Stop the mouth-to-mouth; just keep pushing, hard and fast.
New guidelines to be released in Canada and the United States on Monday are urging bystanders who aren’t trained in CPR – or those who fear their skills are rusty – to provide "hands-only" or compression-only CPR if they see an adult collapse, and not stop to give "rescue breaths."
The emphasis is to "push hard and fast" on the centre of the chest, between the nipples, at a rate of at least 100 compressions per minute.
Think of pushing to the beat of the ’70s Bee Gees song Stayin’ Alive, says Dr. Andrew Travers, chair of the Heart and Stroke Foundation of Canada’s policy advisory committee on resuscitation and one of the expert co-authors of the new guidelines.
The disco hit has a tempo of about 103 beats per minute.
If the victim doesn’t respond to a voice and isn’t breathing, or not breathing normally, or gasping, "go right out of the cage and start chest compressions" after calling 911, Travers said.
Compressions need to be forceful and deep – for adults, at least five centimetres into the chest, "or the height of your pinky finger" – and about four centimetres for children and infants.
People shouldn’t be afraid of breaking ribs.
"You can’t hurt someone if they don’t live to survive to see another day. If you’re not doing effective chest compressions, the patient is going to die," said Travers.
For years, CPR instructors taught people to give 15 chest compressions followed by two mouth-to-mouth ventilations. New guidelines in 2005 bumped compressions to 30 for every two breaths.
But now – 50 years after modern CPR was born – evidence is mounting that critical seconds are lost in moving from one step to another.
A study published this month in the Journal of the American Medical Association of 4,415 out-of-hospital cardiac arrests in Arizona – where a statewide program was launched five years ago teaching and advocating compression-only CPR – found 13.3 per cent of patients given compression-only CPR survived long enough to be discharged from the hospital, compared to 7.8 per cent of those given traditional CPR.
Another analysis, this one published last week by The Lancet, found that cardiac arrest victims are 22 per cent more likely to survive if their rescuers skip mouth-to-mouth breathing and are guided by 911 dispatchers to do chest compressions only.
With cardiac arrest, "the majority of those patients have a heart attack, and then the heart stops beating," says Dr. Peter Nagele, the principal investigator of the Lancet study and chief of trauma anesthesiology at Barnes-Jewish Hospital in St. Louis. The person normally has sufficient oxygen in their body, "so rescue breaths aren’t as vital to survival" as chest compressions to keep oxygen-rich blood flowing to the heart and brain, Nagele says.
"You’re buying time until someone with a defibrillator arrives" to shock the heart back into rhythm.
According to the new CPR guidelines, which are reviewed every five years, all bystanders trained in CPR should "at a minimum" provide chest compressions and, if they’re able to, rescue breaths as well, at a ratio of 30 compressions to two breaths.
A pioneer in compression-only CPR argues the guidelines should advocate compression-only CPR for all.
Ventilations "are not only not helpful, they can be harmful," says Dr. Gordon Ewy, a professor of medicine and director of the Sarver Heart Center at the University of Arizona College of Medicine.
"The reason I can sit here and talk to you without fainting – I don’t have a heart in my leg pumping the blood up – is because every time I take a breath, I make a vacuum in my chest and air comes in and blood returns from the lower part of the body.
"But if I’m in cardiac arrest and you’re pressing on my chest, the forward blood flow is so marginal that if you ventilate for me, you actually increase the pressure inside the chest and decrease venous return," or blood flow back to the heart.
In their studies, Sarver Heart Center researchers have shown that it takes a lay person newly certified in CPR, on average, 16 seconds to lift the chin, pinch the nose, make a seal, blow into the person’s mouth and then repeat for a second breath before returning to chest compressions. "That means they’re only giving chest compressions about half the time," Ewy says.
"So we said, ‘Well, how about a young, enthusiastic, well-trained medical students certified in CPR?’ It took them 14 seconds. How about the professionals – the paramedics? It takes them 11 seconds. Nobody can do it fast enough," Ewy says.
The updated guidelines also recommend a change in the sequence of steps, from A-B-C (airway, breathing, chest compressions) to C-A-B (chest compressions, airway, breathing) for adults, children and infants. The new sequence shortens the time to the first compressions.
About 40,000 Canadians experience cardiac arrest each year.
Without CPR and defibrillation, fewer than five per cent of those who have a cardiac arrest outside hospital survive.
Doing chest compressions compared to doing nothing increases a person’s chance of surviving cardiac arrest fourfold, says Travers, an emergency physician in Halifax and provincial medical director for emergency health services in Nova Scotia.
But a Heart and Stroke Foundation survey of 2,003 Canadians in September found only 40 per cent of those trained in CPR would attempt to revive a person in cardiac arrest.
"People worry that they’ll hurt the person, or they’re uncertain of their skills, or they worry they’ll get infected," Travers said. "We’re telling them, it’s all right just to do chest compressions."
Travers said rescue breathing remains important for children and infants.
"A lot of time when children go into cardiac arrest it isn’t because of a heart problem, but a lung problem." Under those circumstances, as well as with drownings, the person needs oxygen. "We don’t want people to think it’s OK to just do chest compressions alone in children and infants. It’s important to do effective respirations as well," Travers says.
Andre Corriveau is alive today because of the quick actions of a teammate and an arena worker who revived Corriveau with CPR and a defibrillator after the Ottawa man collapsed during a hockey game last fall.
"I dropped on the ice. I had no warning at all," Corriveau said. "You would think a couple of seconds before I would have had problems breathing, or a headache or chest pain. I had none of that. One second I’m skating around. The next, I’m on my back."
Another player "jumped over the boards, he was at my side in seconds" and started CPR immediately, Corriveau says. Within minutes, a rink operator who saw the commotion had rushed to the ice with a defibrillator.
Corriveau, now 57, underwent triple bypass surgery. Last week, he played his first hockey game since his heart surgery.
"I’m feeling good. I joke sometimes that I feel as good as I did two seconds before I dropped on the ice," he says.
"I was lucky, there’s no doubt about it. The stars were lined up that day. These guys just jumped in immediately and saved my life."
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