Part I of our series discussed the recognition of cardiac arrest and getting help. We’ll now discuss bystander initiated CPR and the obstacles that prevent CPR from being started immediately. This will lead us into Part III – Public Access Defibrillation which will discuss use of an automated external defibrillator (AED) and deployment strategies.
Hands Only CPR
When cardiac arrest occurs in the public setting, it should be assumed that bystanders will not be carrying pocket masks and breathing barriers on their person. Keychain pocket masks provide convenient personal protection for delivering rescue breaths, but most trained rescuers do not carry these. Bystanders and healthcare providers are not expected to provide mouth to mouth resuscitation.
Q. What do you do when you come upon a cardiac arrest victim with no way to safely deliver rescue breaths?
A. Hands Only CPR. Hands only CPR provides chest compressions to victims of a cardiac arrest victim when no breathing barrier is available. A bystander that finds a person who is not responsive and is not breathing normally should call 911, request an AED, and start Hands Only CPR.
Is the person responsive? NO
Is the person breathing normally? NO
We are going to start CPR. GO
The first two actions of calling 911 and retrieving an AED should be delegated to another bystander if someone else is nearby. Be sure to specify the bystander(s) that will complete these actions. If you’re alone, call 911 and retrieve the AED first before providing care.
To provide hands-only CPR, remove clothing to bare the person’s chest.
Interlock your fingers and place the heel of your hand on the lower half of the breastbone, in-line with the nipples.
Lock your elbows and use your body weight to compress the chest about two inches. Repeat at a rate of 100 compressions per minute (the same tempo as Staying Alive by the Bee Gees or your choice of another CPR song).
If other bystanders are available, rotate rescuers every two minutes.
Continue providing hands-only CPR until trained help arrives and takes over. If the person begins to breathe normally or have meaningful movement, stop chest compressions and watch them until help arrives. Be prepared to start chest compressions again if they stop breathing normally.
Here are the important notes to remember for providing high-quality hands only CPR:
PUSH HARD: Compress the chest two inches. Allow full chest recoil – there should be no pressure on the chest between each compression.
PUSH FAST: Compress the chest at a rate of 100 compressions per minute. Avoid pushing too fast (over 120 compressions per minute).
MINIMIZE INTERRUPTIONS: Gaps in chest compressions kill cardiac arrest victims. Avoid any interruptions in CPR. Communicate when you’re switching rescuers so the next rescuer can restart compressions without missing a beat. The rescuer using the AED can also apply the pads while the rescuer is providing chest compressions.
Overcoming Obstacles for Bystander Initiated CPR
The Cardiac Arrest Registry to Enhance Survival (CARES) collects data on cardiac arrest victims provided by 1,400 EMS providers and 1,900 hospitals nationwide. This collaboration provides a snapshot of cardiac arrest incidence, implementation of chain of survival steps, and patient outcomes. The reports can provide a comparison for how a particular community, state, or region performs in these metrics.
The most pertinent metrics to consider when evaluating the frequency of bystander initiated CPR include whether or not the cardiac arrest was witnessed and whether or not bystanders initiated CPR before EMS arrived.
In 2017, approximately 49% of cardiac arrests reported to CARES were witnessed. Of these witnessed cardiac arrests, only 38% received bystander initiated CPR and only 11% of public cardiac arrests had an AED applied.
When we talk about the low rates of bystander initiated CPR, it is important for us to recognize the obstacles that bar people from acting:
- Unable to recognize cardiac arrest: Part I of our series identified the difficulties of recognizing whether someone is in cardiac arrest. If the cardiac arrest victim doesn’t closely resemble a CPR manikin (on their back, not responding, and not breathing or gasping), bystanders may not recognize cardiac arrest and may not initiate CPR.
- Fear: This is a pretty strong barrier to overcome and encompasses a handful of areas:
- Fear of Being Harmed: When cardiac arrest is not caused by trauma, the risk of being injured by stepping in to help is small. If the patient is in cardiac arrest as the result of injury, the risk to bystanders and rescuers becoming injured as well becomes elevated. Regardless of the cause of the victim’s emergency, bystanders and rescuers should be vigilant in evaluating the scene for safety before taking any action.
- Fear of Harming the Person: Bystanders who are not confident that a person is in cardiac arrest, may be afraid of harming the victim by providing CPR. A person in cardiac arrest has a 0% chance of survival if they do not receive CPR. If the person is not responding and not breathing normally, CPR should be started.
- Fear of Litigation: Bystanders may be afraid of being sued by a victim if they do something wrong. Fortunately, all 50 states have enacted some form of “Good Samaritan Law” which provides protection from litigation when bystanders act in an emergency. Check your state’s Good Samaritan Law to learn more about the protections it provides you.
- Fear of Public Performance: Stage fright is a thing and it certainly prevents people from acting in an emergency. When an emergency happens, bystanders have a tendency to watch what’s happening. The survival of a cardiac arrest victim is directly related to whether or not a bystander can perform CPR in front of a crowd.
- Skills Confidence: Rescuers who have never learned or practiced CPR skills or have not reviewed skills in some time may not feel confident in performing skills and are less likely to act in an emergency.
Part III of our series will discuss the use of Automated External Defibrillators in cardiac arrest and deployment strategies.