Advances & Insights: Heart Health
January 09, 2009
What the news means for you
Paul Anaya, MD, PhD
Hands-only CPR means bystanders more likely to help
Cardiopulmonary resuscitation, better known as CPR, is a set of skills designed to maintain respiration and circulation in someone whose heart has stopped beating.
“Compressions are at least as effective as a combination of compressions and respiration in situations that do not involve asphyxiation.”
In 1997 when the AHA guidelines were released, there was limited information about how hands-only CPR works. At that time, compressions with respirations was thought to be best. Since then new information has come to light suggesting compressions are at least as effective as a combination of compressions and respiration in situations that do not involve asphyxiation (oxygen deficiency), such as drowning, drug overdose or chest trauma that impairs the ability to take in a breath.
No change for some groups
Pediatric patients have not been studied using this approach, and so the recommendations for children remain the same as before. Infants, children and victims of asphyxiation all have the best chance of survival if they receive both chest compressions and rescue breaths.
Training in CPR
By making the application of CPR easier, the hands-only CPR approach is likely to encourage a wider participation by members of the lay public when they are called upon to use it. Receiving formal CPR training is still very important because it serves several purposes. First, it places emphasis on recognizing when a person is in distress and on how to activate the emergency response system. Second, by utilizing mock scenarios, people can learn “how” to act in an efficient and orderly manner if ever placed in a real life situation. Finally, the formal training provides an opportunity to learn and demonstrate the manual skills of delivering good-quality chest compressions and ventilations under the supervision of a trained instructor.
“In an out-of-hospital setting, without CPR a victim of sudden cardiac arrest has almost a zero percent chance of survival.”
Hands-only CPR in action
If a bystander sees an adult collapse, it is important for the witness to see if the victim is conscious. Next, check to see if they are breathing and then see if they have a pulse.
If the adult person is not a drowning or drug-overdose victim, hands-only compressions can be administered. Compressions are designed to maintain adequate circulation. As a reminder, if the victim is a child, compressions together with rescue breathing should be administered.
If you are trained and comfortable in rescue breathing then it is still good to perform both rescue breaths and compressions.
If CPR is extended to more than 10-15 minutes without breathing/respiration, the body will begin to succumb to prolonged oxygen deprivation. Rescue breaths might be needed here. If you are going to give rescue breathing it should be at a rate of 30 compressions to two rescue breaths, keeping interruptions to compressions at a minimum, especially in the first few minutes. Continue CPR until the patient recovers or until you can use a defibrillator or emergency help arrives.
In both hands-only CPR and traditional CPR it is very important to deliver good-quality compressions. The publication defined good quality compressions as compressions that “must be at an adequate rate and depth, with full chest recoil.” In lay terms, I think it would be appropriate to give compressions at a rate of about 100 beats per minute. The compressions need to be deep enough that you actually feel the chest wall recoil.
It is helpful if you can have someone around to provide assistance and verify your compressions are adequate by feeling for a pulse. If they feel near the groin for the femoral pulse, they ought to feel the pulse with your compressions. If you don't have assistance, the chest recoil is adequate proof your compressions are working.
It's important to try
It is important to remember that in an out-of-hospital setting, without CPR a victim of sudden cardiac arrest has almost a zero percent chance of survival. With CPR, the rate of survival increases substantially to about 40 percent in just a randomly selected population. In places where the lay public is very well trained, the survival rate can approach 90 percent or greater. That speaks volumes of the importance of training to help ensure survival. CPR has a very positive impact on survival when it is it is done quickly and correctly.
To help increase the survival rate in the Lexington area, a few things have to happen:
- We need to get the word out that CPR saves lives;
- We must ensure the public is aware of opportunities to receive formal training in CPR; and
- We need more CPR training facilities and frequent training sessions. Then if the situation arises, you increase the likelihood that someone will know what to do and give that patient a better chance of surviving.
There is still a lot of work to do to educate the public. The lay public should take some responsibility upon themselves to understand CPR, the implications of it, and to find training opportunities.
To find a CPR class near you, visit the American Heart Association (www.americanheart.org), click “Find a Class Near You” and enter your zip code.
Dr. Anaya is a cardiologist at the Gill Heart Institute and an assistant professor of medicine in the UK College of Medicine. He also conducts biomedical research in the field of general cardiology.
CPR made simpler
In a significant change, the American Heart Association (AHA) released new recommendations for cardiopulmonary resuscitation (CPR) in March 2008. The AHA endorsed the effectiveness of continuous chest compressions (known as hands-only CPR) without ventilation (mouth-to-mouth). Previously, the 2005 guidelines had recommended bystanders who witness an adult collapse perform both chest compressions and rescue breaths.
“Of three major studies, none demonstrates a negative impact on survival when mouth-to-mouth ventilations were not delivered.”
The new AHA recommendations are based on an expert review of three major studies, none of which demonstrates a negative impact on survival when mouth-to-mouth ventilations were not delivered.
30-day survival studies
In the Kanto region of Japan, researchers performed a prospective, multicenter, observational study of 4,068 adult patients who had out-of-hospital cardiac arrest. Between Sept. 1, 2002, and Dec. 31, 2003, paramedics arriving at the scene assessed the type of resuscitation performed by bystanders. Of this group, 439 (11 percent) received cardiac-only resuscitation from bystanders, 712 (18 percent) conventional CPR, and 2,917 (72 percent) received no bystander CPR. Any resuscitation attempt was associated with a higher proportion having favorable neurological outcomes (5.0 percent) at 30 days post-arrest than no resuscitation (2.2 percent). There was no evidence of any benefit from the addition of mouth-to-mouth ventilation in any subgroup studied.
The researchers concluded, “Cardiac-only resuscitation by bystanders is the preferable approach to resuscitation for adult patients with witnessed out-of-hospital cardiac arrest, especially those with apnoea, shockable rhythm or short periods of untreated arrest.”
Swedish researchers led by Katarina Bohm, RN, sought to compare one-month survival rates among patients who had experienced out-of-hospital cardiac arrest and were given bystander CPR. They studied patients reported to the Swedish Cardiac Arrest Register between 1990 and 2005. Among 11,275 patients, 73 percent received standard CPR and 10 percent received chest compression only. However, they found no significant difference in one-month survival between patients who received standard CPR (7.2 percent) and those who received chest compression only (6.7 percent).
One-year survival study
Taku Iwami, MD, PhD, of Kyoto University Health Service, and other researchers carried out a prospective, population-based, observational study involving consecutive patients with emergency responder resuscitation attempts from May 1, 1998, through April 30, 2003. The primary outcome measure was one-year survival with favorable neurological outcome. Among the 4,902 witnessed cardiac arrests, 783 received conventional CPR and 544 received cardiac only resuscitation. The group excluded very-long-duration cardiac arrests (>15 minutes) and found that cardiac-only resuscitation yielded a higher rate of one-year survival with favorable neurological outcome than no bystander CPR (4.3 percent versus 2.5 percent), and conventional CPR showed similar effectiveness (4.1 percent). The researchers concluded bystander-initiated cardiac-only resuscitation and conventional CPR are similarly effective for most adult out-of-hospital cardiac arrests. For very prolonged cardiac arrests, the addition of rescue breathing may be of some help.
The recommendation for adult CPR has been simplified to get more laypersons to help in the event they see someone go into sudden cardiac arrest. The average proportion of cases of out-of-hospital cardiac arrest that receive bystander CPR is only 27.4 percent. However, studies show effective bystander CPR, if provided immediately, can double or triple a victim's chance of survival. When an adult suddenly collapses, the AHA now recommends bystanders first call 9-1-1 and then begin continual compressions by pushing hard and fast in the center of the chest until professional help arrives.
Although the new guidelines make CPR simpler for bystanders, the AHA still recommends the public become trained in traditional CPR. In traditional CPR, in all victims infants to adults (except newborns), the AHA recommends 30 compressions to every 2 respirations for all single rescuers. Compressions should be hard and fast at the rate of about 100 compressions per minute. After each compression the chest should recoil (return to normal position) and interruptions to compressions should be limited to deliver optimal blood flow. With each breath given, the chest should visibly rise and fall; breaths should be given over one second.
Importance of CPR
According to the AHA, brain death starts to occur approximately four to six minutes after a person experiences sudden cardiac arrest if no CPR or defibrillation occurs during that time. Additionally, if bystander CPR is not provided, a sudden cardiac arrest victim's chances of survival fall 7 to 10 percent for every minute of delay until defibrillation. This makes it imperative that CPR is begun immediately after collapse.
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