How to deliver high-quality, hands-only CPR

More than 356,000 people experience sudden cardiac arrest (SCA) outside of hospital settings each year in the United States. Ofentimes, this happens away from emergency medical service (EMS) staff trained to provide lifesaving measures such as cardiopulmonary resuscitation (CPR). But did you know that even if you aren’t CPR-certified, you can still provide a person in cardiac arrest with hands-only CPR and early defibrillation using an automated external defibrillator (AED)?

Without emergency first aid to get the person’s heart beating effectively again, brain damage can set in after five minutes since the heart no longer pumps blood and oxygen to it. Death can occur after eight minutes.

Knowing how to promptly and properly provide hands-only CPR and early defibrillation can save a person’s life and lower the risk of health complications stemming from SCA.

What is CPR?

CPR is a lifesaving technique that helps resuscitate someone in SCA. During cardiac arrest, the heart’s electrical system malfunctions and causes a life-threatening abnormal heart rhythm called an arrhythmia. This can cause the heart to not beat effectively.

Cardiac arrest may follow various life-threatening events, such as:

• Chest trauma (which may cause commotio cordis)
• Choking
• Drug overdose (such as from opioids)
• Drowning
• Heart attack
• Poisoning (by carbon monoxide, for example)

Why do people hesitate to give CPR?

A person is much more likely to survive when bystanders perform high-quality CPR while waiting for EMS to arrive, according to multiple studies. This includes a 2023 review of studies published in BMC Cardiovascular Disorders, which notes that prompt and effective bystander CPR raises the rate of survival almost four times higher.

But despite the fact that bystanders often witness people collapsing or are among the first to arrive on the scene, they initiate CPR fewer than 50 percent of the time, according to a 2020 review of studies published in Resuscitation Plus. Even among those with CPR certification, less than half attempt the technique when needed.

CPR can feel intimidating, even for those who’ve taken a class. In fact, 70 percent of Americans report feeling helpless or unsure of what to do during a cardiac emergency, per the American Heart Association (AHA).

Other common barriers to initiating CPR include the “overwhelming emotion” of emergency situations and concerns about being able to perform the procedure, according to the 2023 review of studies published in BMC Cardiovascular Disorders. Many people are afraid of hurting a victim of cardiac arrest or themselves while they perform the physical components of high-quality CPR.

Are people reluctant to give mouth-to-mouth resuscitation?

Some are reluctant to give CPR to a stranger, such as if the person needing help appears impaired due to alcohol or drugs. Others fear they’ll catch an infection such as COVID-19 if they give rescue breaths using mouth-to-mouth resuscitatation.

Rescue breathing techniques involve ventilating (blowing air) into a person’s airway when they can’t breathe on their own. Mouth-to-mouth resuscitation is one such technique. It entails placing your mouth tightly over the person’s mouth (or using a barrier device called a CPR mask, if you have quick access to one) to deliver breaths.

Rescue breaths are key components of high-quality CPR. But keep in mind they must only be given by people trained and competent in CPR.

How to get CPR-certified and boost your skills and confidence

Laying the foundation for your skills can start with taking a CPR class approved by the AHA or American Red Cross. Earning your CPR certification and keeping it current can help you feel more prepared and able to take proper action if cardiac arrest occurs. But getting CPR-certified isn’t for everyone, and that’s okay.

Why are chest compressions and early defibrillation important?

If you aren’t CPR-certified or you feel out of practice, you can still perform hands-only CPR in an emergency situation. This means you’re giving aid with chest compressions and without rescue breaths.

A 2021 review and analysis of studies published in Cardiology Journal found that standard CPR (chest compressions and rescue breathing) and hands-only CPR produce strikingly similar outcomes when bystanders perform either. Performing the full steps of CPR had only a slight advantage.

Chest compressions and defibrillation are priority components of high-quality CPR you can perform with or without CPR certification. Chest compressions help restart blood flow to and from the heart. Prompt defibrillation with an AED helps restart the vital organ and reset two types of dangerous arrhythmias that affect the ventricles of the heart: ventricular fibrillation and pulseless ventricular tachycardia.

What to do before starting hands-only CPR

Before starting hands-only CPR on an adult, be sure to follow these essential steps:

1. Check the scene for safety and hazards.
2. Check to see if the person responds by tapping or shaking their shoulder firmly and asking loudly and clearly, “Are you OK?”
3. If the person remains unconscious, direct another bystander to call 911 and get an AED machine, if one’s available. If you’re the lone bystander and have immediate access to a phone, call 911 and then get an AED.
4. Lay the person on their back on a firm, flat surface. If you don’t suspect a spinal injury, gently place their head and neck straight and facing up in neutral position.
5. Simultaneously look to see if the person’s chest moves up and down, listen for breath sounds with your ear close to their mouth and nose, and feel for a carotid pulse (heart rate) on the side of the neck. Look, listen, and feel in this way at the same time for a total of 5 to 10 seconds.

The steps for prepping for hands-only CPR on a child 1 to 12 years-old or infant younger than 12 months-old are mostly the same. The difference is you’ll:

• Feel for a brachial pulse on an infant, which can be felt on the inside of the upper arm between the elbow and shoulder.
• Perform hands-only CPR (see intructions below) for two minutes before getting the AED.

How to perform hands-only CPR with early defibrillation

Start chest compressions if the:

• Adult doesn’t have a pulse you can feel or the child or infant has a pulse rate less than 60 beats per minute, and
• The person isn’t breathing, or
• Has few or occasional agonal breaths only. These brain stem reflexes cause a person to gasp, grunt, gurgle, or moan but they aren’t effective breathing.

Step 1: Get into position to perform high-quality CPR

Get into position by kneeling to one side of the person. Quickly pull open or remove bulky clothes covering their chest and torso, if they aren’t too hard to take off.

Place the heel of your palm on the person’s sternum (the flat bone in the center of the chest) in between the nipples. Place your other palm on top of the hand already in position. Interlock your fingers and raise them slightly to give you leverage when compressing. Align your shoulders directly over your hands.

To give CPR to a child, position the heel of just one of your hands in the middle of their sternum. To perform CPR on an infant, place two fingers side by side in the middle of their sternum just below the nipple line.

You can also position yourself at the baby’s feet and place your thumbs side by side in the middle of their sternum just below the nipple line. Wrap the rest of your fingers around the sides and back of their chest for support.

Step 2: Perform high-quality chest compressions

Perform hands-only CPR for two minutes. For high-quality chest compressions, the AHA recommends you compress the chest:

• Hard: At a depth of 2- to 2.4-inches for adults and children, and 1.5 inches for infants. (This is about one-third the diameter of their chest.)
• Fast: With 100 to 120 chest compressions per minute

Use your body weight and straight arms to apply force. Allow the chest to fully recoil between compressions. This means the person's chest rises back up all the way before you compress again.

Step 3: Use the AED right away

Make this the first step, even before you’ve started hands-only CPR, if an AED machine is already available to use. If two rescuers are performing CPR when the AED arrives, one rescuer must continue providing chest compressions while the other one prepares the AED machine and pads to analyze the person’s heart rhythm.

Once you have the AED:

1. Turn it on and follow the voice prompts given by the device.
2. Place the AED pads on the person’s bare skin. Wipe their chest dry, if needed.
3. Apply one pad to the upper right chest and the other one on the left side of the chest a few inches below their armpit, or
4. If the pads touch in this position, apply one pad in the middle of the person’s chest and the other on their back between the shoulder blades.
5. Connect the cable attached to the pads to the AED machine, if needed.
6. Clear the scene to ensure no one is touching the AED or person whose heart rhythm will be analyzed by stating in a loud, commanding voice, “Everyone, stand clear!”
7. Push the “analyze” button on the AED machine, if the device requires you to do so. Wait for the AED to analyze the person’s heart rhythm.
8. If a shock is advised by the AED, clear the scene again and make sure no one is touching the AED or person. State loudly, “Everyone, stand clear!”
9. Push the “shock” button on the AED to deliver a single shock.

Step 4: Resume hands-only CPR

Resume hands-only CPR immediately after one shock is delivered or once the AED finishes analyzing the person’s heart rhythm if the AED didn’t advise a shock. Take no more than 5 to 10 seconds to get back into position and restart chest compressions.

Step 5: Recheck the person’s heart rhythm after two minutes

Continue hands-only CPR for two minutes. Then recheck the person’s heart rhythm with the AED. Follow the AED prompts, including giving another shock, if advised.

If you don’t have an AED, quickly check for responsiveness again. Simultaneously look for chest movement, listen for breath sounds, and feel for their pulse for a total of 5 to 10 seconds.

Step 6: Repeat hands-only CPR steps with AED defibrillation

Repeat these steps until EMS arrives or the person shows signs of life such as a steady and strong pulse, breathing normally, moving around, or speaking.

If they show signs of life, stop CPR and defibrillation and place them in recovery position, also called lateral recumbent position. This helps keep the person’s airway open and lower the risk of choking from fluids and other contents draining from their stomach such as vomit.

To place the person in CPR recovery position:

1. Kneel on one side of the person (often their left side).
2. Grab one of their legs and shoulders and roll them toward you until they’re on their side. Roll them on their left side if possible, especially if the person is further along in their pregnancy. This helps keep the fetus from compressing the main blood vessels in the person’s abdomen.
3. Bend the top leg and knee at a right angle.
4. Cross the top leg over and in front of the bottom leg and lay it on the ground.
5. Tilt the head back gently to keep their airway open.

What to do if you get tired while performing hands-only CPR?

If you’re doing hands-only CPR correctly, you’ll likely get exhausted as you continue compressing the chest. If you’re alone with the person and too tired to keep giving high-quality CPR, take a break every two minutes for up to 10 seconds, as needed. Stay by their side during these breaks.

If someone else at the scene can take over, ask them to do so. Before stopping CPR, be sure the person taking over is in position and ready to assume chest compressions to minimize delays.

If you’re performing CPR alongside another rescuer, swap roles every two minutes or anytime one of you becomes too tired to perform chest compressions effectively. CPR delays can lead to decreased blood flow to and from the heart and other vital organs such as the brain, so try to take no more than 10 seconds to swap roles.

Which CPR song beats help you find your compression rhythm?

"Stayin' Alive" by the Bee Gees has become an iconic song used to perform chest compressions because it clocks within the ideal range of 100 to 120 beats per minute. But if disco isn’t your preferred music style, there are plenty of other songs that can help you find your CPR beat.

Sites like Spotify have specially curated CPR playlists filled with songs between 100 and 120 beats per minute. Some good options include:

• “Can’t Stop the Feeling!” by Justin Timberlake
• “Don’t Wanna Know” by Maroon 5, featuring Kendrick Lamar
• “Just a Girl” by No Doubt
• “Let’s Get It Started” by Black Eyed Peas
• “Summer Nights” by Rascal Flatts
• “Uptown Funk” by Mark Ronson, featuring Bruno Mars
• “Work it” by Missy Elliot

No matter your taste in music, finding your rhythm and knowing how to perform high-quality, hands-only CPR and use an AED may one day help you save a person’s life.