CPR NOTES
(AHA-American Heart Association)
What are the new AHA Guidelines for CPR?
The AHA continues to make a strong recommendation for chest compressions of at
least two inches but not more than 2.4 inches in the adult patient, based on
moderate quality evidence. In contrast, there is a moderate-strength for compression
rates of 100-120 compressions per minute, based on moderate quality evidence.Nov 2,
2020
AHA Guidelines 2020: An EMS
overview
Examining recommendations for EMS treatment of adult
and pediatric cardiac arrest related to epinephrine,
compression depth and rate, and double sequential
defibrillation
Nov 3, 2020
The American Heart Association recently released the new American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care 2020. These Guidelines represent the culmination of a rigorous
evidence review process spanning multiple years.
In total, the AHA made 491 evidence-based recommendations across six
resuscitation categories. While it might be tempting to believe strong evidence
drives the recommendations, that is simply not the case. High-quality evidence
from more than one randomized controlled trial accounted for only 1% of the
recommendations [1]. The expert writing teams based more than half of their
recommendations on limited evidence, with expert opinion forming the basis of an
additional 17% of the recommendations [1]. This article will provide an overview of
the major clinical, educational and system of care recommendations in the AHA
CPR and ECC Guidelines 2020.
ADULT BASIC AND ADVANCED LIFE SUPPORT
Over the past decade or so, researchers have directed considerable resources into
using research to guide resuscitation education practices as well as driving system
of care changes to help optimize survival. (Getty Images)
Chest compression quality. While not altering current recommendations for
compression depth and rate in adult patients, the AHA CPR Guidelines 2020
reaffirm the importance of chest compression quality in achieving improved
survival measures. The AHA continues to make a strong recommendation for chest
compressions of at least two inches but not more than 2.4 inches in the adult
patient, based on moderate quality evidence. In contrast, there is a moderate-
strength for compression rates of 100-120 compressions per minute, based on
moderate quality evidence.
Double sequential defibrillation. Although many EMS agencies around the
country include double sequential defibrillation in their treatment protocols,
previous AHA guidelines were silent on the subject [2]. Current published evidence
on the usefulness of this strategy for shock-refractory episodes of ventricular
fibrillation or pulseless ventricular tachycardia remains limited and weak. Because
of this level and quality of evidence, the strongest recommendation the AHA can
make in 2020 is that resuscitation team mays consider the strategy.
Intraosseous access. Another interesting recommendation involves the manner in
which resuscitation teams gain access to the vascular space for medication
administration. Historically, venous cannulation was the primary access strategy.
Recently however, many EMS agencies began moving away from initial IV attempts
during resuscitation in favor of intraosseous access. Unfortunately, a rigorous
review of the evidence questions the efficacy of the IO route when compared to the
IV route. Based on moderate quality evidence not involving a randomized trial, the
AHA believes it is reasonable for resuscitation teams to first attempt IV access.
When IV attempts are unsuccessful or access is not feasible, there is a weaker
recommendation for the teams to consider establishing an IO.
The use of epinephrine in cardiac arrest. Last year, a focused update on the use
of epinephrine in cardiac arrest concluded that resuscitation teams should
continue to administer epinephrine for the treatment of cardiac arrest in adult
patients at 3-5 minute intervals for the duration of the resuscitation attempt [3].
The AHA CPR Guidelines 2020 strongly reaffirm that position, based on moderate
quality evidence. With respect to timing, the AHA Guidelines 2015 made a weak
recommendation that resuscitation teams consider giving epinephrine as soon as
feasible when the patient presents with a non-shockable rhythm [2]. The AHA CPR
Guidelines 2020 now strengthen that recommendation with moderate quality
evidence based on limited data. The AHA Guidelines 2015 made no
recommendation on when resuscitation teams should administer epinephrine to
patients with shockable rhythms. The 2019 AHA focused update recommended
epinephrine administration for shockable rhythms after initial defibrillation
attempts have failed [3]. The AHA CPR Guidelines 2020 reaffirm that position as a
weak recommendation based on limited data. Changes to the algorithm now depict
epinephrine administration as appropriate after the second defibrillation attempt
for shock refractory rhythms.
PEDIATRIC BASIC AND ADVANCED LIFE SUPPORT
Chest compression rate and depth. As with the adult patient, the AHA CPR
Guidelines 2020 do not alter previous compression depth and rate
recommendations for pediatric patients. The AHA makes a moderate-strength
recommendation for chest compressions depths of one-third the anterior-posterior
diameter of the chest for infants and children, based on limited data. Limited data
also supported the AHA CPR Guidelines 2020 reaffirmation of the moderate-
strength recommendation for compression rates of 100-120 compressions per
minute.
Advanced airway management. One recommendation specifically addressed to
prehospital care involves the decision to use an advanced airway during pediatric
resuscitation. Last year, the AHA addressed whether EMS providers should
provide bag-mask ventilation with or without an advanced airway [4]. At that time,
the AHA stated the strength and quality of the evidence prohibited a
recommendation for or against the use of an advanced airway during the pediatric
resuscitation attempt. They also could not recommend one type of advanced
airway device as clearly superior to another device. Based on limited data, the AHA
CPR Guidelines 2020 reviewers conclude that rates of survival to hospital discharge
and survival with good neurologic outcome are similar between pediatric patients
treated with BVM ventilation and those treated with endotracheal tube ventilation.
The AHA makes a moderate-strength recommendation for the use of bag-mask
ventilation over endotracheal tube ventilation.
Ventilation rates. One of the most interesting recommendations related to
pediatric resuscitation involves updates to assisted ventilation rates. For years, the
AHA warned about the very real dangers of overventilation during cardiac arrest.
Increasing assisted ventilation rates during CPR raises intrathoracic pressure, which
reduces venous return to the heart. However, results from a large multi-center
observational trial found in-hospital resuscitation teams often provide ventilation
rates in excess of recommended rates [5]. More importantly, researchers found an
association between faster ventilation rates and improved survival to hospital
discharge for infants with endotracheal intubation. Thus, based on limited data, the
AHA CPR Guidelines 2020 make a weak recommendation for providing one breath
every 2-3 seconds (20-30 breaths/min) for infants and children with an advanced
airway.
The use of epinephrine in cardiac arrest. No high-quality evidence drives intra-
resuscitation drug administration recommendations for infants and children who
suffer cardiac arrest. The basis for all 2020 AHA recommendations is limited data.
The AHA CPR Guidelines 2020 reaffirm the previous moderate-strength
recommendation for the use of epinephrine during pediatric resuscitation
attempts. The AHA CPR Guidelines 2020 also make a moderate-strength
recommendation for resuscitation teams to administer the first dose of
epinephrine within the five minutes after beginning chest compressions. This
recommendation should prompt EMS systems to evaluate their current pediatric
resuscitation practices for ways to meet this recommendation. Resuscitation teams
should continue to administer epinephrine at 3-5 minute intervals. Finally, the AHA
CPR Guidelines 2020 reaffirm a previous moderate-strength recommendation for
the use of either amiodarone or lidocaine for shock-refractory V-fib/pVT.
This article examines only a glimpse of the recommendations related to major
clinical topics associated with resuscitation following cardiac arrest. There are many
other clinical recommendations that do not apply to the prehospital environment,
although they do contribute to overall survivability. In addition, over the past
decade or so, researchers have directed considerable resources into using research
to guide resuscitation education practices as well as driving system of care changes
to help optimize survival. Over the next few weeks, we will explore all of these
recommendations in more detail.
REFERENCES
1. Merchant, RM; Topjian, AA; Panchal, AR; Cheng, A; et al. (2020). Part 1:
Executive summary: 2020 American Heart Association guidelines for
cardiopulmonary resuscitation and emergency cardiovascular
care. Circulation, 142(16 Suppl 2), S337-S357.
doi:10.1161/CIR.0000000000000918
2. Link, MS; Berkow, LC; Kudenchuk, PJ; Halperin, HR; et al. (2015). Part 7: Adult
advanced cardiovascular life support: 2015 American Heart Association
guidelines update for cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation, 132(18 Suppl 2), S444-S464.
doi:10.1161/CIR.0000000000000261
3. Panchal, AR; Berg, KM; Hirsch, KG; Kudenchuk, PJ; et al. (2019). 2019
American Heart Association focused update on advanced cardiovascular life
support: Use of advanced airways, vasopressors, and extracorporeal
cardiopulmonary resuscitation during cardiac arrest: An update to the
American Heart Association guidelines for cardiopulmonary resuscitation
and emergency cardiovascular care. Circulation, 140(24), e881-e894.
doi:10.1161/CIR.0000000000000732
4. Duff, JP; Topjian, AA; Berg, MD; Chan, M; et al. (2019). 2019 American Heart
Association focused update on pediatric advanced life support: An update to
the American Heart Association guidelines for cardiopulmonary resuscitation
and emergency cardiovascular care. Circulation, 140(24), e904-e914.
doi:10.1161/CIR.0000000000000731
5. Sutton, RM; Reeder, RW; Landis, WP; Meert, KL; et al. (2019). Ventilation rates
and pediatric in-hospital cardiac arrest survival outcomes. Critical Care
Medicine, 47(11), 1627–1636. doi:10.1097/CCM.00000
What Are the Seven
Steps of CPR?
The seven steps of CPR (cardiopulmonary resuscitation) involve checking the scene and the
person, calling 911 for assistance, opening the airway, checking for breathing, chest
compressions, delivering rescue breaths, and repeating CPR steps.
Medical Editor: John P. Cunha, DO, FACOEP
Reviewed on 9/15/2022
Privacy & Trust Info
CardioPulmonary Resuscitation (CPR) - First
Aid
The seven steps of CPR (cardiopulmonary resuscitation) involve checking the scene and the person,
calling 911 for assistance, opening the airway, checking for breathing, chest compressions, delivering
rescue breaths, and repeating CPR steps.
CPR stands for CardioPulmonary Resuscitation, an emergency procedure that is a
combination of chest compressions and artificial ventilation (breathing) used to save a
person’s life when a person’s heart stops beating or breathing ceases. When
performed right away, CPR can increase a person’s chances of survival after cardiac
arrest.
What Are the 7 Steps of CPR In Order?
The American Red Cross guidelines for performing CPR are as follows:
Before Giving CPR:
1. Check the scene and the person
Make sure the setting is safe
Tap the person on the shoulder and shout, “Are you OK?” to make sure the
person needs help
2. Call 911 for assistance
If it's clear help is needed, call 911 (or ask a bystander to call)
Send someone to get an AED if one is available
If there is no AED available or there is no bystander to access it, stay with the
victim, call 911, and prepare to give assistance
3. Open the airway
With the person lying on his or her back, tilt the head back slightly to lift the chin
4. Check for breathing
Listen carefully for sounds of breathing, for no more than 10 seconds (occasional
gasping sounds are not the same as breathing)
If there is no breathing, begin CPR
Red Cross CPR Steps
5. Begin chest compressions
Position hands one on top of the other in the middle of the chest
Push hard, push fast
Use your body weight to help administer compressions at least 2 inches deep and
delivered at a rate of at least 100 compressions per minute
6. Deliver rescue breaths*
With the person's head tilted back slightly and the chin lifted, pinch the nose shut
and place your mouth over the person's mouth to make a complete seal
Blow into the person's mouth to make the chest rise
Deliver two rescue breaths, then continue compressions
Note: If the chest does not rise with the initial rescue breath, re-tilt the head
before delivering the second breath. If the chest doesn't rise with the second
breath, the person may be choking. After each subsequent set of 30 chest
compressions, and before attempting breaths, look for an object (inner mouth)
and, if seen, remove it.
*Note: Rescue breaths are recommended by the American Red Cross. The
American Heart Association recommends calling 911 and delivering chest
compressions only.
7. Continue CPR steps
Continue with cycles of chest compressions and breathing until:
The person exhibits signs of life, such as breathing
An AED becomes available, once it is applied continue CPR if the patient is still
unresponsive
EMS or a trained medical responder arrives on the scene and takes over
Note: End the cycles if the scene becomes unsafe or you are unable to continue
performing CPR due to exhaustion
QUESTION
Emotional trauma is best described as a psychological response to a
deeply distressing or life-threatening experience.See Answer
NICE TO KNOW NOTES ABOUT CPR
Hands-Only CPR has just two easy steps: If you see
a teen or adult suddenly collapse(AHA guidelines)
(1) Call 9-1-1; and
(2) Push hard and fast in the center of the chest
to the beat of the disco song “Stayin' Alive.”
FAQ: Hands-Only CPR HANDS-ONLY CPR
Q: What is Hands-Only CPR?
Hands-Only CPR is CPR without rescue breaths. If you see a teen or adult
collapse, you can perform Hands-Only CPR with just two easy steps:
1) Call 911 and
2) Push hard and fast in the center of the chest to the beat of the Bee Gees’
classic disco song “Stayin’ Alive.”
The song is 100 beats per minute – the minimum rate you should push on the
chest during HandsOnly CPR.
Q: Why would you use Hands-Only CPR?
With 70 percent of all out-of-hospital cardiac arrests happening at home, if you’re
called on to perform Hands Only CPR, you’ll likely be trying to save the life of
someone you know and love. Hands-Only CPR carried out by a bystander has
been shown to be as effective as CPR with breaths in the first few minutes during
an out-ofhospital sudden cardiac arrest for an adult victim (please read the
Hands-Only CPR vs. CPR with Breaths section below to learn more.)
Q: Does learning Hands-Only CPR increase the chance of a bystander taking
action in a cardiac emergency?
Yes. Most Americans (70 percent) feel helpless to act during a cardiac emergency
because they don’t know how to administer CPR or they’re afraid of hurting the
victim. According to the American Heart Association, people are more likely to
remember the correct pace when trained to the beat of the disco classic “Stayin’
Alive" or another familiar song with 100 to 120 beats per minute – the rate you
should push on the chest during CPR. HANDS-ONLY CPR CAMPAIGN
Q: Who can learn Hands-Only CPR?
Anyone can learn Hands-Only CPR and save a life. Hands-Only CPR has just two
easy steps: If you see a teen or adult suddenly collapse, (1) Call 9-1-1; and (2) Push
hard and fast in the center of the chest to the beat of the disco song “Stayin’
Alive.” You can view these materials at heart.org/handsonlycpr or heart.org/rcp
(Spanish resources). 2 HANDS-ONLY CPR KIOSKS
Q: Can music help people learn Hands-Only CPR?
Music is a great learning tool in any situation, especially when training for an
emergency. During CPR, you should push on the chest at a rate of 100 to 120
compressions per minute. The beat of “Stayin’ Alive" is a perfect match for this,
and research shows that people are more likely to remember the correct pace
when trained to the beat of a familiar song.
The American Heart Association recommends that you take a CPR course to
practice and learn the full skills of CPR, including rescue breaths and high-quality
chest compressions. The American Heart Association also recommends CPR with
compressions and breaths for infants; children; victims of drowning or drug
overdose; or people who collapse due to breathing problems. People who have
had CPR training are more 3 likely to give high-quality chest compressions and are
more confident about their skills than those who have not been trained (or have
not trained in the last 5 years).
Q: Not all people who suddenly collapse are in cardiac arrest. Will CPR seriously
hurt them?
Adults who suddenly collapse and are not responsive are likely experiencing
sudden cardiac arrest. Their chance of survival is nearly zero unless someone
takes action immediately. According to the American Heart Association, about 90
percent of people who suffer out-of-hospital cardiac arrests die. Hands-Only CPR
is an easy, effective way for any bystander, especially if they act immediately, to
double or triple a cardiac arrest victim’s chance of survival. You should call 9-1-1
and start pushing hard and fast in the center of the chest with minimal
interruptions. If an adult has collapsed for reasons other than cardiac arrest,
Hands-Only CPR could still help by causing the person to respond (begin to move,
breathe normally or speak). If that occurs, Hands-Only CPR can be stopped.
Otherwise, chest compressions should continue until EMS providers arrive. Q: Is
there a danger in jumping in and giving CPR without being trained? In the majority
of cases, any attempt to provide CPR to a victim is better than no attempt to
provide help. HANDS-ONLY CPR vs. CPR WITH BREATHS
Q: What is the difference between Hands-Only CPR and CPR with breaths?
Which one am I supposed to do in an emergency?
Hands-Only CPR performed by a bystander has been shown to be as effective as
CPR with breaths in the first few minutes of an out-of-hospital sudden cardiac
arrest for an adult victim. If you do not know how to administer CPR with breaths,
don’t be afraid to act in an emergency; your actions can only help. Any attempt at
CPR is better than no attempt. If you see an unconscious, unresponsive adult, call
9-1-1 and push hard and fast in the center of the chest to the beat of the classic
disco song “Stayin’ Alive.” This song, and other songs with a rhythm of 100 to 120
beats per minute, mimic the rate you should push on the chest during CPR. The
AHA still recommends CPR with compressions and breaths for infants, children,
victims of drowning or drug overdose, or people who collapse due to breathing
problems.
AED – AUTOMATED EXTERNAL DEFIBRILLATOR
An AED, or automated external defibrillator, is used to help those
experiencing sudden cardiac arrest. It's a sophisticated, yet easy-to-use,
medical device that can analyze the heart's rhythm and, if necessary,
deliver an electrical shock, or defibrillation, to help the heart re-establish an
effective rhythm.
What is an AED and how does it work?
An AED is a type of computerized defibrillator that automatically analyzes the
heart rhythm in people who are experiencing cardiac arrest. When appropriate, it
delivers an electrical shock to the heart to restore its normal rhythm.Feb 9, 2021
What Is an Automated External Defibrillator?
An automated external defibrillator (AED) is a lightweight, portable device that
delivers an electric shock through the chest to the heart. The shock can
potentially stop an irregular heart beat (arrhythmia) and allow a normal rhythm
to resume following sudden cardiac arrest (SCA). SCA occurs when the heart
malfunctions and stops beating unexpectedly. If not treated within minutes, it
quickly leads to death. Most SCAs result from ventricular fibrillation (VF). VF is a
rapid and unsynchronized heart rhythm that originates in the heart’s lower
chambers (the ventricles). The heart must be “defibrillated” quickly, because a
victim’s chance of surviving drops by seven to 10 percent for every minute a
normal heartbeat isn’t restored.
Why are AEDs important?
AEDs make it possible for more people to respond to a medical emergency where
defibrillation is required. Because AEDs are portable, they can be used by
nonmedical people (lay-rescuers). They can be made part of emergency response
programs that also include rapid use of 9-1-1 and prompt delivery of cardio
pulmonary resuscitation (CPR). All three of these activities are vital to improving
survival from SCA. How does an AED work? A built-in computer checks a victim’s
heart rhythm through adhesive electrodes. The computer calculates whether
defibrillation is needed. If it is, a recorded voice prompts the rescuer to press the
shock button on the AED. This shock momentarily stuns the heart and stops all
activity. It gives the heart the chance to resume beating effectively. Audible
prompts guide the user through the process. AEDs advise a shock only for
ventricular fibrillation or another life-threatening condition called pulseless
ventricular tachycardia.
Who can use an AED?
Non-medical personnel such as police, fire service personnel, flight attendants,
security guards and other lay rescuers who have been trained in CPR can use
AEDs. Although formal training in the use of an AED is not required, it is
recommended to help the rescuer increase their comfort and level of confidence.
However, AEDs are intended for use by the general public. Most AEDs use audible
voice prompts to guide the user through the process. Are AEDs safe to use? AEDs
are safe to use by anyone. Some studies have shown that 90% of the time AEDs
are able to detect a rhythm that should be defibrillated. This data suggests that
AEDs are highly effective in detecting when (or when not) to deliver a shock.
Where should AEDs be placed?
All first-response vehicles, including ambulances, lawenforcement vehicles and
many fire engines should have an AED. AEDs also should be placed in public areas
such as sports venues, shopping malls, airports, airplanes, businesses, convention
centers, hotels, schools and doctors’ offices. They should also be in any other
public or private place where large numbers of people gather or where people at
high risk for heart attacks live. They should be placed near elevators, cafeterias,
main reception areas, and on walls in main corridors.
