a post-anesthesia care unit (PACU), often called the recovery room, where nurses will care for and observe you. A nurse will check your vital signs and bandages and ask about your pain level.
How quickly you recover from anesthesia depends on the type of anesthesia you received, your response to the anesthesia, and whether you received other medicines that may prolong your recovery. As you begin to awaken from general anesthesia, you may experience some confusion, disorientation, or difficulty thinking clearly. This is normal. It may take some time before the effects of the anesthesia are completely gone.
Your age and general health also may affect how quickly you recover. Younger people usually recover more quickly from the effects of anesthesia than older people. People with certain medical conditions may have difficulty clearing anesthetics from the body, which can delay recovery.

After anesthesia

Some of the effects of anesthesia may persist for many hours after the procedure. For example, you may have some numbness or reduced sensation in the part of your body that was anesthetized until the anesthetic wears off completely. Your muscle control and coordination may also be affected for many hours following your procedure. Other effects may include:

• Pain. As the anesthesia wears off, you can expect to feel some pain and discomfort from your surgery. In some cases, additional doses of local or regional anesthesia are given to block pain during initial recovery. Pain following surgery can cause restlessness as well as increased heart rate and blood pressure. If you experience pain during your recovery, tell the nurse who is monitoring you so that your pain can be relieved.
• Nausea and vomiting. You may experience a dry mouth and/or nausea. Nausea and vomiting are common after any type of anesthesia. It is a common cause of an unplanned overnight hospital stay and delayed discharge. Vomiting may be a serious problem if it causes pain and stress or affects surgical incisions. Nausea and vomiting are more likely with general anesthesia and lengthy procedures, such as surgery on the abdomen, the middle ear, or the eyes. In most cases, nausea after anesthesia does not last long and can be treated with medicines called antiemetics.
• Low body temperature (hypothermia). You may feel cold and shiver when you are waking up. A mild drop in body temperature is common during general anesthesia because the anesthetic reduces your body's heat production and affects the way your body regulates its temperature. Special measures are often taken during surgery to keep a person’s body temperature from dropping too much (hypothermia).

When your normal body functions have returned, you either will be transferred to another location in the hospital to complete your recovery or allowed to go home.
In many cases minor surgical procedures are done on an outpatient basis, which means you will go home the same day. Before you are discharged from an outpatient clinic, you should be alert and able to understand and remember instructions. You will also want to make sure you have regained muscle control and coordination enough to walk safely, take fluids without vomiting, and take oral pain medicines safely. Depending on your medical history, your surgeon may also want you to be able to urinate before you are discharged.
When you are discharged, make sure you have:

• Reliable transportation to your home and for return to the hospital if complications develop. Do not plan to drive yourself home.
• A competent adult caregiver who can be with you for 24 hours after discharge.
• Access to a telephone so you can call for assistance if complications develop.
• Access to a pharmacy so you can obtain prescriptions.

If you are not ready to go home, you will be transferred to another area in the hospital to complete your recovery. The length of your stay will depend on your response to your surgery.

Nurse anesthetist

A nurse anesthetist is a nurse who specializes in the administration of anesthesia.
In the United States, a Certified Registered Nurse Anesthetist (CRNA) is an advanced practice registered nurse (APRN), a registered nurse (RN) who has acquired graduate-level education in anesthesia overseen by the American Association of Nurse Anesthetists's (AANA), Council on Accreditation of Nurse Anesthesia Educational Programs.

Training & Education

Nurse anesthetists must first complete a four-year bachelor's degree, usually a Bachelor of Science in Nursing but it can be a Bachelor of Science in another science-related subject in some instances. They must be a licensed registered nurse. In addition, candidates are required to have a minimum of one year of full-time nursing experience in an acute care setting, such as medical intensive care unit or surgical intensive care unit.^[16] Following appropriate experience, applicants apply to a Council on Accreditation (COA) accredited program of anesthesia education for an additional 24 to 36 months, 6 to 9 contiguous semesters (only 2 out of the existing 107 programs are 2 years).^[16] Realistically, it takes a CRNA 8 - 10 years of education, clinical training, and experience to attain this goal.
Although all nurse anesthetists currently graduate with a master's degree, one may continue their education to the terminal degree level, either earning a Ph.D. or similar research doctorate (DNS, DNSc), or a clinical/practice doctorate such as a DNAP (Doctor of Nurse Anesthesia Practice), or DNP/DrNP (Doctor of Nursing Practice). At the terminal degree level, nurse anesthetists have available a wider variety of professional opportunities. They may teach, participate in administration, or pursue research. Currently, the American Association of Colleges of Nursing has endorsed a position statement that will move the current entry level of training for nurse anesthetists in the United States to the Doctor in Nursing Practice (DNP/DrNP) or Doctor of Nurse Anesthesia Practice (DNAP).^[17] This move will affect all advance practice nurses, with a mandatory implementation by the year 2015.^[18] The AANA announced in August 2007 support of this advanced clinical degree as an entry level for all nurse anesthetists, but with a target date of 2025. In accordance with traditional grandfathering rules, all those in current practice will not be affected.^[17]
The didactic curricula of nurse anesthesia programs are governed by the Council on Acceditation (COA) standards and provide students the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. The basic nurse anesthesia academic curriculum and prerequisite courses focus on coursework in anesthesia practice: pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry (105 contact hours); anatomy, physiology, and pathophysiology (135 contact hours); professional aspects of nurse anesthesia practice (45 contact hours); basic and advanced prinicples of anesthesia practice including physics, equipment, tehcnology and pain management (105 contact hours); research (30 contact hours); and clinical correlation conferences (45 contact hours).^[16] Because all programs will be converting to a doctorate level education, the length of the programs, in most cases, will need to increase to 36 months (9 semesters) per the recommendation of the COA of Nurse Anesthesia Programs.^[16]
Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.^[16]
Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems. Students gain experience with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions. The results of a 1998 survey of program directors show that nurse anesthesia programs provide an average of 1,595 hours of clinical experience for each student.^[16]Depending upon academic requirements, and all are at the master's degree level or higher.
The certification and recertification process is governed by the National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA). CRNAs also have continuing education requirements and recertification every two years thereafter, plus any additional requirements of the state in which they practice.^[16]

Compensation

In the United States, numerous salary reports throughout the years indicate that CRNAs remain the highest compensated of all nursing specialties as well as other non-physician healthcare providers. In 2009, the median annual salary for nurse anesthetists was $157,724 annually (not including call-pay, bonuses, pension, or benefits) as reported by the AMGA Medical Group Compensation and Financial Survey.

Armed forces

In the United States armed forces, nurse anesthetists provide a critical peacetime and wartime skill. During peacetime and wartime, nurse anesthetists have been the principal providers of anesthesia services for active duty and retired service members and their dependents.^[34] Nurse anesthetists function as the only licensed independent anesthesia practitioners at many military treatment facilities, including U.S. Navy ships at sea. They are also the leading provider of anesthesia for the Veterans Administration and Public Health Service medical facilities.
During World War I, America's nurse anesthetists played a vital role in the care of combat troops in France. From 1914 to 1915, three years prior to America entering the war, Dr. George Crile and nurse anesthetists Agatha Hodgins and Mabel Littleton served in the Lakeside Unit at the American Ambulance at Neuilly-sur-Seine in France.^[35][36] In addition, they helped train the French and British nurses and physicians in anesthesia care. After the war, France continued to use nurse anesthetists, however, Britain adopted a physician-only policy that continues today. In 1917, the American participation in the war resulted in the U.S. military training nurse anesthetists for service. The Army and Navy sent nurses to various hospitals, including the Mayo Clinic at Rochester and the Lakeside Hospital in Cleveland, for anesthesia training, before overseas service.^[37]
Among notable nurse anesthetists are Sophie Gran Winton, who served with the Red Cross at an army hospital in Château-Thierry, France, and earned the French Croix de Guerre in addition to other service awards;^[38] Anne Penland, who was the first nurse anesthetist to serve on the British Front and was decorated by the British government and ^[39]
American nurse anesthetists also served in World War II and Korea, receiving numerous citations and awards.^[40] Second Lieutenant Mildred Irene Clark provided anesthesia for casualties from the Japanese attack on Pearl Harbor.^[41] During the Vietnam War, nurse anesthetists served as both CRNAs and flight nurses, and also developed new field equipment.^[42] Nurse anesthetists have been casualties of war. Lieutenants Kenneth R. Shoemaker, Jr. and Jerome E. Olmsted, were killed in an air evac mission in route to Qui Nhon, Vietnam.^[43]
At least one nurse anesthetist was a prisoner of war; Army nurse anesthetist Annie Mealer endured a three-year imprisonment by the Japanese in the Philippines, and was released in 1945.^[44] During the Iraq War, nurse anesthetists comprise the largest group of anesthesia providers at forward positioned medical treatment facilities.^[45] In addition, they play a role in the continuing education and training of Department of Defense nurses and technicians in the care of wartime trauma patients.

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Disaster Management

                Emergency management (or disaster management) is the discipline of dealing with and avoiding risks.^[1] It is a discipline that involves preparing for disaster before it occurs, disaster response (e.g., emergency evacuation, quarantine, mass decontamination, etc.), and supporting, and rebuilding society after natural or human-made disasters have occurred. In general, any Emergency management is the continuous process by which all individuals, groups, and communities manage hazards in an effort to avoid or ameliorate the impact of disasters resulting from the hazards. Actions taken depend in part on perceptions of risk of those exposed.^[2] Effective emergency management relies on thorough integration of emergency plans at all levels of government and non-government involvement. Activities at each level (individual, group, community) affect the other levels. It is common to place the responsibility for governmental emergency management with the institutions for civil defense or within the conventional structure of the emergency services. However, emergency management actually starts at the lowest level and only increases to the next higher organizational level after the current levels resources have been exhausted. In the private sector, emergency management is sometimes referred to as business continuity planning.
Emergency Management is one of a number of terms which, since the end of the Cold War, have largely replaced Civil defense, whose original focus was protecting civilians from military attack. Modern thinking focuses on a more general intent to protect the civilian population in times of peace as well as in times of war. Another current term, Civil Protection is widely used within the European Union and refers to government-approved systems and resources whose task is to protect the civilian population, primarily in the event of natural and human-made disasters. Within EU countries the term Crisis Management emphasises the political and security dimension rather than measures to satisfy the immediate needs of the civilian population.^{[citation needed]} An academic trend is towards using the term disaster risk reduction, particularly for emergency management in a development management context. This focuses on the mitigation and preparedness aspects of the emergency cycle

Phases and professional activities

The nature of management depends on local economic and social conditions. Some disaster relief experts such as Fred Cuny have noted that in a sense the only real disasters are economic.^[3] Experts, such as Cuny, have long noted that the cycle of emergency management must include long-term work on infrastructure, public awareness, and even human justice issues. This is not important in developing nations. The process of emergency management involves four phases: mitigation, preparedness, response, and recovery.

A graphic representation of the four phases in emergency management.

Mitigation

Mitigation efforts attempt to prevent hazards from developing into disasters altogether, or to reduce the effects of disasters when they occur. The mitigation phase differs from the other phases because it focuses on long-term measures for reducing or eliminating risk.^[1] The implementation of mitigation strategies can be considered a part of the recovery process if applied after a disaster occurs.^[1] Mitigative measures can be structural or non-structural. Structural measures use technological solutions, like flood levees. Non-structural measures include legislation, land-use planning (e.g. the designation of nonessential land like parks to be used as flood zones), and insurance.^[4] Mitigation is the most cost-efficient method for reducing the impact of hazards, however it is not always suitable. Mitigation does include providing regulations regarding evacuation, sanctions against those who refuse to obey the regulations (such as mandatory evacuations), and communication of potential risks to the public.^[5] Some structural mitigation measures may have adverse effects on the ecosystem.
A precursor activity to the mitigation is the identification of risks. Physical risk assessment refers to the process of identifying and evaluating hazards.^[1] The hazard-specific risk (R_h) combines both the probability and the level of impact of a specific hazard. The equation below states that the hazard multiplied by the populations’ vulnerability to that hazard produces a risk Catastrophe modeling. The higher the risk, the more urgent that the hazard specific vulnerabilities are targeted by mitigation and preparedness efforts. However, if there is no vulnerability there will be no risk, e.g. an earthquake occurring in a desert where nobody lives.

Preparedness

Preparedness is a continuous cycle of planning, organizing, training, equipping, exercising, evaluation and improvement activities to ensure effective coordination and the enhancement of capabilities to prevent, protect against, respond to, recover from, and mitigate against natural disasters, acts of terrorism, and other man-made disasters.^[6]
In the preparedness phase, emergency managers develop plans of action to manage and counter their risks and take action to build the necessary capabilities needed to implement such plans. Common preparedness measures include:

• communication plans with easily understandable terminology and methods.
• proper maintenance and training of emergency services, including mass human resources such as community emergency response teams.
• development and exercise of emergency population warning methods combined with emergency shelters and evacuation plans.
• stockpiling, inventory, and maintain disaster supplies and equipment^[7]
• develop organizations of trained volunteers among civilian populations. (Professional emergency workers are rapidly overwhelmed in mass emergencies so trained, organized, responsible volunteers are extremely valuable. Organizations like Community Emergency Response Teams and the Red Cross are ready sources of trained volunteers. The latter's emergency management system has gotten high ratings from both California, and the Federal Emergency Management Agency (FEMA).)

Another aspect of preparedness is casualty prediction, the study of how many deaths or injuries to expect for a given kind of event. This gives planners an idea of what resources need to be in place to respond to a particular kind of event.
Emergency Managers in the planning phase should be flexible, and all encompassing - carefully recognizing the risks and exposures of their respective regions and employing unconventional, and atypical means of support. Depending on the region - municipal, or private sector emergency services can rapidly be depleted and heavily taxed. Non-governmental organizations that offer desired resources, i.e., transportation of displaced homeowners to be conducted by local school district buses, evacuation of flood victims to be performed by mutual aide agreements between fire departments and rescue squads, should be identified early in planning stages, and practiced with regularity.

Response

The response phase includes the mobilization of the necessary emergency services and first responders in the disaster area. This is likely to include a first wave of core emergency services, such as firefighters, police and ambulance crews. When conducted as a military operation, it is termed Disaster Relief Operation (DRO) and can be a follow-up to a Non-combatant evacuation operation (NEO). They may be supported by a number of secondary emergency services, such as specialist rescue teams.
A well rehearsed emergency plan developed as part of the preparedness phase enables efficient coordination of rescue. Where required, search and rescue efforts commence at an early stage. Depending on injuries sustained by the victim, outside temperature, and victim access to air and water, the vast majority of those affected by a disaster will die within 72 hours after impact.^[8]
Organizational response to any significant disaster - natural or terrorist-borne - is based on existing emergency management organizational systems and processes: the Federal Response Plan (FRP) and the Incident Command System (ICS). These systems are solidified through the principles of Unified Command (UC) and Mutual Aid (MA)

Recovery

The aim of the recovery phase is to restore the affected area to its previous state. It differs from the response phase in its focus; recovery efforts are concerned with issues and decisions that must be made after immediate needs are addressed.^[1] Recovery efforts are primarily concerned with actions that involve rebuilding destroyed property, re-employment, and the repair of other essential infrastructure.^[1] Efforts should be made to "build back better", aiming to reduce the pre-disaster risks inherent in the community and infrastructure.[2] An important aspect of effective recovery efforts is taking advantage of a ‘window of opportunity’^[9] for the implementation of mitigative measures that might otherwise be unpopular. Citizens of the affected area are more likely to accept more mitigative changes when a recent disaster is in fresh memory.
In the United States, the National Response Plan dictates how the resources provided by the Homeland Security Act of 2002 will be used in recovery efforts.^[1] It is the Federal government that often provides the most technical and financial assistance for recovery efforts in the United States.^[1]

Phases and personal activities

Mitigation

Personal mitigation is mainly about knowing and avoiding unnecessary risks. This includes an assessment of possible risks to personal/family health and to personal property.
One example of mitigation would be to avoid buying property that is exposed to hazards, e.g., in a flood plain, in areas of subsidence or landslides. Home owners may not be aware of a property being exposed to a hazard until it strikes. However, specialists can be hired to conduct risk identification and assessment surveys. Purchase of insurance covering the most prominent identified risks is a common measure.
Personal structural mitigation in earthquake prone areas includes installation of an Earthquake Valve to instantly shut off the natural gas supply to a property, seismic retrofits of property and the securing of items inside a building to enhance household seismic safety. The latter may include the mounting of furniture, refrigerators, water heaters and breakables to the walls, and the addition of cabinet latches. In flood prone areas houses can be built on poles, as in much of southern Asia. In areas prone to prolonged electricity black-outs installation of a generator would be an example of an optimal structural mitigation measure. The construction of storm cellars and fallout shelters are further examples of personal mitigative actions.
Mitigation involves Structural and Non-structural measures taken to limit the impact of disasters.
Structural Mitigation:-

This involves proper layout of building, particularly to make it resistant to disasters.

Non Structural Mitigation:-

This involves measures taken other than improving the structure of building.

Preparedness

While preparedness is aimed at preventing a disaster from occurring, personal preparedness focuses on preparing equipment and procedures for use when a disaster occurs, i.e., planning. Preparedness measures can take many forms including the construction of shelters, installation of warning devices, creation of back-up life-line services (e.g., power, water, sewage), and rehearsing evacuation plans. Two simple measures can help prepare the individual for sitting out the event or evacuating, as necessary. For evacuation, a disaster supplies kit may be prepared and for sheltering purposes a stockpile of supplies may be created. The preparation of a survival kit such as a "72-hour kit", is often advocated by authorities. These kits may include food, medicine, flashlights, candles and money.

Response

The response phase of an emergency may commence with search and rescue but in all cases the focus will quickly turn to fulfilling the basic humanitarian needs of the affected population. This assistance may be provided by national or international agencies and organisations. Effective coordination of disaster assistance is often crucial, particularly when many organisations respond and local emergency management agency (LEMA) capacity has been exceeded by the demand or diminished by the disaster itself.
On a personal level the response can take the shape either of a shelter in place or an evacuation. In a shelter-in-place scenario, a family would be prepared to fend for themselves in their home for many days without any form of outside support. In an evacuation, a family leaves the area by automobile or other mode of transportation, taking with them the maximum amount of supplies they can carry, possibly including a tent for shelter. If mechanical transportation is not available, evacuation on foot would ideally include carrying at least three days of supplies and rain-tight bedding, a tarpaulin and a bedroll of blankets being the minimum.

Recovery

The recovery phase starts after the immediate threat to human life has subsided. During reconstruction it is recommended to consider the location or construction material of the property.
The most extreme home confinement scenarios include war, famine and severe epidemics and may last a year or more. Then recovery will take place inside the home. Planners for these events usually buy bulk foods and appropriate storage and preparation equipment, and eat the food as part of normal life. A simple balanced diet can be constructed from vitamin pills, whole-meal wheat, beans, dried milk, corn, and cooking oil.^[10] One should add vegetables, fruits, spices and meats, both prepared and fresh-gardened, when possible.

As a profession

Emergency managers are trained in a wide variety of disciplines that support them through out the emergency life-cycle. Professional emergency managers can focus on government and community preparedness (Continuity of Operations/Continuity of Government Planning), or private business preparedness (Business Continuity Management Planning). Training is provided by local, state, federal and private organizations and ranges from public information and media relations to high-level incident command and tactical skills such as studying a terrorist bombing site or controlling an emergency scene.
In the past, the field of emergency management has been populated mostly by people with a military or first responder background. Currently, the population in the field has become more diverse, with many experts coming from a variety of backgrounds without military or first responder history. Educational opportunities are increasing for those seeking undergraduate and graduate degrees in emergency management or a related field. There are eight schools in the US with emergency management-related doctorate programs, but only one doctoral program specifically in emergency management.^[11]
Professional certifications such as Certified Emergency Manager (CEM) and Certified Business Continuity Professional (CBCP) are becoming more common as the need for high professional standards is recognized by the emergency management community, especially in the United States.

Principles of Emergency Management

In 2007, Dr. Wayne Blanchard of FEMA’s Emergency Management Higher Education Project, at the direction of Dr. Cortez Lawrence, Superintendent of FEMA’s Emergency Management Institute, convened a working group of emergency management practitioners and academics to consider principles of emergency management. This project was prompted by the realization that while numerous books, articles and papers referred to “principles of emergency management,” nowhere in the vast array of literature on the subject was there an agreed-upon definition of what these principles were. The group agreed on eight principles that will be used to guide the development of a doctrine of emergency management. The summary provided below lists these eight principles and provides a brief description of each.
Principles: Emergency management must be: 1. Comprehensive – emergency managers consider and take into account all hazards, all phases, all stakeholders and all impacts relevant to disasters. 2. Progressive – emergency managers anticipate future disasters and take preventive and preparatory measures to build disaster-resistant and disaster-resilient communities. 3. Risk-driven – emergency managers use sound risk management principles (hazard identification, risk analysis, and impact analysis) in assigning priorities and resources. 4. Integrated – emergency managers ensure unity of effort among all levels of government and all elements of a community. 5. Collaborative – emergency managers create and sustain broad and sincere relationships among individuals and organizations to encourage trust, advocate a team atmosphere, build consensus, and facilitate communication. 6. Coordinated – emergency managers synchronize the activities of all relevant stakeholders to achieve a common purpose. 7. Flexible – emergency managers use creative and innovative approaches in solving disaster challenges. 8. Professional – emergency managers value a science and knowledge-based approach; based on education, training, experience, ethical practice, public stewardship and continuous improvement.
A fuller description of these principles can be found at Principles of Emergency Management

Tools

In recent years the continuity feature of emergency management has resulted in a new concept, Emergency Management Information Systems (EMIS). For continuity and interoperability between emergency management stakeholders, EMIS supports the emergency management process by providing an infrastructure that integrates emergency plans at all levels of government and non-government involvement and by utilizing the management of all related resources (including human and other resources) for all four phases of emergencies. In the healthcare field, hospitals utilize HICS (Hospital Incident Command System) which provides structure and organization in a clearly defined chain of command with set responsibilities for each division.

Within other professions

Practitioners in emergency management (disaster preparedness) come from an increasing variety of backgrounds as the field matures. Professionals from memory institutions (e.g., museums, historical societies, libraries, and archives) are dedicated to preserving cultural heritage—objects and records contained in their collections. This has been an increasingly major component within these field as a result of the heightened awareness following the September 11 attacks in 2001, the hurricanes in 2005, and the collapse of the Cologne Archives.
To increase the opportunity for a successful recovery of valuable records, a well-established and thoroughly tested plan must be developed. This plan must not be overly complex, but rather emphasize simplicity in order to aid in response and recovery. As an example of the simplicity, employees should perform similar tasks in the response and recovery phase that they perform under normal conditions. It should also include mitigation strategies such as the installation of sprinklers within the institution. This task requires the cooperation of a well-organized committee led by an experienced chairperson.^[12] Professional associations schedule regular workshops and hold focus sessions at annual conferences to keep individuals up to date with tools and resources in practice in order to minimize risk and maximize recovery.

Tools

The joint efforts of professional associations and cultural heritage institutions have resulted in the development of a variety of different tools to assist professionals in preparing disaster and recovery plans. In many cases, these tools are made available to external users. Also frequently available on websites are plan templates created by existing organizations, which may be helpful to any committee or group preparing a disaster plan or updating an existing plan. While each organization will need to formulate plans and tools which meet their own specific needs, there are some examples of such tools that might represent useful starting points in the planning process. These have been included in the External Links section.
In 2009, the US Agency for International Development created a web-based tool for estimating populations impacted by disasters. Called Population Explorer the tool uses Landscan population data, developed by Oak Ridge National Laboratory, to distribute population at a resolution 1 km² for all countries in the world. Used by USAID's FEWS NET Project to estimate populations vulnerable and or impacted by food insecurity, Population Explorer is gaining wide use in a range of emergency analysis and response actions, including estimating populations impacted by floods in Central America and a Pacific Ocean Tsunami event in 2009.
In 2007, a checklist for veterinarians pondering participation in emergency response was published in the Journal of the American Veterinary Medical Association, it had two sections of questions for a professional to ask themself before assisting with an emergency: Absolute requirements for participation: Have I chosen to participate?, Have I taken ICS training?, Have I taken other required background courses?, Have I made arrangements with my practice to deploy?,Have I made arrangements with my family?
Incident Participation: Have I been invited to participate?, Are my skill sets a match for the mission?, Can I access just-in-time training to refresh skills or acquire needed new skills?, Is this a self-support mission?, Do I have supplies needed for three to five days of self support?
While written for veterinarians, this checklist is applicable for any professional to consider before assisting with an emergency.^[13]

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Cardiopulmonary Resuscitation (CPR)

Heart disease is the number 1 killer in the United States. Each year, almost 330,000 Americans die from heart disease. Half of these will die suddenly, outside of the hospital, because their heart stops beating.

• The most common cause of death from a heart attack in adults is a disturbance in the electrical rhythm of the heart called ventricular fibrillation.
  • Ventricular fibrillation can be treated, but it requires applying an electrical shock to the chest called defibrillation.
  • If a defibrillator is not readily available, brain death will occur in less than 10 minutes.
• One way of buying time until a defibrillator becomes available is to provide artificial breathing and circulation by performing cardiopulmonary resuscitation, or CPR.
  • The earlier you give CPR to a person in cardiopulmonary arrest (no breathing, no heartbeat), the greater the chance of a successful resuscitation.
  • By performing CPR, you keep oxygenated blood flowing to the heart and brain until a defibrillator becomes available.
• Because up to 80% of all cardiac arrests occur in the home, you are most likely to perform CPR on a family member or loved one.
• CPR is one link in what the American Heart Association calls the "chain of survival." The chain of survival is a series of actions that, when performed in sequence, will give a person having a heart attack the greatest chance of survival.
  • When an emergency situation is recognized, the first link in the chain of survival is early access. This means activating the emergency medical services, or EMS, system by calling 911 (check your community plan, some communities require dialing a different number).
  • The next link in the chain of survival is to perform CPR until a defibrillator becomes available.
  • In some areas of the country, simple, computerized defibrillators, known as automated external defibrillators, or AEDs, may be available for use by the lay public or first person on the scene. If available, early defibrillation becomes the next link in the chain of survival.
  • Once the EMS unit arrives, the next link in the chain of survival is early advanced life support care. This involves administering medications, using special breathing devices, and providing additional defibrillation shocks if needed.

There is no substitute for learning cardiopulmonary resuscitation (CPR), but emergencies don't wait for training. These instructions are for conventional adult CPR. If you've never been trained in CPR and the victim collapsed in front of you, use hands-only CPR.
For kids, use the following guidelines:

• Infant CPR for kids under 1 year.
• Child CPR for kids 1-8 years old.

Not every CPR class is the same. There are CPR classes for healthcare professionals as well as CPR classes for the layperson. Before you take a CPR class, make sure the class is right for you.

 

These are the steps to perform adult CPR:

Difficulty: Easy

Time Required: CPR should start as soon as possible
Here's How:

1. Stay Safe! The worst thing a rescuer can do is become another victim. Follow universal precautions and wear personal protective equipment if you have it. Use common sense and stay away from potential hazards.
2. Attempt to wake victim. Briskly rub your knuckles against the victim's sternum. If the victim does not wake, call 911 and proceed to step 3. If the victim wakes, moans, or moves, then CPR is not necessary at this time. Call 911 if the victim is confused or not able to speak.
3. Begin rescue breathing. Open the victim's airway using the head-tilt, chin-lift method. Put your ear to the victim's open mouth:
   • look for chest movement
   • listen for air flowing through the mouth or nose
   • feel for air on your cheek
   If there is no breathing, pinch the victim's nose; make a seal over the victim's mouth with yours. Use a CPR mask if available. Give the victim a breath big enough to make the chest rise. Let the chest fall, then repeat the rescue breath once more. If the chest doesn't rise on the first breath, reposition the head and try again. Whether it works on the second try or not, go to step 4.
4. Begin chest compressions. Place the heel of your hand in the middle of the victim's chest. Put your other hand on top of the first with your fingers interlaced. Compress the chest about 1-1/2 to 2 inches (4-5 cm). Allow the chest to completely recoil before the next compression. Compress the chest at a rate equal to 100/minute. Perform 30 compressions at this rate.
5. Repeat rescue breaths. Open the airway with head-tilt, chin-lift again. This time, go directly to rescue breaths without checking for breathing again. Give one breath, making sure the chest rises and falls, then give another. Remember, if the chest doesn't rise on the first breath, reposition the head before you give the second breath.
6. Perform 30 more chest compressions. Repeat steps 5 and 6 for about two minutes.
7. After 2 minutes of chest compressions and rescue breaths, stop compressions and recheck victim for breathing. If the victim is not breathing, continue chest compressions and rescue breaths.
8. Keep going until help arrives.

Tips:

1. If you have acces to an automated external defibrillator, attach it to the victim after approximately one minute of CPR (chest compressions and rescue breaths).
2. Chest compressions are extremely important. If you are not comfortable giving rescue breaths, still perform chest compressions!
3. It's normal to feel pops and snaps when you first begin chest compressions - DON'T STOP! You aren't going to make the victim any worse. Cardiac arrest is as bad as it gets.
4. When performing chest compressions, do not let your hands bounce. Let the chest fully recoil, but keep the heel of your hand in contact with the sternum at all times.
5. For more information on these steps go to the Emergency Cardiac Care (ECC) Guidelines

Cardiac Arrest

When a person develops cardiac arrest, the heart stops beating. There is no blood flow and no pulse. With no blood flowing to the brain, the person becomes unresponsive and stops breathing normally.

• When you discover a person whom you believe is experiencing a medical emergency, the first thing to do is check for responsiveness. Gently shake the victim and shout, "Are you OK?"
• If the person does not respond to your voice or touch, they are unresponsive. If the victim is unresponsive and you are alone, leave the victim and immediately call 911. If someone is with you, tell him or her to call 911 and then return to help you.
• If an AED is available, bring it back to the person's side. The moment an AED becomes available, IMMEDIATELY press the "on" button. The AED will begin to speak to you. Follow its directions to use the AED.

Rescue Breathing

You now need to check to see if the person is breathing normally.

• You do this by first opening the person's airway. Tilt the victim's head back by lifting the chin gently with one hand, while pushing down on the forehead with the other hand.
• Next, place your ear next to the victim's mouth and nose and look, listen, and feel: Look to see if the chest is rising, listen for any sounds of breathing, and feel for any air movement on your cheek. Taking no more than 5-10 seconds, if you do not see, hear, or feel any signs of normal breathing, you must breathe for the victim.
• While keeping the victim's head tilted back, place your mouth around the victim's mouth and pinch the victim's nose shut. Give 2 slow breaths, making sure that the person's chest rises with each breath.

Chest Compressions

 

After giving 2 breaths immediately begin chest compressions.

• Place the heel of one hand on the center of the chest, right between the nipples. Place the heel of your other hand on top of the first hand. Lock your elbows and position your shoulders directly above your hands. Press down on the chest with enough force to move the breastbone down about 2 inches. Compress the chest 30 times, at a rate of about 100 times per minute (slightly faster than once every second).
• After 30 compressions, stop, open the airway again, and provide the next 2 slow breaths. Then, position your hands in the same spot as before and perform another 30 chest compressions. Continue the cycles of 30 compressions and 2 breaths until an AED becomes available or until EMS providers arrive.
• This technique of performing CPR may be used on anyone older than eight years of age.

CPR in Children

Sudden cardiac arrest is less common in children than it is in adults. It usually happens when there is a lack of oxygen caused by a breathing problem such as choking, near-drowning, or respiratory infections. Because oxygen often corrects the problem in a child, when an unresponsive, non-breathing child is found, CPR is performed for 1 minute before activating the EMS system. This may reverse the lack of oxygen and revive the child.
In order to use an AED on a child from one year of age through eight years of age a special pediatric cable is used to reduce the amount of energy provided by the electrical shock.
Doing CPR on children aged one year to eight years is similar to doing CPR on adults. However, there are some minor differences. Most are due to the child's smaller size.

• When compressing the chest, the heel of only 1 hand is used instead of 2 hands, and the chest is pressed down about ½ of its depth.
• Perform 5 cycles of 30 chest compressions followed by 2 breaths, then use an AED to evaluate the heart rhythm if available.. If an AED is not available, and the child is still not breathing normally, coughing, or moving, continue cycles of 30 compressions to 2 breaths until help arrives.

CPR in Infants

An infant is defined as a child younger than one year of age. Because an infant is smaller than a child, the CPR technique for infants contains further changes.

• Even smaller breaths are given-enough to just get the chest to rise. Only 2 fingers are used to compress the chest down about 1 inch.
• Otherwise, the CPR sequence is the same as for the child.
• There are no recommendations for the use of AEDs in children less than one year of age.

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