Experts now recommend hands-only CPR

By STEPHANIE NANO
You can skip the mouth-to-mouth breathing and just press on the chest to save a life. In a major change, the American Heart Association said Monday that hands-only CPR — rapid, deep presses on the victim's chest until help arrives — works just as well as standard CPR for sudden cardiac arrest in adults.
Experts hope bystanders will now be more willing to jump in and help if they see someone suddenly collapse. Hands-only CPR is simpler and easier to remember and removes a big barrier for people skittish about the mouth-to-mouth breathing.
"You only have to do two things. Call 911 and push hard and fast on the middle of the person's chest," said Dr. Michael Sayre, an emergency medicine professor at Ohio State University who headed the committee that made the recommendation.
Hands-only CPR calls for uninterrupted chest presses — 100 a minute — until paramedics take over or an automated external defibrillator is available to restore a normal heart rhythm.
This action should be taken only for adults who unexpectedly collapse, stop breathing and are unresponsive. The odds are that the person is having cardiac arrest — the heart suddenly stops — which can occur after a heart attack or be caused by other heart problems. In such a case, the victim still has ample air in the lungs and blood and compressions keep blood flowing to the brain, heart and other organs.
A child who collapses is more likely to primarily have breathing problems — and in that case, mouth-to-mouth breathing should be used. That also applies to adults who suffer lack of oxygen from a near-drowning, drug overdose, or carbon monoxide poisoning. In these cases, people need mouth-to-mouth to get air into their lungs and bloodstream.
But in either case, "Something is better than nothing," Sayre said.
The CPR guidelines had been inching toward compression-only. The last update, in 2005, put more emphasis on chest pushes by alternating 30 presses with two quick breaths; those "unable or unwilling" to do the breaths could do presses alone.
Now the heart association has given equal standing to hands-only CPR. Those who have been trained in traditional cardiopulmonary resuscitation can still opt to use it.
Sayre said the association took the unusual step of making the changes now — the next update wasn't due until 2010 — because three studies last year showed hands-only was as good as traditional CPR. Hands-only will be added to CPR training.
An estimated 310,000 Americans die each year of cardiac arrest outside hospitals or in emergency rooms. Only about 6 percent of those who are stricken outside a hospital survive, although rates vary by location. People who quickly get CPR while awaiting medical treatment have double or triple the chance of surviving. But less than a third of victims get this essential help.
Dr. Gordon Ewy, who's been pushing for hands-only CPR for 15 years, said he was "dancing in the streets" over the heart association's change even though he doesn't think it goes far enough. Ewy (pronounced AY-vee) is director of the University of Arizona Sarver Heart Center in Tucson, where the compression-only technique was pioneered.
Ewy said there's no point to giving early breaths in the case of sudden cardiac arrest, and it takes too long to stop compressions to give two breaths — 16 seconds for the average person. He noted that victims often gasp periodically anyway, drawing in a little air on their own.
Anonymous surveys show that people are reluctant to do mouth-to-mouth, Ewy said, partly because of fear of infections.
"When people are honest, they're not going to do it," he said. "It's not only the yuck factor."
In recent years, emergency service dispatchers have been coaching callers in hands-only CPR rather than telling them how to alternate breaths and compressions.
"They love it. It's less complicated and the outcomes are better," said Dallas emergency medical services chief Dr. Paul Pepe, who also chairs emergency medicine at the University of Texas Southwestern Medical Center.
One person who's been spreading the word about hands-only CPR is Temecula, Calif., chiropractor Jared Hjelmstad, who helped save the life of a fellow health club member in Southern California
Hjelmstad, 40, had read about it in a medical journal and used it on Garth Goodall, who collapsed while working out at their gym in February. Hjelmstad's 15-year-old son Josh called 911 in the meantime.
Hjelmstad said he pumped on Goodall's chest for more than 12 minutes — encouraged by Goodall's intermittent gasps — until paramedics arrived. He was thrilled to find out the next day that Goodall had survived.
On Sunday, he visited Goodall in the hospital where he is recovering from triple bypass surgery.
"After this whole thing happened, I was on cloud nine," said Hjelmstad. "I was just fortunate enough to be there."
Goodall, a 49-year-old construction contractor, said he had been healthy and fit before the collapse, and there'd been no hint that he had clogged heart arteries.
"I was lucky," he said. Had the situation been reversed, "I wouldn't have known what to do."
"It's a second lease on life," he added.

New CPR Method Shows Promise

WEST LAFAYETTE, Ind., Sept. 6 -- A new approach to cardiopulmonary resuscitation may improve the poor results of the life-saving procedure, according to researchers here.
In the new method, a rescuer presses on the abdomen, rather than the rib cage, according to Leslie Geddes, Ph.D., D.Sc., of Purdue University, and colleagues.
Because the abdominal organs contain about 25% of the body's blood supply, the abdominal pressure sharply increases the flow to the heart, compared with the flow from standard CPR, Dr. Geddes and colleagues reported in the September issue of the American Journal of Emergency Medicine.
"There are major problems with standard CPR," Dr. Geddes said. "One is the risk of breaking ribs if you push too hard -- but if you don't push hard you won't save the person. Another problem is the risk of transferring infection with mouth-to-mouth breathing."
Dr. Geddes said a new method of CPR is needed because the standard method has a success rate of only 5% to 10%, depending on how fast rescuers respond and how well the procedure is performed.
For every minute of delay, he said, the resuscitation rate decreases by 10%. "In other words, at 10 minutes, the resuscitation is absolutely ineffective," Dr. Geddes noted.
The new method -- dubbed "only abdominal compression cardiopulmonary resuscitation," or OAC-CPR -- eliminates the risk of broken ribs, Dr. Geddes and colleagues noted.
But -- at least in experimental pigs -- it also increases blood flow to the heart during ventricular fibrillation by up to 60%, they said.
The researchers used a compression plate -- shaped roughly like a baseball home plate -- to compress the abdomens of pigs during an induced ventricular fibrillation. Repeated series of 30 abdominal compressions (100 lbs, at 100/min) were followed by two deep breaths.
They compared the resulting coronary perfusion to that seen when the heart was beating normally and to that seen during standard CPR.
To make the comparisons, they used a new measure -- called the coronary perfusion index, or CPI -- which was defined as the difference between aortic and right atrial pressures, summed over one minute.
Coronary perfusion then was defined as CPI/60, Dr. Geddes and colleagues noted.
In the normally beating pig heart, the CPI averaged 2,046 mm Hg. When OAC-CPR was performed, the CPI averaged 922 mm/Hg and the ratio was 0.24.
In other words, Dr. Geddes and colleagues said, OAC-CPR delivered 25% of the normal blood flow.
In a second series of experiments, using standard CPR, the comparable figures were 3,781 mm/Hg for the normally beating heart and 645 during CPR, for a ratio of 0.17.
When the researchers compared blood flow under the two forms of CPR, the average ratio was 1.60 -- or a 60% increase in blood flow using OAC-CPR, compared with standard CPR.
In standard CPR, the right atrial pressure sometimes exceeds the aortic pressure, leading to a backward flow of blood through the heart, Dr. Geddes said.
"This retrograde flow reduces the likelihood of resuscitation," he said.
On the other hand, in OAC-CPR aortic pressure was always higher than the right atrial pressure, eliminating the backward flow, he and colleagues found.
The research was supported by the Purdue Trask Fund. The researchers made no statement regarding potential conflicts. Primary source: American Journal of Emergency MedicineSource reference: Geddes LA et al. "A New CPR Method Employing Only Rhythmic Abdominal Compression: A preliminary report." Am J Emerg Med 2007;25(7):

Study finds 30-minute CPR classes just as effective as multihour courses

Dr. Lynn Roppolo (right), assistant professor of emergency medicine, and Dr. Ahamed Idris, professor of emergency medicine, were part of a group of researchers who have found that a user-friendly,...
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DALLAS – July 25, 2007 -- UT Southwestern Medical Center researchers have found that a user-friendly, 30-minute, video-based cardiopulmonary resuscitation training session is just as effective as the traditional three- to four-hour course in teaching basic life-saving techniques to laypersons. In addition, at six months after the training – a critical point for CPR skill retention – those who took the shorter course performed CPR and used an automated external defibrillator (AED) just as well or better than those who take the traditional training.
These findings, published in the August issue of the journal Resuscitation, are the first to evaluate and document the effectiveness of long-term retention of the new 30-minute CPR-AED training.
“The results of this formal investigation should not only facilitate more widespread training and frequent re-training in CPR techniques, but it also diminishes some of the inefficiencies and labor-intensity inherent in traditional CPR training,” said Dr. Paul Pepe, chief of emergency medicine at UT Southwestern.
Traditional CPR courses last half a day, as six to eight people take turns practicing their skills on a shared manikin. The remainder of the time is spent listening to instruction, leaving little time for skills practice, the researchers report.
“Using individualized kits, the trainees can focus on uninterrupted skills practice and develop muscle memory from more intensive, focused and reiterative practice,” said Dr. Pepe.
The shorter course is much more convenient and easily accessible, said Dr. Lynn Roppolo, assistant professor of emergency medicine and lead author of the study.
“Individuals practice while they learn, allowing more time to perform and retain the critical hands-on skills required to provide more effective CPR,” Dr. Roppolo said. “All of these factors will likely translate into more people knowing what to do – and doing it right – whenever CPR is needed. As a result, hopefully, many more lives will be saved in years to come.”
For the study, volunteers recruited in Fort Worth were selected randomly to take either the 30-minute course or a traditional three-hour session.
The short course consisted of a 23-minute digital video disc program, developed by the American Heart Association, which covers basic adult CPR skills, including recognition of signs of life, calling for help, opening the airway, rescue breaths and chest compressions.
As two dozen or more students watched the video in each session simultaneously, they practiced the CPR techniques almost continuously for nearly 20 minutes on their own personal mini-manikin, supervised by a “facilitator” who generally only needed to answer an occasional question from the trainees once the DVD was started.
Also included was a three-minute discussion and demonstration on the recognition of and best procedures for choking, as well as a five-minute demonstration of the use of an AED.
In the traditional course, students attended a three-hour session consisting of lectures supplemented by related video-based instruction, practice of basic CPR skills, choking procedures and instruction and hands-on practice in the use of an AED. During this course, there was one certified instructor for every six to eight students during the skills practice.
After their respective training, the students from both groups were tested using a life-sized manikin, which was connected to a laptop computer that objectively measured parameters such as the rate and depth of ventilations and chest compressions.
In addition to the computer measurements, overall CPR performance and AED use were videotaped and later judged as being appropriate by CPR training experts, who graded each study participant without knowing whether the he or she had taken the half-hour course or the traditional training.
Immediately after taking the class, there were no significant differences in CPR performance between the students who took the three-hour course as compared to those who took the 30-minute course.
After six months, however, trainees who took the 30-minute course called 9-1-1 and provided adequate ventilation more frequently than those who took the longer course. Also, both at the initial and six-month follow-up test, the students who took the traditional course took 30 percent longer to assess for signs of life, and they took significantly more time to pause between chest compressions to perform ventilations.
In grading AED use immediately after the courses, the trainees who took the 30-minute course placed the AED pads and delivered a shock correctly in 98 percent of the cases, compared to 92 percent of those who took the longer course. Moreover, at the critical six-month follow-up, 93 percent of those in the half-hour course still operated the AED well and 93 percent were still judged to be performing chest compressions adequately.
“The results of this investigation were very compelling. This study suggests that hands-on practice is not necessary to learn how to operate an AED, a device that directly provides the rescuer with vocal instructions once it is turned on,” said Dr. Roppolo. “Thus, training tools that utilize cognitive modes, such as the Internet and DVD demonstrations, may be just as effective.”

Without Mouth-to-Mouth, CPR Still Works

Chest compressions — not mouth-to-mouth resuscitation — seem to be the key in helping someone recover from cardiac arrest, according to new research that further bolsters advice from heart experts.
A study in Japan showed that people were more likely to recover without brain damage if rescuers focused on chest compressions rather than on rescue breaths, and some experts advised dropping the mouth-to-mouth part of CPR altogether. The study was published yesterday in The Lancet.
More than a year ago, the American Heart Association revised CPR guidelines to put more emphasis on chest presses, recommending 30 instead of 15 for every two breaths given. Stopping chest compressions to blow air into the lungs of someone who is unresponsive detracts from the more important task of keeping blood moving to provide oxygen and nourishment to the brain and heart.
Another big advantage to dropping the rescue breaths is that it could make bystanders more willing to provide CPR. Many are unwilling to do the mouth-to-mouth part, become flummoxed or are fearful of getting the ratio of breaths to chest compressions right in an emergency
.http://www.nytimes.com/2007/03/17/health/17cpr.html?ex=1331784000&en=93d7b2b0e266a88c&ei=5088&partner=rssnyt&emc=rss

Hold the Breath for Bystander CPR

TOKYO, March 16 -- Bystander CPR with no mouth-to-mouth ventilation doubled the chance that those in cardiac arrest would have a good neurologic outcome, researchers here reported.
"Cardiac-only resuscitation by bystanders is the preferable approach to resuscitation for adult patients with witnessed out-of-hospital cardiac arrest, especially those with apnea, shockable rhythm, or short periods of untreated arrest," wrote Ken Nagao, M.D., and colleagues, of Surugadai Nihon University Hospital, in the March 17 issue of The Lancet.
They found in a study of more than 4,000 cardiac arrest cases that while any attempt at out-of-hospital resuscitation was better than doing nothing at preserving neurologic function, cardiac-only resuscitation doubled, or nearly doubled, the chance that patients would have a favorable neurologic outcome.
This was especially so when CPR was started within four minutes of cardiac arrest or in those with apnea or a shockable cardiac rhythm.
http://www.medpagetoday.com/Cardiology/MyocardialInfarction/tb1/5268