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CPR Often Bungled by Doctors, Medics

Pros Get Low Marks for Lifesaving Technique; New Guidelines Advised

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Jan. 18, 2005 - CPR saves lives. But even medical professionals often bungle the lifesaving technique, two new studies show.

A person who suddenly collapses and doesn't respond to shouts or shaking needs cardiopulmonary resuscitation -- CPR -- until medical help arrives. It's not the simplest technique in the world. But it isn't exactly rocket science.

Yet a European study shows that emergency medical personnel get it wrong about half the time. And a U.S. study shows frequent, serious errors even when CPR is given in a hospital. The studies appear in the Jan. 19 issue of The Journal of the American Medical Association. An editorial by Arthur B. Sanders, MD, and Gordon A. Ewy, MD, of the Arizona Sarver Heart Center, accompanies the reports.

"CPR is a very difficult skill," Sanders tells WebMD. "Even with health professionals who do this all the time, often we are not delivering what we think we are."

This doesn't mean that you shouldn't try your hand at CPR if you're nearby when a person suddenly collapses, says emergency medicine expert Benjamin S. Abella, MD. Abella, an assistant professor at the University of Chicago Hospitals, led the U.S. CPR study.

"Don't worry about being scrutinized for doing it right -- doing something is better than doing nothing," Abella tells WebMD. "So if someone collapses, there are two fundamentals: Call 911 and call them as soon as possible -- then do CPR."

How to Save a Life

An adult who suddenly collapses usually has suffered cardiac arrest. That means his or her heart has stopped beating.

"Death is certain unless lifesaving measures are taken," Abella says. "With every minute of no blood flow, mortality increases 10% to 15% -- so if you are down with no blood flow for 10 minutes, the game is up. Paramedics need to get there in 10 minutes. The best way to extend that time is to give CPR until professional help arrives."

How do you do it? By far the best way to learn is by taking an approved CPR course. The Red Cross and the American Heart Association offer free courses. Here are the basics:

  1. If a person collapses, call 911 immediately.
  2. If the person does not respond to shaking or to shouts, begin CPR.
  3. For adults only: Using both hands, press firmly on the chest at a point directly between the nipples. Press hard enough to compress the chest by about an inch and a half or two inches. Release. Do this 100 times a minute - faster than once a second.
  4. After every 15 compressions, breathe two quick breaths into the victim's mouth. This is done by tilting the head back, making sure the throat is clear, pinching the nostrils, and blowing into the mouth until the chest rises.

"The chest is like a fireplace bellows. Pressing it moves enough blood to keep the system going," Abella says. "It can't take the place of a beating heart, but it works well enough to keep a person alive. And one needs to give rescue breaths, where you do mouth-to-mouth breathing. The combination of putting air in the lungs and moving blood does everything your body needs to stay alive."

CPR guidelines are different for children and for infants. If you're alone, children need a minute of CPR before calling 911. Use just the heel of one hand to press the chest down by one to one-and-a-half inches. And since children are much more likely to have a breathing problem than a cardiac arrest, there should be one full breath followed by five chest compressions, followed by another breath, another set of compressions, and so on until help arrives.

For infants, extra care is needed not to tilt the head too far back. Breaths should be small and gentle - only just enough to make the baby's chest rise. Use only two fingers to press the chest one-half to one inch. Begin with two breaths before the first set of five compressions, then repeat with cycles of one breath and five compressions.

New Guidelines on the Way

What CPR does is to keep a trickle of oxygen-rich blood flowing to the brain, heart, and other organs. For adults, Sanders says, the chest compressions are the most important part.

"In cardiac arrest, the only blood that flows to the brain and heart and other organs is what you deliver by pressing on the chest," he says. "Even when done correctly, that is only 10% to 30% of normal blood flow. So if you are not doing enough compressions, that is even more compromising than not giving enough breaths."

Yet Abella's study - and the European study led by Lars Wik, MD, PhD, of Norway's Ulleval University Hospital - found that even medical personnel often give too few compressions and spend too much time on breaths when performing CPR.

"To only give a few breaths feels weird to people. So ventilation is overemphasized," Abella says. "As of now, people now should just continue to do ventilations. But it is under discussion whether you should just do compressions. CPR rates might go up if you didn't have to touch lips with a stranger. And maybe people should focus on what really makes a difference in a life-or-death situation."

Next week, Abella and Sanders will participate in the American Heart Association's once-every-five-years meeting to review CPR guidelines. Both will argue that the guidelines should be simplified.

"Our advice is to try to simplify CPR," Sanders says. "We can be somewhat selective in terms of what we teach. For an adult who suddenly collapses, it is usually a cardiac arrest rather than a pulmonary arrest. For that population, where an adult just suddenly goes down, we should be doing more compressions and not providing too many rescue breaths per minute. We are not against rescue breaths, but these long interruptions of compression aren't working."

Abella notes that the next generation of automated external defibrillators - the AEDs you see in airport corridors and other public places -- will also coach users on how to give CPR.

"Imagine a person who sees someone collapse in an airport," he says. "You go to the AED hanging on the wall, but now it has sticky pads to put on the victim's body that monitor how you do CPR. It will speak to you and say, for example, that you need to speed up your compressions. We can all get better instrumentation and feedback -- medics as well as lay people -- and, hopefully, save lives."

Show Sources

SOURCES: Abella, B.S. The Journal of the American Medical Association, Jan. 19, 2005; vol 293: pp 305-310. Wik, L. The Journal of the American Medical Association, Jan. 19, 2005; vol 293: pp 299-304. Sanders, A.B. and Ewy, G.A. The Journal of the American Medical Association, Jan. 19, 2005; vol 293: pp 363-365. Arthur B. Sanders, MD, Arizona Sarver Heart Center. Benjamin S. Abella, assistant professor, University of Chicago Hospitals.
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