9.2 CPR Protocols, AED Operation & Choking Relief (Adult & Child)

CPR Protocols, AED Operation & Choking Relief (Adult & Child)

Core Principle: Sudden cardiac arrest is an absolute life-or-death emergency where every minute of delay reduces casualty survival probability by 7% to 10%. Immediate, high-quality chest compressions circulating oxygenated blood to the brain and myocardium, combined with rapid defibrillation via an Automated External Defibrillator (AED), form the cornerstone of adult and pediatric resuscitation.

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Sudden Cardiac Arrest vs. Heart Attack

A critical distinction tested on the Ontario Security Guard Licensing Test is the fundamental difference between a heart attack and sudden cardiac arrest:

• Heart Attack (Myocardial Infarction): A circulatory/plumbing problem. A coronary artery supplying oxygenated blood to the heart muscle becomes blocked by a thrombus (blood clot) or plaque rupture. The heart muscle begins dying from lack of oxygen, but the heart usually continues beating. The casualty is typically conscious, complaining of severe crushing chest pressure, radiating arm/jaw pain, and shortness of breath.
• Cardiac Arrest: An electrical problem. The heart's electrical conduction system malfunctions abruptly, degenerating into chaotic, uncoordinated quivering or cessation of electrical activity. The heart immediately ceases pumping blood to the brain and vital organs. The casualty collapses, becomes instantly unresponsive, stops breathing normally (or exhibits agonal gasps), and will die within minutes without immediate CPR and defibrillation.

The Out-of-Hospital Chain of Survival

The Heart and Stroke Foundation of Canada establishes a six-link Chain of Survival for out-of-hospital cardiac arrest (OHCA):

1. Early Recognition & 911 Activation: Identifying cardiac arrest symptoms immediately and dispatching emergency medical resources.
2. Early High-Quality CPR: Initiating prompt chest compressions to maintain coronary and cerebral perfusion.
3. Rapid Defibrillation: Applying an AED within 3 to 5 minutes of collapse to terminate lethal arrhythmias.
4. Advanced Life Support: Early arrival of advanced care paramedics providing advanced airway management and intravenous pharmacological therapy.
5. Post-Cardiac Arrest Care: Specialized neurological, cardiology, and hypothermia protocols in a hospital critical care setting.
6. Recovery & Rehabilitation: Ongoing psychological, physiological, and emotional recovery support.

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High-Quality Adult Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary Resuscitation mechanically mimics the heart's pumping action. When performing chest compressions, the heart is compressed between the sternum and thoracic spine, forcing blood out of the cardiac chambers into systemic and cerebral circulation. When pressure is released, negative intrathoracic pressure draws venous blood back into the heart chambers. Aligned with current Heart & Stroke Foundation and ILCOR guidelines, the foundational parameters of high-quality CPR include:

1. Compression-to-Ventilation Ratio

• Adult Resuscitation: The standard ratio is 30 chest compressions to 2 rescue breaths (30:2). This ratio applies to both single-rescuer and two-rescuer adult resuscitation scenarios.
• If a rescuer is unwilling, unable, or untrained to deliver rescue breaths (or lacks a pocket mask), they must perform continuous Hands-Only CPR (uninterrupted chest compressions at 100 to 120 bpm).

2. Compression Rate

• Chest compressions must be delivered at a steady tempo of 100 to 120 compressions per minute.
• Compressing slower than 100 bpm provides inadequate cardiac output; compressing faster than 120 bpm prevents the heart chambers from filling properly between compressions (diminishing stroke volume). A common acoustic pacing reference is the beat of the song "Stayin' Alive".

3. Compression Depth

• In adults, compress the center of the chest to a depth of at least 5 cm (2 inches), but not exceeding 6 cm (2.4 inches).
• Inadequate compression depth is the most prevalent error among novice rescuers, failing to generate sufficient coronary perfusion pressure.

4. Complete Chest Recoil

• Allow the chest to recoil completely to its natural anatomical resting position after every single compression.
• Avoid leaning on the casualty's chest between compressions. Incomplete chest recoil maintains elevated intrathoracic pressure, severely reducing venous return to the heart and decreasing cardiac output.

5. Minimizing Interruptions

• Minimize all pauses in chest compressions. Rescuers must deliver compressions continuously, keeping interruptions (e.g., delivering breaths, switching rescuers, or applying AED pads) to less than 10 seconds.
• Coronary perfusion pressure drops precipitously to zero the moment compressions stop; it requires 10 to 15 continuous compressions to re-establish effective perfusion levels.

6. Effective Ventilation Technique

• Deliver 2 rescue breaths using a pocket mask equipped with a one-way filter valve.
• Maintain a tight seal using the "C-E clamp" technique: thumb and index finger form a "C" pressing the mask onto the face, while the remaining three fingers form an "E" lifting the bony jawbone into the mask.
• Each breath is delivered over 1 second, with just enough tidal volume to produce visible chest rise.
• Avoid excessive ventilation (hyperventilation), which causes gastric distension, regurgitation of stomach contents into the lungs, and increased intrathoracic pressure that impedes blood return to the heart.

                                [ RESCUER POSITIONING ]
                                           |
                                           v
                      Casualty supine on hard, flat surface
                      Rescuer kneels beside casualty's chest
                                           |
                                           v
                          [ HAND & BODY PLACEMENT ]
                      • Heel of dominant hand on center of chest
                        (lower half of sternum / breastbone)
                      • Second hand laced directly on top
                      • Arms locked straight, shoulders over hands
                                           |
                                           v
                         [ 30 CHEST COMPRESSIONS ]
                      • Depth: At least 5 cm (2 inches)
                      • Rate: 100-120 per minute
                      • Complete chest recoil after each thrust
                      • Do not bounce or lean on chest
                                           |
                                           v
                           [ 2 RESCUE BREATHS ]
                      • Head-tilt chin-lift, seal pocket mask
                      • Deliver 2 breaths (1 second each)
                      • Observe visible chest rise
                      • Total pause < 10 seconds
                                           |
                                           v
                          [ REPEAT 30:2 CYCLES ]
                      Switch compressors every 2 minutes

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Pediatric Resuscitation Variations (Child & Infant)

Pediatric cardiac arrests differ fundamentally from adult arrests: while adult arrests are overwhelmingly cardiac/arrhythmic in origin, pediatric arrests are primarily respiratory in origin (asphyxia, severe choking, drowning, or acute asthma resulting in secondary cardiac arrest).

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Automated External Defibrillator (AED) Operations & Protocols

An Automated External Defibrillator (AED) is a portable, computerized medical device that automatically analyzes a casualty's cardiac rhythm and determines whether electrical defibrillation is required. Defibrillation delivers a controlled electrical shock through the myocardium to momentarily depolarize all cardiac muscle fibers simultaneously, terminating chaotic electrical impulses and allowing the heart's natural pacemaker (the sinoatrial node) to resume an organized, perfusing rhythm.

Shockable vs. Non-Shockable Cardiac Rhythms

An AED will only advise a shock for two specific lethal arrhythmias:

1. Ventricular Fibrillation (V-Fib): The heart's ventricles quiver chaotically and erratically. The heart muscle receives disorganized electrical signals and cannot pump blood, producing immediate collapse and pulselessness. Defibrillation is highly effective if delivered early.
2. Pulseless Ventricular Tachycardia (pVT): The ventricles contract at a catastrophically rapid rate (often > 200 bpm). The heart beats so fast that the ventricles cannot fill with blood between beats, resulting in zero cardiac output and absence of a palpable pulse.

Non-Shockable Rhythms: The AED will announce "No shock advised" if the casualty is in:

• Asystole: Complete absence of all electrical and mechanical cardiac activity ("flatline"). A shock cannot restart a heart with zero electrical activity; high-quality CPR and advanced medications (epinephrine) are required.
• Pulseless Electrical Activity (PEA): Organized electrical activity is present on the monitor, but the heart muscle fails to contract mechanically, resulting in no pulse.

Step-by-Step AED Operational Sequence

1. Power On the AED Immediately: The first action upon the AED's arrival is to open the lid or press the green power button. All modern AEDs provide automated voice prompts and visual cues that guide the rescuer.
2. Expose and Prepare the Bare Chest: Rapidly remove all clothing from the casualty's chest (cut clothing if necessary using the trauma shears in the AED kit). The chest must be bare and dry.
3. Apply Electrode Pads (Standard Anterolateral Placement): Peel the protective plastic backing from the self-adhesive pads and apply them firmly to the bare skin in the standard anterolateral configuration:
   • Upper Right (Anterior) Pad: Placed on the casualty's upper right chest, directly below the collarbone (clavicle) and to the right of the breastbone.
   • Lower Left (Lateral) Pad: Placed on the casualty's lower left ribcage, below and to the side of the left breast, along the mid-axillary line.
4. Clear the Casualty for Rhythm Analysis: When the AED states "Analyzing heart rhythm, do not touch the patient," the rescuer must immediately hold their hands up and shout loudly: "Stand clear!" Ensure no rescuer or bystander is touching the casualty or clothing, as movement disrupts computerized rhythm analysis.
5. Deliver the Shock (if Advised): If a shock is advised, the AED will charge its capacitor. The rescuer must perform a visual sweep from head to toe, command loudly: "I'm clear, you're clear, everyone's clear!", confirm no one is in contact with the patient, and firmly press the flashing orange/red shock button (or stand back if using a fully automatic AED).
6. Immediately Resume CPR: The instant the shock is delivered (or immediately after the AED announces "No shock advised"), resume high-quality CPR immediately, starting with 30 chest compressions. Do not pause to check the casualty's pulse or breathing. Continue CPR for 2 minutes (approx. 5 cycles of 30:2) until the AED automatically prompts that it is re-analyzing the rhythm.

Special AED Operational Considerations

• Excessive Chest Hair: Dense hair prevents pads from adhering to the skin, causing an "attach pads" error. Rapidly shave the pad placement sites using the razor included in the AED response kit. If no razor is present and a second set of pads is available, apply the first set firmly and rip them off quickly to remove hair, then apply the second set.
• Water and Wet Surfaces: Moisture conducts electricity across the skin surface, creating an electrical arc and preventing current from penetrating the heart muscle. If the casualty is lying in water, drag them to dry ground. If the chest is sweaty or wet, quickly wipe it dry with a towel before applying pads. It is safe to use an AED on snow or damp concrete as long as the chest itself is wiped dry.
• Implanted Pacemakers / Defibrillators: Look for a hard, raised surgical lump under the skin below the clavicle (usually upper left, occasionally upper right) with a surgical scar. Do not place an AED pad directly over an implanted device. Place the pad at least 2.5 cm (1 inch) away from the unit.
• Transdermal Medication Patches: Medical patches (e.g., nitroglycerin, nicotine, fentanyl) block electrical transmission and can smoke, arc, or cause skin burns during defibrillation. With a gloved hand, peel the patch off and wipe the skin clean before applying the AED pad.
• Pediatric Defibrillation: For children under 8 years of age (or under 25 kg / 55 lbs), use pediatric attenuated pads if available. If pediatric pads are unavailable, use adult pads. Ensure the pads do not touch or overlap each other. If the child's chest is too small to maintain separation between pads, place one pad on the center of the chest (anterior) and the second pad on the center of the back between shoulder blades (posterior).

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When to Stop or Discontinue CPR

Once initiated, a security guard must continue high-quality CPR and follow AED instructions without stopping. CPR may be legally and procedurally discontinued only under six specific conditions:

1. Spontaneous Signs of Life Appear: The casualty begins breathing normally, coughing, moving purposefully, or regains consciousness. Place them in the recovery position and monitor ABCs.
2. AED Directs Rescuers to Stand Clear: Compressions are paused briefly during AED rhythm analysis or shock delivery.
3. EMS or Equal/Higher Medical Authority Arrives: Advanced care paramedics, fire department medical crews, or an emergency physician arrives and verbally assumes direct responsibility for casualty care.
4. Physical Rescuer Exhaustion: The rescuer is completely physically exhausted and unable to maintain effective compressions, and no other trained person is available to take over.
5. Scene Becomes Dynamically Hazardous: The physical scene becomes unsafe (e.g., structural collapse, spreading fire, toxic gas leak, violent armed assailant) threatening the rescuer's life.
6. Valid Legal DNR Confirmation: A valid, original Ministry of Health Do Not Resuscitate (DNR) Confirmation Form (or an authorized Advance Directive) is presented to the guard confirming that resuscitation must be withheld.

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Foreign Body Airway Obstruction (Choking) Relief

Choking occurs when a foreign object (typically unchewed food, small items, or dental prosthetics) lodges in the pharynx or larynx, obstructing air flow to the lungs.

Differentiating Choking Severity

• Mild (Partial) Airway Obstruction: The casualty is conscious, coughing forcefully, able to speak or make vocal sounds, and able to breathe between coughs. Wheezing sounds may be heard.
  • Action: Do NOT perform physical intervention. Do not hit the person on the back (which can dislodge the object deeper into the trachea). Encourage continuous forceful coughing: "Keep coughing, try to cough it out!" Monitor the casualty closely.
• Severe (Complete) Airway Obstruction: The foreign object completely blocks the trachea. The casualty cannot speak, cry, or cough forcefully, exhibits high-pitched stridor or silent coughing, exhibits cyanosis (blue/grey lips and skin), and instinctively grasps their neck with both hands (the Universal Distress Signal for Choking).
  • Action: Immediate, life-saving physical intervention is mandatory.

Conscious Adult and Child Choking Protocol

Stand behind the casualty and explain you are going to help. Deliver alternating cycles of back blows and abdominal thrusts:

1. Five Back Blows: Stand to the side and slightly behind the casualty. Support the casualty's chest with one hand and lean them forward so the object can exit the mouth rather than slide down. Deliver up to 5 firm, distinct back blows between the shoulder blades using the heel of your hand.
2. Five Abdominal Thrusts (The Heimlich Maneuver):
   • Stand directly behind the casualty. Wrap both arms around their waist.
   • Make a fist with one hand and place the thumb side of the fist against the casualty's abdomen, just above the navel (belly button) and well below the xiphoid process (breastbone tip).
   • Grasp your fist firmly with your other hand.
   • Press your fist into the abdomen with a quick, forceful upward and inward thrust.
   • Each thrust is a distinct attempt to compress the diaphragm, generate artificial cough pressure, and expel the object.
3. Continue Cycles: Repeat cycles of 5 back blows and 5 abdominal thrusts until the foreign body is expelled or the casualty becomes unresponsive.
4. Special Adaptation for Pregnancy and Severe Obesity: If the casualty is visibly pregnant or too large to wrap your arms around the abdomen, stand behind them, place your hands around the middle of the breastbone (sternum), and deliver quick, firm chest thrusts backward.

Unconscious Choking Protocol (Adult & Child)

If a conscious choking casualty loses consciousness and becomes unresponsive during intervention:

1. Support and Lower the Casualty: Carefully support the casualty and ease them gently to the floor onto their back, protecting their head and neck from impact.
2. Activate 911 / EMS Immediately: If not already called, shout for someone to call 911 and retrieve an AED.
3. Initiate Chest Compressions (CPR): Immediately begin CPR starting with 30 chest compressions. Rhythmic chest compressions build positive intrathoracic pressure that can dislodge the obstructing foreign body from the trachea into the pharynx.
4. Inspect the Airway (Visual Check): Open the casualty's airway using the head-tilt chin-lift maneuver. Look inside the mouth:
   • If a foreign object is clearly visible, perform a finger sweep using a hooked index finger to remove the object.
   • CRITICAL RULE — NEVER PERFORM A BLIND FINGER SWEEP: Rescuers must NEVER blindly insert fingers into a casualty's throat. Blind sweeping can push an unseen foreign object deeper into the larynx, cause vocal cord trauma, or trigger laryngospasm.
5. Attempt Rescue Breaths: Deliver 2 rescue breaths using a barrier pocket mask. If the chest does not rise (airway remains blocked), reposition the head to re-open the airway and attempt 2 breaths again.
6. Repeat Cycles: Deliver 30 chest compressions, open the mouth to inspect for an expelled foreign object, remove it if clearly visible, and attempt 2 rescue breaths. Continue this 30:2 sequence until the obstruction is cleared, spontaneous normal breathing resumes, or advanced paramedics arrive.