"If a bystander is not trained in CPR, then the bystander should provide hands-only CPR. The rescuer should continue hands-only CPR until an automated external defibrillator arrives and is ready for use or EMS providers take over care of the victim."

Encouraging Hands-Only CPR

A study published in Circulation last year found that CPR knowledge and confidence to use hands-only CPR can be increased through large-scale community training.

Hands-only CPR recommendations1 from the American Heart Association's Emergency Cardiovascular Care Committee were released nine years ago, in April 2008. Chiefly, the goal of the recommendations was to raise the rate of bystander CPR, which the committee noted remained low in most U.S. cities at approximately 27-33 percent.

"Reducing barriers to bystander action can be expected to substantially improve cardiac arrest survival rates. Reasons cited prospectively for the reluctance to perform CPR often include concerns about disease transmission related to performing mouth-to-mouth ventilation," the committee noted, adding that studies of actual bystanders found they "most often cited panic and fear of causing harm as reasons for failing to perform CPR," and the fear of infection in fact was not a prominent concern.

Recent studies suggest the prevalence of bystander CPR remains stubbornly low, however. Writing in Emergency Medicine Australasia in April 2017, Dr. Janet E. Bray of Monash University's Department of Epidemiology and Preventive Medicine and colleagues reported2 that their phone survey in April 2016 of adult residents of the Australian state of Victoria found that 68 percent of the 404 adults surveyed had received CPR training. Only 50 percent of them had heard of hands-only CPR, though; among those who had undergone training, the majority, 52 percent, had received their training more than five years before, and only 28 percent had received training or refreshed training during the previous 12 months.

Most who had been trained received their training in a first-aid class, and 67 percent had received training as a requirement for work. The most common reasons for not having been trained were: They had never thought about it (59 percent), did not have time (25 percent), and did not know where to learn (15 percent), reported Bray, Ph.D., who is the associate director of The Australian Resuscitation Outcomes Consortium (Aus-ROC, https://www.ausroc.org.au/), and her colleagues.

They did find that more respondents were willing to provide hands-only CPR than standard CPR for strangers.

Joseph Hanson, who invented and patented medical products such as a disinfecting sharps disposer and a hands-only CPR device, cited a 2015 report by the American Heart Association in an article3 that same year for this magazine. The AHA study concluded 326,200 people experienced out-of-hospital cardiac arrest in the United States in 2011 and survival to hospital discharge was only 10.6 percent. "Even though nearly 40 percent of out-of-hospital cardiac arrests are witnessed by a bystander, just 31.4 percent of those victims survive. Many of these deaths occur because bystanders do not perform CPR—as many as 70 percent of Americans may feel helpless to act either because they don’t know CPR or because their training has significantly lapsed," he wrote.

Sudden cardiac arrest typically is caused by an electrical disturbance in the heart that disrupts its rhythm. He explained that it is characterized by these symptoms:

  • Sudden collapse
  • No pulse
  • Not breathing
  • Loss of consciousness

A study published last year in Circulation concluded that there was no impact on bystander CPR performance or outcomes from a blanket approach to community CPR education (offering one-time, compression-only CPR training to passersby at seven locations in Grand Rapids, Mich., in May 2014). Only 37 percent of out-of-hospital SCA cases receive bystander CPR in Kent County, Mich., the Michigan State University authors reported. But a second Circulation study published last year found that CPR knowledge and confidence to use hands-only CPR can be increased through large-scale community training—in this case, 15-minute group sessions repeated in 10 Texas cities during February 2016. A total of 4,250 people were trained, and the number who reported they were comfortable performing hands-only CPR rose from 59 percent to 96 percent. More than 60 percent indicated they were willing to be contacted in six months to assess how much of their training they had retained, the authors found.

The Chain of Survival
AHA introduced the concept of the Chain of Survival in 1991, urging communities to adopt the principle of early defibrillation in sudden cardiac arrest cases. The links in the chain are:

  • Early Access to the emergency response system
  • Early CPR to support circulation to the heart and brain until normal heart activity is restored
  • Early Defibrillation to treat cardiac arrest caused by ventricular fibrillation
  • Early Advanced Care by EMS and hospital personnel

The ECC Committee said in 2008 that all victims of cardiac arrest should receive, at a minimum, high-quality chest compressions. Its recommendations, to support that goal and to save more lives, included these:

"When an adult suddenly collapses, trained or untrained bystanders should—at a minimum—activate their community emergency medical response system (e.g., call 911) and provide high-quality chest compressions by pushing hard and fast in the center of the chest, minimizing interruptions.

"If a bystander is not trained in CPR, then the bystander should provide hands-only CPR. The rescuer should continue hands-only CPR until an automated external defibrillator arrives and is ready for use or EMS providers take over care of the victim.

"If a bystander was previously trained in CPR and is confident in his or her ability to provide rescue breaths with minimal interruptions in chest compressions, then the bystander should provide either conventional CPR using a 30:2 compression-to-ventilation ratio or hands-only CPR. The rescuer should continue CPR until an automated external defibrillator arrives and is ready for use or EMS providers take over care of the victim.

"If the bystander was previously trained in CPR but is not confident in his or her ability to provide conventional CPR including high-quality chest compressions (i.e., compressions of adequate rate and depth with minimal interruptions) with rescue breaths, then the bystander should give hands-only CPR. The rescuer should continue hands-only CPR until an automated external defibrillator arrives and is ready for use or EMS providers take over the care of the victim."

The committee noted that, while all cardiac arrest victims will benefit from delivery of high-quality chest compressions, some victims may benefit from the administration of conventional CPR. So it continued to encourage the public to obtain CPR training to learn the skills required to care for a wide range of cardiovascular- and respiratory-related medical emergencies.

References
1. http://circ.ahajournals.org/content/117/16/2162
2. Vol. 29, Issue 2, pp. 158-164, http://onlinelibrary.wiley.com/wol1/doi/10.1111/1742-6723.12720/full
3. https://ohsonline.com/Articles/2015/06/01/Chain-of-Survival-Starts-with-Awareness-and-Preparedness.aspx

This article originally appeared in the June 2017 issue of Occupational Health & Safety.

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