Cardiopulmonary Resuscitation (CPR)

CPR -- cardiopulmonary resuscitation -- is a potentially life-saving procedure that can restart a person's heartbeat and breathing. CPR is often used to revive victims of electric shock, near-drowning, and heart attack. According to the National Institutes of Health, quick CPR can triple a victim's chances for survival. The best way to learn the technique is to take a certified training class. (See http://www.americanheart.org to find a class near you.) The following tips offer a quick introduction to CPR, but they can't take the place of training.

When to use CPR

Before performing CPR, check to see if the victim is responsive. Ask him if he's okay and touch him on the shoulder. If he responds or is breathing, CPR isn't necessary. If he doesn't respond, you need to get emergency help right away. Call 911 or have someone call for you. If you're alone, you may have to leave the victim for a few moments to call for emergency help. CPR is intended to keep a victim alive until medical help arrives.

Note: If you are alone, there are times when it is more important to start CPR immediately than to take the time to call 911 first.

If reviving an unresponsive infant or young child, perform CPR for two minutes before stopping to call 911. According to the Washington University School of Medicine, an immediate attempt to correct airway blockage a common cause of cardiac arrest in infants -- should take precedence over calling 911.

If an unresponsive adult has been a victim of near-drowning, trauma, or drug overdose, the American Heart Association says it is more important to start CPR immediately than to delay while you call 911.

Performing CPR

The American Heart Association (AHA) announced a new lifesaving option for bystanders who witness an adult collapse due to cardiac arrest. After calling 9-1-1, people who are not trained in conventional CPR or aren't confident in their ability to give chest compressions and mouth-to-mouth breaths should use a simple technique called Hands-Only CPR.

"This involves providing high-quality chest compressions by pushing hard and fast in the middle of the victim's chest, without stopping until emergency medical services responders arrive," said Michael Sayre, M.D., chair of the AHA statement writing committee. To learn more about Hands-Only CPR, go to http://www.americanheart.org/handsonlycpr.

The committee found that Hands-Only CPR was on par with conventional CPR when used for an adult who has suddenly collapsed due to cardiac arrest. Hands-Only CPR should not be used for infants, children, and adults whose cardiac arrest was a result of drug overdose or near-drowning. It also should not be used for an unwitnessed cardiac arrest. In these cases, conventional CPR with chest compression and breaths would benefit the patient most.

Changes in protocol during the COVID-19 pandemic

The American Red Cross has given the following guidance:

"While CPR with breaths has been shown to be beneficial when compared to compression-only CPR, during the COVID-19 outbreak, it is currently recommended that no rescue breaths be performed for adult cardiac arrest patients with confirmed or suspected COVID-19, due to the risk of disease transmission.

"We recommend wearing PPE as recommended by CDC, this would be wearing respiratory protection using a respirator (e.g. N-95 mask), eye protection, disposable gloves and a disposable isolation gown if possible. Per CDC guidance facemasks are an acceptable alternative when there is shortage of N-95.

"We recommend placing a face mask or face covering over the mouth and nose of the victim. If only 1 mask is available and it is simple face mask or face covering, we recommend placing it on the victim.

"Cardiac arrests that occur after a breathing problem (which is often the case in infants and young children), drowning and drug overdoses may benefit from standard CPR that includes compressions and rescue breaths. Note: It is recognized that in some of the cases, the victim may also have COVID-19. However, if a lay responder is unable or unwilling to provide rescue breathing with CPR, compression-only CPR should be initiated."

Post-pandemic, whenever that may be

Although Hands-Only CPR can save lives, conventional CPR is still an important skill to learn.

Carefully roll the victim over onto his back if he isn't positioned that way already. If the victim does not appear to be breathing normally, begin CPR. Tilt his head back, pinch his nose closed and cover his mouth completely with your mouth. Give him two, full breaths, each lasting about one second. The victim's chest should rise. If it doesn't rise, check to see if something is blocking his airway. If you see something, try to remove it with your fingers. Try again to get air into his lungs.

If this attempt fails, but you see that a solid object is blocking the airway, perform the Heimlich maneuver by giving the victim a quick upward thrust on his upper abdomen until the blockage is expelled. (However, do not use the Heimlich maneuver to expel water, as its is quickly absorbed into the body: If the water is causing someone to choke, you need to remove it by suction. In fact, the American Heart Association warns against routine use of the Heimlich maneuver for drowning victims, calling it unnecessary and potentially dangerous.)

If the victim is still not breathing regularly, coughing, or moving, begin chest compressions immediately. Place the heel of one hand right in the center of the breastbone (between the nipples). Put the heel of your other hand on top of the first and press straight down about one and a half to two inches into the chest. (For small children, you may need to only use one hand or two fingers.) Give the victim 30 compressions without any pauses. The compressions should be at a rate of at least 100 per minute, or faster than one per second. The key, according to the American Heart Association, is to "push hard and push fast."

After 30 compressions, tilt the victim's head back, pinch his nose, and give him two more deep breaths.

Repeat the cycle of breaths and compression until help arrives or until the victim shows signs of recovery such as moving, breathing, or coughing.

CPR on an infant

When performing CPR on an infant, tilt the baby's head back to open the airway, cover both the nose and mouth with your mouth, and give two gentle breaths. Each breath should be one second long. Then position your third and fourth fingers in the center of the baby's chest, about half an inch below the nipples. Give 30 quick, gentle compressions, pressing down about one third to one half the depth of the chest. The compression rate should be the same as for adults -- about 100 per minute, or faster than one per second. Repeat a cycle of two breaths and 30 compressions for about two minutes before calling 911. Continue the cycle of breathing and compressions until the baby starts breathing or help arrives.

Keep in mind:

Don't perform chest compressions if a person is breathing, coughing, or moving. His heart is already beating, and chest compressions could actually stop it.

Don't waste time looking for a pulse. Leave this to the professionals.

If a victim vomits, turn him on his side and clear out the vomit with your fingers.

It's possible to crack a rib during chest compressions, especially if the victim is elderly.

It is important, regardless of the risk of rib fractures, to perform compressions with enough force to get the heart going. In true emergencies that require CPR, a cracked rib is usually a small price to pay for a chance at survival.

Protecting yourself from bodily fluids during CPR

The American Red Cross recommends the use of protective breathing barriers during CPR to protect the rescuer from bodily fluids such as blood, vomit, and saliva. Called "pocket masks," these barriers are either reusable or disposable, and have one-way valves that allow air into the victim but prevent the rescuer from having contact with the victim's fluids. The chances of disease transmission during direct mouth-to-mouth rescue are very low, but if you're worried about bloodborne viruses such as HIV or Hepatitis C, keep a pocket mask at the ready in your first aid kit. Contact your local Red Cross chapter for purchasing information.

Further Resources

You can find illustrated guides on performing CPR on the University of Washington School of Medicine's web site.

References

University of Washington School of Medicine. Learn CPR: You can do it!

First Aid/CPR/AED Care During COVID-19. American Red Cross.https://www.redcross.org/take-a-class/coronavirus-...

National Institutes of Health. Medical Encyclopedia: CPR --Adult.

Harvard Medical School Family Health Guide. CPR on a child 8 years or older or on an adult.

Cardiopulmonary Resuscitation (CPR) American Heart Association. P.1http://www.americanheart.org/presenter.jhtml?ident...

Cardiopulmonary Resuscitation (CPR). Mayo Clinic. http://www.mayoclinic.com/invoke.cfm?id=FA00061

Emergency Cardiovascular Care (ECC) Revisions for the Lay Rescuer. American Red Cross. http://www.redcross.org/services/hss/resources/ecc...

Interview with Mickey Eisenberg, MD, emergency medicine specialist, University of Washington Medical Center.

American Heart Association announced updated emergency care guidelines.

Rosen P. et al. The use of the Heimlich maneuver in near drowning: Institute of Medicine report. Journal of Emergency Medicine. 13(3):397-405.

American Heart Association. News release: Hands-Only CPR Simplifies Saving Lives For Bystanders.

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