Harder, Faster, Deeper–CPR for the RN

May 30th, 2012


By , BSN, RN

I have to go take a CPR (cardiopulmonary resuscitation) class today. It is something that as a nurse I must do every two years in order to keep working in healthcare. Most hospitals have the same requirement; that nurses must be up to date on their CPR certification in order to work in the facility.

CPR is a lifesaving technique that is used to circulate blood when a person’s heart has stopped functioning. The American Heart Association (AHA) states that, “Immediate CPR can double, or even triple, a victim’s chance of survival.”

Now the AHA has actually certified me in CPR since I was a teenager and a lifeguard at summer camps. It lapsed for a few years in my late 20s but the rest of the time, every two years like clockwork I meet up with Resusci Anne and test out my skills. I am pleased to announce I have never actually needed them, but I am ready if the occasion presents.

I have always believed that it is a mandatory requirement that all nursing staff in hospitals must have up-to-date CPR certification. I’d swear that’s what I was once told. As a traveling nurse I was always being reminded to keep my CPR current or I wouldn’t be able to work. I have even worked places that tell the nursing staff “you can’t work until your CPR certification is up to date and we will send you home without pay until you have a certification.” As it turns out, this is a bit extreme and, in fact, who and how many must have CPR certification is really a judgment call.

According to The Joint Commission (JCAHO):

Standard PC.9.30 Resuscitation services are available throughout the hospital.

  • Policies, procedures, processes, or protocols govern the provision of resuscitation services.
  • Equipment is appropriate to the patient population (for example, adult, pediatric).
  • Appropriate equipment is placed strategically throughout the hospital.
  • An evidence-based training program(s) is used to train appropriate staff to recognize the need for and use of designated equipment and techniques in resuscitation efforts.

There you have it in the last requirement—“appropriate staff.” That means a hospital can deem any number of people as an “appropriate” number of staff trained to deliver CPR. That would actually explain why at my last hospital no one got that worked up when my CPR certification ran out while I was working. They just said get it done when you can. That really makes more sense since there were literally hundreds of other CPR certified people around at any given time.

CPR Guidelines

It was 1891 when Dr. Friedrich Maass performed the first equivocally documented chest compression in humans. Unfortunately, it was 1903 before Dr. George Crile reported the first successful use of external chest compressions in human resuscitation. We’ve been compressing ever since.

CPR, as we know it today, was developed in 1960. The AHA started a program to acquaint physicians with close-chest cardiac resuscitation and became the forerunner of CPR training for the general public. In 2005 new guidelines were released with new compression: ventilation ratios and changes to using Automated External Defibrillators (AEDs).

In 2010 the AHA released another new set of guidelines for providing CPR and those are the instruction we are still using. The number one focus goes all the back to 1891—it’s really all about the chest compressions.

CPR Today

The differences between the 2005 and 2010 CPR guidelines are slight—but important:

  • No More Alphabetical Order – The focus used to be on A-B-Cs (airway, breathing, chest compressions). Now, Compressions are number one and the order reads C-A-B. After you give a guy a fighting chance at blood circulation to the brain do you focus on Airway and Breathing. In fact, in 2008 the AHA said Hands Only CPR is completely acceptable, particularly when the provider witnesses the victim’s Sudden Cardiac Arrest (SCA). This applies to Adult, Child, and Infant CPR. The reason for this is simple. You can hold your breath for a minute or two without having brain damage. In fact, your brain can go longer than that even without breathing but it really needs the blood to be moving.
  • Look, Listen, and Feel Is Out – Move, move, move. It has become clear that the longer it takes to start compressions, the lower the likelihood of survival. Assessment is for later. It is time wasted to be putting your ear over someone’s mouth or be looking for chest rise and fall when their heart isn’t beating. Besides, it’s a pretty good bet if someone falls to the floor, out cold, they probably aren’t breathing well.
  • Harder, Faster, and Don’t Stop – When you are in position, hands on the lower half of the breast bone, arms straight and shoulders over hands parallel to the victims body—go, go, go. For adults the AHA says you want to push at least two inches deep into the chest and you need to do it every time.

    Every time means 100 compressions a minute. Let me tell you, that is fast and tiring—30 compressions at that rate takes about 18 seconds.

    Not stopping is the final key. Every interruption in chest compressions interrupts blood flow to the brain. No blood flow to the brain leads to brain death. That is really, truly dead. And, it’s not immediate gratification. It takes several chest compressions to get blood moving again and then you must keep it moving.

    Again, Hands Only is acceptable. Once the AED arrives, analyze the heart and as soon as that is done it’s back to compressions immediately.

Now clearly, this is not the whole story, just the changes made in the last two years. There are more steps, different methods for if you are alone or have help and slight variations for children, infants, and others such as pregnant women. And despite the order above you can’t go wrong with more compressions—harder, faster, deeper.

So, I am off to class having completed the workbook portion (on the computer now, of course) and in a few hours after the requisite videos and practice sessions I will once again be a certified CPR provider. And once again, I hope I never need it.

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