Hands-only CPR

To carry out a chest compression:

1. Place the heel of your hand on the breastbone at the centre of the person’s chest. Place your other hand on top of your first hand and interlock your fingers.
2. Position yourself with your shoulders above your hands.
3. Using your body weight (not just your arms), press straight down by 5-6cm (2-2.5 inches) on their chest.
4. Keeping your hands on their chest, release the compression and allow the chest to return to its original position.  
5. Repeat these compressions at a rate of 100 to 120 times per minute until an ambulance arrives or you become exhausted.

When you call for an ambulance, telephone systems now exist that can give basic life-saving instructions, including advice about CPR. These are now common and are easily accessible with mobile phones.

CPR with rescue breaths

If you’ve been trained in CPR, including rescue breaths, and feel confident using your skills, you should give chest compressions with rescue breaths. If you're not completely confident, attempt hands-only CPR instead (see above).

Adults

1. Place the heel of your hand on the centre of the person's chest, then place the other hand on top and press down by 5-6cm (2-2.5 inches) at a steady rate of 100 to 120 compressions per minute.
2. After every 30 chest compressions, give two rescue breaths.
3. Tilt the casualty's head gently and lift the chin up with two fingers. Pinch the person’s nose. Seal your mouth over their mouth and blow steadily and firmly into their mouth for about one second. Check that their chest rises. Give two rescue breaths.
4. Continue with cycles of 30 chest compressions and two rescue breaths until they begin to recover or emergency help arrives.

Children over one year old

1. Open the child's airway by placing one hand on the child’s forehead and gently tilting their head back and lifting the chin. Remove any visible obstructions from the mouth and nose.
2. Pinch their nose. Seal your mouth over their mouth and blow steadily and firmly into their mouth, checking that their chest rises. Give five initial rescue breaths.
3. Place the heel of one hand on the centre of their chest and push down by 5cm (about two inches), which is approximately one-third of the chest diameter. The quality (depth) of chest compressions is very important. Use two hands if you can't achieve a depth of 5cm using one hand.
4. After every 30 chest compressions at a rate of 100 to 120 per minute, give two breaths.
5. Continue with cycles of 30 chest compressions and two rescue breaths until they begin to recover or emergency help arrives.

Infants under one year old

1. Open the infant's airway by placing one hand on their forehead and gently tilting the head back and lifting the chin. Remove any visible obstructions from the mouth and nose.
2. Place your mouth over the mouth and nose of the infant and blow steadily and firmly into their mouth, checking that their chest rises. Give five initial rescue breaths.
3. Place two fingers in the middle of the chest and push down by 4cm (about 1.5 inches), which is approximately one-third of the chest diameter. The quality (depth) of chest compressions is very important. Use the heel of one hand if you can't achieve a depth of 4cm using the tips of two fingers.
4. After 30 chest compressions at a rate of 100 to 120 per minute, give two rescue breaths.
5. Continue with cycles of 30 chest compressions and two rescue breaths until they begin to recover or emergency help arrives.

Child and baby CPR steps

1. Ensure the area is safe

• Check for hazards, such as electrical equipment or traffic.

2. Check your child's responsiveness

• Gently stimulate your child and ask loudly, "Are you all right?". 

3a. If your child responds by answering or moving

• Leave them in the position they were found in (provided they're not in danger).
• Check their condition and get help if needed.
• Reassess the situation regularly.

3b. If your child doesn't respond

• Shout for help.
• Carefully turn the child on their back. 

If the child is under one year old:

• Ensure the head is in a neutral position, with the head and neck in line and not tilted.
• At the same time, with your fingertips under the point of your child's chin, lift the chin. Don't push on the soft tissues under the chin as this may block the airway.

If the child is over one year old:

• Open your child's airway by tilting the head and lifting the chin.
• To do this, place your hand on their forehead and gently tilt their head back.
• At the same time, with your fingertips under the point of your child's chin, lift the chin. Don't push on the soft tissues under the chin as this may block the airway.

If you think there may have been an injury to the neck, tilt the head carefully, a small amount at a time, until the airway is open. Opening the airway takes priority over a possible neck injury, however.

4. Check their breathing

Keeping the airway open, look, listen and feel for normal breathing by putting your face close to your child's face and looking along their chest.

• Look for chest movements.
• Listen at the child's nose and mouth for breathing sounds.
• Feel for air movement on your cheek.

Look, listen and feel for no more than 10 seconds before deciding that they're not breathing. Gasping breaths should not be considered to be normal breathing.

5. If your child is breathing normally

• Turn them on their side.
• Check for continued breathing.
• Send or go for help – do not leave your child unless absolutely necessary.

5b. If your child isn't breathing or is breathing infrequently and irregularly

• Carefully remove any obvious obstruction in the mouth.
• Give five initial rescue breaths (mouth-to-mouth resuscitation) – see below.
• While doing this, note any gag or cough response – this is a sign of life.

Rescue breaths for a baby under one year

• Ensure the head is in a neutral position and lift the chin.
• Take a breath, then cover your baby's mouth and nose with your mouth, making sure it's sealed. If you can't cover both the mouth and nose at the same time, just seal one with your mouth. If you choose the nose, close the lips to stop air escaping.
• Blow a breath steadily into the baby's mouth and nose over one second. It should be sufficient to make the chest visibly rise.
• Keeping their head tilted and chin lifted, take your mouth away and watch for the chest to fall as air comes out.
• Take another breath and repeat this sequence four more times.

Rescue breaths for a child over one year

• Tilt the head and lift the chin.
• Close the soft part of their nose using the index finger and thumb of the hand that's on their forehead.
• Open their mouth a little, but keep the chin pointing upwards.
• Take a breath, then place your lips around their mouth, making sure it's sealed.
• Blow a breath steadily into their mouth over about one second, watching for the chest to rise.
• Keeping their head tilted and chin lifted, take your mouth away and watch for the chest to fall as air comes out.
• Take another breath and repeat this sequence four more times. Check that your child's chest rises and falls in the same way as if they were breathing normally.

5c. Obstructed airway

If you have difficulty achieving effective breathing in your child, the airway may be obstructed.

• Open the child's mouth and remove any visible obstruction. Don't poke your fingers or any object blindly into the mouth.
• Ensure there's adequate head tilt and chin lift, but the neck isn't overextended.
• Make up to five attempts to achieve effective breaths (enough to make the chest visibly rise). If this is still unsuccessful, move on to chest compressions combined with rescue breaths.

6. Assess the circulation (signs of life)

Look for signs of life. These include any movement, coughing, or normal breathing – not abnormal gasps or infrequent, irregular breaths.

Signs of life present

If there are definite signs of life:

• Continue rescue breathing until your child begins to breathe normally for themselves.
• Turn the child on their side into the recovery position and send for help.
• Continue to check for normal breathing and provide further rescue breaths if necessary.

No signs of life present

If there are no signs of life:

• Start chest compressions immediately.
• Combine chest compressions with rescue breaths, providing two breaths after every 30 compressions.

7. Chest compressions: general guidance

• To avoid compressing the stomach, find the point where the lowest ribs join in the middle, and then one finger's width above that. Compress the breastbone.
• Push down 4cm (for a baby or infant) or 5cm (a child), which is approximately one-third of the chest diameter.
• Release the pressure, then rapidly repeat at a rate of about 100-120 compressions a minute.
• After 30 compressions, tilt the head, lift the chin, and give two effective breaths.
• Continue compressions and breaths in a ratio of two breaths for every 30 compressions.

Although the rate of compressions will be 100-120 a minute, the actual number delivered will be fewer because of the pauses to give breaths.

The best method for compression varies slightly between infants and children.

Chest compression in babies less than one year

• Do the compressions on the breastbone with the tips of two fingers, not the whole hand or with two hands.
• The quality (depth) of chest compressions is very important. If the depth of 4cm cannot be achieved with the tips of two fingers, use the heel of one hand – see advice for children, below. 

Chest compression in children over one year

• Place the heel of one hand over the lower third of the breastbone, as described above.
• Lift the fingers to ensure pressure is not applied over the ribs.
• Position yourself vertically above the chest and, with your arm straight, compress the breastbone so you push it down 5cm, which is approximately one-third of the chest diameter. The quality (depth) of chest compressions is very important.
• In larger children or if you're small, this may be done more easily by using both hands with the fingers interlocked, avoiding pressure on the ribs.

If nobody responded to your shout for help at the beginning and you're alone, continue resuscitation for about one minute before trying to get help – for example, by dialling 999 on a mobile phone.

8. Continue resuscitation until

• Your child shows signs of life – normal breathing, coughing, movement of arms or legs.
• Further qualified help arrives.
• You become exhausted.

• If the heart stops pumping, it is known as a cardiac arrest. Cardiopulmonary resuscitation (CPR) is a combination of techniques, including chest compressions, designed to pump the heart to get blood circulating and deliver oxygen to the brain until definitive treatment can stimulate the heart to start working again.
  
  A heart attack occurs when part of the heart is starved of oxygen. A heart attack can ‘stun’ the heart and interrupt its rhythm and ability to pump. This is because the heart does not receive enough oxygen and cannot pump blood around the body. There is no heartbeat (pulse) because the heart is not working. The medical term for a heart attack is an acute myocardial infarction (AMI).
  
  When the blood stops circulating, the brain is starved of oxygen and the person quickly becomes unconscious and stops breathing. Without treatment, the person will die.
  

  Causes of cardiac arrest

  A cardiac arrest can be caused by many things and causes tend to differ from adults to children.
  
  For adults, they may include:
  • heart disease – the most common cause of reversible adult cardiac arrest (70%)
  • trauma
  • respiratory illness
  • hanging.
  For children, they may include:
  • SIDS – this is the leading cause of reversible cardiac arrest in children
  • cardiac disease (usually congenital)
  • trauma
  • respiratory illness.
  
  

  CPR can be life-saving first aid

  CPR can be life-saving first aid and increases the person’s chances of survival if started soon after the heart has stopped beating. If no CPR is performed, it only takes three to four minutes for the person to become brain dead due to a lack of oxygen.
  
  By performing CPR, you circulate the blood so it can provide oxygen to the body, and the brain and other organs stay alive while you wait for the ambulance. There is usually enough oxygen still in the blood to keep the brain and other organs alive for a number of minutes, but it is not circulating unless someone does CPR. CPR does not guarantee that the person will survive, but it does give that person a chance when otherwise there would have been none.
  
  If you are not sure whether a person is in cardiac arrest or not, you should start CPR. If a person does not require CPR, they will probably respond to your attempts. By performing CPR, you are unlikely to cause any harm to the person if they are not actually in cardiac arrest.
  
  
  

  The basic steps of CPR

  CPR is most successful when administered as quickly as possible. It should only be performed when a person shows no signs of life or when they are:
  • unconscious
  • unresponsive
  • not breathing or not breathing normally (in cardiac arrest, some people will take occasional gasping breaths – they still need CPR at this point. Don’t wait until they are not breathing at all).
  It is not essential to search for a pulse when a person is found with no signs of life. It can be difficult to find a person’s pulse sometimes and time can be wasted searching. If CPR is necessary, it must be started without delay.
  
  The basic steps for performing CPR can be used for adults, children and infants. They are based on guidelines updated in 2010 that are easy to follow and remember. This information is only a guide and not a substitute for attending a CPR course.
  
  The basic steps are:
  D – Dangers?
  R – Response?
  S – Send for help
  A – Open airway
  B – Normal breathing
  C – Start CPR
  D – Attach defibrillator (AED).
  
  

  1. Dangers? Check for dangers. Consider why the person appears to be in trouble – is there gas present or have they been electrocuted? Might they be drunk or drug-affected and consequently a hazard to you? Approach with care and do not put yourself in danger. If the person is in a hazardous area (such as on a road), it is okay to move them as gently as possible to protect both your and their safety.

  2. Response? Look for a response. Is the victim conscious? Gently shake them and shout at them, as if you are trying to wake them up. If there is no response, get help.

  3. Send for help. Dial triple zero (000) – ask for an ambulance.

  4. Open airway. Check the airway. It is reasonable to gently roll the person on their back if you need to. Gently tilt their head back, open their mouth and look inside. If fluid and foreign matter is present, gently roll them onto their side. Tilt their head back, open their mouth and very quickly remove any foreign matter (for example, chewing gum, false teeth, vomit). It is important not to spend much time doing this, as performing CPR is the priority. Chest compressions can help to push foreign material back out of the upper airway.

  5. Normal breathing? Check for breathing – look, listen and feel for signs of breathing. If the person is breathing normally, roll them onto their side. If they are not breathing, or not breathing normally, go to step 6. The person in cardiac arrest may make occasional grunting or snoring attempts to breathe and this is not normal breathing. If unsure of whether a person is breathing normally, start CPR as per step six.

  6. Start CPR  Cardiac compressions: Place the heel of one hand on the lower half of the person’s breastbone. Place the other hand on top of your first hand and either grasp your own wrist or interlock your fingers, depending on what is comfortable for you. The depth of compression should be one third of the chest depth of the person. The rate is either: 30 compressions to two breaths (mouth-to-mouth as per step 7) aiming for 100 compressions and no more than eight breaths per minute, OR If unwilling to do mouth-to-mouth, perform continuous compressions at a rate of approximately 100 per minute. Thinking of the music ‘Staying alive’ by the Bee Gees and performing compressions on the beat can assist to keep the correct rhythm. Sometimes, people will have their ribs broken by chest compressions. This is still better than the alternative of not receiving CPR. If it occurs, pause and reposition your hands before continuing. Chest compressions are tiring and fatigue will affect the quality. If any other rescuers are available and willing to assist, rotate the person performing compressions every two minutes, even if you don’t feel tired yet.

  Establishing compressions is the clear priority. If a rescuer cannot coordinate the breathing or finds it too time-consuming or too unpleasant, effective chest compressions alone will still be of benefit. It is important not to avoid all resuscitation efforts because of the mouth-to-mouth component. 7. Mouth-to-mouth. If the person is not breathing normally, make sure they are lying on their back on a firm surface and: Open the airway by tilting the head back and lifting their chin. Close their nostrils with your finger and thumb. Put your mouth over the person’s mouth and blow into their mouth. Give 2 full breaths to the person (this is called ‘rescue breathing’). Make sure there is no air leak and the chest is rising and falling. If their chest does not rise and fall, check that you’re tilting their head back, pinching their nostrils tightly and sealing your mouth to theirs. If still no luck, check their airway again for any obstruction. If you cannot get air into their lungs, go back to chest compressions. If there is an airway obstruction, compressions may help shift the object. Continue CPR, repeating the cycle of 30 compressions then 2 breaths until professional help arrives. Chest compressions are tiring and fatigue will affect the quality. If any other rescuers are available and willing to assist, rotate the person performing compressions every 2 minutes, even if you don’t feel tired yet.

  8. Attach automated external defibrillator (AED) as soon as one becomes available. Only use an adult AED on any person over the age of eight years, who is unresponsive and not breathing normally. For children under the age of eight, ideally, a paediatric AED and pads should be used. Devices differ and instructions should be followed in each instance. CPR must be continued until the AED is turned on and the pads are attached. Place pads following the diagram instructions on the pads. Pad-to-skin contact is important for successful defibrillation. Remove any medication pads, excess moisture or excessive chest hair (if this can be done with minimum delay). It is important to follow the prompts on the AED. Do not touch the victim during analysis or shock delivery.

  CPR techniques for young children and infants
  CPR steps for children aged eight years or younger are the same as for adults and older children, but the technique is slightly different.
  

  CPR for children aged 1–8 years

  To perform CPR on children aged 1–8 years:
  • Use the heel of one hand only for compressions, compressing to one third of chest depth.
  • Follow the basic steps for performing CPR described above.

  CPR for infants (up to 12 months of age)

  To perform CPR on infants (up to 12 months of age):
  • Place the infant on their back. Do not tilt their head back or lift their chin (this is not necessary as their heads are still large in comparison to their bodies).
  • Perform mouth-to-mouth by covering the infant’s nose and mouth with your mouth – remember to use only a small breath.
  • Do chest compressions, using two fingers of one hand, to about one third of chest depth.
  • Follow the basic steps for performing CPR described above.
  What to do if the person recovers during CPR
  CPR may revive the person before the ambulance arrives. If they do revive:
  • Review the person’s condition if signs of life return (coughing, movement or normal breathing). If the person is breathing on their own, stop CPR and place them on their side with their head tilted back.
  • If the person is not breathing, continue full CPR until the ambulance arrives.
  • Be ready to recommence CPR if the person stops breathing or becomes unresponsive or unconscious again. Stay by their side until medical help arrives. Talk reassuringly to them.
  It is important not to interrupt chest compressions or stop CPR prematurely to check for signs of life – if in doubt, continue full CPR until help arrives. It is unlikely you will do harm if you give chest compressions to someone with a beating heart. Regular recovery (pulse) checks are not recommended as they may interrupt chest compressions and delay resuscitation.
  
  Stopping CPR
  Generally, CPR is stopped when:
  • the person is revived and starts breathing on their own
  • medical help such as ambulance paramedics arrive to take over
  • the person performing the CPR is forced to stop from physical exhaustion.
  Where to get help
  • In an emergency, call triple zero (000)
  • For training in CPR, contact St John Ambulance Australia, Victoria Tel. 1300 360 455
  • For training in CPR, contact Australian Red Cross Tel. 1300 367 428
  Things to remember
  • Always call triple zero (000) in an emergency.
  • Cardiopulmonary resuscitation (CPR) combines mouth-to-mouth resuscitation and cardiac compressions to deliver oxygen and artificial circulation to an unresponsive person until medical help arrives.
  • Cardiac or chest compressions are the priority in CPR. If you don’t want to do mouth-to-mouth, chest compressions alone may still be life-saving.
  • CPR is a life-saving skill that everyone should learn.
  • This fact sheet is not a substitute for proper CPR training by an accredited organisation.
  • The goal of CPR is to resuscitate a person whose breathing or pulse is absent. The technique involves rescue breathing and chest compressions. CPR for adults can be done in two different ways: the “full” version, which focuses on circulation, airway, and breathing (CAB), and the “hands only” version, recommended for people who haven’t been trained.

    If you haven’t received formal training in CPR, theAmerican Heart Association recommends performing hands-only CPR. This helps increase blood circulation to prevent death. First, call 911. After calling 911, push hard on the center of the person’s chest. Repeat this in a fast motion. Many people are afraid to perform hands-only CPR, but the fact is that it’s worse to take no action.

    Full CPR has two more steps. These are the cornerstones of CPR:

    • To regain blood circulation, place the heel of your hand over the center of the person’s chest and push. You should compress the chest by 2 inches and push 100 times per minute. Many CPR instructors advise people to compress the chest in rhythm with the Bee Gees’ song “Stayin’ Alive.” This song has the right rhythm to simulate a heartbeat.
    • Next, you need to clear the airway. After pushing the chest at least 30 times, tilt the individual’s head and lift the chin in a forward position. Perform mouth-to-mouth breathing if you suspect a lack of breathing.
    • Rescue breathing is necessary for people who show signs of not being able to take in oxygen through the lungs. Remember that gasping for air is not normal breathing. If the person is gasping for air, you should initiate CPR. If the person’s mouth has an injury and you can’t open it, you can perform rescue breathing into their nose. Give two quick breaths and watch for the chest to rise. According to the University of Washington, each breath should take about one second. If the chest doesn’t rise, repeat the CAB cycle.

    If the person responds, either by speaking, beginning to move, or breathing normally, you can stop performing CPR.

    It is also important to know that techniques vary between CPR procedures for adults, children, and infants. Never perform adult CPR on children.

    Practice Essentials

    Cardiopulmonary resuscitation (CPR) consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest (see the images below). Although survival rates and neurologic outcomes are poor for patients with cardiac arrest, early appropriate resuscitation—involving early defibrillation—and appropriate implementation of post–cardiac arrest care lead to improved survival and neurologic outcomes.

    Delivery of chest compressions. Note the overlapping hands placed on the center of the sternum, with the rescuer's arms extended. Chest compressions are to be delivered at a rate of at least 100 compressions per minute.

    Delivery of mouth-to-mouth ventilations.

    Indications and contraindications

    CPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Assessment of cardiac electrical activity via rapid “rhythm strip” recording can provide a more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options.

    Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing arrhythmias include the following:

    • Ventricular fibrillation (VF)
    • Pulseless ventricular tachycardia (VT)
    • Pulseless electrical activity (PEA)
    • Asystole
    • Pulseless bradycardia

    CPR should be started before the rhythm is identified and should be continued while the defibrillator is being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory shock until a pulsatile state is established.

    Contraindications

    The only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced directive indicating a person’s desire to not be resuscitated in the event of cardiac arrest. A relative contraindication to performing CPR is if a clinician justifiably feels that the intervention would be medically futile.

    Equipment

    CPR, in its most basic form, can be performed anywhere without the need for specialized equipment. Universal precautions (ie, gloves, mask, gown) should be taken. However, CPR is delivered without such protections in the vast majority of patients who are resuscitated in the out-of-hospital setting, and no cases of disease transmission via CPR delivery have been confirmed. Some hospitals and EMS systems employ devices to provide mechanical chest compressions. A cardiac defibrillator provides an electrical shock to the heart via 2 electrodes placed on the patient’s torso and may restore the heart into a normal perfusing rhythm.

    Technique

    In its full, standard form, CPR comprises the following 3 steps, performed in order:

    • Chest compressions
    • Airway
    • Breathing

    For lay rescuers, compression-only CPR (COCPR) is recommended.

    Positioning for CPR is as follows:

    • CPR is most easily and effectively performed by laying the patient supine on a relatively hard surface, which allows effective compression of the sternum
    • Delivery of CPR on a mattress or other soft material is generally less effective
    • The person giving compressions should be positioned high enough above the patient to achieve sufficient leverage, so that he or she can use body weight to adequately compress the chest

    For an unconscious adult, CPR is initiated as follows:

    • Give 30 chest compressions
    • Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is breathing
    • Before beginning ventilations, look in the patient’s mouth for a foreign body blocking the airway

    Chest compression

    The provider should do the following:

    • Place the heel of one hand on the patient’s sternum and the other hand on top of the first, fingers interlaced
    • Extend the elbows and the provider leans directly over the patient (see the image below)
    • Press down, compressing the chest at least 2 in
    • Release the chest and allow it to recoil completely
    • The compression depth for adults should be at least 2 inches (instead of up to 2 inches, as in the past)
    • The compression rate should be at least 100/min
    • The key phrase for chest compression is, “Push hard and fast”
    • Untrained bystanders should perform chest compression–only CPR (COCPR)
    • After 30 compressions, 2 breaths are given; however, an intubated patient should receive continuous compressions while ventilations are given 8-10 times per minute
    • This entire process is repeated until a pulse returns or the patient is transferred to definitive care
    • To prevent provider fatigue or injury, new providers should intervene every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest while another rescuer continues CPR

    Ventilation

    If the patient is not breathing, 2 ventilations are given via the provider’s mouth or abag-valve-mask (BVM). If available, a barrier device (pocket mask or face shield) should be used.

    To perform the BVM or invasive airway technique, the provider does the following:

    • Ensure a tight seal between the mask and the patient’s face
    • Squeeze the bag with one hand for approximately 1 second, forcing at least 500 mL of air into the patient’s lungs

    To perform the mouth-to-mouth technique, the provider does the following:

    • Pinch the patient’s nostrils closed to assist with an airtight seal
    • Put the mouth completely over the patient’s mouth
    • After 30 chest compression, give 2 breaths (the 30:2 cycle of CPR)
    • Give each breath for approximately 1 second with enough force to make the patient’s chest rise
    • Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion
    • After giving the 2 breaths, resume the CPR cycle

    Complications

    Complications of CPR include the following:

    • Fractures of ribs or the sternum from chest compression (widely considered uncommon)
    • Gastric insufflation from artificial respiration using noninvasive ventilation methods (eg, mouth-to-mouth, BVM); this can lead to vomiting, with further airway compromise or aspiration; insertion of an invasive airway (eg, endotracheal tube) prevents this problem

    ACLS

    In the in-hospital setting or when a paramedic or other advanced provider is present, ACLS guidelines call for a more robust approach to treatment of cardiac arrest, including the following:

    • Drug interventions
    • ECG monitoring
    • Defibrillation
    • Invasive airway procedures

    Emergency cardiac treatments no longer recommended include the following:

    • Routine atropine for pulseless electrical activity (PEA)/asystole
    • Cricoid pressure (with CPR)
    • Airway suctioning for all newborns (except those with obvious obstruction)

    Background

    For patients with cardiac arrest, survival rates and neurologic outcomes are poor, though early appropriate resuscitation, involving cardiopulmonary resuscitation (CPR), early defibrillation, and appropriate implementation of post–cardiac arrest care, leads to improved survival and neurologic outcomes. Targeted education and training regarding treatment of cardiac arrest directed at emergency medical services (EMS) professionals as well as the public has significantly increased cardiac arrest survival rates.^[1]

    CPR consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest. A variation of CPR known as “hands-only” or “compression-only” CPR (COCPR) consists solely of chest compressions. This variant therapy is receiving growing attention as an option for lay providers (that is, nonmedical witnesses to cardiac arrest events).

    The relative merits of standard CPR and COCPR continue to be widely debated. An observational study involving more than 40,000 patients concluded that standard CPR was associated with increased survival and more favorable neurologic outcomes than COCPR was.^[2] However, other studies have shown opposite results, and it is currently accepted that COCPR is superior to standard CPR in out-of-hospital cardiac arrest.

    Several large randomized controlled and prospective cohort trials, as well as one meta-analysis, demonstrated that bystander-performed COCPR leads to improved survival in adults with out-of-hospital cardiac arrest, in comparison with standard CPR.^{[3, 4, 5]} Differences between these results may be attributable to a subgroup of younger patients arresting from noncardiac causes, who clearly demonstrate better outcomes with conventional CPR.^[2]

     

    The 2010 revisions to the American Heart Association (AHA) CPR guidelines state that untrained bystanders should perform COCPR in place of standard CPR or no CPR (see American Heart Association CPR Guidelines).^[6]

    Of the more than 300,000 cardiac arrests that occur annually in the United States, survival rates are typically lower than 10% for out-of-hospital events and lower than 20% for in-hospital events.^{[7, 8, 9, 10, 11]} A study by Akahane et al suggested that survival rates may be higher in men but that neurologic outcomes may be better in women of younger age, though the reasons for such sex differences are unclear.^[12]

    Additionally, studies have shown that survival falls by 10-15% for each minute of cardiac arrest without CPR delivery.^{[13, 14]} Bystander CPR initiated within minutes of the onset of arrest has been shown to improve survival rates 2- to 3-fold, as well as improve neurologic outcomes at 1 month.^{[15, 16]}

     

    It has also been demonstrated that out-of hospital cardiac arrests occurring in public areas are more likely to be associated with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) and have better survival rates than arrests occurring at home.^[17]

    This article focuses on CPR, which is just one aspect of resuscitation care. Other interventions, such as the administration of pharmacologic agents, cardiac defibrillation, invasive airway procedures, post–cardiac arrest therapeutic hypothermia,^{[18, 19, 20, 21, 22]} the use of echocardiography in resuscitation,^[23] and various diagnostic maneuvers,^{[24, 25]} are beyond the scope of this article. For more information, see the Resuscitation Resource Center; for specific information on the resuscitation of neonates, see Neonatal Resuscitation.

    American Heart Association CPR guidelines

    In 2010, the Emergency Cardiovascular Care Committee (ECC) of the AHA released the Association’s newest set of guidelines for CPR. Changes for 2010 include the following^{[24, 26]} :

    • The initial sequence of steps is changed from ABC (airway, breathing, chest compressions) to CAB (chest compressions, airway, breathing), except for newborns
    • “Look, listen, and feel” is no longer recommended
    • The compression depth for adults should be at least 2 inches (instead of up to 2 inches)
    • The compression rate should be at least 100/min
    • Emergency cardiac treatments no longer recommended include routine atropine for pulseless electrical activity (PEA)/asystole, cricoid pressure (with CPR), and airway suctioning for all newborns (except those with obvious obstruction).
    • Post–cardiac arrest care is covered in a new section ^[27]

    Several studies that looked at the quality of CPR being performed in hospitals and by EMS systems found that providers often did not perform CPR up to the standards of the ECC guidelines.^{[28, 29, 30, 31]} Specifically, they found that providers were often deficient in both rate and depth of chest compressions and often provided ventilations at too high a rate. Other studies demonstrated the impact of inadequate rate and depth on survival.^[32]

     

    The 2010 AHA guidelines state that untrained bystanders should perform COCPR (previous AHA guidelines did not address untrained bystanders separately).^[6]

    Several studies concluded that stopping compressions in order to give ventilations may be detrimental to the patient’s outcome.^{[33, 34, 35]} While a bystander halts compressions to give 2 breaths, blood flow also stops, and this cessation of blood flow leads to a quick drop in the blood pressure that had been built up during the previous set of compressions.^[36]

    Note these guidelines were updated again in 2015 and are available at 2015 American Heart Association Guidelines for CPR & ECC.

    Indications

    CPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Assessment of cardiac electrical activity via rapid “rhythm strip” recording can provide a more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options.

     

    Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing arrhythmias include the following:

    • VF
    • Pulseless VT
    • PEA
    • Asystole
    • Pulseless bradycardia

    Although prompt defibrillation has been shown to improve survival for VF and pulseless VT rhythms,^[37] CPR should be started before the rhythm is identified and should be continued while the defibrillator is being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory shock until a pulsatile state is established. This is supported by studies showing that “preshock pauses” in CPR result in lower rates of defibrillation success and patient recovery.^[32]

     

    In a study involving out-of-hospital cardiac arrests in Seattle, 84% of patients regained a pulse when defibrillated during VF.^[30] Defibrillation is generally most effective the faster it is deployed.

    The American College of Surgeons, the American College of Emergency Physicians, the National Association of EMS Physicians, and the American Academy of Pediatrics have issued guidelines on the withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest.^[38]Recommendations include the following:

    • Withholding resuscitation should be considered in cases of penetrating or blunt trauma victims who will obviously not survive.
    • Standard resuscitation should be initiated in arrested patients who have not experienced a traumatic injury.
    • Victims of lighting strike or drowning with significant hypothermia should be resuscitated.
    • Children who showed signs of life before traumatic CPR should be taken immediately to the emergency room; CPR should be performed, the airway should be managed, and intravenous or intraosseous lines should be placed en route.
    • In cases in which the trauma was not witnessed, it may be assumed that a longer period of hypoxia might have occurred and limiting CPR to 30 minutes or less may be considered.
    • When the circumstances or timing of the traumatic event are in doubt, resuscitation can be initiated and continued until arrival at the hospital.
    • Terminating resuscitation in children should be included in state protocols.

    Contraindications

    The only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced directive indicating a person’s desire to not be resuscitated in the event of cardiac arrest.

     

    A relative contraindication to performing CPR may arise if a clinician justifiably feels that the intervention would be medically futile, although this is clearly a complex issue that is an active area of research.^{[39, 40]}