Written by Sarah Gehrke, MSN, RN, Sarah has worked in various roles at Coffee Medical Center including nurse, education director, and quality assurance director.

As of 2008, the use of hands-only cardiopulmonary resuscitation (CPR) became the best practice when attempting to revive victims of cardiac arrest. Understanding why learning CPR is vital can motivate more people to learn this life-saving skill. This is a change from the previous guidelines, which support the use of both chest compression and mouth-to-mouth ventilation.

Hands-only CPR does not eliminate the need for conventional CPR. Based on three major studies and the agreement from the American Heart Association’s Emergency Cardiovascular Care Committee, the hands-only method works just as well when performed on teens and adults.

Hands-only CPR is beneficial in helping to resolve any unease that untrained bystanders may have about performing CPR due to health concerns regarding mouth-to-mouth ventilation. An increase in bystander participation in cases of cardiac arrest may help to improve the victim’s chances of survival.

When to implement hands-only CPR

Implement hands-only CPR when an adult suddenly collapses and is unresponsive.

There are two basic steps to remember, which makes this method a better option for people who are uncomfortable with, or untrained in, conventional CPR methods.

1. Upon seeing the victim collapse, 911 should immediately be notified either by the person who is preparing to perform CPR or if there are other people nearby, one of them should be instructed to make the call; and get an AED (see automated external defibrillator usage); this saves the CPR provider valuable time.

2. Immediately after placing the call, firm chest compressions should be started at a rate of 100–120 beats per minute until emergency personnel arrives.

   Note: When performing the traditional method of CPR, there must be 30 chest compressions made at a rescue breathing rate of 100–120 per minute for every two breaths given to the victim. For more detailed guidance check out our CPR training online, CPR renewal online or get ACLS Medical Training.

Cardiac arrest versus heart attack

The term cardiac arrest throws some people off—it is often used interchangeably with heart attack, but they are two different scenarios.

Heart attacks usually occur because a block in an artery prevents blood rich oxygen from reaching the heart. Classic symptoms include: Gripping, heavy chest pain that may often spread to the jaw, either arm, or the back; difficulty breathing; nausea; or fatigue.

Cardiac arrest is when the normal heartbeat is interrupted. The lower chambers of the heart, the ventricles, chaotically quiver (ventricular fibrillation), race (ventricular tachycardia), or may stop pumping altogether—blood then stops circulating. During a cardiac arrest, the victim will suddenly collapse and lose consciousness—the brain is not getting the blood it needs. Other systems, such as the respiratory system, quickly shut down.

The confusion about the difference between cardiac arrest and heart attack is that a heart attack is a common trigger of cardiac arrest. People with “clean” coronary arteries are victims of cardiac arrest as well, for various reasons, including defects in the systems that pump the heart.

Approximately every year, 300,000 Americans suffer cardiac arrest outside of a hospital. Cardiac arrest is often dramatized as occurring in a public place; however, 80% of the time people are in a residential setting or at home. Some stereotypes ring some factuality: a prototypical victim is a man in his 50s or 60s.

Statistics: Hands-only CPR

It is estimated that 94% of people suffering from sudden cardiac arrest die before reaching the hospital. Part of this because only 24% of these victims received any type of CPR from bystanders upon collapse.

The chance of survival when hands-only CPR is given doubles and may even triple if delivered in a timely fashion.

Hands-only CPR is more efficient than conventional CPR for people in whom out-of-hospital cardiac arrest is observed and shocked with public-access automated external defibrillator (AED).

When it came to the patients that were given conventional CPR, only 7.8% survived; this was, however, still better than the 5.2% survival rate of those who did not receive any form of CPR.

Resources

Chest-compression-only CPR (CCO-CPR): https://pubmed.ncbi.nlm.nih.gov/23230315/

Chest compression-only CPR: A meta-analysis: https://pmc.ncbi.nlm.nih.gov/articles/PMC2987687/

Bystander-initiated chest compression-only CPR is better than standard CPR in out-of-hospital cardiac arrest: https://pmc.ncbi.nlm.nih.gov/articles/PMC3484593/

What is a heart attack: https://www.nhlbi.nih.gov/health/heart-attack

What is sudden cardiac arrest: https://www.nhlbi.nih.gov/health/cardiac-arrest

The circulatory system: https://pacificmedicaltraining.com/scribe/circulatory-system-info-for-scribes

Out-of-hospital cardiac arrest (OHCA)

Overview

The number of out-of-hospital cardiac arrests (OHCA) is more than 356,000 in the US annually, out of which 90% are fatal. Based on the Cardiac Arrest Registry to Enhance Survival (CARES) data, the survival rate remains low. OHCA is the third major contributor to significant morbidity in the US.

In 2017, laypersons delivered a shock in roughly 2% of cases, used AEDs in 6% of cases, and initiated CPR in 39% of the cases. Witnessed OHCA occurs in 69.5% of cases at home, 18.8% in public, and 11.7% in nursing homes. Individuals lost, on average, 20.1 healthy years when OHCA occurred, translating to 4.3 million healthy life years lost nationally in the US.

Signs of ventricular fibrillation

Ventricular fibrillation (VF) is the most common initial rhythm in out-of-hospital sudden cardiac arrest. Thankfully, VF has ten times the survival rate of other arrest rhythms when defibrillation is delivered promptly. Time is the most important factor; as minutes pass, the chance of successful defibrillation decreases sharply.

Updated recommendations call for rescuers to integrate AED use with CPR. After calling 911, the caller should start CPR while preparing the AED. If two rescuers are present, one can call emergency services while the other begins compressions. When VF persists for more than a few minutes, the myocardium becomes depleted of oxygen and metabolic substrates. Chest compressions help restore perfusion and support a return to a perfusing rhythm. Even without a clear mandate for 90–180 seconds of CPR before defibrillation, compressions should continue while the AED is prepared. For additional instruction, review our CPR course.

Why fast action is crucial

A Swedish study following 14,065 people demonstrated that survival drops from approximately 50% with minimal delay to 5% at 15 minutes. When bystanders deliver CPR, survival decreases more gradually—about 3%–4% per minute. Early CPR can double or triple the chance of survival, yet disparities remain: people in white or high-income neighborhoods are more likely to receive bystander CPR than those in Black, Hispanic, or low-income communities.

Roughly seven out of ten OHCAs occur at home, but half of these people never receive CPR from bystanders. If you witness a collapse, call 911 immediately and begin compressions until EMS arrives. Prompt defibrillation is equally critical. Although CPR prolongs VF and delays asystole, it rarely terminates VF on its own—patients still require advanced care.

Any delay in compressions or defibrillation reduces survival. Interestingly, simply supplying more AEDs to responders does not improve survival if emphasis on CPR falls. One study of 639 VF patients found that providing 90 seconds of CPR before the shock increased survival when response times were at least four minutes. Two other randomized trials, however, showed no survival benefit to delaying shocks. The shared takeaway: integrate CPR and defibrillation seamlessly and avoid pauses.

Shock defibrillation protocols

Studies comparing shock strategies show that single-shock protocols offer better survival than the older three-stacked approach. Rescuers using monophasic defibrillators should deliver an initial 360 J shock; if VF persists, a second 360 J shock follows. After the shock, resume compressions immediately while assessing rhythm and pulses. Minimizing the pause between compressions and defibrillation increases the likelihood of success, so teams should choreograph their movements ahead of time.

Conclusion

High-quality compressions paired with prompt defibrillation remain the key to return of spontaneous circulation (ROSC) in VF. Modern biphasic defibrillators make single-shock strategies more effective than the pre-2005 stacked-shock protocols. When teams practice the choreography between CPR and shock delivery, they limit interruptions and dramatically improve patient outcomes.

References

• https://www.ahajournals.org/doi/10.1161/CIR.0000000000000659
• Learn CPR — Practical skills
• https://jamanetwork.com/journals/jama/article-abstract/189314
• https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1742-6723.2005.00694.x
• https://www.sciencedirect.com/science/article/abs/pii/S0300957208006072
• https://www.ahajournals.org/doi/10.1161/01.cir.0000133323.15565.75
• https://www.sciencedirect.com/science/article/abs/pii/S0300957203001060
• https://www.ahajournals.org/doi/full/10.1161/01.CIR.0000016362.42586.FE
• https://www.ahajournals.org/doi/full/10.1161/circulationaha.105.165674

Related articles

Essential emergency response skills and knowledge:

• Why learning CPR is vital - Understanding the importance of CPR training
• Emergency treatment of cardiac arrest - Comprehensive emergency protocols
• Automated external defibrillator usage - Using AEDs with CPR
• Anatomy of the heart - Understanding what happens during cardiac events