Healing Hands (…only CPR) – A valuable rescue tool for out-of-hospital cardiac arrest

While there are lots of interesting things to read on the Internet, only a few have the potential to help you save a life in the real world. This article intends to help you potentially save a life by equipping you with the tools you will need to rescue a person who has suffered a potentially fatal sudden Cardiac arrest.

 

What is cardiac arrest?

Cardiac arrest is an immediately life threatening condition characterised by the absence of blood flow out of the heart (i.e. the heart stops beating effectively). This is typically caused by the onset of a lethal arrhythmia or abnormal electrical pattern in the heart. Without immediate and aggressive treatment, cardiac arrest is always fatal.

Data from the American Heart Association found that only 12% of people who suffered a cardiac arrest in the community (out of hospital) survived to discharge from hospital. During the same period patients were around twice as likely to survive a cardiac arrest if it occurred in a hospital (25%). The higher rate of survival for ‘in-hospital’ cardiac arrest is likely influenced by a number of factors including a higher proportion of trained responders and the existence of well-refined rapid response systems.

N.B. A cardiac arrest (where the heart stops beating entirely) is different from a myocardial infarction or ‘heart attack’ where an artery in the heart is blocked causing chest pain and damage to the heart muscle. Without timely treatment a ‘heart attack’ can lead to cardiac arrest.

 

How is cardiac arrest treated?

The treatment of cardiac arrest involves a number of different techniques & interventions that work together to achieve 2 main goals:

  1. Restarting the heart (restoring cardiac output)
  2. Supporting blood flow to organs while the heart is stopped

The fundamental techniques used to treat a cardiac arrest are commonly grouped under the term ‘basic life support’ (BLS). Basic life support encompasses both the assessment of a collapsed person and the provision of cardiopulmonary resuscitation (CPR) and automated defibrillation. Basic life support is the foundation of cardiac arrest management, both inside and outside the hospital. The primary goal of basic life support is to optimally support blood flow to the vital organs for a person in cardiac arrest – in a number of cases these measure alone (including automated defibrillation) may be effective in restarting the patient’s heart.

The DRSABCD approach that accompanies traditional basic life support covers most of the links in the ‘chain or survival’ (the vital steps in rescuing a person from sudden cardiac arrest), However, this approach also carries additional complexity by incorporating rescue breaths and a compression/ventilation ratio the rescuer must remember.

Beyond the scope of the traditional BLS principles, patients being treated in specialised healthcare environments like hospitals may receive other, more invasive treatments for their cardiac arrest. These treatments range from traditional ‘advanced life support’ measures (including intravenous drugs, controlled defibrillation and the correction of reversible causes) to the use of mechanical CPR devices and percutaneous coronary intervention (PCI) during the cardiac arrest. In select settings, highly specialised clinicians are even starting patients on ECMO (extra corporeal membrane oxygenation – effectively a heart & lung bypass machine) intra-arrest in an attempt to sidestep the acutely dysfunctional heart. While all of these interventions sound wonderful in theory (and some even show promise in the emerging literature), they all face the same barrier in their application to people suffering ‘out of hospital’ cardiac arrest:

Without the timely delivery of high quality CPR, the brain very quickly becomes irreversibly damaged due to the lack of blood flow. Even in the face of the most advanced hospital based interventions – without timely CPR, the resulting hypoxic brain injury will routinely make it impossible for patients to return to the life they remember

(If they survive the initial arrest).

 

Moving away from ‘Basic Life Support’ (in the community)

While the in-depth BLS method remains the standard for training healthcare professionals to respond to cardiac arrest, there has been a recent shift in the approach to training first responders in the community. While the full DRSABCD approach covers the majority of links in the ‘chain of survival’, it can be complicated and requires people to perform / consider performing tasks that they may consider uncomfortable (I.e. mouth-to-mouth on a potentially vomit covered stranger to deliver breaths).

Enter, the simplified ‘Hands Only’ method.

 

What is ‘Hands Only’ CPR?

Hands only CPR is exactly what it sounds like: an approach to cardiopulmonary resuscitation using only the hands of the rescuer. For amateur rescuers, this approach replaces the complex basic life support approach with a handful of basic steps:

  • Determine if the person is in cardiac arrest
  • Send for help (Shout for help & Call an ambulance – 000)
  • Perform uninterrupted external chest compressions until help arrives

The way the chest compressions are performed in hands only CPR is exactly the same as it has always been taught in traditional BLS / first aid (use 2 hands to press hard and fast on the centre on the patients chest). In fact, the hands only version is significantly easier to comprehend in the sense that you don’t have to stop for breaths to be delivered, you just start pressing and don’t stop until you are fatigued – none of this 30 to 2 business!

 

Why is it better?

When compared to traditional basic life support the hands only CPR approach is significantly less complicated. This utilitarian approach is easier to train and subsequently, the knowledge is easier to absorb and retain for trainees.

The hands only approach also addresses one of the biggest barriers to rescuers actually attempting resuscitation – mouth to mouth (Locke, Berg & Sanders, 1995). By removing the need to even consider locking lips with an arrested person from the equation, hands only CPR potentially increases the likelihood that a bystander will attempt some life saving measures while awaiting definitive help. This allows the ‘handsomeness / likelihood-of-rescue’ ratio can be forgotten (n.b. this ratio is not scientific, but you get the point).

Screenshot 2018-10-03 18.10.35

By adopting an approach that is easy to train & understand, that is also potentially less gross, the intention is to significantly increase the number of potentially willing rescuers in the community – thus strengthening the safety net for people suffering out of hospital cardiac arrest.

 

Evidence

There is a significant body of evidence suggesting that the effectiveness of hands only CPR is directly comparable to that of traditional BLS with rescue breaths included. A meta-analysis by Hupfl, Selig & Nagele (2010) found that the chance of survival significantly increased with hands only CPR (guided by an ambulance dispatcher) compared to traditional CPR.

Because hands only CPR is associated with several benefits including ease of training and simplicity, it is supported by international resuscitation bodies including ILCOR and the Australia and New Zealand Resuscitation Council. This method of resuscitation is also promoted and trained by the American Heart Association and British Heart Foundation.

While each of these professional bodies recognises that traditional CPR with rescue breaths remains the ideal standard, they recommend that a hands only (or compression only) approach is a suitable alternative that has the potential to increase the rate of bystander rescue in out of hospital cardiac arrest.

The primary recommendation from each of these bodies is that all patients in cardiac arrest require chest compressions first with the addition of rescue breaths and other resuscitation measures (such as automated defibrillation) where they are available (ILCOR, 2017).

 

Why does this matter?

Hands only CPR is a life saving approach that takes virtually no training to be effective. While this approach is user friendly and easy to adopt, it relies on a large number of people in the community being familiar with the technique for it to be most effective.

With this in mind, this article has a dual purpose (depending on your existing level of experience with CPR):

  1. If you are already trained in basic or advanced life support – You should feel empowered to use your knowledge train others (your friends, family, team mates, drinking buddies, anyone). This is easy to do and gives you a real chance to build a stronger safety net in the community and increase your life saving potential.
  2. If you are not yet trained in CPR – I will show you how to do it (and in turn, you can share the knowledge in your own way).

 

Already trained (experienced):

For those with an understanding of basic or advanced life support, you are already a part of the safety net built to save community members when a sudden cardiac arrest occurs. By maintaining your skills and willingness to help in an emergency, you are actively increasing the likelihood that a person suffering a sudden cardiac arrest in the community will have a meaningful recovery (good job)!

With the knowledge that you carry, one of the best ways for you to increase your ability to save a life is to share your knowledge with those close to you. While many people receive some CPR training at work, it’s often difficult to absorb and retain (due to a number of factors) and may not leave people feeling ready or able to help in a crisis. By taking some time to discuss the process of hands only CPR with your family, friends and colleagues you are actively broadening (and strengthening) the safety net we all reply on.

While the act of training people to perform such a vital skill may sounds intimidating, remember – there are only a small handful of steps involved in learning ‘hands only CPR’ & there are endless resources available to support you (including this article). In my experience, people can be familiarised with the essential steps of hands only CPR in a matter of minutes, with little to no equipment (pro tip: a firm pillow is often as good as an expensive mannequin for practicing chest compressions). This is also supported by the fact that inexperienced bystanders can be effectively coached to provide hands only CPR by ambulance dispatchers as identified in Rea et al’s 2010 study (among others).

 

Not yet trained (beginner):

If you have never been trained in CPR or cannot easily recall what’s involved, this is for you. The following section will guide you on how to provide high quality ‘hands only’ CPR for any person suffering a sudden cardiac arrest. This skill is easy to learn, recall and perform and will serve you as a skill for life, wherever you go.

The first step in this process is to determine exactly who needs CPR. The answer is remarkably simple – people who need CPR are:

  • Unconscious AND not breathing

Therefore, if the patient is unconscious (you can’t wake them with a shout and a firm touch) AND they do not appear to be breathing – commence CPR. Some people express concern that they will commence CPR incorrectly on someone who is actually breathing shallow breaths that they could not detect – don’t get hung up of this, it’s a trap. If the person doesn’t wake up when stimulated and doesn’t tell you off for pressing on their chest, chances are the breathing they may (or may not) have been doing wasn’t sufficient anyway (meaning CPR was the right call). Checking for breathing is as simple as looking for movement of the chest (rise and fall), listening for normal breathing sounds and feeling for air escaping from the mouth or nose. If you think they aren’t breathing – they very likely aren’t.

If a patient is unconscious and isn’t breathing (presumably from cardiac arrest) there are two main things that need to happen: 1) Medical help must be requested and 2) high quality chest compressions must start (and not stop until the aforementioned help arrives).

Screenshot 2018-10-07 14.29.35

Image reproduced from: https://cpr.heart.org/AHAECC/CPRAndECC/Programs/HandsOnlyCPR/UCM_473196_Hands-Only-CPR.jsp

The actual task of performing chest compressions is extremely straightforward:

  1. Position the person lying flat on their back – ensuring no acute danger is present (e. electricity, fire, crocodiles etc.).
  2. Join your hands on the middle of the patient’s chest with both palms facing down (as illustrated in the picture below).
  3. Press hard and fast until help arrives.

 

Screenshot 2018-10-05 17.20.16

Images reproduced from: https://resus.org.au/download/section_6/anzcor-guideline-6-compressions-jan16.pdf

N.b. you can estimate the ‘middle’ of the chest, but you should feel bony ribs under your hands – if it feels soft you are either on the belly or the neck…or worse!

The gold standard for rate (rhythm) and depth of external chest compressions is 100-120 compressions per minute, compressing one-third the depth of the patient’s chest (approximately 5cm). This is understandably a physically demanding task, thus making it all the more important to ensure help is called in a timely manner. If other bystanders are present don’t be afraid to swap over chest compressors when you feel tired – this will prevent the quality of your compressions from dropping off.

While there aren’t many accessible or reliable methods for ensuring you reach the appropriate depth of compression, it’s safe to advocate that people simply push ‘hard’ on the chest, as this is exactly what is required to achieve suitable result. Rate on the other hand has a number of reliable means of ensuring compressions are delivered at the required speed. Most notably, the rhythmic compression of the chest in CPR can be performed to the beat of any song with a tempo of between 100 and 120 beats per minute. Listed below are some of my favourite songs to help keep the required tempo during a resuscitation attempt:

  • Staying alive – The Bee Gee’s
  • Another one bites the dust – Queen
  • I will survive – Gloria Gaynor (use the verse or chorus not the ‘at first I was afraid’ intro bit – while dramatic, it’s too slow)

And no, the irony of these titles in the context of resuscitation is not lost on me!

It is also helpful to know that the act of pushing the chest down is only half the battle. For the best result it is important to allow the chest to recoil back to it’s starting position after each compression (Lurie et al, 2016). This gives the heart a chance to fill with blood that can subsequently be ejected around the body during the next compression.

To summarise, when you come across a collapsed person who may have potentially suffered a cardiac arrest you should consider the following 3 steps:

  1. Check that the patient is unconscious and not breathing (suspected cardiac arrest)
  2. Call for help (Shout and phone ‘000’)
  3. Start chest compressions (push hard and fast until help arrives)

While this is well and good to read, there is a lot to be said for seeing it in action. In 2012 the British Heart Foundation created an excellent ‘Hands only CPR’ campaign featuring notorious tough guy Vinnie Jones. While this video is brief and light hearted, it provides an outstanding visual summary of the techniques we are talking about in hands only CPR. It is definitely worth a look and is a great way to burn this idea into your brain.

British Heart Foundation, 2012

There are also a number of other awesome hands only CPR videos that you can check out. The best of the rest would have to be the American Heart Association spin off with Ken Jeong (of ‘The Hangover’ fame) https://vimeo.com/91028687 and the ‘children’s’ version of the British Heart Foundation video with an excellently cast ‘Mini Vinnie’ https://www.youtube.com/watch?v=jks0Yxd4E28.

 

Some other tips…

Remember to call for help

When calling for help, remember to phone 000 for help ASAP. If you have an extra person available to help, get them to make the call. If you are a solo rescuer, call 000, put your phone on loudspeaker and place it on the floor next to the patient. This way you can commence chest compressions while summoning assistance.

 

Trouble shooting

While it is great to aim for 1/3 the depth of the chest and 100-120 per minute, remember that any attempt to save a life is better than no attempt at all. If in doubt, press hard and fast in the middle of the chest until help arrives.

If you’re unsure whether an unconscious person is breathing or not – start CPR! It is often extremely difficult to determine how ‘arrested’ a person is, even for healthcare professionals. So if in doubt, press it out (...’it’ being the patients chest). If the person doesn’t need the compressions they will moan, groan, potentially swear & push you away (all excellent ways of indicating CPR is not required). In this case do your best to keep them safe until help arrives (consider positioning them on their left hand side, and don’t be afraid to attempt CPR again if they deteriorate and stop breathing)!

While chest compressions are a life saving intervention, it is important to understand that the procedure is quite forceful and can lead to some incidental injury. The most common injuries associated with chest compressions are broken ribs. Performing chest compressions on a patient with broken ribs can often lead to an unpleasant ‘crunching’ feeling under the hands. It is important to note that broken ribs are NOT an indication that you are doing the compressions wrong – they can be caused by even the most perfectly delivered chest compressions. In a person who remains unconscious and aponeic (not breathing), it is very important that you continue to deliver chest compressions to the best of your ability until help arrives (or the patients responds) – even if you feel some broken ribs. Remember that time will heal broken bones, but an arrested patient will certainly die without chest compressions.

 

Legal issues

One of the major barriers standing in the way of bystanders providing CPR on collapsed strangers is the concern that they will get in trouble if something goes wrong. While this is a valid concern, there is legal precedent that protects rescuers who are making a genuine attempt to help someone who is in perceived danger (even untrained civilians). This is never better exemplified than in the case of a bystander attempting to resuscitate a stranger in cardiac arrest.

‘Good Samaritan’ legislation (Civil Liability Act) provides the legal protection for any person acting in ‘good faith’ to provide help to an afflicted individual. Essentially what this rule boils down to is that if you are acting in a way that would be deemed reasonable or necessary to prevent harm to a person, you are protected from liability in the event that an adverse outcome occurred while you were providing assistance. To grossly oversimplify – you wont be sued if you attempt to resuscitate someone (to the best of your own understanding and ability) and they die, or if you break someone’s ribs while providing CPR.

If you would like a more extensive breakdown of the ins and outs of the Good Samaritan legislation, an excellent evaluation can be found on the ‘Australian Emergency Law’ blog at the link below:

https://emergencylaw.wordpress.com/2015/03/27/good-samaritan-legislation-and-scope-of-practice/

 

What about the children (won’t somebody please think of the children)

While hands only CPR is significantly better than nothing, it is not recommended as the ‘best’ option for infants or young children suffering cardiac arrest (hands only CPR is generally advocated for adults and teenagers). For children, a standard basic life support approach with 30 compressions to 2 rescue breaths (or even 15 compressions to 2 breaths in neonates) is advocated. The reason for this is that children are far more likely to suffer cardiac arrest caused by low oxygen levels (hypoxia) – as such, they are theoretically more likely to benefit from the supplemental breaths described in standard BLS.

That being said, if your memory goes out the window in a crisis (as mine often does), any attempt to rescue someone (including the default hands only method) is FAR better than nothing!

 

Where to next?

If you are looking to further refine your understanding of hands only CPR, there are a variety of excellent resources available. Both the American Heart Association and British Heart Foundation have excellent instructions at the following links:

https://cpr.heart.org/AHAECC/CPRAndECC/Programs/HandsOnlyCPR/UCM_473196_Hands-Only-CPR.jsp

https://www.bhf.org.uk/how-you-can-help/how-to-save-a-life/hands-only-cpr

There are also countless instructional videos on sharing sites like YouTube and Vimeo (including the Vinnie Jones and Ken Jeong videos listed above). In terms of mobile apps there are lots of useful resources here as well. The St John Ambulance ‘first aid’ apps have great instruction on CPR and are easy to access and use in a crisis which makes them all the more useful.

If this strikes a chord with you and you want to learn more about first aid and resuscitation, there are also a multitude of excellent resources available to expand your knowledge and ability to help in a crisis. The best option is to locate and attend a first aid / CPR course in your area. Many widely regarded organisations like the Red Cross and St John Ambulance run CPR courses regularly around the country, and in some cases you may be able to locate a free CPR course in your area. The best way to find something that suits you is just to Google “CPR course near me” and choose the one that fits your needs.

Whichever way you go, finding information to make you a better first aider is a breeze. But after reading this, you should have the tools you need to be an effective rescuer and potentially save a life if you are faced with a patient in cardiac arrest outside the hospital environment.

 

References

Australia New Zealand Resuscitation Council. (2017). Compression only CPR (frequently asked questions). Retrieved from: https://resus.org.au/faq/compression-only-cpr/

American Heart Association. (2018). CPR: resuscitation science. Retrieved from: https://cpr.heart.org/AHAECC/CPRAndECC/ResuscitationScience/UCM_477263_AHA-Cardiac-Arrest-Statistics.jsp%5BR=301,L,NC%5D

ANZCOR. (2016). Guideline 6: Compressions. Retrieved from: https://resus.org.au/guidelines/anzcor-guidelines/

International Liaison Committee on Resuscitation (ILCOR), Basic Life Support Task Force, Available from: http://www.ilcor.org

Hupfl, M., Selig, H. F. & Nagele, P. (2010). Compression only CPR: a meta analysis. Lancet; 376(9752). Retrieved form: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2987687/

Locke CJ, Berg RA, Sanders AB, et al. (1995). Bystander cardiopulmonary resuscitation: concerns about mouth-to-mouth contact. Arch Int Med.

Lurie, K. G., Nemergut, E. C,, Yannopoulos, D. & Sweeney, M. (2016). The physiology of cardiopulmonary resuscitation. Anesthesia & Analgesia. 122(3): 767-783.

Olasveengen T, Mancini MB, Berg, RA, et al. (2017). CPR: Chest Compression to Ventilation Ratio-Bystander- Adult Consensus on Science and Treatment Recommendation [Internet].

Rea, T., Fahrenbruch, C., Culley, L et al. (2010). CPR with chest compression alone or with rescue breathing. NEJM. 363: 423-433. Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJMoa0908993

1 Comment

  1. You forgot the row row row your boat song – ** all depends on how fast you sing **

    There is some evidence that suggests up to 2 mins of viable oxygen exists from the point of collapse and needs to be pumped around.

    Also when calling “000” for help – 911 + 112 will also work, and even if the mobile phone is locked, the numbers can be dialed

    Liked by 1 person

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