CPR REVIEW - KEEPING IT REAL
CPR Review / Keeping it Real & Other things to Consider
The "Keeping it Real" is a translation of what the information really means and personal commentary based on the current and past information. With over 41 years of combined public community service as a First Responder I will be providing additional insight or real world and reality CPR. Things that are written in the training material or what is seen on a training video may be confusing. HEARTSAVER will translation the information as it relates to performing real world CPR in real life situations. There is more to the foundational information that is currently being shown on computers, videos or what is written in training material. The guidelines are recommendations however, with new updates things that you were in the guidelines in the past have now been deemphasized, reaffirmed or new topics that will discussed. This section will provide you with a better translate of the information, the reality of how things really work and what to expect in the real world.
Most of the information in the 2020 AHA Guidelines are reaffirming the information from the prior 2010 or 2015 Guidelines. (There are no changes to the technique or critical concepts when performing High Quality CPR or the Hand's-Only Compressions).
The Information in RED will be sources directly from the American Heart Association's Guidelines or Student Manuals or other sources. Reference page numbers of those sources will be included.
The Information in BLUE is my "Keeping it Real" Commentary & Other Things to Consider.
Disclaimer
Some of the additional options or information mentioned may be opinions based on reality in "real world" CPR. Any information not written by the American Heart Association will be considered Non-AHA Content. However, the additional information is based on real world CPR and many years as a First Responder. Real life personal experiences or information taken from the Emergency Medical Technician (EMT) books are other sources that are included and additional information that would be considered "Non AHA Content"
Pattern:
In the 2005 JAMA (Journal of the American Medical Association)
"In the 19 January 2005 issue of JAMA, the researchers show that, even in the hospital setting, chest compressions during CPR are often too slow, too shallow and too frequently interrupted, and ventilation rates are usually to high". Source: (University of Chicago of Medicine January 17, 2005)
Sources: (Vol. 293 No3, January 19, 2005 issue of JAMA)
In 2009 a Medicare study that was published in the New England of Medicine
" The odds of surviving cardiac after getting CPR in a hospital are slim and have not improved in more than a decade. Even when CPR is given by these highly trained hospital staffer, chest compressions often are too slow or too shallow to be effective". Sources: MSNBC, CBS/AP, USA Today, ABC News (July 2, 2009) & Published in the New England Journal of Medicine.
In the 2020 Guidelines now includes a CPR Coach (Added to the High-Performance Teams / Code Team).
"The CPR Coach's main responsibilities are to help team members provide high quality CPR and minimizes pauses in compressions".
" The CPR Coach gives feedback and performance or compression depth, rate and chest recoil".
"The CPR Coach gives team members feedback about ventilation rate and volume".
" The CPR Coach communicates with the team to help minimize the length of pauses in compressions. Pauses happen when the team defibrillates, switches compressors, and places and advanced airway". Source: (2020 BLS Provider Manual pg 31)
It appears and may suggest that the problems from 2005 & 2009 of hospital staffer not pushing hard and fast has not been resolved. I also think that the bigger and foundational problem or patterns from the past of proper translating of the information and real speed illustration and demonstrations. The recommended numbers or depths on paper no one will actually know. Most people do not understand numbers that they can't count and depths that they can't measure. Most people copy illustrations or demonstrations that are slower and are going the bear minimum or less if you actually used a counter. Most people copy what they see and think the illustrations that are shown reflects everyone's hard and fast. Showing illustrations showing real time speed and numbers to reflect that speed may help however, no one will know those numbers in the real world. As humans we are not robots, computers, clickers or flashing lights. The term and instructions to push hard and fast is subjective to each person who is actually doing it. Everyone don't have the same physical fitness level, sustainability and no one will know what size of the victim. (Petite or supersized)
In my opinion, it may be helpful not to focus on numbers that no one will ever know or can count that fast and get away from depth in inches that no one can actually measure or will know. Most often CPR training don't talk about making adjustments, adapting and make modifications as needed if the typical way is not working.
The Hand's-Only instruction (Push hard and fast in the center of the chest) most people would understand. I would just add to use proper technique by keeping your arms straight and elbows locked to allow chest recoil. Just by saying that make CPR instruction simplified. No numbers, no breathing, no counting. Also consider other factors such and stress, epinephrine and adrenaline that is uncontrollable bodies response that helps creates the faster rate. The hard and fast compressions numbers and speeds are subjective and probably should not be given a specific static number.
Most people still may not understand and should be said in training, that the rescuer becomes the heartbeat for that person and taking over the job and functions of the heart. The function of the heart is circulation oxygenated blood to the brain, heart and throughout the body. If the heart is not beating on its own or compressions are not being performed, the brain is going to die. The brain cells begin to die with 4 to 6 minutes without oxygen and brain damage in about 10 minutes. The heartrate of a adult may range from 60 to 100/min based on fitness level. If we look at the current 100-120/min range that still may be still on the slow side. Any stressful, physical activity and even performing CPR heartrates are going to be higher that a normal heartbeat range. The reality is in a fight or flight situation the heart rate is going to be faster.
If the instructions are to "Push Hard - Push Fast no instructor or anyone should tell someone that they are going to fast. However. I think putting a number or a range on someone's hard and fast is a contradiction because everyone' hard and fast speed is subjective to the rescuer who's actually performing CPR. The guidelines recommendations to push hard and fast are pretty clear. Those using proper technique and allowing chest recoil will normally be going fast enough. One study suggests that if someone are going over 120/min they may not go deep enough. On the flip side, it also means that some people may go deep enough. Those who are using proper technique will generally go deep enough. However, those people not using proper technique by bending their arms or not allowing the chest to recoil, those are the people who generally will not go deep enough. With feedback device manikins, students should be encouraged to go deep enough to hear the click or see the light on the manikins that may represent what at least 2 inches may be. In training all students should hear the click or see the light on feedback device manikins to show adequate depth. However, real people don't have clickers and people will not know a measurement in inches.
I am unsure why most of the illustrations or demonstrations are still showing the bear minimum speed of 100/min or less. The guidelines stated that studies showed improved survival rate speed as fast as 120/min and should probably be the desired target range if it improves survival.
Every 5 years there are changes or updates to the AHA guidelines.
2005: About 100/min
2010: At Lease 100/min (With better survival rates as fast of 120/min
2015: Target Range 100 to 120/min
2020: Target Range 100 to 120/min
By using a simple stopwatch and a counter in reality HEARTSAVER can prove that most students who did what felt natural, find pushing hard and fast rhythmic flow while using proper technique, going deep enough were doing 100-120/min. In reality most students actually do about 125 to 133/min by just doing what feel natural and stainable. I have learned and can prove that when students just react to the body's normal rhythm, they are able to be maintained that speed for up to 4 minutes. For additional training I have students do 2 minutes on the adult followed by 2 minutes on the child while using the AED. Students are given time to develop muscle memory and time to develop their hard and fast flow or rhythm that are validated with a counter that shows student actual numbers that students can see. When students see what they are actually doing in real times builds the students confidence. Students should be trained to react, leave their training confident and able to provide high-quality CPR.
As you see those number are subjective based on each student's fitness level however it is the reality of what the heart rate should be with physical activity or stress. So, expecting everyone to have the exact number in every case is not realistic.
The training DVD does not reflect real time speed and only going 80/min during 1 Rescuer BLS demonstration. Most instructor don't have a clue of that speed therefore students or even some "Code Teams or High-Performance Teams" may not aware of the slower speed. However, there is a section in the training DVD insert makes that makes reference that it does not reflect real time CPR.
"Dramatization of material is designed for demonstration purposes and does not reflect the extensive variations and challenges faced by rescuers faced by rescuers during actual resuscitation attempts". Source: Insert from 2010, 2015 & 2020 BLS Provider DVD.
People copy what they see on the video DVD. Some instructors have not personally performed CPR, seen it being done, been part of the code team or ER team and may not know what it looks like to push hard and fast in reality. Also consider other factors such and stress, epinephrine and adrenal that is uncontrollable bodies response that helps creates the faster rate. Some people still be encouraged to use the song "Staying Alive" a song from 1977. Using that song back in 2005 was reasonable back in 2005 when the recommendations were to go about 100/min. The mindset back then is something is better than nothing that still true today. However, the beat of that song was going about 103 times a minute according to a news team reporting the story. I am not sure why someone would think that younger people, those from different nationalities, cultures and races have ever heard that or other songs. On paper it sounds nice however you don't see illustrations or have someone practicing for more than a minute if that. However, something is better than nothing, but it needs to be fast.
I think people would be better served if they are trained to react to the crisis and do what feels normal and natural just by pushing hard / push fast that is a rhythmic flow in the center of the chest. Most people who have actually performed CPR know, that in a crisis you will not be thinking or trying to remember a phase or song. Most often those songs are never practiced for an extended amount of time.
On paper this is what it says. But what does the information actually mean and how does it relate to real world CPR?
OVERVIEW (Keeping it Real-Reality)
The AHA Guidelines are giving you numbers that you really can't count (100-120/min compressions that is in 60 seconds) and compression depths that you can't really measure (1-1/2 inches on the infant, about 2 inches on a child and at least 2 inches but no more than 2.4 inches). People in society comes in different shapes and sizes such as petite size and supersized. Compression depths are subjective based on the size of the person and if you think you are compressing the heart between the sternum and spine. No one actually has a ruler sticking out of their chest to measure. Real people don't have clicker or lights that flash to let you know if you are going deep or fast enough. (Find a rhythm and a flow that is hard and fast, go deep enough where you think you are smashing/compressing the heart between the sternum and spine on a hard flat or firm surface. Best guess based on the size person you are doing compressions on.
The DVD training video are demonstrating technique only as it indicates in the insert of the DVD. However, it may not be clear to instructors or students. The DVD are showing illustrations that are slow and don't represent real world CPR speed or the current compression speed of 100-120/min during the 1 Rescuer BLS section. Using a stopwatch and a counter reveals that the illustrations shows that they are going 80/min. I only imagine that most students and instructors assume what they are seeing what is looks like in reality. Sometimes doctors slow nurses down and CPR instructor's slow student down. It would be inconsistent to follow the guidelines and student manual instructions to push hard and fast then have someone tell you that you are going too fast.
Regarding "team dynamics" and based on what is shown and illustrated it may be assumed that everyone that is taking a BLS Provider course all work in a hospital setting, are part of a "Code Team or High-Performance Team," work in the Emergency Room or on a medic unit where they all have a team that have crash cart and cardiac drugs. However, if the healthcare providers are not part of one of those classifications, they're on their own and have to react and deal with the situation.
Unfortunately, those other healthcare providers who don't work in a hospital setting or have teams such as " those work home health, work in a doctor's office, work in clinics, travel nurses, pharmacist, dentist and others" will all be on their own. Most work location may not have a team and most likely have not trained together as a team or have or developed an action plan for their facility. They also don't have the luxury of pushing a button to active the Code Team or High-Performance Team to respond and come do all of the work. If the organization don't have a cardiac crash cart or cardiac drugs probably don't have a "Code Team" or understand team dynamics or that concept. Some Healthcare Providers may not be mentally prepared to react to a crisis outside of a hospital setting like on the street, office or at home. New information suggests the 77% of cardiac arrest occurs outside of a hospital setting (your home and 50% of that is unwitnessed.
If you're own your own, the best information regarding CPR and to keep things short and sweet with (HAND'S ONLY CPR / COMPRESSION's ONLY) Call 911 and to Push Hard and Fast in the Center of the Chest. There are (No Numbers, No Breathing and No Counting). I would just add to use proper technique by keep your arms straight, elbows locked and allow full chest recoil. Because of COVID or for other safety concerns AHA has information to cover your nose and mouth with a mask or cloth, cover victim's nose and mouth with a mask or cloth and do Hands-Only compressions.
At HEARTSAVER you will practice pushing hard and fast in real time speed, pushing deep in real time depth, doing several minutes of compressions to develop muscle memory and a rhythmic sustainable flow. In crisis you will react based on your training.
Because the foundational training DVD video does not reflect real time speed, the manikins does not represent the size, shapes and weight of real people in society somethings are not realist. The make-up of society is diverse, and no one will know if the victim will be petite size or supersized. It may be necessary to adjust, adapt and modify if the foundational information is not working. Rescuers should do whatever it takes and work through the problems by adjusting, adapting and overcoming issues in order to perform "High Quality CPR". Real people are not robots, computers and everyone may not react the same. Also consider the human factor such a stress, epinephrine and adrenaline that are also factors while performing those lifesaving efforts.
The new 2020 Student Manuals and Guidelines now include information about (Stroke, Anaphylaxis, Drowning, Heart Attack and CPR on Pregnant Women). However that information is not being shown in the training DVD video and it refer back to the student manual.
HEARTSAVER instructors will also demonstrate all of the skills and provide the information that is in the DVD training video however, it will be demonstrated and illustrated and shown in real time speed 100-120/min. Most people copy what they see. HEARTSAVER provides additional time for students to practice in order to develop muscle memory and a hard/ fast rhythm, instructor will use a counter to actually show students what their hard/fast rhythm speed is, provide feedback, be sure students are using proper technique. When students understand the information and how it relates to real world CPR and if it makes sense to them it will build confidence. Most students will have done over 600 compressions each at HEARTSAVER.
If students are not trained properly, are not confident or understand the foundational information they may not react, may panic or freeze and unable to provide High Quality CPR when it really mattered. It would be even worse if that person had to try to perform CPR on a family member or someone there care about. In a crisis you will revert back to your training.
Healthcare Providers are those who work in the medical field. However, titles of a doctor or a nurse are subjective and does not mean they are all trained the same. What kind or doctor or nurse are they? Doctors and nurses are not trained as First Responders and may not be properly prepared to deal with any emergency situations outside of the hospital setting in a real world situation on the street. Most will be out of their field of expertise "out of their lane". Most healthcare providers have specialized skills and training for the area or unit that they are working such as doctors that are trained to treat the eyes, nose, bones, surgical procedures, medical doctors, cardiac or infection disease doctors. All doctors and nurses are not normally trained in same or in all areas. Doctors give referrals to patients because it may be out of their lane of practice or expertise. Most people do not know that most nurses have not been trained in first aid and something that I have mentioned in all of my classes.
The problem may be that a person with a PhD, a veterinarians, pharmacist or dentist are also examples of those that may be called doctors. A nurse may be trained to work in a nursing home, hospice or in a doctors office. If does mean they are also trained to deal with delivering babies, assisting in surgery or in an emergency room. Most nurses of those in the medical may not have taken a formal class First Aid class unless they that the class on their own. BLS Provider course normally covered CPR/AED and choking but does not include first aid too.
The new 2020 BLS Provider Student Manual content will have information on the follow topics. However, some of that information is not shown or in the new DVD training videos.
NOTE: Please be aware that some online CPR sites or other organizations may indicate that they are (AHA) American Heart Association compliant, equivalent to, or follow AHA guidelines. However most may not be accepted by some healthcare facilities as they are not the official (AHA) American Heart Association provider and don't provide students with the official American Heart Association certification card. Some online training may have do CPR and use by clicking a computer mouse click. Some hospitals may put students into a room with a computer and manikin alone without someone to provide feedback, a way for students to ask questions or be corrected if the they were using bad technique.
Rescuers need to understand the information and learn proper technique. Proper training and mastery of these skill requires hands on training, feeling confident and understanding the information will help students retain the information. Going through the motions will not prepare anyone when a real crisis occurs. In a crisis most people will revert back to their training.
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CPR Critical Concepts
HIGH-QUALITY CPR
- At least 1/3 the depth of the chest, about 2 inches (5 cm), for children
- At least 1/3 the depth of the chest, about 1-1/2 inches (4 cm), for infants
Use proper technique by keeping your arms straight and elbows locked. (Most will not go deep enough if arms are bent).
The universal compression rate for all cardiac victims is (100-120/min) (All the same for the adult, child & infant).
The compression-to ventilation ratio for 1 person CPR (30:2) (All the same for the adult, child & infant).
For 2 person CPR for child & infant (Ratio 15:2) for healthcare providers. It is still (30:2) for the adult.
Hands-Only: Doing only compressions. (No numbers, No breathing and No counting). Only pushing hard and fast in the center of the chest.
In my opinion; putting your mouth on anyone especially on any stranger should not be an option. With COVID that has been proving deathly for some plus other health risk consideration, doing mouth to mouth should be revaluated as it may be a unsafe practice or recommendation. However, you can put your mouth and do mouth to mouth on anyone that you want to gives breaths to. In 2020 the AHA provided the following information.
COVID-19 and Adult CPR
In my opinion when talking about Hand's - Only CPR, the word CPR should not be used as it does not represent what you are doing or represents the abbreviation. The word CPR in this case should be changed to (Chest Compressions) because all you are only doing are chest compressions. The (C) in CPR (C) for cardio that refers to the heart and performing (compressions) (P) for pulmonary that refer to the lungs and giving (breaths) (R) for resuscitation that refers to performing both compressions and breaths.
(CPR) Cardiopulmonary resuscitation: The 2 key components of CPR are chest compressions and breaths. Hand's-Only CPR providing chest compressions without breaths. (2020 Student Manual pg 108) (No numbers, no breathing and no counting).
On paper you are given (speeds) you can't count in a minute and (depths) that you can't measure. Detecting breathing has been deemphasized and pulse checks have been deemphasized. The look, listen and feel had been removed in 2010 because rescuers failed to start CPR when they saw agonal gasping.
Most people would not have a clue what agonal gasping is unless they have work in hospice, a nursing home or was in a room when the person died.
Keeping it Real
The compression rate of (100-120/min) for your speed and the depths of (2 inches on the adult, about 2 inches on the child and 1-1/2 on the inches) may be confusing and really serves no purpose to give those numbers. The reality is that no one will know their actual speed in numbers or know the depths is inches on a real person. However, the Hand's Only instructions of push hard and fast in the center of the chest. I would also add use proper technique by keeping your arms straight and elbows locked you will most likely go deep enough. If you push hard and fast as instructed in most cases you will be going fast enough. There are no numbers, no breathing and no counting. Use a protective mask or protective shield if you choose to give breaths too. However, with Covid the AHA steps for CPR are to cover yours and the victim's nose and mouth with a mask or cloth and do Hand's Only CPR.
HEARTSAVER uses and counter and stop watch and show students actual numbers and valid their pushing hard and fast real time speed. As a results all students leaves the class confident, more likely to render aid and understand that their normal response is regarding speed. Most are normally going within the 100-120/min range. Some may be slightly more as you also have to factor in the human element such as stress, epinephrine and adrenaline that is closer to 125 to 132/min and would represent the speed of the heart is the real life in a fight or flight situation. As a experiment see what your heart rate is after running on a treadmill or after physical activity. I have student with fitbit watch see what their heartrate is after doing 4 minutes of CPR training. I have ranges from 125 to180/min that will be subjective to each person. If the instructions are to push hard and fast no one should be telling anyone that they are going to fast. Your body and you fitness level will help determine what your (hard and fast speed is. It is your sustainability and your rhythm or flow. If your arms are straight, your elbows are locked and allow the chest recoil/allowing the blood to return back into the heart; then you are providing High Quality CPR.
One study stated that some people may not go deep enough if they went over 120/min. However, you're not going to know those numbers and those are the people who are not using proper technique. Bending arms and not allow the recoil / or blood return back into the heart during compression is not proper technique. It is not about a number that you will never going to know it is about pushing hard and fast that will be based on everyone's own personal body and fitness level too.
Because no one has a ruler sticking out of their chest and with society with different shapes and sizes no one will really know what 2 inches or 2.4 inches are on the adult. Everyone is not the same size of a training manikin. Some people may be supersized or petite size. Understand that you need to go deep enough to compress/ smush the heart between the sternum and spine to force the blood out of the heart whatever that may be based on the size of the victim.
In reality, if you push hard and fast in the center of the chest while using proper technique by keeping you arms straight, elbows locked to allow chest recoil / heart to refill you probably with going fast and deep enough.
Translation of what High Quality CPR really means
Keeping it Real (DVD Training Video)
Most CPR instructors and students are not aware of the statement information in the AHA DVD training video insert. Students are not normally informed that the DVD video is a demonstration and does not reflect how things are in actual resuscitation attempts. However people copy what they see and most think what they are seeing reflects how things are done in "real world/real time" CPR. Those doctors who are not part of the "Code Team or High Performance Team" may slow nurses down and instructors slowing students down. The instruction to "Push hard/Push Fast is pretty clear. The compression rate speed in the training video are slow.
Source: Statement that is in the BLS Provider DVD Training Video Insert from 2010, 2015 & 2020
"The American Heart Association's Basic Life Support Course teaches foundational skills essential for saving lives. Educational material developed in the form of animations, images, descriptive text, and reenactment scenarios creates a rich learning experience for learners. Dramatization of material is designed for demonstration purposes and does not reflect the extensive variations and challenges faced by rescuers faced by rescuers during actual resuscitation attempts. For specifics on ratio, timing, cycles and duration of these lifesaving techniques and maneuvers, learners are encouraged to refer to the BLS Providers Manual and published comprehensive AHA Guidelines for CPR and ECC as the primary source". (Insert from the DVD Training Video)
"Creating an effective strategy to translate BLS skills to real-world circumstances presents a challenge. This section updates the adult guideline goals of incorporating new scientific information while acknowledging the challenges of real world application". (Source: 2010 AHA Guidelines pg S686)
Keeping it Real
The compression speed in the training DVD for 1-Rescuer Adult BLS is illustrated slower to show proper technique, hand landmarks and foundational skills. I think the key phase is ("designed for demonstration purposes and does not reflect") The illustrations in the DVD does not reflect real time CPR speed and is only going 80/min while they are perform 1-Rescuer Adult BLS. That speed does not reflect the extensive variation and challenges and clearly does not reflect real time speed when someone is pushing hard and fast. The recommended speed is 100-120/min. Most instructors are not aware of that statement and don't let their students know. Most student have been learning and copying things that doesn't reflect real time speed and better survival rate speed. However, something is better than nothing.
Source: Statement at the beginning of the DVD Training Video:
"Products are shown for demonstration purposes only, The AHA does not endorse or recommend any specific manufacturer or product"
"In order to show skills clearly, the healthcare providers in this video do not always use recommended personal protective equipment (such as gloves)".
The training video shows you the proper hand landmark locations, proper technique and foundational information to give you an idea how things are done. However real time CPR is faster and is not being reflected in the videos. No instructor should tell students that they are going to fast when the 2010 & 2015 student manuals tells you to push hard & push fast.
Source: (2010 BLS Student Manual pg 2 & 2015 Student Manual pg 3, 2015 First Aid CPR AED Student Manual pg 85)
Most instructors have not personally done CPR in real life or been part of a code team to see and understand the extensive variations and challenges faced by rescuers during actual resuscitation attempts. (A range of 100/min to 120/min in 60 seconds is fast). Push Hard/Push Fast is what it means. Epinephrine and adrenaline is a human element and factor that you have no control over in a real life situation. HEARTSAVER uses a tally counter to prove and to show students exactly what their compression speed is and where they are in the 100-120/min range. It makes a difference and builds confidence when students find out and see that their normal reaction will generally putting them in that range or slightly more.
SCENE SAFETY
Be sure that the scene is safe for you.
Keeping it Real
Be sure you are not putting yourself in harms way. You can't help anyone if you are injured or dead. (Active shooter, electrical wire, poisons, car accident scenes etc).
LOOK, LISTEN AND FEEL (Was Removed in 2010)
Look for chest rise, listen for breaths and feel for air on your cheek.
(Guidelines now tells you to scan victim's chest for rise and fall for no more than 10 seconds)
In 2010 the AHA Guidelines removed the look, listen and feel as a mechanism for assessment. It use to be open airway, look for chest rise and fall, listen and feel air on you cheek. HEARTSAVER have been telling students prior to that change; in the real world especially if you were outside you would not be able to hear someone breathing or feel breaths on your cheek because of the wind, crowd, traffic and the environment. Also it would be challenging to see chest rise and fall if they were wearing things like a hoodie, sweats, layers of clothes or coat or jacket. However, the AHA removed it from the assessment step because bystanders failed to start CPR when they observed agonal gasping.
"Another key change is the removal of "look, listen and feel for breathing from the assessment step. This step was removed because bystanders often failed to start CPR when they observed agonal gasping. Source: (2010 BLS Student Manual pg 4)
"The BLS Algorithm has been simplified, and the "Look, Listen and Feel " has been removed from the algorithm. Performance of these steps is inconsistent and time consuming". Source: (2010 AHA Guidelines pg S643)
"The directive to look, listen, and feel for breathing to aid recognition is no longer recommended". Source: (2010 AHA Guidelines pg S678)
"These 2010 Guidelines for CPR and ECC deemphasize checking for breathing. Professional as well as lay rescuers may be unable to accurately determine the presence or absence of adequate or normal breathing in unresponsive victims because the airway is not open or because the victim has occasional gasp, which can occur in the first minutes after SCA sudden cardiac arrest and may be confused with adequate breathing". (Source 2010 AHA Guidelines pg S689)
AGONAL GASPS
Agonal gasps are not normal breathing. Agonal gasps may be present in the first minutes after sudden cardiac arrest.
"Agonal Gasps are not normal breathing. Agonal gasps may be present in the first minutes after sudden cardiac arrest". A person who gasps usually looks like he is drawing air in very quickly. The mouth may be open and the jaw, head, or neck may move with gasps. Gasps may appear forceful or weak. Some time may pass between gasps because they usually happen at a slow rate. The gasp may sound like a snort, snore or groan. Gasping is not normal breathing. It is sign of cardiac arrest. Source: (2015 BLS Student Manual pg 17)
"Another key change is the removal of "look, listen and feel for breathing from the assessment step. This step was removed because bystanders often failed to start CPR when they observed agonal gasping. Source: (2010 BLS Student Manual pg 4)
Keeping it Real (Agonal Gasp)
In 2010 the AHA removed the look, listen and feel from the assessment steps because people failed to start CPR on people with agonal gasping. I think the bigger problem is that most people including doctors, nurses and the general public are not going to know what it is or what it sound like. Most people have not been around someone who died while they were still in the room. Depending on where someone works like those who work hospice with terminally ill patients, work in a nursing home or had a family or friend die when you were in the room; they may have some idea of what agonal gasps sound or looks like.
In the text it describes it as sounding like a snort, snore or groan. However, on the training video the illustration and show what some people may describe as a goldfish or guppy trying to breath out of water. The nicknames that have been around for many years is the (death rattle). It may sound like gurgling or fluid in back of the throat. (Zombie sounding)
If you cut the head off of a chicken the chicken is dead but the body is still running around or if you cut of head off a snake, the snake is dead by the body is is moving they are both dead but you seeing things moving after the fact. The victim is dead but you are hearing sounds after the fact.
Some may also describe agonal gasps:
* Agonal gasps may sound like a snort, snore of groan.
* A gold fish or guppy trying to breathe out of water.
* Bubbly or gurgling sound. (Nicknamed the death rattle).
CHECK RESPONSIVENESS
Tap the victim's should and shout, "Are you OK? If the victims is not responsive shout for nearby help and have some call 911.
Scan chest for rise and fall.
Keeping it Real (Check Responsiveness)
Assessing by tapping shoulder asking if they are OK to check for a response, and now scanning chest to check for breathing or gasping in my opinion may be subjective. Most people may not understand they are looking for or pretending to feel for a pulse. Most citizens and most healthcare provider are unable to reliable able to detect or feel and pulse within 5 to 10 seconds. Most can't find a carotid pulse on their own neck. I
If someone is drunk, on drugs, have a head injury or is unconscious because of low blood sugar diabetic reaction they may not respond to someone tapping the shoulder. If your spouse worked all night or they have been drinking all night or on medication see if tapping them is going to wake them up. Try waking up your child by tapping them to get them up for school. If they don't respond to those taps are you going to start CPR on them too? What about the older person that has a hearing aid or has poor hearing. How loud is considered loud enough.
When it come to (Shouting) how loud do you shout? HEARTSAVER recommends using a stronger louder voice and tone. My suggestion if it is a female yell "ma'am can you hear me, open your eyes" and for the guys say "sir" staying the same thing. Using a strong loud voice as a verbal stimuli.
The new thing for in 2010 is scanning the chest to check for breathing. This still may challenging to check for breathing if the person is wearing a jacket, hoodie, sweatshirts, several layers of clothing of something bulky.
Keeping it Real (Additional Assessment Options)
Because of the different stories I hear of people starting CPR on someone who is drunk, passed out, hearing of non-medical or in the medical field that tried to start CPR on someone who is stating "get off me, get off me" is can be problem for the person down. Those issues may be avoided if students have obvious indicators that can be done and detected as rescuers are assessing for scene safety and checking for response. I understate when in doubt do CPR. However, I think students should do whatever is needed to be done or use whatever observations skills to lessen that doubt. Some may say if you perform CPR on someone who don't need it that it will not hurt that bad. However, if you were on the the receiving end those compressions you understand the reality of what happens. Remember that compressions depth are to go at least 2 inches that would normally separate the costal cartilage from the sternum similar to a flail chest. Someone that ever bruised or their ribs would confirm that it is painful and uncomfortable for many months. Things like breathing and getting in and out of bed would be discomforting in many cases.
Non AHA Content: Some may consider an options of doing what the EMT's paramedics emergency room doctors and nurses do to get a response. Although called sternum rub you are vigorously rubbing your knuckles up and down the upper part of their chest (sternum). The sternum rub may be an additional option and tool as it is routinely used by EMT's Paramedics, ER - Emergency Room doctors and nurses to get a response because it works within seconds. It is used because it works. Some information suggest using the sternum rub to try to get a response for the suspected of opioid overdose. Other options also found the EMT books that you may consider; loud verbal stimuli, firmly pinching the ear lobe, press on bone above eye or gently but firmly pinch the muscles of the neck,
The sternum rub is not anything that the American Heart Association tells you to do. I think an additional options should be considered to give the rescuer a tool to assure that the victim is actually unresponsive and not breathing. Tapping someone shoulders, looking chest rise on people with layers of clothes and listening for agonal gasps the most people haven't seen to know what it is may be challenging as the only assessment tool. With today's social climate of claims of women being touched I think additional safeguards should be considered. Compressions are done in the center of the chest. The Anne CPR manikins are female however the chest doesn't represent the breast sizes of female and most may assume that they are training on a male manikin.
TIMES WE LIVE IN
I recently heard that a women wanted to file a claim against some guy that did CPR on her because he touched her without her consent. Heart attack is the number one leading cause of death in women. Ironically, it may remain number one as some may not want to do CPR or touch a women. With exposing chest for AED pad placement and doing compressions in the center of the chest may be concerning as possible false claims. Everyone is covered by the Good Samaritan Law if you are acting in good faith. You are also covered by Implied Consent when you render aid on a victim that is unconscious and if it is a life threatening emergency.
CPR should not be started on someone who is stating, "get off me, get off me".
The 2020 Guidelines now recommends doing CPR over the clothes if the person has bulking clothing that can't be removed at that time until the AED arrives.
(Non-AHA Content) Something that the First Responders, EMT's Medics and ER Doctors and Nursed may do is the sternum rub. The sternum rub is noninvasive and you should get a response or reaction within seconds. Patient will quickly push your hand away if they are conscious or flinch or have a grimacing facial expression if the are unconscious. Anyone pink and moving should be a good indicator that they are alive and CPR would not be needed. The sternum rub is a very uncomfortable sensation and should get a quick response. Those doing the sternum should be trained to do it and always know where the victim's hands are.
(Currently tapping shoulders and asking if they are OK, scanning the chest for breathing and listening for agonal gasp are the steps).
People sometimes don't hear what happens to that victim post CPR. A problem is some people are starting CPR on someone that is still breathing and has a heartbeat. Most people don't know or talk about the costal cartilage that separates from the sternum creating a possible flail chest that may take 3 month or up to 2 years to heal according to those who work post care. It is important that patients are properly assess to determine if they actually are not breathing, not responding and don't have a heartbeat. Looking for additional signs and indicators may help you make a better decision to start CPR.
In the opioid training other sources recommend that you use the sternum rub on the victim to try to get them to respond.
PULSE CHECK
Ideally, the pulse check is performed simultaneously with the check for no breathing or only gasping, to minimize delay in detection of cardiac arrest and initiation of CPR. Lay rescuers will not check for a pulse.
PULSE CHECK
"To minimize delay in starting CPR, you may assess breathing at the same time as you check the pulse. This should take no more than 10 seconds".
Source: (2015 BLS Student Manual pg 17)
"To perform a pulse check in an adult, palpate a carotid pulse. If you do not definitely feel a pulse within 10 begin high quality CPR starting with chest compressions". Source: (2015 BLS Student Manual pg 17)
"Studies have shown that both lay rescuer and healthcare provider have difficulty detecting a pulse. Healthcare providers also may take to long to check for pulse. The lay rescuer should not check for pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally. The healthcare provider should take no more than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that period, the rescuer should start chest compressions". Source: (2010 AHA Guidelines page 687)
Continued de-emphasis of the pulse check :"It can be difficult to determine the presence or absence of a pulse within 10 seconds, especially in an emergency, and studies show that both healthcare providers and lay rescuers are unable to reliably detect a pulse. If the victim is unresponsive and not breathing or only gasping, healthcare providers may take up to 10 seconds to attempt to feel for a pulse (brachial in an infant and carotid or femoral in a child). If within 10 seconds you don't feel a pulse or are not sure if you feel a pulse, begin chest compressions. Source: (2010 BLS Student Manual pg 5)
"These 2010 AHA Guidelines for CPR and ECC also de-emphasized the pulse check as a mechanism to identify cardiac arrest. Studies have shown that both layperson and healthcare provider have difficulty detecting a pulse. For this reason the pulse check was deleted from training for lay rescuers several years ago, and is de-emphasized in training for healthcare providers. The lay rescuer should assume that cardiac arrest is present and should being CPR in an adult suddenly collapses or an unresponsive victim is not breathing or not breathing normally (i.e only gasping). Healthcare providers may take too long to check for a pulse and have difficulty determining if a pulse is present or absent". Source: (2010 AHA Guidelines pg S689)
"It can be difficult for BLS providers to determine the presence or absence of a pulse in any victim, particularly in an a infant or child. So if you do not definitely feel a pulse within 10 seconds, start CPR, beginning with chest compressions".Source: (2015 Student Manual pg 47)
"As recommended in the 2010 Guidelines, healthcare providers will continue to check for a pulse, limiting the time to no more than 10 seconds to avoid delay in initiation of chest compressions. Ideally, the pulse check is performed simultaneously with the check for not breathing or only gasping, to minimize delay in detection of cardiac arrest and initiation of CPR. Lay rescuers will not check for a pulse". Source: (2015 AHA Guidelines pg S415)
"Pulse detection alone is often unreliable, even when performed by trained rescuers, and it may require additional time".
(Source 2010 AHA Guidelines pg S678)
It can be difficult for BLS providers to determine the presence or absence of a pulse in any victim, particularly in an infant or child. If you do not definitely feel a pulse within 10 seconds, start high-quality CPR, beginning with chest compressions. Source: (2020 Student Manual pg 50)
"It has been shown previously that all rescuers may have difficulty detecting a pulse, leading to delays in CPR, or in some cases CPR not being performed at all for patients in cardiac arrest. Recognition for cardiac arrest by lay rescuers, therefore is determined on the basis of level of consciousness and the respiratory effort of the victim. Recognition of cardiac arrest by healthcare providers includes a pulse check, but the importance of not prolonging efforts to detect a pulse is emphasized. Source: (2020 AHA Guidelines p S371)
"Protracted delays in CPR can occur when checking for a pulse at the outset of resuscitation efforts as well as between successive cycles of CPR. Healthcare providers often take too long to check for a pulse and have difficulty determining if a pulse is present or absent. There is no evidence, however, that checking for breathing, coughing, or movement is superior to a pulse check for detection of circulation. Thus, healthcare providers are directed to quickly check for a pulse and promptly start compressions when a pulse is not definitively palpated. Source: (2020 AHA Guidelines pg S372)
Keeping it Real
Most people pretend to feel for a carotid pulse on the neck. However most have not been trained, have difficulty or taking to long to find it. Most people can't find their own.
The Guidelines is for rescuers to check for a pulse the same time you are checking to see if they are unresponsive and breathing (agonal gasp). All 3 steps are now done at the same time so you are not wasting time checking for a pulse that most people are unable to detect or take too long to find. As you see from the 2010 , 2025 & 2020 Guidelines and student manuals it is clear that most healthcare providers and others are unable to detect a pulse. Depending on where you work and what you job is all healthcare providers don't routinely put their hand on people's neck for vital. Pulse oxy and monitor may routinely be used in hospital what setting that you are in; taking a pulse on the wrist may be done by those using old school methods.
Most healthcare providers are not experienced or have the opportunity to routinely feel for a carotid pulse (on neck) in adults, femoral pulse (groin area) in an child or brachial (bicep area) in an infants. The general public generally will not know how to feel for a pulse and why it is not recommended for them to do pulse checks. Both the general public and healthcare providers may go through the motions, fake it or pretend that the know what they a feeling for because they have be programmed to based on seeing it on TV. In training and with illustrations are pretending to feel for a pulse on a manikin that doesn't have a pulse. Most have been programmed and are going through the motions and most can't find a pulse on themselves. Healthcare providers also includes dentist, chiropractors, pharmacist and others who normally don't routinely feel for pulses anywhere on their clients.
Keeping it Real Pulse Check)
I personally thought that the pulse check would have been removed for healthcare provider in 2015 & 2020 based on the information and finding in the 2010 Guidelines and being reaffirmed. The lay-rescuer are not trained to feel for a pulse.
Keeping it Real (Indicators)
If the person his pink skin, lips, fingers, nailbeds, hands, soles of feet generally means that they are breathing. If that color have do change and consistent that general means that they have consistent pressure and circulation. That generally mean that the person have a heartbeat and pulse. However, if that person has bluish or purplish skin, lips, finger, nailbeds , hands, soles of feet that may be a good indicator that they are not breathing, have and heartbeat and pulse.
Light skinned people normally will have pink skin coloring to their face, lips, hands and fingers that you can see as you look at them. Those who are breathing will have oxygenated blood in their system and will have pink face, pink lips and is obvious when you look at them. The thing that is keeping the oxygenated blood and the pink face, lips and extremities is the beating heart. The function of the heart is to move oxygenated blood to the brain, heart and vital organs. If someone have a pink face and lips that would be a good indicator that they are alive, breathing and have a heartbeat. No CPR needed if victim is breathing and have a heartbeat. If they have a heartbeat they also will have a pulse. The color of the person's face and lip, palms of their hand and nail beds are the best indicators if they are alive or dead.
Diversity information to address different skin tones
In the student manual it briefly talks about signs of poor perfusion. I think we need to take a closer look and hear some additional information and may be the key and a better way to assess someone who is down. Light skinned people may look darker (bluish, purplish or grayish) which is not normal for their normal pink color. Those with darker skinned people may look lighter, ashy, dusky, pallor (grayish) and not normal for their normal color. If the person is not breathing you will notice color change on their face, lip, hands and nail beds.(Bluish, purplish, grayish or pale) If they are not breathing and don't have a heartbeat what color their face is going to turn (Bluish, purplish, grayish or pale). Seeing a change in the skin color is a red flag.
When someone calls the dispatcher will want to know if the person in responsive and breathing. Most people may not know that answer. I think the question should be is the person pink or purplish/bluish. Pink skin, palms, nail bed would indicate that they are breathing. If skin remains pink would indicate that there is pressure (heartbeat) that is circulating that blood.
C-A-B (Chest Compression- Airway- Breathing) over the A-B-C
The 2010, 2015, and 2020 guidelines reaffirm still using the C-A-B sequence. Compression, Airway then Breathing for those needing CPR.
This information needs better clarification because during your first contact with the victim several things normally occurs. As you approach be sure that the scene is safe. At the same time you are quickly assessing the person's A-Airway, B-breathing and C-Circulation without realizing that is what you are doing just by looking at them. If they are pink, talking, reacting or moving they have a airway, they are breathing and have circulation. Scanning someone's chest for 5 to10 seconds to see if their chest is going up and down is challenging and will be hard to tell if the person has bulky or multiple layers of clothes. Unlike the videos that you see that normally shows the chest already exposed or the button down shirts that they pop the buttons off when they open it.
Something else to consider may be looking or D-disability (stoke symptoms) E- environmental (allergies) and something some EMT's Emergency Medical Technicians may look for or ask when talking to the person as part of their primary assessment.
C-A-B however are the steps for CPR (compressions and breaths) for the person that is not responding, not breathing or agonal gasp. Rescuer would start with C-compressions, A- open Airway, B and give breaths (if properly protected). To keep it simple if the are pink and responding, moving or pushing your hand away they are alive. If they are purplish, bluish or grayish and not responding or reacting to your painful and verbal stimuli or your tap and shout CPR or Hand's Only chest compressions would be indicated.
When you are doing compression, you are compressing the heart between the breastbone (sternum) and spine. This is why you need to be on a hard flat surface. When you are doing compressions you are forcing oxygenated blood in and out of the heart that goes to the brain, heart and vital organs. (YOU ARE THE HEARTBEAT FOR THE VICTIM) and buying time for the medics come with supplemental oxygen and AED. You can't hurt someone who is already dead.
"Each time you stop chest compressions, the blood flow to the heart and brain decreases significantly. Once you resume compressions it takes several compressions to increase blood flow to the heart and brain back to to the levels present before the interruption. Thus, the more often chest compressions are interrupted and the longer the interruptions are the lower the blood supply to the heart and brain is." Source: (2015 BLS Student Manual pg 19)
" Chest compressions create blood flow to the heart through filling of the coronary arteries. Every time compressions are stopped, blood flow and thus perfusion to the heart and brain drops to zero. It takes 5 to 10 compressions to reestablish effective blood flow to the heart after chest compressions are resumed. Avoid frequent or prolonged interruptions in chest compressions, which lead to poor patient outcomes".
Source: EMT Book (Emergency Care and Transportation of the Sick and Injured 11th Edition pg 522)
CHEST COMPRESSIONS
C-A-B Compression- Airway-Breathing
Source: (2010 BLS Student Manual pg 3)
"Chest compressions are consist of forceful rhythmic applications of pressure cover the lower half of the sternum. These compressions create blood flow by increasing intrathoracic pressure and directly compressing the heart. This generates blood flow and oxygen delivery into the myocardium and brain".
Source: (2010 AHA Guidelines pg S687)
"Chest Compressions are the key component of effective CPR. Characteristic of chest compressions include their depth, rate and degree of recoil. The quality of CPR can also be characterized by the frequency and durations of interruptions in chest compressions when such interactions are minimized, the chest compression fraction (percent of total resuscitation time that compressions are performed) is higher. Finally, with high-quality CPR the rescuer avoids excessive ventilations. These CPR performance elements affect intrathoracic pressure, coronary perfusion pressure, cardiac output, in turn clinical outcomes".Source: (2015 AHA Guidelines pg S419)
COMPRESSION DEPTH
Adult: At least 2 inches - 5 cm (using 2 hands) while avoiding excessive chest compression depth greater than 2.4 inches or 6 cm.
Child: Approximately 2 inches - 5 cm (using 1 or both hands)
Infant: Approximately 1-1/2 inches.(using fingers)
Chest compression are more of often too shallow than too deep. However research suggest that compression depth greater than 2.4 inches in adults may cause injuries. If you have a CPR quality feedback device, it is optimal to target your compression depth from 2 to 2.4 inches.
"During manual CPR, rescuers should perform chest compressions to a depth or at least 2 inches or 5 cm for an average adult, while avoiding excessive chest compression depths greater than 2.4 inches or 6 cm". Source: (2015 AHA Guidelines pg S419)
"Importantly, chest compressions performed by professional rescuers are more likely to be too shallow". Source: (2015 AHA Guidelines pg S419)
Keeping it Real (Compression Depth)
The reality is that you're not going to know what at least 2 inches is on the adult, about 2 inches on a child and about 1-1/2 inches on the infant or what 2.4 inches is. People don't have a ruler sticking out of their chest and you will never what size person you may be performing CPR on. In our society there are people come in different body shapes and sizes (supersize or petite size). Compression depths are subjective based on the size of the victims. You are not going to hurt someone who is already dead. You will need to determine how deep to go (depth) based on if you think you are going deep enough to compress/smash the heart between the sternum and spine. That is the intent and why you are pushing hard, fast and deep as you now become the heart beat for the person and the reason why you need to perform compressions on a hard or firm flat surface. Rescuer objective is trying to compress deep enough to compress (downward motion) smashing the heart (that forces blood out of the heart) and allow the chest to recoil (upward motion that allows the blood to return back into the heart). Blood goes out / blood goes in. The objective is to have a fast rhythmic up and down motion or flow because you now become the heartbeat for that person.
The key is and to help you go deep enough is using proper technique by keeping your arms straight, elbows locked, body directly over the victim, going straight down and allow the chest to recoil back up (blood returning back into the heart). The length of your arm will allow time for the recoil. You will not go deep enough if your arms are bent and it is not proper technique. When you are pushing hard and fast you are just doing what your body's normal reaction is you will probably will be going deep enough.
The reality is that you are doing compressions the same way it is do with the (Hand's-Only Compression-Only). Push hard and fast in the center of the chest. Keep your arms straight, elbows locked to allow full chest recoil i.e. for the blood to return to / refill the heart. No numbers or counting.
The current CPR manikins don't necessarily represent the shape and sizes of the population as some are petite size or supersized. You need to go deep enough where you think your are compressing the heart between the sternum and spine that would be based on who was in front of you. With a supersized person you may need to use more of you body weight to get the depth that you need to compress the heart. Use less of your body weight on a petite size person. HEARTSAVER has an obese manikin without a clicker that forces students to use their judgement if you think you are going deep enough to compress the heart between the sternum and spine. Real people on the street don't have clickers and you would have to use your judgment on how deep to go based on the victim's shape and size. (Best guess based on the size of the victim)
FIRM SURFACE
"Compressions pump the blood in the heart to the rest of body to make compressions as effective as possible place the victim on a firm surface, such as the floor or backboard. If the victim is on a soft surface, such as a mattress, the force used to compress the chest will simply push the body into the soft surface. A firm surface allows compression of the chest and heart to create blood flow."
Source: (2015 BLS Student Manual pg 19)
Keeping it Real
You are trying to compress/smash the heart between the sternum and spine. Going deep enough trying to compress/smash the blood out of the heart and allowing the blood to return is the recoil. (Blood is being forced out by the compression and refilling(blood returning back into the heart) is the recoil). In the case of Michael Jackson, you had a heart doctor trying to perform CPR on the bed with the mattress and springs. Jackson should have been pulled off the bed and CPR should have been performed on the floor that was a hard flat surface. Hospitals may use a backboard, or a hard device that they put under patients back. Some of the newer beds may you push a button the make the bed firm.
CHEST RECOIL
It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest.
(Information from the Guidelines)
"Full chest wall recoil occurs when the sternum returns to its natural position during the decompression phase of CPR. Chest wall recoil creates a relative negative intrathoracic pressure that promotes venous return and cardiopulmonary blood flow. Leaning on the chest wall between compressions precludes full chest wall recoil". Source: (2015 AHA Guidelines pg S420)
"Chest recoil allows blood to flow into the heart. Incomplete chest recoil reduces the filling of the heart between compressions and reduces the blood flow created by chest compressions. Chest compression and chest recoil/relaxation times should be about equal". (2015 Student Manual pg 20)
Keeping it Real (Technique)
When you are performing proper chest compressions; your arms should be straight and elbows should be locked out and not bent. When you are performing CPR you are compressing down smashing /compressing the heart between the breastbone (sternum) and spine that forces the blood out of the heart. When you are coming back up you are allowing the heart to refill (chest recoil) allowing the blood to return back into the heart. The key is keeping your arms straight and elbows locked as if you are a plunger. Don't bend your arms. You need to be on a hard flat surface in order to compress the heart between the sternum and spine. With your compressions you become the heartbeat for the victim and the heart normally don't stop.
CHEST COMPRESSION LOCATION
Chest compression are performed in the center of the chest on the lower half of the sternum/breastbone nipple line area. Avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest.
Keeping it Real
False claims of being touched may be coming a concern for those doing CPR on women as society has created that environment. We all have been doing CPR training using the adult, child and infants for many years. However, we all thought we have been trained and practiced on male manikins. However Little Anne manikin is a female. Because of the size of the chest we never paid much attention to where our hand are related to the breast. We never thought about where are hands and being placed. We have not been desensitized to that and would not have thought that someone may have an issue.
Unfortunately because of today's society and sue happy people or those with an agenda some people may be hypersensitive and make false claims of women being inappropriately touched during CPR. If a female has a heart attack or sudden cardiac arrest your hand placement is in the center of the chest is for both male and female as it has been on the onset of CPR. The Anne CPR manikins are female manikins, however the manikin's breast size are small like a male so those who have been trained have not had a visual image of a female anatomy with breast. You are not inappropriately touching someone while you are doing compressions in the center of the chest.
Heart attack is the number killer of women. Unfortunately it probably may remain that way as some people may not want to touch a women to perform CPR on them for fear of the possibility of unfounded claims. We may need to have more discussions about the Good Samaritan Law and Implied consent that are safeguards that are designed to protect rescuers in these situations.
COMPRESSION SPEED - Optimal Target Range 100/min to 120/min (Push Hard - Push Fast)
The old information in 2005 stated compression rate speed about 100/min, in 2010 they changed the wording to at least 100/min. The 2015 guidelines states the optimal target rate is between 100/min to 120/min. They are trying to get people to push harder and faster as long as there is chest recoil (going up and down). In 2020 the target range remains the same 100 to 120/min.
PUSH HARD - PUSH FAST in the Center of the Chest
2010, 2015 & 2020 Guidelines
Keeping it Real
In my opinion no instructors or anyone should tell students that they are going to fast when the 2010, 2015 and 2020 Guideline instructions clearly tells rescuers to push hard and fast. If you are performing CPR you are trying to do 100 to 120 compressions and give breaths in 60 seconds so that is fast. The most important key for CPR compressions is using proper technique by keeping your arms straight, elbows lock, going deep enough to compress the heart between the sternum & spine and allowing the chest recoil. You will not go deep enough and get tired quicker if your arms are bent or not allowing the chest to recoil. There is currently no current illustrations in training video that actually show students actual real time compression speed while showing actual numbers per minute. (HEARTSAVER uses a counter and a timer to show student actual speed).
Keeping it Real (Using Songs)
Doing something is better than nothing. There are some songs or suggested songs out there. If you think using a song will help it needs to be a fast song. On paper it may sound like a good idea however, I think using a song may be more of a distraction for most. In reality you are just reacting, doing what feels normal and natural and finding a fast rhythmic flow. Pushing hard and fast is subjective to each person because everyone in different. Everyone has different physical activity and some people may not be in the best shape, has physical challenges have not developed muscle memory.
Some are still telling people to use the song "Staying Alive". The problem is that was something that they came up with in 2005 when the recommendations were to go about 100/min that would be the bear minimum the current 2020 range. In the 2010 Guidelines also talked about better survival with compression rate as high as 120/min. Now what about the younger people or people from different cultures and backgrounds or have never listened to disco music.
However if you don't listen to songs from the 1970's, listen to rap, disco country or kids songs those suggestion may not be relevant to you. To simplify, if you just push hard and fast in the center of the at a consistent rhythmic flow you generally will be going 100-120/min range. Just do what feels normal and natural. Also consider other human factors that is not discussed such as stress, epinephrine and adrenaline that will make things faster. It is not about a number that you will never see or know. It is about doing what the heart would be doing while fighting for its life.
Source: According to a report from MSNBC on 10/16/2008 it stated " Turns out the 1977 disco hit his 103 per minute, a perfect to maintain and retain the best rhythm for performing cardiopulmonary resuscitation, or CPR"
The news report also made mention of another song," Another Bite the Dust". During that time period back in 2005 the Guidelines had the compression rate was to go about 100/min so it made sense in 2005. The 2010 Guidelines was changed to go at least 100/min. making those songs the bare minimum. The 2015 Guidelines have a range of 100 to 120/min. 2015 guidelines also states the studies shows improved survival rate as fast as 120/min
COMPRESSION SPEED 100-120/min
"The compression rate refers to the speed of compression, not the actual number of chest compression delivered per minute. The actual numbers delivered per minute is determined by the rate of chest compression and the number and duration of interruptions to open the airway, deliver rescue breaths and allow AED analysis". Source: (2010 AHA Guidelines pg S690)
"The study also demonstrated that improved survival occurred with chest rates as high as 120/min".Source: (2010 AHA Guidelines pg S690)
"Chest compression rate is defined as the actual rate used during each continuous period of chest compressions. This rate differs from the number of chest compressions delivered per unit of time, which takes into account any interruption in chest compressions". Source: (2015 AHA Guidelines pg S419)
"These investigations suggest that there may be an optimal zone for the rate of manual chest compressions between 100 to 120/min that on average is associated with improved survival". Source: (2015 AHA Guidelines pg S419)
Keeping it Real & Other things to Consider (Compressions)
Something is better then nothing. Don't be focused on actual numbers that you never are going to know, going to see or can't actually count. With Hands-Only CPR (No Numbers, No Breathing and No Counting). In reality you are not doing CPR because CPR is compressions and breaths. Hand's Only actually refers to doing compression's only without giving breaths. All you are doing is just pushing hard and fast in the center of the chest.
To make in more complete I would just add and include using proper technique by keeping your arms straight, elbows locked to allow full chest recoil or the blood returning back into the heart. Pushing Hard, Pushing Fast is subjective to each person who is doing it and is a rhythmic flow and a speed that is comfortable and sustainable for each person. The key is using proper technique because in the real world no one will know numbers, no one counts numbers and no one cares about numbers on the street. If songs are being used to determine your speed in may be easier to do what is suggested and just push hard and fast. Moving oxygenated blood to the brain and throughout the body is what the heart does and why you are doing CPR. You are the heartbeat for the person that is fighting for its life.
Compression speed range is 100-120/min. The 2015 guidelines also indicates that better survival rate as high as 120/per min. Because there is 60 seconds in a minute no one can actually count 100-120 in 60 seconds. No one actually knows how fast they are doing it. In a crisis or in a high stressful situation the bodies normal reaction will produce epinephrine & adrenaline that you have no control of. Feedback manikins give you an idea if you are in the range however don't tell you if you are in the low range or high range.
HEARTSAVER will show students real time numbers that reflects where each person are in that range. Instructor uses a tally counter and timer to prove and show that if the student is doing what feel natural while pushing hard and fast with a rhythmic flow, with equal up and down compressions normally will be going within that 100 to 120/min range or slightly more. It is not about a number that you are never going to know or see it; is about a rhythmic speed and flow that is equal and sustainable while using proper technique and recoil. Only you and your body will determine what your rhythmic flow and sustainable speed is for you. You are not a robot, computer or a machine and everyone's comfortable rhythm will be slightly different and will be slightly changing the longer you are doing CPR.
One study stated "that if someone who did over 120/min they may not go deep enough". That may also means that if you are performing CPR and using proper technique some may be going deep enough. If you are bending your arms you may not go deep enough and is not proper technique. You also may get tired quicker. When using a training manikin with a feedback with a clicker or light it would indicate that you are going deep enough. Be consistent with the compressions while using proper technique by pushing hard and fast with a rhythmic flow that is equal and sustainable, keep your arms straight and your elbows locked out, allowing the chest to recoil that will allow the blood to return back into the heart.
At HEARTSAVER we have students check their heart rate after doing 2 or 4 minutes of compressions. Depending on their fitness level we see ranges from 120 up to 180/min. There heart is not beating to fast and is just doing what the heart is suppose to do under physical exertion, or stress. In real time CPR you are going to be under stress and when the epinephrine and adrenaline kicks in the heart rate and speed are going to be fast. See what your heart rate the next time you are jogging on the treadmill.
In 2005 the JAMA (Journal of the American Medical Association) had published information that CPR performed in hospitals were not pushing fast or deep enough. Sources: (January 19, 2005 issue of JAMA)
On July 2009, there was a Medicaid study that stated "The odds of surviving cardiac arrest after getting CPR in a hospital are slim and have not improved in more than a decade, a big Medicare study concludes. Only about 18% of such patients live long enough to leave the hospital , researcher found. Black fared worse than whites a disparity on partly explained by more of the being treated in hospital that did a poorer job of CPR". There were news articles and reports on national news on MSNBC, CBS, USA Today & ABC news repeating the findings Those finding were also published in the New England of Medicine
Source: Published in the New England of Medicine (Information in 2009 from New Reports from MSNBC, CPR/AP, USA Today, & ABC News)
The phase push hard and fast started to be used in 2010. People just don't understand what real time compression speed looks like and the numbers that reflect that speed. It can't be an exact number because of the one thing that is being left out of the equation is the human element of (stress, epinephrine and adrenaline) Rescuer are not robot, machines or computers and everyone fitness level is different.
Ironically those who have not been trained in CPR may do a better job of CPR because they are pushing hard and fast just going on their instinct with the addition of epinephrine and adrenaline kicking in. They have not been programmed or trained to try to figure out numbers that no one is going to see or know anyway. The reality is that we are given information about numbers that we can't count and depths we can't measure. The Hand's-Only instructions are to push hard/push fast in the center of the chest. There are no counting, no numbers and no breaths. Something is better than nothing.
CPR Coach
"Studies have shown that resuscitations teams with a CPR Coach perform higher-quality CPR with a higher CCF ( chest compression fraction) and shorter pause durations than teams that do not use a CPR Coach".
"The CPR Coach's main responsibilities are to help team members provide high quality CPR and minimizes pauses in compressions". " The CPR Coach gives feedback and performance or compression depth, rate and chest recoil". "The CPR Coach gives team members feedback about ventilation rate and volume". " The CPR Coach communicates with the team to help minimize the length of pauses in compressions. Pauses happen when the team defibrillates, switches compressors, and places and advanced airway". Source: (2020 BLS Provider Manual pg 31)
The Code Team - High Performance Team was normally 6 person team with specific duties and responsibilities.
(Airway, Recorder, Compression, AED, Medication & Team Leader)
In the 2020 Guidelines they added a CPR Coach to the (High Performance Team - Code Team) blended with AED duties. Apparently there still may a problems with compression speeds, compression depths and interruptions from those performing CPR in hospital for this to be added. The CPR coach duties are to be sure that those who are performing CPR are pushing hard and fast enough, going deep enough, being sure that when switching to another rescuer is faster and not interrupted and starting compressions immediate after delivery of the shock from the AED. It appears that there are still delays and interruptions. I see a pattern of hospital staffers not pushing hard and fast from the Journal of Medical Association JAMA report in 2005 and the 2009 study that was published in the New England of Journal of Medicine.
HAND'S ONLY - COMPRESSIONS ONLY
(Untrained - Lay Rescuer)
For lay rescuer, compression-only CPR is a reasonable alternative to conventional CPR 30 compression and 2 breaths in the adult cardiac arrest patient. For trained healthcare rescuers, it is reasonable to provide ventilation in addition to chest compressions for the adult in cardiac arrest.
Untrained lay rescuers should provide compression-only CPR, with or without dispatcher assistant. The rescuer should continue compression only CPR until the arrival of an AED or rescuers with additional training.
Trained Lay Rescuer
All trained rescuers should, at a minimum, provide chest compressions. In addition, if the trained lay rescuer is able to perform rescue breaths, he of she should all rescue breaths in a ratio of 30 compressions to 2 breaths. The rescuer should continue CPR until an AED arrives and is ready for use or EMS providers take over care of the victim.
Keeping it Real & Other things to Consider
Hands-Only/Compressions Only without the breaths. The instructions are clear to push hard and fast in the center of the chest. No numbers, no breathing and no counting. You are never going to know numbers and numbers are not relevant. Hands - Only compressions represent what a heart would be doing if it was functioning. That is beating continually to circulate oxygenated blood to the brain, heart and vital organs. With your compressions, you are and now become the heartbeat for the victim.
In the Guidelines and Student manual still talks about mouth to mouth, mouth to stoma or trachea tube. I think that information should be re-evaluated especial now with Covid. However, because of Covid in 2020 the AHA have the following steps for adult CPR. Hand's - Only with everyone nose and mouth covered with a mask or cloth. No will know if they have Covid or any other contagious disease. In my opinion putting your mouth on any stranger should not be an option and removed unless using a barrier device such as a CPR mask the most people don't have or carry in a first aid kit if they have one.
COVID-19 and Adult CPR (2020 Information)
HANDS-ONLY
"Encourage Hands-Only (compressions only) CPR for the untrained lay rescuer. Hands-Only CPR is easier to perform by those with no training and can be more readily guided by dispatchers over the phone. (Source: 2010 AHA Guidelines pg S643)
"Observational studies of adults with cardiac arrest treated by lay rescuers showed similar survival rates among victim receiving Hands-Only versus conventional CPR with breaths".Source: (2010 AHA Guidelines pg S691)
"Rescue breaths are not as important as chest compressions because to oxygen level in the blood remains adequate for the first several minutes after cardiac arrest. In addition, many cardiac victims exhibit gasping or agonal gasps, and gas exchange allows for some oxygenation and carbon dioxide elimination. If the airway is open, passive chest recoil during the relaxation phase of the chest compressions can also provide some air exchange. However, at some time during prolonged CPR supplementary oxygen with assisted ventilation is necessary".
Source: (2010 AHA Guidelines pg S691)
"Bystander CPR rates remain unacceptably low in many communities. Because compression-only CPR is easier to teach, remember, and perform, it is preferred for "just -in-time" teaching for untrained lay rescuers".Source: (2015 AHA Guidelines pg S417)
"Multiple studies have shown no difference in survival when adult victims of out of hospital cardiac arrest received compression-only CPR versus conventional CPR". Source: (2015 AHA Guidelines pg S417)
"We found that survival in the chest compression along group was 12.5% and survival in the conventional CPR group was 11%".
Source: (WebMD July 2010)
Keeping it Real & Other things to Consider (Hand's - Only Compressions)
CPR are for those who haven't been trained in CPR and those who are not equipped with a barrier CPR shield or CPR mask. With the Hands Only no breathing, no numbers and no counting. When you call 911 you will be instructed to do the (Hand Only / Compressions Only). Always be sure that someone called 911 as they come with the supplemental oxygen that will be needed along with a defibrillator. The oxygen level remain adequate for the first several minutes. Medics come with oxygen to supplement that oxygen loss. Hopefully that arrive within the first several minutes.
Definition:
Cardiopulmonary resuscitation (CPR): A lifesaving emergency procedure for a victim who has signs of cardiac arrest (i.e unresponsive, no normal breathing, and no pulse. The 2 key components are chest compressions and breaths. Sources: 2015 BLS Provider Manual pg 3 &13 and 2020 BLS Provider Manual pg 108
Hands- Only CPR: Providing chest compressions without rescue breathing during CPR. Sources: 2015 BLS Provider Manual pg 3 &13 and 2020 BLS Provider Manual pg 108
In the 2010 Guidelines indicated that those who did the (Hands Only - Compressions Only) and those who did it the conventional way 30:2 had similar survival rates. It also indicates that rescue breaths are not as important as chest compression because the oxygen level remain adequate for the first several minutes after sudden cardiac arrest. Source: Web-MD indicates that those who did the Hands Only - Compressions Only had a survival rate of 12.5%. Those who did it the conventional way (30 compressions and 2 breaths) had a survival rate of 11%.
You are the heartbeat for the person and are taking over the job of the heart that is fight for its life. Fight or flight speeds are fast. The instructions to push hard and fast is what it means. When you are doing chest compressions you are moving the oxygenated blood that is already in the bloodstream/system and waiting for the medics to come with supplemental oxygen and using a mask or an advanced airway to provide a high supply of oxygen back into the bloodstream. They also come with a defibrillator, man power and medications. Possible brain damage and dead of the brain's cell starts to die within 4-6 minutes. In 6-10 minutes brain damage very likely. More than 10 minutes without oxygen there may be irreversible brain damage.
The Hand Only - Compressions Only speed realistically will be faster than CPR speed of 100-120/min as you are no longer giving breaths that is normally illustrated or demonstrated in training and on the videos. CPR is with both compressions and breaths.
Keeping it Real & Other things to Consider (Function of the Heart)
Hands Only CPR represents the heart's function the best because the compressions are continuous and consistent just like the heartbeat. The heart continuously circulates the oxygenated blood to the brain and vital organs. Any delay even with given 1 second breaths to get the chest to rise disrupts the consistent flow. It may take about 5 to 10 compressions to (prime the pump) to restore the flow and pressure once the flow has been stopped according to the latest EMT book. Remember that if the heart is not beating or no one is doing compressions; that the brain cells began to die within 4 to 6 minutes and that person will become brain damaged at about 10 minutes with oxygen or circulation.
AIRWAY
Open the airway by tilting the head back. The head tilt -chin lift relieve airway obstruction in an unresponsive victim. When the victim is unresponsive, the tongue can block the upper airway. The head tilt chin lift maneuver lifts the tongue from the back of the throat relieving the airway obstruction.
Keeping it Real & Other things to Consider (Airway)
Once you tilt the head back the airway is open. Most people in training may have the tendency with the chin lift is to push the chin to hard and actually close the mouth. When the head is In the neutral position the tongue is resting on back of the throat blocking the airway. Tilting the head back opens the airway and the tongue is not longer blocking the airway.
Check for BREATHING
If you choose to give breaths you should protect yourself by using a CPR mask or a shield. The ratio is (30:2) 30 compressions and 2 breaths. Because the child or infant problems are normally breathing/respiratory related, it is preferred that they get some form of ventilation. It is your choice if you choose to put your mouth on a stranger. It is reasonable to pause compressions less than 10 seconds to deliver 2 breaths.
In 2010 the AHA removed the look, listen and feel for breathing in 2010. They now want you to check breathing by scanning the chest.
BREATHING:
"To check for breathing, scan the victim's chest for rise and fall for no more than 10 seconds. If the victim is breathing, monitor the victim until additional help arrives. If the victim is not breathing or is only gasping, this is not considered normal breathing is a sign of cardiac arrest".
Source: (2015 BLS Student Manual pg 17)
"These 2010 AHA Guidelines for CPR and ECC deemphasize checking for breathing. Professional as well as lay rescuers may be unable to accurately determine the presence or absence or adequate or normal breathing in unresponsive victims because the airway is not open or because the victim has occasional gasps, which can occur in the first minutes after SCA and may be confused with adequate breathing". Source: (2010 Guidelines pg S689)
"Another key change is the removal of "look, listen, and feel for breathing" from the assessment steps. This step was removed because bystanders often fail to start CPR when they observed agonal gasping". Source: (2010 Student Manual pg 4)
Keeping it Real & Other things to Consider (Breathing)
In the 2010 Guidelines the look, listen and feel was removed. Listening for breathing and feeling air on you face was challenging. Consider this, the reality is if you're outside you will not be able hear anyone breathing or feel breaths on your cheek. Things like the outside environment where there is traffic, wind and the crowd would have made it challenging and you wouldn't be able to hear or feel anything.
The 2010 & 2015 Guidelines now tells you to scan the chest for rise and fall for no more than 10 seconds. On paper and in books you are seeing words. However, in reality it is hard to see someone's chest rise and fall of people within 10 seconds. Now add things like someone wearing a sweatshirt, jacket, hoodie or bulking clothing. This still will be challenging to scan the chest. Most people may not even look or understand what they are looking for. In 2010 the AHA Guidelines deemphasized checking for breathing.
Consider this, if the person is not breathing the heart will eventually stop. If the heart is not beating there is no circulation or oxygenated blood going to the extremities, lips or face. I strongly suggest looking at their face. That may be the best red flag for you is if you are seeing changes from someone's normal pink colored face, lips, hands, finger & toes extremities. If the victim's skin color has changed to pale, grayish, bluish or purplish lips and face and not seeing chest go up and down that may be a good indicator that the person may not be breathing. For people of color or darker complexion the face may turn pale, grayish, dusty or ashy looking. The lips, fingers and nail bed may be turning purplish or bluish.
Pink face, hand and nail beds may represents that they are breathing. The face that remains pink may represent that they have a heart beat and pulse.
Gastric Inflation:
If you breaths too quickly or with too much force, air is likely to enter the stomach rather than the lungs. This can cause gastric inflation (filling of the stomach with air). Gastric inflation frequently develops during mouth-to mouth, mouth-to mask, of bag mask ventilation. It can result in serious complications. Rescuer can reduce the risk of gastric inflation by avoiding giving breaths too rapid, too forcefully, or with too much volume. During high-quality CPR, however gastric inflation may still develop even when rescuer give breaths correctly.
"Deliver each breath over 1 second. Deliver just enough air to make the victim's chest rise".
Source: (2015 BLS Student Manual pg 64)
Keeping it Real & Other things to Consider (Gastric Inflation)
Did you know that when you giving mouth to mouth breaths that some victims may vomit into your mouth. The primary reason is gastric inflation. If you breath to fast and forceful air may go in the the stomach. You are to give 1 second breath just to get the chest to rise. Your lung capacity and their lung capacity are not the same. You need to look at the chest to see it rise. When you see the chest rise and feel some resistance their lungs are full and you need to stop trying to give breaths. Most people try to give everything that they have in their lungs which may cause the air to overflow and go into the victim's stomach which may lead to that person vomiting and the stomach becoming distended (gastric inflation). If you choose to perform mouth to mouth on someone you may get vomit in your mouth. They may also throw up if they just got done eating.
When giving ventilation/breaths by shield, mask, mouth or bag valve mask give only enough air just to get the chest to rise. Excessive ventilation can lead to gastric inflation and/or vomiting. Don't keep blowing because you still have air in your lungs. Hands only or Compressions only would be the best course of action if you don't have something to protect yourself. I would not recommend doing mouth to mouth on any adult stranger. Those days are over. However you choose what you want to do.
COSTAL CARTILAGE - BROKEN RIBS
Keeping it Real & Other things to Consider (Costal Cartilage)
People routinely talk about breaking ribs. The ribs of the thoracic cavity helps protect your vital organs. It contains your ribs, sternum (breastbone) and something most people don't know about is the costal cartilage. The costal cartilage is actually attached to the sternum and your ribs. The older you are the harder the costal cartilage gets. If you are compressing someone chest at least 2 inches you may hear what most think is of the breaking ribs. However, what most people are actually hearing is the separation of the costal cartilage from the sternum. Because the older you get the hard the costal cartilage gets it may sound like you are breaking ribs. Separation of the costal cartilage or breaking of ribs is painful when victim is breathing and moving. You probably may end up with a flail chest.
However, if you are doing compressions on an older person or someone with brittle bones there may be collateral damage such as broken ribs. You are doing nothing wrong when you hear that. It is not normal to compress someone's chest at least 2 inches deep. Most may not know that once the costal cartilage is separated you can't fix it. It may take 3 month up to a year or two for it to heal on its own and you start feeling better. Occupational therapist that does post cardiac care normally sees the after effect. The older they are expect hearing the costal cartilage separating from the sternum. Expect it less on infants or younger children that still have softer and pliable.
I had a 21 year share his story. He was playing football he go knock out after a hard hit. He woke up to someone doing compressions on him although he was still breathing and had a heartbeat. He stated that he will still sore after 2 years as he still tries to stay active with fitness. The bones and cartilage of the child or infant are soft and can absorb a lot. Unfortunately some people start CPR on people that don't need it. (Someone who had fainted, passed out, low blood sugar or drunk are examples).
AED - Automated External Defibrillator
For witnessed adult cardiac arrest when an AED is immediately available, it is reasonable that the defibrillator be used as soon a possible. For adults with un-monitored cardiac arrest or for whom an AED is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation, if indicated, be attempted as soon as the device is ready for use.
Immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting. AED can be used on pregnant women.
Keeping it Real & Other things to Consider (AED)
The objective of shocking the heart is to stop the abnormal activity. The best illustration is a computer. If you computer becomes frozen or not working properly you may shut it off. When you turn it back on it goes back to the default setting resetting and restoring back to normal operation. When the AED delivers a shock; it stops the heart .Hopefully the heart will go back to the default setting, reset, reboot and hopefully restore the heart beat back to a normal rhythm so the heart can do it own job and beat normally. The AED is going to have you do 2 minutes of CPR for the circulation then stop you to check for the fibrillating heart (heart quivering) for you.
Always leave the AED machine and pads on so the AED can continue to monitor behind the scene and assess the heart after every 2 minute. I like to say that the AED is the paramedic in a box. The AED does what a real paramedic do by assessing for ventricular fibrillation (quivering heart) or ventricular tachycardia (very fast heart beat) and allow you to shock it. The AED will continue to check and monitor the heart for those abnormal rhythms on your behalf and will allow you shock a shock-able abnormal heart rhythm when it is detected. The AED will continue to check the heart for you after every two minutes.
The AED pads have pictures showing where is goes on the chest and will needs to be applied to the chest. Pad are going to be on opposite sides of the chest/ heart. The easiest way to put the pad on are to hold both pads next to the patient's face/ head with the head on the pad facing the same direction of the patients head. Peel the pads off the backing placing the sticky side firmly on the bear chest of the patient as illustrated. There are two things that may prevent the pads from sticking firmly to the chest. (Water/sweat/blood and chest hair). You will need to wipe the chest with something so the pads can stick firmly on the chest. Hair can be removed with a razor that may come with the AED unit, or using an extra set of pads that may come with the unit. Some organizations may use duct tape.
Follow the prompts and be sure not to push the shock button until you are sure that no one else is touching the patient including arms, legs, IV pole, bed etc. That is why you say "Clear" to be sure that it is safe and help prevent other from being shocked accidentally. After pushing the shock button the AED will say if needed start CPR" and you would continue with CPR. The AED is the paramedic in a box will have you do 2 minutes of CPR for the circulation than will stop you for about 10 seconds to (analyzing) to check to see if the heart has a shockable rhythm.
The AED only looks and allows you to check two shockable rhythms: VF-Ventricular Fibrillation (when the heart quivering) or VT- Ventricular Tachycardia (when the heartbeat is extremely fast not allowing the blood to return to the heart). The shock goes from pad A through the heart to pad B and the reason why the pads are on opposite sides of the chest. Some child pads may show one pad in front and one pad in back.
AED are in most schools mainly for student athletes who may die from sudden cardiac arrest. Those athletes in sporting events such is soccer, volleyball, football, track, swimming, competitive cheerleader and dancers etc. may have sudden cardiac arrest. It is normally is a electrical signal problem in the heart. This is where you learn that the athlete had some un-diagnosed irregular heartbeat, genetic heart defect or enlarged heart. Drinking large amounts of energy drinks are now being shown to be contributing factor to sudden cardiac arrest in kids and athletes
FINAL OVERVIEW
You are given numbers that you can't count and depth that you can't measure. Checking for breathing and a pulse was deemphasized in the 2010 Guidelines. When you are to push hard and push fast use proper technique by keeping your arms straight, elbows locked and allowing the chest to recoil. You are going deep enough where you think you are compressing/smashing the heart between the sternum and spine.(Blood goes out / Blood goes in). You need to be on a hard flat surface so the compressions are effective.
When you give breaths blow until you see the chest rise. Seeing the chest rise and feeling a little resistance is letting you know that the lungs are full. If you give breaths too quickly or with too much force, air is likely to enter the stomach rather than the lung. This can cause gastric inflation and the primary reason why victim may throw up. If you are not properly prepared with a protective barrier device (CPR mask or shield) or don't want to do mouth-to mouth on a stranger you may consider doing Hand-Only CPR compressions without the breaths.
You have the options of the conventional (30:2) CPR with compressions and breaths or Hands-Only CPR (chest compressions only). If you don't have a CPR mask or a barrier device you can choose if you want to give breaths to a stranger. You don't have to put yourself in harms way. Be sure that you properly assess the victim and be sure that the victim is actually not responding or breathing. If they are purplish or bluish and not responding to your assessment to determine if they are unresponsive and not breathing start CPR. HEARTSAVER'S personal favorite and recommends learning about the sternum rub or as that is what the First Responders, EMT, Paramedics and ER Doctor or Nurses do because it works. However that is Non AHA Content. It is noninvasive and you should get a reaction with seconds. If they don't respond to the sternum rub the clearly would not have responded to the tap and shout.
When you are doing chest compressions, you are pushing hard and fast moving, circulating the oxygenated blood that is already in the bloodstream to the brain, heart and vital organs. However, that oxygenated blood remain adequate for the first several minutes. Be sure 911 have been called and the medics are en-route within the first several minutes.
With compressions you are now the heartbeat for that victim. In a crisis the heart will be accelerated (like if you are on a treadmill or involved strenuous physical activity like CPR) everything is going to be fast and also factor in the human element that is not normally talked about or mentioned.Epinephrine and adrenaline that you have no control of will help most rescuers push hard and fast. When rescuers are performing CPR you are also buying time (bridging the gap) until EMS 911 (medics) arrive who will provide the most important supplemental oxygen, brings a defibrillator and provider advanced life support. Always be sure that someone has called 911 first. Performing CPR is not going to fix a clogged/blocked artery (Heart Attack) or a fibrillating heart (quivering) that is a abnormal electrical signal problem of the heart known as (Sudden Cardiac Arrest). Only a surgery is going to fix a clogged artery and only a defibrillator can fix a heart that is fibrillating.
Time delay, lack of oxygen and not using a defibrillator are contributing factors for poor survival rates. CPR and the use of the defibrillator are a package deal and goes hand and hand. The chance of brain damage is possible after only 4 to 6 minutes without oxygen. Irreversible brain damage may occur after 10 minutes. You have a little window that you are working within.
In the "real world" no one will ever know when, where or how any event may occur. On the streets or at home you need to take whatever actions needed to get the results that you are looking for. In class you will learn proper technique and learn where the landmarks are for hand placement for CPR and for choking. In some cases you may need to adjust, adapt, or modify somethings based on the situation such as location, your physical health, the person sizes your weakness may be factors. Our job is to (Work the Problem) react and perform High Quality CPR.
All 50 states and the District of Columbia have some type of Good Samaritan Law. The details of Good Samaritan laws/acts vary by jurisdiction, including who is protected from liability and under what circumstances.
CPR Review / Keeping it Real & Other things to Consider
The "Keeping it Real" is a translation of what the information really means and personal commentary based on the current and past information. With over 41 years of combined public community service as a First Responder I will be providing additional insight or real world and reality CPR. Things that are written in the training material or what is seen on a training video may be confusing. HEARTSAVER will translation the information as it relates to performing real world CPR in real life situations. There is more to the foundational information that is currently being shown on computers, videos or what is written in training material. The guidelines are recommendations however, with new updates things that you were in the guidelines in the past have now been deemphasized, reaffirmed or new topics that will discussed. This section will provide you with a better translate of the information, the reality of how things really work and what to expect in the real world.
Most of the information in the 2020 AHA Guidelines are reaffirming the information from the prior 2010 or 2015 Guidelines. (There are no changes to the technique or critical concepts when performing High Quality CPR or the Hand's-Only Compressions).
The Information in RED will be sources directly from the American Heart Association's Guidelines or Student Manuals or other sources. Reference page numbers of those sources will be included.
The Information in BLUE is my "Keeping it Real" Commentary & Other Things to Consider.
Disclaimer
Some of the additional options or information mentioned may be opinions based on reality in "real world" CPR. Any information not written by the American Heart Association will be considered Non-AHA Content. However, the additional information is based on real world CPR and many years as a First Responder. Real life personal experiences or information taken from the Emergency Medical Technician (EMT) books are other sources that are included and additional information that would be considered "Non AHA Content"
Pattern:
In the 2005 JAMA (Journal of the American Medical Association)
"In the 19 January 2005 issue of JAMA, the researchers show that, even in the hospital setting, chest compressions during CPR are often too slow, too shallow and too frequently interrupted, and ventilation rates are usually to high". Source: (University of Chicago of Medicine January 17, 2005)
Sources: (Vol. 293 No3, January 19, 2005 issue of JAMA)
In 2009 a Medicare study that was published in the New England of Medicine
" The odds of surviving cardiac after getting CPR in a hospital are slim and have not improved in more than a decade. Even when CPR is given by these highly trained hospital staffer, chest compressions often are too slow or too shallow to be effective". Sources: MSNBC, CBS/AP, USA Today, ABC News (July 2, 2009) & Published in the New England Journal of Medicine.
In the 2020 Guidelines now includes a CPR Coach (Added to the High-Performance Teams / Code Team).
"The CPR Coach's main responsibilities are to help team members provide high quality CPR and minimizes pauses in compressions".
" The CPR Coach gives feedback and performance or compression depth, rate and chest recoil".
"The CPR Coach gives team members feedback about ventilation rate and volume".
" The CPR Coach communicates with the team to help minimize the length of pauses in compressions. Pauses happen when the team defibrillates, switches compressors, and places and advanced airway". Source: (2020 BLS Provider Manual pg 31)
It appears and may suggest that the problems from 2005 & 2009 of hospital staffer not pushing hard and fast has not been resolved. I also think that the bigger and foundational problem or patterns from the past of proper translating of the information and real speed illustration and demonstrations. The recommended numbers or depths on paper no one will actually know. Most people do not understand numbers that they can't count and depths that they can't measure. Most people copy illustrations or demonstrations that are slower and are going the bear minimum or less if you actually used a counter. Most people copy what they see and think the illustrations that are shown reflects everyone's hard and fast. Showing illustrations showing real time speed and numbers to reflect that speed may help however, no one will know those numbers in the real world. As humans we are not robots, computers, clickers or flashing lights. The term and instructions to push hard and fast is subjective to each person who is actually doing it. Everyone don't have the same physical fitness level, sustainability and no one will know what size of the victim. (Petite or supersized)
In my opinion, it may be helpful not to focus on numbers that no one will ever know or can count that fast and get away from depth in inches that no one can actually measure or will know. Most often CPR training don't talk about making adjustments, adapting and make modifications as needed if the typical way is not working.
The Hand's-Only instruction (Push hard and fast in the center of the chest) most people would understand. I would just add to use proper technique by keeping your arms straight and elbows locked to allow chest recoil. Just by saying that make CPR instruction simplified. No numbers, no breathing, no counting. Also consider other factors such and stress, epinephrine and adrenaline that is uncontrollable bodies response that helps creates the faster rate. The hard and fast compressions numbers and speeds are subjective and probably should not be given a specific static number.
Most people still may not understand and should be said in training, that the rescuer becomes the heartbeat for that person and taking over the job and functions of the heart. The function of the heart is circulation oxygenated blood to the brain, heart and throughout the body. If the heart is not beating on its own or compressions are not being performed, the brain is going to die. The brain cells begin to die with 4 to 6 minutes without oxygen and brain damage in about 10 minutes. The heartrate of a adult may range from 60 to 100/min based on fitness level. If we look at the current 100-120/min range that still may be still on the slow side. Any stressful, physical activity and even performing CPR heartrates are going to be higher that a normal heartbeat range. The reality is in a fight or flight situation the heart rate is going to be faster.
If the instructions are to "Push Hard - Push Fast no instructor or anyone should tell someone that they are going to fast. However. I think putting a number or a range on someone's hard and fast is a contradiction because everyone' hard and fast speed is subjective to the rescuer who's actually performing CPR. The guidelines recommendations to push hard and fast are pretty clear. Those using proper technique and allowing chest recoil will normally be going fast enough. One study suggests that if someone are going over 120/min they may not go deep enough. On the flip side, it also means that some people may go deep enough. Those who are using proper technique will generally go deep enough. However, those people not using proper technique by bending their arms or not allowing the chest to recoil, those are the people who generally will not go deep enough. With feedback device manikins, students should be encouraged to go deep enough to hear the click or see the light on the manikins that may represent what at least 2 inches may be. In training all students should hear the click or see the light on feedback device manikins to show adequate depth. However, real people don't have clickers and people will not know a measurement in inches.
I am unsure why most of the illustrations or demonstrations are still showing the bear minimum speed of 100/min or less. The guidelines stated that studies showed improved survival rate speed as fast as 120/min and should probably be the desired target range if it improves survival.
Every 5 years there are changes or updates to the AHA guidelines.
2005: About 100/min
2010: At Lease 100/min (With better survival rates as fast of 120/min
2015: Target Range 100 to 120/min
2020: Target Range 100 to 120/min
By using a simple stopwatch and a counter in reality HEARTSAVER can prove that most students who did what felt natural, find pushing hard and fast rhythmic flow while using proper technique, going deep enough were doing 100-120/min. In reality most students actually do about 125 to 133/min by just doing what feel natural and stainable. I have learned and can prove that when students just react to the body's normal rhythm, they are able to be maintained that speed for up to 4 minutes. For additional training I have students do 2 minutes on the adult followed by 2 minutes on the child while using the AED. Students are given time to develop muscle memory and time to develop their hard and fast flow or rhythm that are validated with a counter that shows student actual numbers that students can see. When students see what they are actually doing in real times builds the students confidence. Students should be trained to react, leave their training confident and able to provide high-quality CPR.
As you see those number are subjective based on each student's fitness level however it is the reality of what the heart rate should be with physical activity or stress. So, expecting everyone to have the exact number in every case is not realistic.
The training DVD does not reflect real time speed and only going 80/min during 1 Rescuer BLS demonstration. Most instructor don't have a clue of that speed therefore students or even some "Code Teams or High-Performance Teams" may not aware of the slower speed. However, there is a section in the training DVD insert makes that makes reference that it does not reflect real time CPR.
"Dramatization of material is designed for demonstration purposes and does not reflect the extensive variations and challenges faced by rescuers faced by rescuers during actual resuscitation attempts". Source: Insert from 2010, 2015 & 2020 BLS Provider DVD.
People copy what they see on the video DVD. Some instructors have not personally performed CPR, seen it being done, been part of the code team or ER team and may not know what it looks like to push hard and fast in reality. Also consider other factors such and stress, epinephrine and adrenal that is uncontrollable bodies response that helps creates the faster rate. Some people still be encouraged to use the song "Staying Alive" a song from 1977. Using that song back in 2005 was reasonable back in 2005 when the recommendations were to go about 100/min. The mindset back then is something is better than nothing that still true today. However, the beat of that song was going about 103 times a minute according to a news team reporting the story. I am not sure why someone would think that younger people, those from different nationalities, cultures and races have ever heard that or other songs. On paper it sounds nice however you don't see illustrations or have someone practicing for more than a minute if that. However, something is better than nothing, but it needs to be fast.
I think people would be better served if they are trained to react to the crisis and do what feels normal and natural just by pushing hard / push fast that is a rhythmic flow in the center of the chest. Most people who have actually performed CPR know, that in a crisis you will not be thinking or trying to remember a phase or song. Most often those songs are never practiced for an extended amount of time.
On paper this is what it says. But what does the information actually mean and how does it relate to real world CPR?
OVERVIEW (Keeping it Real-Reality)
The AHA Guidelines are giving you numbers that you really can't count (100-120/min compressions that is in 60 seconds) and compression depths that you can't really measure (1-1/2 inches on the infant, about 2 inches on a child and at least 2 inches but no more than 2.4 inches). People in society comes in different shapes and sizes such as petite size and supersized. Compression depths are subjective based on the size of the person and if you think you are compressing the heart between the sternum and spine. No one actually has a ruler sticking out of their chest to measure. Real people don't have clicker or lights that flash to let you know if you are going deep or fast enough. (Find a rhythm and a flow that is hard and fast, go deep enough where you think you are smashing/compressing the heart between the sternum and spine on a hard flat or firm surface. Best guess based on the size person you are doing compressions on.
The DVD training video are demonstrating technique only as it indicates in the insert of the DVD. However, it may not be clear to instructors or students. The DVD are showing illustrations that are slow and don't represent real world CPR speed or the current compression speed of 100-120/min during the 1 Rescuer BLS section. Using a stopwatch and a counter reveals that the illustrations shows that they are going 80/min. I only imagine that most students and instructors assume what they are seeing what is looks like in reality. Sometimes doctors slow nurses down and CPR instructor's slow student down. It would be inconsistent to follow the guidelines and student manual instructions to push hard and fast then have someone tell you that you are going too fast.
Regarding "team dynamics" and based on what is shown and illustrated it may be assumed that everyone that is taking a BLS Provider course all work in a hospital setting, are part of a "Code Team or High-Performance Team," work in the Emergency Room or on a medic unit where they all have a team that have crash cart and cardiac drugs. However, if the healthcare providers are not part of one of those classifications, they're on their own and have to react and deal with the situation.
Unfortunately, those other healthcare providers who don't work in a hospital setting or have teams such as " those work home health, work in a doctor's office, work in clinics, travel nurses, pharmacist, dentist and others" will all be on their own. Most work location may not have a team and most likely have not trained together as a team or have or developed an action plan for their facility. They also don't have the luxury of pushing a button to active the Code Team or High-Performance Team to respond and come do all of the work. If the organization don't have a cardiac crash cart or cardiac drugs probably don't have a "Code Team" or understand team dynamics or that concept. Some Healthcare Providers may not be mentally prepared to react to a crisis outside of a hospital setting like on the street, office or at home. New information suggests the 77% of cardiac arrest occurs outside of a hospital setting (your home and 50% of that is unwitnessed.
If you're own your own, the best information regarding CPR and to keep things short and sweet with (HAND'S ONLY CPR / COMPRESSION's ONLY) Call 911 and to Push Hard and Fast in the Center of the Chest. There are (No Numbers, No Breathing and No Counting). I would just add to use proper technique by keep your arms straight, elbows locked and allow full chest recoil. Because of COVID or for other safety concerns AHA has information to cover your nose and mouth with a mask or cloth, cover victim's nose and mouth with a mask or cloth and do Hands-Only compressions.
At HEARTSAVER you will practice pushing hard and fast in real time speed, pushing deep in real time depth, doing several minutes of compressions to develop muscle memory and a rhythmic sustainable flow. In crisis you will react based on your training.
Because the foundational training DVD video does not reflect real time speed, the manikins does not represent the size, shapes and weight of real people in society somethings are not realist. The make-up of society is diverse, and no one will know if the victim will be petite size or supersized. It may be necessary to adjust, adapt and modify if the foundational information is not working. Rescuers should do whatever it takes and work through the problems by adjusting, adapting and overcoming issues in order to perform "High Quality CPR". Real people are not robots, computers and everyone may not react the same. Also consider the human factor such a stress, epinephrine and adrenaline that are also factors while performing those lifesaving efforts.
The new 2020 Student Manuals and Guidelines now include information about (Stroke, Anaphylaxis, Drowning, Heart Attack and CPR on Pregnant Women). However that information is not being shown in the training DVD video and it refer back to the student manual.
HEARTSAVER instructors will also demonstrate all of the skills and provide the information that is in the DVD training video however, it will be demonstrated and illustrated and shown in real time speed 100-120/min. Most people copy what they see. HEARTSAVER provides additional time for students to practice in order to develop muscle memory and a hard/ fast rhythm, instructor will use a counter to actually show students what their hard/fast rhythm speed is, provide feedback, be sure students are using proper technique. When students understand the information and how it relates to real world CPR and if it makes sense to them it will build confidence. Most students will have done over 600 compressions each at HEARTSAVER.
If students are not trained properly, are not confident or understand the foundational information they may not react, may panic or freeze and unable to provide High Quality CPR when it really mattered. It would be even worse if that person had to try to perform CPR on a family member or someone there care about. In a crisis you will revert back to your training.
Healthcare Providers are those who work in the medical field. However, titles of a doctor or a nurse are subjective and does not mean they are all trained the same. What kind or doctor or nurse are they? Doctors and nurses are not trained as First Responders and may not be properly prepared to deal with any emergency situations outside of the hospital setting in a real world situation on the street. Most will be out of their field of expertise "out of their lane". Most healthcare providers have specialized skills and training for the area or unit that they are working such as doctors that are trained to treat the eyes, nose, bones, surgical procedures, medical doctors, cardiac or infection disease doctors. All doctors and nurses are not normally trained in same or in all areas. Doctors give referrals to patients because it may be out of their lane of practice or expertise. Most people do not know that most nurses have not been trained in first aid and something that I have mentioned in all of my classes.
The problem may be that a person with a PhD, a veterinarians, pharmacist or dentist are also examples of those that may be called doctors. A nurse may be trained to work in a nursing home, hospice or in a doctors office. If does mean they are also trained to deal with delivering babies, assisting in surgery or in an emergency room. Most nurses of those in the medical may not have taken a formal class First Aid class unless they that the class on their own. BLS Provider course normally covered CPR/AED and choking but does not include first aid too.
The new 2020 BLS Provider Student Manual content will have information on the follow topics. However, some of that information is not shown or in the new DVD training videos.
- Heart Attack
- CPR of Pregnant Women
- Stroke
- Drowning
- Anaphylaxis
NOTE: Please be aware that some online CPR sites or other organizations may indicate that they are (AHA) American Heart Association compliant, equivalent to, or follow AHA guidelines. However most may not be accepted by some healthcare facilities as they are not the official (AHA) American Heart Association provider and don't provide students with the official American Heart Association certification card. Some online training may have do CPR and use by clicking a computer mouse click. Some hospitals may put students into a room with a computer and manikin alone without someone to provide feedback, a way for students to ask questions or be corrected if the they were using bad technique.
Rescuers need to understand the information and learn proper technique. Proper training and mastery of these skill requires hands on training, feeling confident and understanding the information will help students retain the information. Going through the motions will not prepare anyone when a real crisis occurs. In a crisis most people will revert back to their training.
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CPR Critical Concepts
HIGH-QUALITY CPR
- Start compressions within 10 seconds of recognition of cardiac arrest.
- Push hard, push fast: Compress at the rate of 100-120-/min (100-120 compressions and 2 breaths in 60 seconds) with the depth of:
- At least 1/3 the depth of the chest, about 2 inches (5 cm), for children
- At least 1/3 the depth of the chest, about 1-1/2 inches (4 cm), for infants
- Allow complete chest recoil after each compression.
- Minimize interruptions in compressions (try to limit interruptions to less than 10 seconds).
- Give effective breath to make the chest rise.
- Avoid excessive ventilation.
Use proper technique by keeping your arms straight and elbows locked. (Most will not go deep enough if arms are bent).
The universal compression rate for all cardiac victims is (100-120/min) (All the same for the adult, child & infant).
The compression-to ventilation ratio for 1 person CPR (30:2) (All the same for the adult, child & infant).
For 2 person CPR for child & infant (Ratio 15:2) for healthcare providers. It is still (30:2) for the adult.
Hands-Only: Doing only compressions. (No numbers, No breathing and No counting). Only pushing hard and fast in the center of the chest.
In my opinion; putting your mouth on anyone especially on any stranger should not be an option. With COVID that has been proving deathly for some plus other health risk consideration, doing mouth to mouth should be revaluated as it may be a unsafe practice or recommendation. However, you can put your mouth and do mouth to mouth on anyone that you want to gives breaths to. In 2020 the AHA provided the following information.
COVID-19 and Adult CPR
- Call 911 and get an AED.
- Cover your own mouth and nose with a face mask or cloth.
- Cover person's mouth and nose with a face mask or cloth.
- Perform Hand's -Only CPR (Push hard and fast in the center of the chest at a rate of 100-120 compression per minute.
- Use an AED as soon as it is available.
In my opinion when talking about Hand's - Only CPR, the word CPR should not be used as it does not represent what you are doing or represents the abbreviation. The word CPR in this case should be changed to (Chest Compressions) because all you are only doing are chest compressions. The (C) in CPR (C) for cardio that refers to the heart and performing (compressions) (P) for pulmonary that refer to the lungs and giving (breaths) (R) for resuscitation that refers to performing both compressions and breaths.
(CPR) Cardiopulmonary resuscitation: The 2 key components of CPR are chest compressions and breaths. Hand's-Only CPR providing chest compressions without breaths. (2020 Student Manual pg 108) (No numbers, no breathing and no counting).
On paper you are given (speeds) you can't count in a minute and (depths) that you can't measure. Detecting breathing has been deemphasized and pulse checks have been deemphasized. The look, listen and feel had been removed in 2010 because rescuers failed to start CPR when they saw agonal gasping.
Most people would not have a clue what agonal gasping is unless they have work in hospice, a nursing home or was in a room when the person died.
Keeping it Real
The compression rate of (100-120/min) for your speed and the depths of (2 inches on the adult, about 2 inches on the child and 1-1/2 on the inches) may be confusing and really serves no purpose to give those numbers. The reality is that no one will know their actual speed in numbers or know the depths is inches on a real person. However, the Hand's Only instructions of push hard and fast in the center of the chest. I would also add use proper technique by keeping your arms straight and elbows locked you will most likely go deep enough. If you push hard and fast as instructed in most cases you will be going fast enough. There are no numbers, no breathing and no counting. Use a protective mask or protective shield if you choose to give breaths too. However, with Covid the AHA steps for CPR are to cover yours and the victim's nose and mouth with a mask or cloth and do Hand's Only CPR.
HEARTSAVER uses and counter and stop watch and show students actual numbers and valid their pushing hard and fast real time speed. As a results all students leaves the class confident, more likely to render aid and understand that their normal response is regarding speed. Most are normally going within the 100-120/min range. Some may be slightly more as you also have to factor in the human element such as stress, epinephrine and adrenaline that is closer to 125 to 132/min and would represent the speed of the heart is the real life in a fight or flight situation. As a experiment see what your heart rate is after running on a treadmill or after physical activity. I have student with fitbit watch see what their heartrate is after doing 4 minutes of CPR training. I have ranges from 125 to180/min that will be subjective to each person. If the instructions are to push hard and fast no one should be telling anyone that they are going to fast. Your body and you fitness level will help determine what your (hard and fast speed is. It is your sustainability and your rhythm or flow. If your arms are straight, your elbows are locked and allow the chest recoil/allowing the blood to return back into the heart; then you are providing High Quality CPR.
One study stated that some people may not go deep enough if they went over 120/min. However, you're not going to know those numbers and those are the people who are not using proper technique. Bending arms and not allow the recoil / or blood return back into the heart during compression is not proper technique. It is not about a number that you will never going to know it is about pushing hard and fast that will be based on everyone's own personal body and fitness level too.
Because no one has a ruler sticking out of their chest and with society with different shapes and sizes no one will really know what 2 inches or 2.4 inches are on the adult. Everyone is not the same size of a training manikin. Some people may be supersized or petite size. Understand that you need to go deep enough to compress/ smush the heart between the sternum and spine to force the blood out of the heart whatever that may be based on the size of the victim.
In reality, if you push hard and fast in the center of the chest while using proper technique by keeping you arms straight, elbows locked to allow chest recoil / heart to refill you probably with going fast and deep enough.
Translation of what High Quality CPR really means
- Assessment: Once you do a proper assessment and determine that the person is not responding or breathing normally or gasping start CPR.
- Push Hard, Push Fast: Rescuers find a fast rhythmic speed/flow that is consistent, sustainable while using proper technique by keeping arms straight, elbows locked and allowing the chest to fully recoil. Your hard and fast is what your body allows you to do. The reality is that no one should be telling someone else that they are going too fast. Doing 100 to 120 compressions and giving 2 breaths in 60 seconds is fast.
- Depth: You are trying to smash/compress the heart between the sternum and spine. Victim needs to be on a hard/firm flat surface. When compressing you are going deep enough to force blood out of the heart. The reality is that no one has a ruler sticking out of the chest so you are not going to know what a least 2 inches on a adult, about 2 inches on a child or about 1-1/2 inches on and infant. (Depths are subjective and based on the shape & size of the victim). Go deep enough where you think it is deep enough to force blood out of the heart.
- Recoil: Is when you are coming back up allowing the blood to return/refill the heart. (Blood goes out heart when you are doing a compression/ Blood is refilling/returning back into the heart when you coming back up. (You become the Heartbeat)
- Interruptions: Any time you stop compression to disrupt oxygenated blood going to the brain. When you start again now you have to prime the pump (may take 5 to 10 compressions to prime the pump) to get that pressure back..
- Breaths: Give breath to get the chest to rise. Once you see the chest rise that is letting you know that the lungs are full. Stop blowing when you see chest rise.
- Excessive Ventilation: Once the chest has rise that means that the lungs are full. If you keep blowing. that air may get redirected and go into the victim stomach causing gastric inflation (air goes into the stomach) resulting in the victim throwing up. If you choose to do mouth to mouth they may throw up in your mouth. With Covid it is probably not the best choice but it is still your choice.
Keeping it Real (DVD Training Video)
Most CPR instructors and students are not aware of the statement information in the AHA DVD training video insert. Students are not normally informed that the DVD video is a demonstration and does not reflect how things are in actual resuscitation attempts. However people copy what they see and most think what they are seeing reflects how things are done in "real world/real time" CPR. Those doctors who are not part of the "Code Team or High Performance Team" may slow nurses down and instructors slowing students down. The instruction to "Push hard/Push Fast is pretty clear. The compression rate speed in the training video are slow.
Source: Statement that is in the BLS Provider DVD Training Video Insert from 2010, 2015 & 2020
"The American Heart Association's Basic Life Support Course teaches foundational skills essential for saving lives. Educational material developed in the form of animations, images, descriptive text, and reenactment scenarios creates a rich learning experience for learners. Dramatization of material is designed for demonstration purposes and does not reflect the extensive variations and challenges faced by rescuers faced by rescuers during actual resuscitation attempts. For specifics on ratio, timing, cycles and duration of these lifesaving techniques and maneuvers, learners are encouraged to refer to the BLS Providers Manual and published comprehensive AHA Guidelines for CPR and ECC as the primary source". (Insert from the DVD Training Video)
"Creating an effective strategy to translate BLS skills to real-world circumstances presents a challenge. This section updates the adult guideline goals of incorporating new scientific information while acknowledging the challenges of real world application". (Source: 2010 AHA Guidelines pg S686)
Keeping it Real
The compression speed in the training DVD for 1-Rescuer Adult BLS is illustrated slower to show proper technique, hand landmarks and foundational skills. I think the key phase is ("designed for demonstration purposes and does not reflect") The illustrations in the DVD does not reflect real time CPR speed and is only going 80/min while they are perform 1-Rescuer Adult BLS. That speed does not reflect the extensive variation and challenges and clearly does not reflect real time speed when someone is pushing hard and fast. The recommended speed is 100-120/min. Most instructors are not aware of that statement and don't let their students know. Most student have been learning and copying things that doesn't reflect real time speed and better survival rate speed. However, something is better than nothing.
Source: Statement at the beginning of the DVD Training Video:
"Products are shown for demonstration purposes only, The AHA does not endorse or recommend any specific manufacturer or product"
"In order to show skills clearly, the healthcare providers in this video do not always use recommended personal protective equipment (such as gloves)".
The training video shows you the proper hand landmark locations, proper technique and foundational information to give you an idea how things are done. However real time CPR is faster and is not being reflected in the videos. No instructor should tell students that they are going to fast when the 2010 & 2015 student manuals tells you to push hard & push fast.
Source: (2010 BLS Student Manual pg 2 & 2015 Student Manual pg 3, 2015 First Aid CPR AED Student Manual pg 85)
Most instructors have not personally done CPR in real life or been part of a code team to see and understand the extensive variations and challenges faced by rescuers during actual resuscitation attempts. (A range of 100/min to 120/min in 60 seconds is fast). Push Hard/Push Fast is what it means. Epinephrine and adrenaline is a human element and factor that you have no control over in a real life situation. HEARTSAVER uses a tally counter to prove and to show students exactly what their compression speed is and where they are in the 100-120/min range. It makes a difference and builds confidence when students find out and see that their normal reaction will generally putting them in that range or slightly more.
SCENE SAFETY
Be sure that the scene is safe for you.
Keeping it Real
Be sure you are not putting yourself in harms way. You can't help anyone if you are injured or dead. (Active shooter, electrical wire, poisons, car accident scenes etc).
LOOK, LISTEN AND FEEL (Was Removed in 2010)
Look for chest rise, listen for breaths and feel for air on your cheek.
(Guidelines now tells you to scan victim's chest for rise and fall for no more than 10 seconds)
In 2010 the AHA Guidelines removed the look, listen and feel as a mechanism for assessment. It use to be open airway, look for chest rise and fall, listen and feel air on you cheek. HEARTSAVER have been telling students prior to that change; in the real world especially if you were outside you would not be able to hear someone breathing or feel breaths on your cheek because of the wind, crowd, traffic and the environment. Also it would be challenging to see chest rise and fall if they were wearing things like a hoodie, sweats, layers of clothes or coat or jacket. However, the AHA removed it from the assessment step because bystanders failed to start CPR when they observed agonal gasping.
"Another key change is the removal of "look, listen and feel for breathing from the assessment step. This step was removed because bystanders often failed to start CPR when they observed agonal gasping. Source: (2010 BLS Student Manual pg 4)
"The BLS Algorithm has been simplified, and the "Look, Listen and Feel " has been removed from the algorithm. Performance of these steps is inconsistent and time consuming". Source: (2010 AHA Guidelines pg S643)
"The directive to look, listen, and feel for breathing to aid recognition is no longer recommended". Source: (2010 AHA Guidelines pg S678)
"These 2010 Guidelines for CPR and ECC deemphasize checking for breathing. Professional as well as lay rescuers may be unable to accurately determine the presence or absence of adequate or normal breathing in unresponsive victims because the airway is not open or because the victim has occasional gasp, which can occur in the first minutes after SCA sudden cardiac arrest and may be confused with adequate breathing". (Source 2010 AHA Guidelines pg S689)
AGONAL GASPS
Agonal gasps are not normal breathing. Agonal gasps may be present in the first minutes after sudden cardiac arrest.
"Agonal Gasps are not normal breathing. Agonal gasps may be present in the first minutes after sudden cardiac arrest". A person who gasps usually looks like he is drawing air in very quickly. The mouth may be open and the jaw, head, or neck may move with gasps. Gasps may appear forceful or weak. Some time may pass between gasps because they usually happen at a slow rate. The gasp may sound like a snort, snore or groan. Gasping is not normal breathing. It is sign of cardiac arrest. Source: (2015 BLS Student Manual pg 17)
"Another key change is the removal of "look, listen and feel for breathing from the assessment step. This step was removed because bystanders often failed to start CPR when they observed agonal gasping. Source: (2010 BLS Student Manual pg 4)
Keeping it Real (Agonal Gasp)
In 2010 the AHA removed the look, listen and feel from the assessment steps because people failed to start CPR on people with agonal gasping. I think the bigger problem is that most people including doctors, nurses and the general public are not going to know what it is or what it sound like. Most people have not been around someone who died while they were still in the room. Depending on where someone works like those who work hospice with terminally ill patients, work in a nursing home or had a family or friend die when you were in the room; they may have some idea of what agonal gasps sound or looks like.
In the text it describes it as sounding like a snort, snore or groan. However, on the training video the illustration and show what some people may describe as a goldfish or guppy trying to breath out of water. The nicknames that have been around for many years is the (death rattle). It may sound like gurgling or fluid in back of the throat. (Zombie sounding)
If you cut the head off of a chicken the chicken is dead but the body is still running around or if you cut of head off a snake, the snake is dead by the body is is moving they are both dead but you seeing things moving after the fact. The victim is dead but you are hearing sounds after the fact.
Some may also describe agonal gasps:
* Agonal gasps may sound like a snort, snore of groan.
* A gold fish or guppy trying to breathe out of water.
* Bubbly or gurgling sound. (Nicknamed the death rattle).
CHECK RESPONSIVENESS
Tap the victim's should and shout, "Are you OK? If the victims is not responsive shout for nearby help and have some call 911.
Scan chest for rise and fall.
Keeping it Real (Check Responsiveness)
Assessing by tapping shoulder asking if they are OK to check for a response, and now scanning chest to check for breathing or gasping in my opinion may be subjective. Most people may not understand they are looking for or pretending to feel for a pulse. Most citizens and most healthcare provider are unable to reliable able to detect or feel and pulse within 5 to 10 seconds. Most can't find a carotid pulse on their own neck. I
If someone is drunk, on drugs, have a head injury or is unconscious because of low blood sugar diabetic reaction they may not respond to someone tapping the shoulder. If your spouse worked all night or they have been drinking all night or on medication see if tapping them is going to wake them up. Try waking up your child by tapping them to get them up for school. If they don't respond to those taps are you going to start CPR on them too? What about the older person that has a hearing aid or has poor hearing. How loud is considered loud enough.
When it come to (Shouting) how loud do you shout? HEARTSAVER recommends using a stronger louder voice and tone. My suggestion if it is a female yell "ma'am can you hear me, open your eyes" and for the guys say "sir" staying the same thing. Using a strong loud voice as a verbal stimuli.
The new thing for in 2010 is scanning the chest to check for breathing. This still may challenging to check for breathing if the person is wearing a jacket, hoodie, sweatshirts, several layers of clothing of something bulky.
Keeping it Real (Additional Assessment Options)
- Check if victim is Awake and Alert or (Pink or Purplish/Bluish)
- Responsive to Verbal Stimuli
- Responsive to Pain
- Unresponsive (does not respond to verbal or painful stimulus).
Because of the different stories I hear of people starting CPR on someone who is drunk, passed out, hearing of non-medical or in the medical field that tried to start CPR on someone who is stating "get off me, get off me" is can be problem for the person down. Those issues may be avoided if students have obvious indicators that can be done and detected as rescuers are assessing for scene safety and checking for response. I understate when in doubt do CPR. However, I think students should do whatever is needed to be done or use whatever observations skills to lessen that doubt. Some may say if you perform CPR on someone who don't need it that it will not hurt that bad. However, if you were on the the receiving end those compressions you understand the reality of what happens. Remember that compressions depth are to go at least 2 inches that would normally separate the costal cartilage from the sternum similar to a flail chest. Someone that ever bruised or their ribs would confirm that it is painful and uncomfortable for many months. Things like breathing and getting in and out of bed would be discomforting in many cases.
Non AHA Content: Some may consider an options of doing what the EMT's paramedics emergency room doctors and nurses do to get a response. Although called sternum rub you are vigorously rubbing your knuckles up and down the upper part of their chest (sternum). The sternum rub may be an additional option and tool as it is routinely used by EMT's Paramedics, ER - Emergency Room doctors and nurses to get a response because it works within seconds. It is used because it works. Some information suggest using the sternum rub to try to get a response for the suspected of opioid overdose. Other options also found the EMT books that you may consider; loud verbal stimuli, firmly pinching the ear lobe, press on bone above eye or gently but firmly pinch the muscles of the neck,
The sternum rub is not anything that the American Heart Association tells you to do. I think an additional options should be considered to give the rescuer a tool to assure that the victim is actually unresponsive and not breathing. Tapping someone shoulders, looking chest rise on people with layers of clothes and listening for agonal gasps the most people haven't seen to know what it is may be challenging as the only assessment tool. With today's social climate of claims of women being touched I think additional safeguards should be considered. Compressions are done in the center of the chest. The Anne CPR manikins are female however the chest doesn't represent the breast sizes of female and most may assume that they are training on a male manikin.
TIMES WE LIVE IN
I recently heard that a women wanted to file a claim against some guy that did CPR on her because he touched her without her consent. Heart attack is the number one leading cause of death in women. Ironically, it may remain number one as some may not want to do CPR or touch a women. With exposing chest for AED pad placement and doing compressions in the center of the chest may be concerning as possible false claims. Everyone is covered by the Good Samaritan Law if you are acting in good faith. You are also covered by Implied Consent when you render aid on a victim that is unconscious and if it is a life threatening emergency.
CPR should not be started on someone who is stating, "get off me, get off me".
The 2020 Guidelines now recommends doing CPR over the clothes if the person has bulking clothing that can't be removed at that time until the AED arrives.
(Non-AHA Content) Something that the First Responders, EMT's Medics and ER Doctors and Nursed may do is the sternum rub. The sternum rub is noninvasive and you should get a response or reaction within seconds. Patient will quickly push your hand away if they are conscious or flinch or have a grimacing facial expression if the are unconscious. Anyone pink and moving should be a good indicator that they are alive and CPR would not be needed. The sternum rub is a very uncomfortable sensation and should get a quick response. Those doing the sternum should be trained to do it and always know where the victim's hands are.
(Currently tapping shoulders and asking if they are OK, scanning the chest for breathing and listening for agonal gasp are the steps).
People sometimes don't hear what happens to that victim post CPR. A problem is some people are starting CPR on someone that is still breathing and has a heartbeat. Most people don't know or talk about the costal cartilage that separates from the sternum creating a possible flail chest that may take 3 month or up to 2 years to heal according to those who work post care. It is important that patients are properly assess to determine if they actually are not breathing, not responding and don't have a heartbeat. Looking for additional signs and indicators may help you make a better decision to start CPR.
In the opioid training other sources recommend that you use the sternum rub on the victim to try to get them to respond.
PULSE CHECK
Ideally, the pulse check is performed simultaneously with the check for no breathing or only gasping, to minimize delay in detection of cardiac arrest and initiation of CPR. Lay rescuers will not check for a pulse.
PULSE CHECK
"To minimize delay in starting CPR, you may assess breathing at the same time as you check the pulse. This should take no more than 10 seconds".
Source: (2015 BLS Student Manual pg 17)
"To perform a pulse check in an adult, palpate a carotid pulse. If you do not definitely feel a pulse within 10 begin high quality CPR starting with chest compressions". Source: (2015 BLS Student Manual pg 17)
"Studies have shown that both lay rescuer and healthcare provider have difficulty detecting a pulse. Healthcare providers also may take to long to check for pulse. The lay rescuer should not check for pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally. The healthcare provider should take no more than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that period, the rescuer should start chest compressions". Source: (2010 AHA Guidelines page 687)
Continued de-emphasis of the pulse check :"It can be difficult to determine the presence or absence of a pulse within 10 seconds, especially in an emergency, and studies show that both healthcare providers and lay rescuers are unable to reliably detect a pulse. If the victim is unresponsive and not breathing or only gasping, healthcare providers may take up to 10 seconds to attempt to feel for a pulse (brachial in an infant and carotid or femoral in a child). If within 10 seconds you don't feel a pulse or are not sure if you feel a pulse, begin chest compressions. Source: (2010 BLS Student Manual pg 5)
"These 2010 AHA Guidelines for CPR and ECC also de-emphasized the pulse check as a mechanism to identify cardiac arrest. Studies have shown that both layperson and healthcare provider have difficulty detecting a pulse. For this reason the pulse check was deleted from training for lay rescuers several years ago, and is de-emphasized in training for healthcare providers. The lay rescuer should assume that cardiac arrest is present and should being CPR in an adult suddenly collapses or an unresponsive victim is not breathing or not breathing normally (i.e only gasping). Healthcare providers may take too long to check for a pulse and have difficulty determining if a pulse is present or absent". Source: (2010 AHA Guidelines pg S689)
"It can be difficult for BLS providers to determine the presence or absence of a pulse in any victim, particularly in an a infant or child. So if you do not definitely feel a pulse within 10 seconds, start CPR, beginning with chest compressions".Source: (2015 Student Manual pg 47)
"As recommended in the 2010 Guidelines, healthcare providers will continue to check for a pulse, limiting the time to no more than 10 seconds to avoid delay in initiation of chest compressions. Ideally, the pulse check is performed simultaneously with the check for not breathing or only gasping, to minimize delay in detection of cardiac arrest and initiation of CPR. Lay rescuers will not check for a pulse". Source: (2015 AHA Guidelines pg S415)
"Pulse detection alone is often unreliable, even when performed by trained rescuers, and it may require additional time".
(Source 2010 AHA Guidelines pg S678)
It can be difficult for BLS providers to determine the presence or absence of a pulse in any victim, particularly in an infant or child. If you do not definitely feel a pulse within 10 seconds, start high-quality CPR, beginning with chest compressions. Source: (2020 Student Manual pg 50)
"It has been shown previously that all rescuers may have difficulty detecting a pulse, leading to delays in CPR, or in some cases CPR not being performed at all for patients in cardiac arrest. Recognition for cardiac arrest by lay rescuers, therefore is determined on the basis of level of consciousness and the respiratory effort of the victim. Recognition of cardiac arrest by healthcare providers includes a pulse check, but the importance of not prolonging efforts to detect a pulse is emphasized. Source: (2020 AHA Guidelines p S371)
"Protracted delays in CPR can occur when checking for a pulse at the outset of resuscitation efforts as well as between successive cycles of CPR. Healthcare providers often take too long to check for a pulse and have difficulty determining if a pulse is present or absent. There is no evidence, however, that checking for breathing, coughing, or movement is superior to a pulse check for detection of circulation. Thus, healthcare providers are directed to quickly check for a pulse and promptly start compressions when a pulse is not definitively palpated. Source: (2020 AHA Guidelines pg S372)
Keeping it Real
Most people pretend to feel for a carotid pulse on the neck. However most have not been trained, have difficulty or taking to long to find it. Most people can't find their own.
The Guidelines is for rescuers to check for a pulse the same time you are checking to see if they are unresponsive and breathing (agonal gasp). All 3 steps are now done at the same time so you are not wasting time checking for a pulse that most people are unable to detect or take too long to find. As you see from the 2010 , 2025 & 2020 Guidelines and student manuals it is clear that most healthcare providers and others are unable to detect a pulse. Depending on where you work and what you job is all healthcare providers don't routinely put their hand on people's neck for vital. Pulse oxy and monitor may routinely be used in hospital what setting that you are in; taking a pulse on the wrist may be done by those using old school methods.
Most healthcare providers are not experienced or have the opportunity to routinely feel for a carotid pulse (on neck) in adults, femoral pulse (groin area) in an child or brachial (bicep area) in an infants. The general public generally will not know how to feel for a pulse and why it is not recommended for them to do pulse checks. Both the general public and healthcare providers may go through the motions, fake it or pretend that the know what they a feeling for because they have be programmed to based on seeing it on TV. In training and with illustrations are pretending to feel for a pulse on a manikin that doesn't have a pulse. Most have been programmed and are going through the motions and most can't find a pulse on themselves. Healthcare providers also includes dentist, chiropractors, pharmacist and others who normally don't routinely feel for pulses anywhere on their clients.
Keeping it Real Pulse Check)
I personally thought that the pulse check would have been removed for healthcare provider in 2015 & 2020 based on the information and finding in the 2010 Guidelines and being reaffirmed. The lay-rescuer are not trained to feel for a pulse.
Keeping it Real (Indicators)
If the person his pink skin, lips, fingers, nailbeds, hands, soles of feet generally means that they are breathing. If that color have do change and consistent that general means that they have consistent pressure and circulation. That generally mean that the person have a heartbeat and pulse. However, if that person has bluish or purplish skin, lips, finger, nailbeds , hands, soles of feet that may be a good indicator that they are not breathing, have and heartbeat and pulse.
Light skinned people normally will have pink skin coloring to their face, lips, hands and fingers that you can see as you look at them. Those who are breathing will have oxygenated blood in their system and will have pink face, pink lips and is obvious when you look at them. The thing that is keeping the oxygenated blood and the pink face, lips and extremities is the beating heart. The function of the heart is to move oxygenated blood to the brain, heart and vital organs. If someone have a pink face and lips that would be a good indicator that they are alive, breathing and have a heartbeat. No CPR needed if victim is breathing and have a heartbeat. If they have a heartbeat they also will have a pulse. The color of the person's face and lip, palms of their hand and nail beds are the best indicators if they are alive or dead.
Diversity information to address different skin tones
In the student manual it briefly talks about signs of poor perfusion. I think we need to take a closer look and hear some additional information and may be the key and a better way to assess someone who is down. Light skinned people may look darker (bluish, purplish or grayish) which is not normal for their normal pink color. Those with darker skinned people may look lighter, ashy, dusky, pallor (grayish) and not normal for their normal color. If the person is not breathing you will notice color change on their face, lip, hands and nail beds.(Bluish, purplish, grayish or pale) If they are not breathing and don't have a heartbeat what color their face is going to turn (Bluish, purplish, grayish or pale). Seeing a change in the skin color is a red flag.
When someone calls the dispatcher will want to know if the person in responsive and breathing. Most people may not know that answer. I think the question should be is the person pink or purplish/bluish. Pink skin, palms, nail bed would indicate that they are breathing. If skin remains pink would indicate that there is pressure (heartbeat) that is circulating that blood.
C-A-B (Chest Compression- Airway- Breathing) over the A-B-C
The 2010, 2015, and 2020 guidelines reaffirm still using the C-A-B sequence. Compression, Airway then Breathing for those needing CPR.
This information needs better clarification because during your first contact with the victim several things normally occurs. As you approach be sure that the scene is safe. At the same time you are quickly assessing the person's A-Airway, B-breathing and C-Circulation without realizing that is what you are doing just by looking at them. If they are pink, talking, reacting or moving they have a airway, they are breathing and have circulation. Scanning someone's chest for 5 to10 seconds to see if their chest is going up and down is challenging and will be hard to tell if the person has bulky or multiple layers of clothes. Unlike the videos that you see that normally shows the chest already exposed or the button down shirts that they pop the buttons off when they open it.
Something else to consider may be looking or D-disability (stoke symptoms) E- environmental (allergies) and something some EMT's Emergency Medical Technicians may look for or ask when talking to the person as part of their primary assessment.
C-A-B however are the steps for CPR (compressions and breaths) for the person that is not responding, not breathing or agonal gasp. Rescuer would start with C-compressions, A- open Airway, B and give breaths (if properly protected). To keep it simple if the are pink and responding, moving or pushing your hand away they are alive. If they are purplish, bluish or grayish and not responding or reacting to your painful and verbal stimuli or your tap and shout CPR or Hand's Only chest compressions would be indicated.
When you are doing compression, you are compressing the heart between the breastbone (sternum) and spine. This is why you need to be on a hard flat surface. When you are doing compressions you are forcing oxygenated blood in and out of the heart that goes to the brain, heart and vital organs. (YOU ARE THE HEARTBEAT FOR THE VICTIM) and buying time for the medics come with supplemental oxygen and AED. You can't hurt someone who is already dead.
"Each time you stop chest compressions, the blood flow to the heart and brain decreases significantly. Once you resume compressions it takes several compressions to increase blood flow to the heart and brain back to to the levels present before the interruption. Thus, the more often chest compressions are interrupted and the longer the interruptions are the lower the blood supply to the heart and brain is." Source: (2015 BLS Student Manual pg 19)
" Chest compressions create blood flow to the heart through filling of the coronary arteries. Every time compressions are stopped, blood flow and thus perfusion to the heart and brain drops to zero. It takes 5 to 10 compressions to reestablish effective blood flow to the heart after chest compressions are resumed. Avoid frequent or prolonged interruptions in chest compressions, which lead to poor patient outcomes".
Source: EMT Book (Emergency Care and Transportation of the Sick and Injured 11th Edition pg 522)
CHEST COMPRESSIONS
C-A-B Compression- Airway-Breathing
Source: (2010 BLS Student Manual pg 3)
"Chest compressions are consist of forceful rhythmic applications of pressure cover the lower half of the sternum. These compressions create blood flow by increasing intrathoracic pressure and directly compressing the heart. This generates blood flow and oxygen delivery into the myocardium and brain".
Source: (2010 AHA Guidelines pg S687)
"Chest Compressions are the key component of effective CPR. Characteristic of chest compressions include their depth, rate and degree of recoil. The quality of CPR can also be characterized by the frequency and durations of interruptions in chest compressions when such interactions are minimized, the chest compression fraction (percent of total resuscitation time that compressions are performed) is higher. Finally, with high-quality CPR the rescuer avoids excessive ventilations. These CPR performance elements affect intrathoracic pressure, coronary perfusion pressure, cardiac output, in turn clinical outcomes".Source: (2015 AHA Guidelines pg S419)
COMPRESSION DEPTH
Adult: At least 2 inches - 5 cm (using 2 hands) while avoiding excessive chest compression depth greater than 2.4 inches or 6 cm.
Child: Approximately 2 inches - 5 cm (using 1 or both hands)
Infant: Approximately 1-1/2 inches.(using fingers)
Chest compression are more of often too shallow than too deep. However research suggest that compression depth greater than 2.4 inches in adults may cause injuries. If you have a CPR quality feedback device, it is optimal to target your compression depth from 2 to 2.4 inches.
"During manual CPR, rescuers should perform chest compressions to a depth or at least 2 inches or 5 cm for an average adult, while avoiding excessive chest compression depths greater than 2.4 inches or 6 cm". Source: (2015 AHA Guidelines pg S419)
"Importantly, chest compressions performed by professional rescuers are more likely to be too shallow". Source: (2015 AHA Guidelines pg S419)
Keeping it Real (Compression Depth)
The reality is that you're not going to know what at least 2 inches is on the adult, about 2 inches on a child and about 1-1/2 inches on the infant or what 2.4 inches is. People don't have a ruler sticking out of their chest and you will never what size person you may be performing CPR on. In our society there are people come in different body shapes and sizes (supersize or petite size). Compression depths are subjective based on the size of the victims. You are not going to hurt someone who is already dead. You will need to determine how deep to go (depth) based on if you think you are going deep enough to compress/smash the heart between the sternum and spine. That is the intent and why you are pushing hard, fast and deep as you now become the heart beat for the person and the reason why you need to perform compressions on a hard or firm flat surface. Rescuer objective is trying to compress deep enough to compress (downward motion) smashing the heart (that forces blood out of the heart) and allow the chest to recoil (upward motion that allows the blood to return back into the heart). Blood goes out / blood goes in. The objective is to have a fast rhythmic up and down motion or flow because you now become the heartbeat for that person.
The key is and to help you go deep enough is using proper technique by keeping your arms straight, elbows locked, body directly over the victim, going straight down and allow the chest to recoil back up (blood returning back into the heart). The length of your arm will allow time for the recoil. You will not go deep enough if your arms are bent and it is not proper technique. When you are pushing hard and fast you are just doing what your body's normal reaction is you will probably will be going deep enough.
The reality is that you are doing compressions the same way it is do with the (Hand's-Only Compression-Only). Push hard and fast in the center of the chest. Keep your arms straight, elbows locked to allow full chest recoil i.e. for the blood to return to / refill the heart. No numbers or counting.
The current CPR manikins don't necessarily represent the shape and sizes of the population as some are petite size or supersized. You need to go deep enough where you think your are compressing the heart between the sternum and spine that would be based on who was in front of you. With a supersized person you may need to use more of you body weight to get the depth that you need to compress the heart. Use less of your body weight on a petite size person. HEARTSAVER has an obese manikin without a clicker that forces students to use their judgement if you think you are going deep enough to compress the heart between the sternum and spine. Real people on the street don't have clickers and you would have to use your judgment on how deep to go based on the victim's shape and size. (Best guess based on the size of the victim)
FIRM SURFACE
"Compressions pump the blood in the heart to the rest of body to make compressions as effective as possible place the victim on a firm surface, such as the floor or backboard. If the victim is on a soft surface, such as a mattress, the force used to compress the chest will simply push the body into the soft surface. A firm surface allows compression of the chest and heart to create blood flow."
Source: (2015 BLS Student Manual pg 19)
Keeping it Real
You are trying to compress/smash the heart between the sternum and spine. Going deep enough trying to compress/smash the blood out of the heart and allowing the blood to return is the recoil. (Blood is being forced out by the compression and refilling(blood returning back into the heart) is the recoil). In the case of Michael Jackson, you had a heart doctor trying to perform CPR on the bed with the mattress and springs. Jackson should have been pulled off the bed and CPR should have been performed on the floor that was a hard flat surface. Hospitals may use a backboard, or a hard device that they put under patients back. Some of the newer beds may you push a button the make the bed firm.
CHEST RECOIL
It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest.
(Information from the Guidelines)
"Full chest wall recoil occurs when the sternum returns to its natural position during the decompression phase of CPR. Chest wall recoil creates a relative negative intrathoracic pressure that promotes venous return and cardiopulmonary blood flow. Leaning on the chest wall between compressions precludes full chest wall recoil". Source: (2015 AHA Guidelines pg S420)
"Chest recoil allows blood to flow into the heart. Incomplete chest recoil reduces the filling of the heart between compressions and reduces the blood flow created by chest compressions. Chest compression and chest recoil/relaxation times should be about equal". (2015 Student Manual pg 20)
Keeping it Real (Technique)
When you are performing proper chest compressions; your arms should be straight and elbows should be locked out and not bent. When you are performing CPR you are compressing down smashing /compressing the heart between the breastbone (sternum) and spine that forces the blood out of the heart. When you are coming back up you are allowing the heart to refill (chest recoil) allowing the blood to return back into the heart. The key is keeping your arms straight and elbows locked as if you are a plunger. Don't bend your arms. You need to be on a hard flat surface in order to compress the heart between the sternum and spine. With your compressions you become the heartbeat for the victim and the heart normally don't stop.
CHEST COMPRESSION LOCATION
Chest compression are performed in the center of the chest on the lower half of the sternum/breastbone nipple line area. Avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest.
Keeping it Real
False claims of being touched may be coming a concern for those doing CPR on women as society has created that environment. We all have been doing CPR training using the adult, child and infants for many years. However, we all thought we have been trained and practiced on male manikins. However Little Anne manikin is a female. Because of the size of the chest we never paid much attention to where our hand are related to the breast. We never thought about where are hands and being placed. We have not been desensitized to that and would not have thought that someone may have an issue.
Unfortunately because of today's society and sue happy people or those with an agenda some people may be hypersensitive and make false claims of women being inappropriately touched during CPR. If a female has a heart attack or sudden cardiac arrest your hand placement is in the center of the chest is for both male and female as it has been on the onset of CPR. The Anne CPR manikins are female manikins, however the manikin's breast size are small like a male so those who have been trained have not had a visual image of a female anatomy with breast. You are not inappropriately touching someone while you are doing compressions in the center of the chest.
Heart attack is the number killer of women. Unfortunately it probably may remain that way as some people may not want to touch a women to perform CPR on them for fear of the possibility of unfounded claims. We may need to have more discussions about the Good Samaritan Law and Implied consent that are safeguards that are designed to protect rescuers in these situations.
COMPRESSION SPEED - Optimal Target Range 100/min to 120/min (Push Hard - Push Fast)
The old information in 2005 stated compression rate speed about 100/min, in 2010 they changed the wording to at least 100/min. The 2015 guidelines states the optimal target rate is between 100/min to 120/min. They are trying to get people to push harder and faster as long as there is chest recoil (going up and down). In 2020 the target range remains the same 100 to 120/min.
PUSH HARD - PUSH FAST in the Center of the Chest
2010, 2015 & 2020 Guidelines
Keeping it Real
In my opinion no instructors or anyone should tell students that they are going to fast when the 2010, 2015 and 2020 Guideline instructions clearly tells rescuers to push hard and fast. If you are performing CPR you are trying to do 100 to 120 compressions and give breaths in 60 seconds so that is fast. The most important key for CPR compressions is using proper technique by keeping your arms straight, elbows lock, going deep enough to compress the heart between the sternum & spine and allowing the chest recoil. You will not go deep enough and get tired quicker if your arms are bent or not allowing the chest to recoil. There is currently no current illustrations in training video that actually show students actual real time compression speed while showing actual numbers per minute. (HEARTSAVER uses a counter and a timer to show student actual speed).
Keeping it Real (Using Songs)
Doing something is better than nothing. There are some songs or suggested songs out there. If you think using a song will help it needs to be a fast song. On paper it may sound like a good idea however, I think using a song may be more of a distraction for most. In reality you are just reacting, doing what feels normal and natural and finding a fast rhythmic flow. Pushing hard and fast is subjective to each person because everyone in different. Everyone has different physical activity and some people may not be in the best shape, has physical challenges have not developed muscle memory.
Some are still telling people to use the song "Staying Alive". The problem is that was something that they came up with in 2005 when the recommendations were to go about 100/min that would be the bear minimum the current 2020 range. In the 2010 Guidelines also talked about better survival with compression rate as high as 120/min. Now what about the younger people or people from different cultures and backgrounds or have never listened to disco music.
However if you don't listen to songs from the 1970's, listen to rap, disco country or kids songs those suggestion may not be relevant to you. To simplify, if you just push hard and fast in the center of the at a consistent rhythmic flow you generally will be going 100-120/min range. Just do what feels normal and natural. Also consider other human factors that is not discussed such as stress, epinephrine and adrenaline that will make things faster. It is not about a number that you will never see or know. It is about doing what the heart would be doing while fighting for its life.
Source: According to a report from MSNBC on 10/16/2008 it stated " Turns out the 1977 disco hit his 103 per minute, a perfect to maintain and retain the best rhythm for performing cardiopulmonary resuscitation, or CPR"
The news report also made mention of another song," Another Bite the Dust". During that time period back in 2005 the Guidelines had the compression rate was to go about 100/min so it made sense in 2005. The 2010 Guidelines was changed to go at least 100/min. making those songs the bare minimum. The 2015 Guidelines have a range of 100 to 120/min. 2015 guidelines also states the studies shows improved survival rate as fast as 120/min
COMPRESSION SPEED 100-120/min
"The compression rate refers to the speed of compression, not the actual number of chest compression delivered per minute. The actual numbers delivered per minute is determined by the rate of chest compression and the number and duration of interruptions to open the airway, deliver rescue breaths and allow AED analysis". Source: (2010 AHA Guidelines pg S690)
"The study also demonstrated that improved survival occurred with chest rates as high as 120/min".Source: (2010 AHA Guidelines pg S690)
"Chest compression rate is defined as the actual rate used during each continuous period of chest compressions. This rate differs from the number of chest compressions delivered per unit of time, which takes into account any interruption in chest compressions". Source: (2015 AHA Guidelines pg S419)
"These investigations suggest that there may be an optimal zone for the rate of manual chest compressions between 100 to 120/min that on average is associated with improved survival". Source: (2015 AHA Guidelines pg S419)
Keeping it Real & Other things to Consider (Compressions)
Something is better then nothing. Don't be focused on actual numbers that you never are going to know, going to see or can't actually count. With Hands-Only CPR (No Numbers, No Breathing and No Counting). In reality you are not doing CPR because CPR is compressions and breaths. Hand's Only actually refers to doing compression's only without giving breaths. All you are doing is just pushing hard and fast in the center of the chest.
To make in more complete I would just add and include using proper technique by keeping your arms straight, elbows locked to allow full chest recoil or the blood returning back into the heart. Pushing Hard, Pushing Fast is subjective to each person who is doing it and is a rhythmic flow and a speed that is comfortable and sustainable for each person. The key is using proper technique because in the real world no one will know numbers, no one counts numbers and no one cares about numbers on the street. If songs are being used to determine your speed in may be easier to do what is suggested and just push hard and fast. Moving oxygenated blood to the brain and throughout the body is what the heart does and why you are doing CPR. You are the heartbeat for the person that is fighting for its life.
Compression speed range is 100-120/min. The 2015 guidelines also indicates that better survival rate as high as 120/per min. Because there is 60 seconds in a minute no one can actually count 100-120 in 60 seconds. No one actually knows how fast they are doing it. In a crisis or in a high stressful situation the bodies normal reaction will produce epinephrine & adrenaline that you have no control of. Feedback manikins give you an idea if you are in the range however don't tell you if you are in the low range or high range.
HEARTSAVER will show students real time numbers that reflects where each person are in that range. Instructor uses a tally counter and timer to prove and show that if the student is doing what feel natural while pushing hard and fast with a rhythmic flow, with equal up and down compressions normally will be going within that 100 to 120/min range or slightly more. It is not about a number that you are never going to know or see it; is about a rhythmic speed and flow that is equal and sustainable while using proper technique and recoil. Only you and your body will determine what your rhythmic flow and sustainable speed is for you. You are not a robot, computer or a machine and everyone's comfortable rhythm will be slightly different and will be slightly changing the longer you are doing CPR.
One study stated "that if someone who did over 120/min they may not go deep enough". That may also means that if you are performing CPR and using proper technique some may be going deep enough. If you are bending your arms you may not go deep enough and is not proper technique. You also may get tired quicker. When using a training manikin with a feedback with a clicker or light it would indicate that you are going deep enough. Be consistent with the compressions while using proper technique by pushing hard and fast with a rhythmic flow that is equal and sustainable, keep your arms straight and your elbows locked out, allowing the chest to recoil that will allow the blood to return back into the heart.
At HEARTSAVER we have students check their heart rate after doing 2 or 4 minutes of compressions. Depending on their fitness level we see ranges from 120 up to 180/min. There heart is not beating to fast and is just doing what the heart is suppose to do under physical exertion, or stress. In real time CPR you are going to be under stress and when the epinephrine and adrenaline kicks in the heart rate and speed are going to be fast. See what your heart rate the next time you are jogging on the treadmill.
In 2005 the JAMA (Journal of the American Medical Association) had published information that CPR performed in hospitals were not pushing fast or deep enough. Sources: (January 19, 2005 issue of JAMA)
On July 2009, there was a Medicaid study that stated "The odds of surviving cardiac arrest after getting CPR in a hospital are slim and have not improved in more than a decade, a big Medicare study concludes. Only about 18% of such patients live long enough to leave the hospital , researcher found. Black fared worse than whites a disparity on partly explained by more of the being treated in hospital that did a poorer job of CPR". There were news articles and reports on national news on MSNBC, CBS, USA Today & ABC news repeating the findings Those finding were also published in the New England of Medicine
Source: Published in the New England of Medicine (Information in 2009 from New Reports from MSNBC, CPR/AP, USA Today, & ABC News)
The phase push hard and fast started to be used in 2010. People just don't understand what real time compression speed looks like and the numbers that reflect that speed. It can't be an exact number because of the one thing that is being left out of the equation is the human element of (stress, epinephrine and adrenaline) Rescuer are not robot, machines or computers and everyone fitness level is different.
Ironically those who have not been trained in CPR may do a better job of CPR because they are pushing hard and fast just going on their instinct with the addition of epinephrine and adrenaline kicking in. They have not been programmed or trained to try to figure out numbers that no one is going to see or know anyway. The reality is that we are given information about numbers that we can't count and depths we can't measure. The Hand's-Only instructions are to push hard/push fast in the center of the chest. There are no counting, no numbers and no breaths. Something is better than nothing.
CPR Coach
"Studies have shown that resuscitations teams with a CPR Coach perform higher-quality CPR with a higher CCF ( chest compression fraction) and shorter pause durations than teams that do not use a CPR Coach".
"The CPR Coach's main responsibilities are to help team members provide high quality CPR and minimizes pauses in compressions". " The CPR Coach gives feedback and performance or compression depth, rate and chest recoil". "The CPR Coach gives team members feedback about ventilation rate and volume". " The CPR Coach communicates with the team to help minimize the length of pauses in compressions. Pauses happen when the team defibrillates, switches compressors, and places and advanced airway". Source: (2020 BLS Provider Manual pg 31)
The Code Team - High Performance Team was normally 6 person team with specific duties and responsibilities.
(Airway, Recorder, Compression, AED, Medication & Team Leader)
In the 2020 Guidelines they added a CPR Coach to the (High Performance Team - Code Team) blended with AED duties. Apparently there still may a problems with compression speeds, compression depths and interruptions from those performing CPR in hospital for this to be added. The CPR coach duties are to be sure that those who are performing CPR are pushing hard and fast enough, going deep enough, being sure that when switching to another rescuer is faster and not interrupted and starting compressions immediate after delivery of the shock from the AED. It appears that there are still delays and interruptions. I see a pattern of hospital staffers not pushing hard and fast from the Journal of Medical Association JAMA report in 2005 and the 2009 study that was published in the New England of Journal of Medicine.
HAND'S ONLY - COMPRESSIONS ONLY
(Untrained - Lay Rescuer)
For lay rescuer, compression-only CPR is a reasonable alternative to conventional CPR 30 compression and 2 breaths in the adult cardiac arrest patient. For trained healthcare rescuers, it is reasonable to provide ventilation in addition to chest compressions for the adult in cardiac arrest.
Untrained lay rescuers should provide compression-only CPR, with or without dispatcher assistant. The rescuer should continue compression only CPR until the arrival of an AED or rescuers with additional training.
Trained Lay Rescuer
All trained rescuers should, at a minimum, provide chest compressions. In addition, if the trained lay rescuer is able to perform rescue breaths, he of she should all rescue breaths in a ratio of 30 compressions to 2 breaths. The rescuer should continue CPR until an AED arrives and is ready for use or EMS providers take over care of the victim.
Keeping it Real & Other things to Consider
Hands-Only/Compressions Only without the breaths. The instructions are clear to push hard and fast in the center of the chest. No numbers, no breathing and no counting. You are never going to know numbers and numbers are not relevant. Hands - Only compressions represent what a heart would be doing if it was functioning. That is beating continually to circulate oxygenated blood to the brain, heart and vital organs. With your compressions, you are and now become the heartbeat for the victim.
In the Guidelines and Student manual still talks about mouth to mouth, mouth to stoma or trachea tube. I think that information should be re-evaluated especial now with Covid. However, because of Covid in 2020 the AHA have the following steps for adult CPR. Hand's - Only with everyone nose and mouth covered with a mask or cloth. No will know if they have Covid or any other contagious disease. In my opinion putting your mouth on any stranger should not be an option and removed unless using a barrier device such as a CPR mask the most people don't have or carry in a first aid kit if they have one.
COVID-19 and Adult CPR (2020 Information)
- Call 911 and get an AED.
- Cover your own mouth and nose with a face mask or cloth.
- Cover person's mouth and nose with a face mask or cloth.
- Perform Hand's -Only CPR (Push hard and fast in the center of the chest at a rate of 100-120 compression per minute.
- Use an AED as soon as it is available.
HANDS-ONLY
"Encourage Hands-Only (compressions only) CPR for the untrained lay rescuer. Hands-Only CPR is easier to perform by those with no training and can be more readily guided by dispatchers over the phone. (Source: 2010 AHA Guidelines pg S643)
"Observational studies of adults with cardiac arrest treated by lay rescuers showed similar survival rates among victim receiving Hands-Only versus conventional CPR with breaths".Source: (2010 AHA Guidelines pg S691)
"Rescue breaths are not as important as chest compressions because to oxygen level in the blood remains adequate for the first several minutes after cardiac arrest. In addition, many cardiac victims exhibit gasping or agonal gasps, and gas exchange allows for some oxygenation and carbon dioxide elimination. If the airway is open, passive chest recoil during the relaxation phase of the chest compressions can also provide some air exchange. However, at some time during prolonged CPR supplementary oxygen with assisted ventilation is necessary".
Source: (2010 AHA Guidelines pg S691)
"Bystander CPR rates remain unacceptably low in many communities. Because compression-only CPR is easier to teach, remember, and perform, it is preferred for "just -in-time" teaching for untrained lay rescuers".Source: (2015 AHA Guidelines pg S417)
"Multiple studies have shown no difference in survival when adult victims of out of hospital cardiac arrest received compression-only CPR versus conventional CPR". Source: (2015 AHA Guidelines pg S417)
"We found that survival in the chest compression along group was 12.5% and survival in the conventional CPR group was 11%".
Source: (WebMD July 2010)
Keeping it Real & Other things to Consider (Hand's - Only Compressions)
CPR are for those who haven't been trained in CPR and those who are not equipped with a barrier CPR shield or CPR mask. With the Hands Only no breathing, no numbers and no counting. When you call 911 you will be instructed to do the (Hand Only / Compressions Only). Always be sure that someone called 911 as they come with the supplemental oxygen that will be needed along with a defibrillator. The oxygen level remain adequate for the first several minutes. Medics come with oxygen to supplement that oxygen loss. Hopefully that arrive within the first several minutes.
Definition:
Cardiopulmonary resuscitation (CPR): A lifesaving emergency procedure for a victim who has signs of cardiac arrest (i.e unresponsive, no normal breathing, and no pulse. The 2 key components are chest compressions and breaths. Sources: 2015 BLS Provider Manual pg 3 &13 and 2020 BLS Provider Manual pg 108
Hands- Only CPR: Providing chest compressions without rescue breathing during CPR. Sources: 2015 BLS Provider Manual pg 3 &13 and 2020 BLS Provider Manual pg 108
In the 2010 Guidelines indicated that those who did the (Hands Only - Compressions Only) and those who did it the conventional way 30:2 had similar survival rates. It also indicates that rescue breaths are not as important as chest compression because the oxygen level remain adequate for the first several minutes after sudden cardiac arrest. Source: Web-MD indicates that those who did the Hands Only - Compressions Only had a survival rate of 12.5%. Those who did it the conventional way (30 compressions and 2 breaths) had a survival rate of 11%.
You are the heartbeat for the person and are taking over the job of the heart that is fight for its life. Fight or flight speeds are fast. The instructions to push hard and fast is what it means. When you are doing chest compressions you are moving the oxygenated blood that is already in the bloodstream/system and waiting for the medics to come with supplemental oxygen and using a mask or an advanced airway to provide a high supply of oxygen back into the bloodstream. They also come with a defibrillator, man power and medications. Possible brain damage and dead of the brain's cell starts to die within 4-6 minutes. In 6-10 minutes brain damage very likely. More than 10 minutes without oxygen there may be irreversible brain damage.
The Hand Only - Compressions Only speed realistically will be faster than CPR speed of 100-120/min as you are no longer giving breaths that is normally illustrated or demonstrated in training and on the videos. CPR is with both compressions and breaths.
Keeping it Real & Other things to Consider (Function of the Heart)
Hands Only CPR represents the heart's function the best because the compressions are continuous and consistent just like the heartbeat. The heart continuously circulates the oxygenated blood to the brain and vital organs. Any delay even with given 1 second breaths to get the chest to rise disrupts the consistent flow. It may take about 5 to 10 compressions to (prime the pump) to restore the flow and pressure once the flow has been stopped according to the latest EMT book. Remember that if the heart is not beating or no one is doing compressions; that the brain cells began to die within 4 to 6 minutes and that person will become brain damaged at about 10 minutes with oxygen or circulation.
AIRWAY
Open the airway by tilting the head back. The head tilt -chin lift relieve airway obstruction in an unresponsive victim. When the victim is unresponsive, the tongue can block the upper airway. The head tilt chin lift maneuver lifts the tongue from the back of the throat relieving the airway obstruction.
Keeping it Real & Other things to Consider (Airway)
Once you tilt the head back the airway is open. Most people in training may have the tendency with the chin lift is to push the chin to hard and actually close the mouth. When the head is In the neutral position the tongue is resting on back of the throat blocking the airway. Tilting the head back opens the airway and the tongue is not longer blocking the airway.
Check for BREATHING
If you choose to give breaths you should protect yourself by using a CPR mask or a shield. The ratio is (30:2) 30 compressions and 2 breaths. Because the child or infant problems are normally breathing/respiratory related, it is preferred that they get some form of ventilation. It is your choice if you choose to put your mouth on a stranger. It is reasonable to pause compressions less than 10 seconds to deliver 2 breaths.
In 2010 the AHA removed the look, listen and feel for breathing in 2010. They now want you to check breathing by scanning the chest.
BREATHING:
"To check for breathing, scan the victim's chest for rise and fall for no more than 10 seconds. If the victim is breathing, monitor the victim until additional help arrives. If the victim is not breathing or is only gasping, this is not considered normal breathing is a sign of cardiac arrest".
Source: (2015 BLS Student Manual pg 17)
"These 2010 AHA Guidelines for CPR and ECC deemphasize checking for breathing. Professional as well as lay rescuers may be unable to accurately determine the presence or absence or adequate or normal breathing in unresponsive victims because the airway is not open or because the victim has occasional gasps, which can occur in the first minutes after SCA and may be confused with adequate breathing". Source: (2010 Guidelines pg S689)
"Another key change is the removal of "look, listen, and feel for breathing" from the assessment steps. This step was removed because bystanders often fail to start CPR when they observed agonal gasping". Source: (2010 Student Manual pg 4)
Keeping it Real & Other things to Consider (Breathing)
In the 2010 Guidelines the look, listen and feel was removed. Listening for breathing and feeling air on you face was challenging. Consider this, the reality is if you're outside you will not be able hear anyone breathing or feel breaths on your cheek. Things like the outside environment where there is traffic, wind and the crowd would have made it challenging and you wouldn't be able to hear or feel anything.
The 2010 & 2015 Guidelines now tells you to scan the chest for rise and fall for no more than 10 seconds. On paper and in books you are seeing words. However, in reality it is hard to see someone's chest rise and fall of people within 10 seconds. Now add things like someone wearing a sweatshirt, jacket, hoodie or bulking clothing. This still will be challenging to scan the chest. Most people may not even look or understand what they are looking for. In 2010 the AHA Guidelines deemphasized checking for breathing.
Consider this, if the person is not breathing the heart will eventually stop. If the heart is not beating there is no circulation or oxygenated blood going to the extremities, lips or face. I strongly suggest looking at their face. That may be the best red flag for you is if you are seeing changes from someone's normal pink colored face, lips, hands, finger & toes extremities. If the victim's skin color has changed to pale, grayish, bluish or purplish lips and face and not seeing chest go up and down that may be a good indicator that the person may not be breathing. For people of color or darker complexion the face may turn pale, grayish, dusty or ashy looking. The lips, fingers and nail bed may be turning purplish or bluish.
Pink face, hand and nail beds may represents that they are breathing. The face that remains pink may represent that they have a heart beat and pulse.
Gastric Inflation:
If you breaths too quickly or with too much force, air is likely to enter the stomach rather than the lungs. This can cause gastric inflation (filling of the stomach with air). Gastric inflation frequently develops during mouth-to mouth, mouth-to mask, of bag mask ventilation. It can result in serious complications. Rescuer can reduce the risk of gastric inflation by avoiding giving breaths too rapid, too forcefully, or with too much volume. During high-quality CPR, however gastric inflation may still develop even when rescuer give breaths correctly.
"Deliver each breath over 1 second. Deliver just enough air to make the victim's chest rise".
Source: (2015 BLS Student Manual pg 64)
Keeping it Real & Other things to Consider (Gastric Inflation)
Did you know that when you giving mouth to mouth breaths that some victims may vomit into your mouth. The primary reason is gastric inflation. If you breath to fast and forceful air may go in the the stomach. You are to give 1 second breath just to get the chest to rise. Your lung capacity and their lung capacity are not the same. You need to look at the chest to see it rise. When you see the chest rise and feel some resistance their lungs are full and you need to stop trying to give breaths. Most people try to give everything that they have in their lungs which may cause the air to overflow and go into the victim's stomach which may lead to that person vomiting and the stomach becoming distended (gastric inflation). If you choose to perform mouth to mouth on someone you may get vomit in your mouth. They may also throw up if they just got done eating.
When giving ventilation/breaths by shield, mask, mouth or bag valve mask give only enough air just to get the chest to rise. Excessive ventilation can lead to gastric inflation and/or vomiting. Don't keep blowing because you still have air in your lungs. Hands only or Compressions only would be the best course of action if you don't have something to protect yourself. I would not recommend doing mouth to mouth on any adult stranger. Those days are over. However you choose what you want to do.
COSTAL CARTILAGE - BROKEN RIBS
Keeping it Real & Other things to Consider (Costal Cartilage)
People routinely talk about breaking ribs. The ribs of the thoracic cavity helps protect your vital organs. It contains your ribs, sternum (breastbone) and something most people don't know about is the costal cartilage. The costal cartilage is actually attached to the sternum and your ribs. The older you are the harder the costal cartilage gets. If you are compressing someone chest at least 2 inches you may hear what most think is of the breaking ribs. However, what most people are actually hearing is the separation of the costal cartilage from the sternum. Because the older you get the hard the costal cartilage gets it may sound like you are breaking ribs. Separation of the costal cartilage or breaking of ribs is painful when victim is breathing and moving. You probably may end up with a flail chest.
However, if you are doing compressions on an older person or someone with brittle bones there may be collateral damage such as broken ribs. You are doing nothing wrong when you hear that. It is not normal to compress someone's chest at least 2 inches deep. Most may not know that once the costal cartilage is separated you can't fix it. It may take 3 month up to a year or two for it to heal on its own and you start feeling better. Occupational therapist that does post cardiac care normally sees the after effect. The older they are expect hearing the costal cartilage separating from the sternum. Expect it less on infants or younger children that still have softer and pliable.
I had a 21 year share his story. He was playing football he go knock out after a hard hit. He woke up to someone doing compressions on him although he was still breathing and had a heartbeat. He stated that he will still sore after 2 years as he still tries to stay active with fitness. The bones and cartilage of the child or infant are soft and can absorb a lot. Unfortunately some people start CPR on people that don't need it. (Someone who had fainted, passed out, low blood sugar or drunk are examples).
AED - Automated External Defibrillator
For witnessed adult cardiac arrest when an AED is immediately available, it is reasonable that the defibrillator be used as soon a possible. For adults with un-monitored cardiac arrest or for whom an AED is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation, if indicated, be attempted as soon as the device is ready for use.
Immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting. AED can be used on pregnant women.
Keeping it Real & Other things to Consider (AED)
The objective of shocking the heart is to stop the abnormal activity. The best illustration is a computer. If you computer becomes frozen or not working properly you may shut it off. When you turn it back on it goes back to the default setting resetting and restoring back to normal operation. When the AED delivers a shock; it stops the heart .Hopefully the heart will go back to the default setting, reset, reboot and hopefully restore the heart beat back to a normal rhythm so the heart can do it own job and beat normally. The AED is going to have you do 2 minutes of CPR for the circulation then stop you to check for the fibrillating heart (heart quivering) for you.
Always leave the AED machine and pads on so the AED can continue to monitor behind the scene and assess the heart after every 2 minute. I like to say that the AED is the paramedic in a box. The AED does what a real paramedic do by assessing for ventricular fibrillation (quivering heart) or ventricular tachycardia (very fast heart beat) and allow you to shock it. The AED will continue to check and monitor the heart for those abnormal rhythms on your behalf and will allow you shock a shock-able abnormal heart rhythm when it is detected. The AED will continue to check the heart for you after every two minutes.
The AED pads have pictures showing where is goes on the chest and will needs to be applied to the chest. Pad are going to be on opposite sides of the chest/ heart. The easiest way to put the pad on are to hold both pads next to the patient's face/ head with the head on the pad facing the same direction of the patients head. Peel the pads off the backing placing the sticky side firmly on the bear chest of the patient as illustrated. There are two things that may prevent the pads from sticking firmly to the chest. (Water/sweat/blood and chest hair). You will need to wipe the chest with something so the pads can stick firmly on the chest. Hair can be removed with a razor that may come with the AED unit, or using an extra set of pads that may come with the unit. Some organizations may use duct tape.
Follow the prompts and be sure not to push the shock button until you are sure that no one else is touching the patient including arms, legs, IV pole, bed etc. That is why you say "Clear" to be sure that it is safe and help prevent other from being shocked accidentally. After pushing the shock button the AED will say if needed start CPR" and you would continue with CPR. The AED is the paramedic in a box will have you do 2 minutes of CPR for the circulation than will stop you for about 10 seconds to (analyzing) to check to see if the heart has a shockable rhythm.
The AED only looks and allows you to check two shockable rhythms: VF-Ventricular Fibrillation (when the heart quivering) or VT- Ventricular Tachycardia (when the heartbeat is extremely fast not allowing the blood to return to the heart). The shock goes from pad A through the heart to pad B and the reason why the pads are on opposite sides of the chest. Some child pads may show one pad in front and one pad in back.
AED are in most schools mainly for student athletes who may die from sudden cardiac arrest. Those athletes in sporting events such is soccer, volleyball, football, track, swimming, competitive cheerleader and dancers etc. may have sudden cardiac arrest. It is normally is a electrical signal problem in the heart. This is where you learn that the athlete had some un-diagnosed irregular heartbeat, genetic heart defect or enlarged heart. Drinking large amounts of energy drinks are now being shown to be contributing factor to sudden cardiac arrest in kids and athletes
FINAL OVERVIEW
You are given numbers that you can't count and depth that you can't measure. Checking for breathing and a pulse was deemphasized in the 2010 Guidelines. When you are to push hard and push fast use proper technique by keeping your arms straight, elbows locked and allowing the chest to recoil. You are going deep enough where you think you are compressing/smashing the heart between the sternum and spine.(Blood goes out / Blood goes in). You need to be on a hard flat surface so the compressions are effective.
When you give breaths blow until you see the chest rise. Seeing the chest rise and feeling a little resistance is letting you know that the lungs are full. If you give breaths too quickly or with too much force, air is likely to enter the stomach rather than the lung. This can cause gastric inflation and the primary reason why victim may throw up. If you are not properly prepared with a protective barrier device (CPR mask or shield) or don't want to do mouth-to mouth on a stranger you may consider doing Hand-Only CPR compressions without the breaths.
You have the options of the conventional (30:2) CPR with compressions and breaths or Hands-Only CPR (chest compressions only). If you don't have a CPR mask or a barrier device you can choose if you want to give breaths to a stranger. You don't have to put yourself in harms way. Be sure that you properly assess the victim and be sure that the victim is actually not responding or breathing. If they are purplish or bluish and not responding to your assessment to determine if they are unresponsive and not breathing start CPR. HEARTSAVER'S personal favorite and recommends learning about the sternum rub or as that is what the First Responders, EMT, Paramedics and ER Doctor or Nurses do because it works. However that is Non AHA Content. It is noninvasive and you should get a reaction with seconds. If they don't respond to the sternum rub the clearly would not have responded to the tap and shout.
When you are doing chest compressions, you are pushing hard and fast moving, circulating the oxygenated blood that is already in the bloodstream to the brain, heart and vital organs. However, that oxygenated blood remain adequate for the first several minutes. Be sure 911 have been called and the medics are en-route within the first several minutes.
With compressions you are now the heartbeat for that victim. In a crisis the heart will be accelerated (like if you are on a treadmill or involved strenuous physical activity like CPR) everything is going to be fast and also factor in the human element that is not normally talked about or mentioned.Epinephrine and adrenaline that you have no control of will help most rescuers push hard and fast. When rescuers are performing CPR you are also buying time (bridging the gap) until EMS 911 (medics) arrive who will provide the most important supplemental oxygen, brings a defibrillator and provider advanced life support. Always be sure that someone has called 911 first. Performing CPR is not going to fix a clogged/blocked artery (Heart Attack) or a fibrillating heart (quivering) that is a abnormal electrical signal problem of the heart known as (Sudden Cardiac Arrest). Only a surgery is going to fix a clogged artery and only a defibrillator can fix a heart that is fibrillating.
Time delay, lack of oxygen and not using a defibrillator are contributing factors for poor survival rates. CPR and the use of the defibrillator are a package deal and goes hand and hand. The chance of brain damage is possible after only 4 to 6 minutes without oxygen. Irreversible brain damage may occur after 10 minutes. You have a little window that you are working within.
In the "real world" no one will ever know when, where or how any event may occur. On the streets or at home you need to take whatever actions needed to get the results that you are looking for. In class you will learn proper technique and learn where the landmarks are for hand placement for CPR and for choking. In some cases you may need to adjust, adapt, or modify somethings based on the situation such as location, your physical health, the person sizes your weakness may be factors. Our job is to (Work the Problem) react and perform High Quality CPR.
All 50 states and the District of Columbia have some type of Good Samaritan Law. The details of Good Samaritan laws/acts vary by jurisdiction, including who is protected from liability and under what circumstances.