The American Heart Association has created a video promoting Hands-Only CPR and posted it on YouTube.
If you’ve ever completed a course in cardiopulmonary resuscitation (CPR), you may wonder if you’d really be able to perform those skills should the adrenaline-soaked situation occur. You picture yourself frantically giving chest compressions to your cell phone, then attempting to dial 911 on the victim’s rib cage.
Your fears are not entirely unfounded. A third or fewer of CPR-trained bystanders actually perform CPR when the dire situation arises. Why? The concern about giving mouth-to-mouth to a stranger seems like an obvious one, but in a study involving actual bystanders, panic and fear (of doing harm, or the wrong thing) were the most cited reasons for doing nothing.
Here’s the good news: CPR just got easier. Anyone can do something. All
you need is a cell phone, two free hands and the beat of the Bee Gees’
“Stayin’ Alive” (more on that concept momentarily).
Earlier this month the American Heart Association (AHA), the governing body of CPR, released a science advisory succinctly titled “Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest.”
On reviewing studies involving bystanders giving CPR, the AHA’s Emergency Cardiovascular Care Committee found that giving chest compressions alone was better than no CPR at all, and that it produced survival rates as good as those victims who got traditional ventilation and chest compression CPR.
In the yin and the yang of resuscitation, the most current science favors more of the yin — chest compressions — and less of the yang — ventilations. That idea led to a major overhaul of the CPR guidelines in 2005, when the ratio of chest compressions to breaths went from 15:1 to 30:1.
But now it’s OK to do no breathing for the victim? What good does it do to force the heart to beat if the lungs aren’t breathing?
Two theories at work
“There are really two theories in resuscitation science: the cardiac pump theory, and the thoracic pump theory,” explained Dr. Charles Lick, emergency medical specialist and co-founder of Take Heart Anoka County, a program designed to improve outcomes in those who suffer cardiac arrest.
“In the cardiac pump theory, it’s the compression of the heart that pumps blood out into the organs, but in the thoracic pump theory we understand that the negative pressure [vacuum] caused by inhalation is what sucks or draws blood back into the chest so that it can be recirculated,” Lick explained.
Think of the circulatory system as a train on a circular, one-way track. The train has to go out, but it also has to come back. Without blood flowing back into the chest, the heart has nothing to squeeze out.
In the vast majority of people who collapse because of a cardiac arrest, the train is dead on the tracks. The heart is not squeezing, it’s fibrillating — a shuttering, seizure-type motion that generates no blood-flow. With the train sitting idle, no blood or oxygen can be delivered to the body, including the heart itself.
As critical as oxygen is, it turns out that in the first several minutes of a cardiac arrest, breathing is not that important. (You heard it here at MinnPost first: Breathing is not that important). There’s a few minutes supply of oxygen stored away in the bloodstream, but still, that blood has to be moving, and for that to happen the heart needs to be squeezing, not fibrillating. That’s why early shocks and chest compressions are so critical.
If the train isn’t moving, you can dump all the oxygen you want on it, but it’s not going anywhere.
Real world vs. ideal world
Wouldn’t it be best to have your cake (oxygen) and inhale it too? Wouldn’t it be better to have oxygen coming in and out of the lung, and the heart squeezing?
In a perfect world, yes, but as the AHA Scientific Advisory points out, that’s often not what happens in the real world. Studies show that for the lone rescuer, the time spent fumbling to breathe for the patient often comes at the expense of critical chest compressions. The AHA Advisory notes that “trained rescuers performing traditional 1-person CPR take much longer to initiate CPR than those trained to perform hands-only CPR.” The AHA also found that it took lay rescuers 16 seconds to move from giving chest compressions to providing rescue breaths, and even for health care providers there was a 10-second delay.
The second problem with trying to ventilate an arrested patient involves the thoracic pump theory and the train on the circular track. Very commonly, panicked rescuers mistakenly over-ventilate the victim by breathing too hard and too fast.
“We’ve been doing this wrong for a long time, over-ventilating people,” said Dr. Lick, explaining that over-inflated lungs create high pressures within the chest. That high pressure pushes back the blood that is trying to return to the heart. For the heart, low input means low output, and low output means low blood pressure. Or no blood pressure at all.
Too many victims
“We don’t talk about CPR ‘patients,’ we talk about CPR ‘victims,’ and that’s because resuscitation outcomes have been so abysmal,” noted Fred Hunter, vice president of Advanced Circulatory Systems Inc., an Eden Prairie company that produces resuscitation technology. “We’ve been doing this [CPR] for over 25 years and the numbers haven’t changed: only 5 percent of people are successfully resuscitated.”
Desperate situations call for desperate actions, and the AHA’s “Call to Action” is definitely that.
“This is the first time the AHA has actually asked non-trained bystanders to become involved,” explained Tim George, a paramedic in Grand Rapids and state chairman of the Emergency Cardiovascular Committee for the AHA. “We’re asking everyone to do something,” he noted, “at a minimum, good quality chest compressions — consistent and uninterrupted.”
The advisory even allows CPR-trained bystanders to just do chest compressions if they don’t feel confident in their ability to give full CPR.
More training in CPR needed
Everyone I talked with who works in the CPR field is in agreement with the AHA — something is better than nothing — but some worry that the public might get the wrong message.
They point out that one can look at the same studies referenced by the AHA and draw a different conclusion: Outcomes for traditional CPR are poor because the CPR was poorly performed (ventilation was too slow, and over ventilation impaired circulation). Yes, untrained bystanders can save lives, but we need more people trained in CPR, particularly in rural areas, where EMS responses are longer and chest compressions alone won’t be enough (the oxygen reservoir in the blood at the time of the arrest gets used up in a few minutes).
Dr. Keith Lurie, a professor of emergency medicine at the University of Minnesota and the developer of a novel CPR device called the ResQPOD, sees it this way. “We have a problem: nearly 1,000 people die each day from sudden cardiac arrest. And they die because people are afraid to intervene because they feel unqualified. This AHA release is saying, ‘If you want to do something, do chest compressions.’ Chest compressions are better than nothing, for sure. But if you really want to do something, get certified in CPR – and you can do that in about 20 minutes.”
That’s right: What used to be a four-hour course can now be completed in 20 minutes, and there are even home options. “The AHA has a ‘Heart Saver Anytime’ program,” Tim George told me. “For $30 you get an inflatable manikin, course book, and a 17-minute DVD. You can teach yourself at home.”
But until everyone gets CPR-certified, chest compressions alone by anyone—trained or untrained—will have to do. After all, bystander CPR more than doubles survival rates for cardiac arrest, which really is better than nothing.
“In some ways we’ve made this too complicated,” Dr. Charles Lick, the co-founder of Take Heart Anoka County told me. “It’s simple: If an adult collapses in front of you, we want you to call 911; then put the palm of your hand on the chest a couple inches below the nipple line, and start pumping away to the beat of the Bee Gees’ ‘Staying Alive.’ The musical choice is physiologic not personal, since the tune is set to a rate of 100 beats per minutes — fast enough to get good blood flow, but slow enough to allow full recoil of the chest.
“You can also use ‘Another One Bites the Dust,’ ” by Queen,” Lick added. “That’s at 100 beats per minute too, but for obvious reasons, I kind of prefer ‘Staying Alive.’ ”