What is Hands-OnlyTM CPR

What is Hands-OnlyTM CPR?

    Hands-OnlyTM CPR is CPR without mouth-to-mouth breaths. It is recommended for use by people who see an adult suddenly collapse in the “out-of-hospital” setting (like at home, at work, in a park). It consists of two steps:

        * 1) Call 911 (or send someone to do that).
        * 2) Begin providing high-quality chest compressions by pushing hard and fast in the center of the chest with minimal interruptions.

Who should receive Hands-OnlyTM CPR?

    Hands-OnlyTM CPR is recommended for use on teens or adults (anyone over the age of 8) whom you witness suddenly collapse.
Will Hands-OnlyTM CPR increase the chance of a bystander taking action in a cardiac emergency?

    Yes. In a national survey, Americans who have not been trained in CPR within the last 5 years stated that they would be more likely to perform Hands-OnlyTM CPR than conventional CPR for an adult who collapses suddenly. In addition, Hands-OnlyTM CPR offers an easy to remember and effective option to those bystanders who have been previously trained in CPR but are afraid to help because they are not confident that they can remember and perform the steps of conventional CPR.

Hands-OnlyTM CPR vs. Conventional CPR with breaths

Are there times when I should use conventional CPR with breaths?

    Yes. There are many medical emergencies that cause a person to be unresponsive and to stop breathing normally. In those emergencies, CPR that includes mouth-to-mouth breathing may provide more benefit than Hands-OnlyTM CPR. The American Heart Association (AHA) recommends conventional CPR (CPR with a combination of breaths and compressions) for:

        * All infants (up to age 1)
        * Children (up to age 8)
        * Adult victims who are found already unconscious and not breathing normally
        * Any victims of drowning, drug overdose or collapse due to breathing problems.

Why don’t adults who suddenly collapse need mouth-to-mouth breathing in the first few minutes after their cardiac arrest?

    When an adult suddenly collapses with cardiac arrest, their lungs and blood contain enough oxygen to keep vital organs healthy for the first few minutes, as long as someone provides high quality chest compressions with minimal interruption to pump blood to the heart and brain.

        * When an adult suddenly collapses with cardiac arrest, the cause is usually an electrical malfunction, an abrupt onset of an abnormal heart rhythm. The most common abnormal rhythm causing sudden cardiac arrest is ventricular fibrillation (VF). VF causes the heart to quiver so it does not pump blood. Before a sudden collapse, the adult was probably breathing normally. At the time of a sudden collapse, the adult's lungs and blood are likely to have a fresh supply of oxygen that can last for at least a few minutes even if breathing stops.
        * Consider when you hold your breath while floating in a pool. Most people can hold their breath for quite a while, as long as they are not moving.
        * Another reason that breaths may not be needed during the first minutes after collapse is that a person in cardiac arrest needs less oxygen than a person who is not in cardiac arrest.
        * For these reasons, the most important thing a bystander can do for a person in sudden cardiac arrest is to pump blood to the brain and to the heart muscle, delivering the oxygen that still remains in the lungs and blood. A rescuer can do this by giving high-quality chest compressions with minimal interruptions. Interruptions in compressions to give breaths (mouth-to-mouth breaths) may bring some additional oxygen to the lungs but the benefit of that oxygen can be offset if you stop the blood flow to the brain and heart muscle for more than a few seconds (especially in the first few minutes after a sudden cardiac arrest when there is still plenty of oxygen in the lungs and blood).

Now that I know about Hands-OnlyTM CPR, do I still need to learn “conventional” CPR with mouth-to-mouth breathing?

    CPR is a psychomotor skill. The AHA continues to recommend that you take a CPR course to practice and learn the skills of CPR, including giving high-quality chest compressions. People who have had CPR training are more likely to give high-quality chest compressions and are more confident about their skills than those who have not been trained (or have not trained in the last 5 years). Even a very short CPR training program that you can do at home, like the AHA’s 22-minute CPR Anytime program, provides skills training and practice that can prepare you to perform high-quality chest compressions.

    Besides, there are many medical emergencies that cause a person to be unresponsive and to stop breathing normally. In those emergencies, CPR that includes mouth-to-mouth breathing may provide more benefit than Hands-OnlyTM CPR. Some examples include:

        * Unresponsive infants and children
        * Adult victims who are found already unconscious and not breathing normally
        * Victims of drowning or collapse due to breathing problems

Is Hands-OnlyTM CPR as effective as conventional CPR?

    Any attempt at CPR is better than no attempt. Hands-OnlyTM CPR performed by a bystander has been shown to be as effective as conventional CPR with mouth-to-mouth breaths in the first few minutes of an out-of-hospital sudden cardiac arrest. Conventional CPR may be better than Hands-OnlyTM CPR for certain victims, though, such as infants and children, adults who are found in cardiac arrest (whom you did not see collapse) or victims of drowning or collapse due to breathing problems.

How and when to provide Hands-OnlyTM CPR

Has the American Heart Association changed its recommendation for healthcare providers?

    No, the current AHA recommendation for healthcare providers has not changed. More research is needed to determine if the existing sequence for professional rescuers can be made more effective.
If I was trained in conventional CPR that includes breathing (30 compressions to 2 breaths) and I see an adult suddenly collapse, what am I supposed to do?

    Call 911 and start CPR.

    If you ARE CONFIDENT in your ability to provide CPR that includes breaths with high-quality chest compressions with minimal interruptions, then provide either the conventional CPR that you learned (CPR with a 30:2 compression to breath ratio) OR Hands-OnlyTM CPR. Continue CPR until an AED arrives and is ready for use or EMS providers take over care of the victim.

    If you ARE NOT CONFIDENT in your ability to provide CPR that includes breaths with high-quality chest compressions with minimal interruptions, then provide Hands-OnlyTM CPR. Continue Hands-OnlyTM CPR until an AED arrives and is ready for use or EMS providers take over care of the victim.
If I was trained in conventional CPR that includes breathing (30 compressions to 2 breaths), how long should I do Hands-OnlyTM CPR before switching to conventional CPR?

    At this point, there is not sufficient data to provide a specific recommendation. Trained rescuers will take over when they arrive at the victim's side. Those rescuers will follow the local protocol, which most often involves providing conventional CPR and the use of specialized equipment. In the meantime, you should give the victim high-quality chest compressions with minimal interruptions. If you are confident in your ability to give breaths with minimal interruptions in chest compressions, then give either Hands-OnlyTM CPR or conventional CPR.
Do I need to take a training course to learn how to do Hands-Only CPR?

    CPR is a psychomotor skill. The AHA continues to recommend that you take a CPR course to practice and learn the skills of CPR, including giving high-quality chest compressions. People who have had CPR training are more likely to give high-quality chest compressions and are more confident about their skills than those who have not been trained (or have not trained in the last 5 years).* Even a very short CPR training program that you can do at home, like the AHA’s 22-minute CPR AnytimeTM program, provides skills training and practice that can prepare you to perform high quality chest compressions.
What do I do if I find an adult who has collapsed but no one saw it happen?

    Call 911 and start CPR. If you learned conventional CPR (with mouth-to-mouth breathing), then call 911 and provide CPR as you learned it. If you only know Hands-OnlyTM CPR, call 911 and give Hands-OnlyTM CPR until an AED arrives and is ready for use or EMS providers take over care of the victim.
What if I am using an AED that prompts CPR with breathing, should I just give chest compressions?

    Follow the directions provided by the AED and minimize any interruptions to chest compressions. Remember, all victims of cardiac arrest should receive high-quality chest compressions. You should push hard and fast in the center of the chest with minimal interruption.
What should I do if I am getting tired from giving chest compressions before more help arrives?

    Continue to provide hard and fast chest compressions with minimal interruption to the best of your ability. We realize that giving good quality chest compressions at 100 times per minute is hard work. Most people will get tired after only a few minutes of delivering any type of CPR. If someone else is nearby, ask that person to take over chest compressions after about 2 minutes or about 200 compressions. If you are alone, then just do your best.
Not all people who suddenly collapse are in cardiac arrest. Will CPR seriously hurt them?

    Adults who suddenly collapse and are not responsive are likely to have sudden cardiac arrest and their chance of survival is nearly zero unless someone takes action immediately. You should call 911 and start giving hard and fast chest compressions in the center of the chest, with minimal interruptions. If sudden cardiac arrest is the cause of the collapse, Hands-OnlyTM CPR is an easy, effective way for any bystander to more than double the victim's chance for survival. If an adult has collapsed for reasons other than sudden cardiac arrest, Hands-Only CPR could still help by causing the person to respond (begin to move, breathe normally or speak). If that occurs, Hands-OnlyTM CPR can be stopped. Otherwise, chest compressions should continue until EMS providers arrive.
Can you break people’s ribs doing CPR?

    Yes. A 2004 review of scientific literature showed that conventional CPR can cause fractures of ribs and/or the breastbone (sternum) in at least 1/3 of cases.† In a related study of people who had received such injuries from CPR, the fractures did not cause any serious internal bleeding and, thus, mortality.‡ On the other hand, the chance of surviving an out-of-hospital cardiac arrest is near zero for a victim who does not immediately receive high-quality chest compressions with minimal interruptions, followed by additional therapy within minutes (a defibrillating shock and/or more advanced care from EMS personnel).
Is there a danger in jumping in and giving CPR without being trained?

    On average, any attempt to provide CPR to a victim is better than no attempt to provide help.

Science and Guidelines Information

Why did the American Heart Association decide to recommend Hands-OnlyTM CPR for adults you witness suddenly collapse?

    This recommendation clarifies and elaborates the 2005 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care. Those guidelines noted that there was a need to increase the prevalence and quality of bystander CPR. The guidelines also contained the recommendation that lay persons should do Hands-OnlyTM CPR (the guidelines used the term “compression-only CPR”) if they are unable or unwilling to provide breaths.

    Since the publication of the 2005 AHA Guidelines, several studies showed that Hands-OnlyTM CPR can be as effective as conventional CPR (CPR with breathing) in the out-of-hospital setting. As a result, American Heart Association volunteer scientists authored an Advisory Statement for the Public. This Advisory Statement, Hands-Only (compression-only) CPR: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest, was published in the journal Circulation on March 31. The statement applies to bystanders who see an adult collapse suddenly in the out-of-hospital setting. The purpose of this statement is to encourage the use of Hands-OnlyTM CPR by untrained bystanders and by trained bystanders who are not confident that they can perform conventional CPR. The statement also notes that trained bystanders who are confident that they can perform conventional CPR with minimal interruption to chest compressions can do so or they can perform Hands-OnlyTM CPR.
How does this recommendation differ from the 2005 AHA Guidelines for CPR and ECC?

    This scientific advisory amends the 2005 Guidelines on Hands-OnlyTM CPR (compression-only CPR) by increasing the circumstances for which Hands-OnlyTM CPR is recommended. Previously, use of Hands-OnlyTM CPR was recommended only for: “Laypersons . . . who are unable or unwilling to provide breaths...” and for dispatcher CPR instructions to bystanders by telephone. Recently published evidence demonstrates that Hands-OnlyTM CPR can be as effective as conventional CPR (CPR with breaths) when performed by bystanders. Therefore, the AHA now recommends that Hands-OnlyTM CPR can be used by any bystander who witnesses an adult suffer a sudden collapse outside of the hospital setting.
Is the previous AHA recommendation for bystanders wrong?

    No. With the publication of the 2005 AHA Guidelines for CPR and ECC, the AHA emphasized that the most critical component of performing CPR is delivery of high-quality chest compressions with minimal interruptions. That remains true and can be accomplished for all victims of cardiac arrest using conventional CPR, that is, CPR with breathing (mouth-to-mouth). AHA experts recognize that mouth-to-mouth breathing is a relatively complex skill. If rescuers have not practiced the combination of breathing with chest compressions, the delivery of breaths can result in long and potentially detrimental interruptions to chest compressions. In addition, recent evidence demonstrates that bystander Hands-OnlyTM CPR is as effective as conventional CPR in the first few minutes of out-of-hospital sudden cardiac arrest. Therefore, Hands-OnlyTM CPR is now considered an appropriate bystander response to out-of-hospital adult sudden cardiac arrest. The breathing (mouth-to-mouth) component of CPR remains important in the treatment of other cardiovascular emergencies:

        * All unresponsive infants and children
        * Adult victims who are found already unconscious and not breathing normally
        * Any victims of drowning or collapse due to breathing problems

Hands-OnlyTM CPR was released as a Scientific Statement in 2008. What is the American Heart Association process for releasing Scientific Statements?

    Researchers and clinicians who serve as volunteer experts for the American Heart Association continually monitor and review the scientific literature related to cardiovascular disease and treatment. When experts agree that published evidence supports a new or changed recommendation, a group of experts is commissioned to draft a scientific statement for publication in a peer-reviewed journal. http://www.americanheart.org/presenter.jhtml?identifier=3023366

Additional Information:

Does AHA offer products that teach Hands-OnlyTM CPR?

    All CPR training courses that include skills practice will teach you to perform the essential skill of Hands-OnlyTM CPR, that is, high-quality chest compressions. In addition, all students taking an AHA BLS course will receive a Hands-Only informational flyer, specific for their level of training.

    The AHA's Family & FriendsTM CPR AnytimeTM www.cpranytime.org provides CPR training in 22 minutes in the comfort of your own home. You can also find information about instructor-led CPR courses by going to www.americanheart.org/cpr or calling 1-877-AHA-4CPR.
I am about to purchase an AED for use in [a public location, my business, my home, my boat, etc.] and I plan to buy one that provides audio instructions for CPR. What should it be programmed to instruct... Hands-OnlyTM CPR or conventional CPR?

    Follow the default instructions that are programmed in the AED. All devices cleared by the Food & Drug Administration for marketing in the US provide instructions that are consistent with the 2005 AHA Guidelines for CPR and ECC. If the AED is programmed to instruct you to provide breaths but you are not confident that you can do so with minimal interruption to chest compressions, use Hands-OnlyTM CPR when prompted by the AED to perform CPR.

* Data on skills performance is from the 2005 CPR Anytime study using an “untrained” control group. Data about confidence/willingness to act is from a 2007 national survey, in which Americans who were trained within the last 5 years were almost twice as likely (45% vs. 24%) to say they'd begin CPR immediately in a real emergency as those not trained or not trained in the last five years.

† Hoke RS, Chamberlain D. (2004). Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation. 63(3):327-38.

‡ Lederer W, Mair D, Rabl W, Baubin M. (2004). Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray. Resuscitation. 60(2):157-62.....