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• Cardiopulmonary resuscitation (CPR): First aid

Learn the steps to perform this lifesaving technique on adults and children.

Cardiopulmonary resuscitation (CPR) is a lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped. For example, when someone has a heart attack or nearly drowns. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders.

If you're afraid to do CPR or unsure how to perform CPR correctly, know that it's always better to try than to do nothing at all. The difference between doing something and doing nothing could be someone's life.

Here's advice from the American Heart Association:

• Untrained. If you're not trained in CPR or worried about giving rescue breaths, then provide hands-only CPR . That means uninterrupted chest compressions of 100 to 120 a minute until paramedics arrive (described in more detail below). You don't need to try rescue breathing.
• Trained and ready to go. If you're well-trained and confident in your ability, check to see if there is a pulse and breathing. If there is no pulse or breathing within 10 seconds, begin chest compressions. Start CPR with 30 chest compressions before giving two rescue breaths.
• Trained but rusty. If you've previously received CPR training but you're not confident in your abilities, then just do chest compressions at a rate of 100 to 120 a minute. Details are described below.

The above advice applies to situations in which adults, children and infants need CPR , but not newborns. Newborns are babies up to 4 weeks old.

CPR can keep oxygen-rich blood flowing to the brain and other organs until emergency medical treatment can restore a typical heart rhythm. When the heart stops, the body no longer gets oxygen-rich blood. The lack of oxygen-rich blood can cause brain damage in only a few minutes.

If you are untrained and have immediate access to a phone, call 911 or your local emergency number before beginning CPR . The dispatcher can tell you how to do the proper procedures until help arrives. To learn CPR properly, take an accredited first-aid training course, including CPR and how to use an automated external defibrillator (AED).

Before you begin

Before starting CPR , check:

• Is the environment safe for the person?
• Is the person conscious or unconscious?
• If the person appears unconscious, tap or shake their shoulder and ask loudly, "Are you OK?"
• If the person doesn't respond and you're with another person who can help, have one person call 911 or the local emergency number and get the AED , if one is available. Have the other person begin CPR .
• If you are alone and have immediate access to a telephone, call 911 or your local emergency number before beginning CPR . Get the AED if one is available.
• As soon as an AED is available, deliver one shock if instructed by the device, then begin CPR .

Remember to spell C-A-B

Chest compressions

To perform chest compressions, kneel next to the person's neck and shoulders. Place the heel of one hand over the center of the person's chest and your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands. Using your upper body weight, push straight down on the chest about 2 inches (5 centimeters), but not more than 2.4 inches (6 centimeters). Push hard at a rate of 100 to 120 compressions a minute. If you haven't been trained in CPR , continue chest compressions until there are signs of movement or until emergency medical personnel take over. If you have been trained in CPR , go on to opening the airway and rescue breathing.

Open the airway

If you're trained in CPR and you've performed 30 chest compressions, open the person's airway using the head-tilt, chin-lift maneuver. Put your palm on the person's forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to open the airway.

Rescue breathing

Open the airway using the head-tilt, chin-lift maneuver. Pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal. Give the first rescue breath, lasting one second, and watch to see if the chest rises. If it rises, give the second breath. If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver first and then give the second breath. Be careful not to provide too many breaths or to breathe with too much force. After two breaths, immediately restart chest compressions to restore blood flow.

The American Heart Association uses the letters C-A-B to help people remember the order to perform the steps of CPR .

• C: compressions
• B: breathing

Compressions: Restore blood flow

Compressions means you use your hands to push down hard and fast in a specific way on the person's chest. Compressions are the most important step in CPR . Follow these steps for performing CPR compressions:

• Put the person on their back on a firm surface.
• Kneel next to the person's neck and shoulders.
• Place the lower palm of your hand over the center of the person's chest, between the nipples.
• Place your other hand on top of the first hand. Keep your elbows straight. Place your shoulders directly above your hands.
• Push straight down on the chest at least 2 inches (5 centimeters) but no more than 2.4 inches (6 centimeters). Use your entire body weight, not just your arms, when doing compressions.
• Push hard at a rate of 100 to 120 compressions a minute. The American Heart Association suggests performing compressions to the beat of the song "Stayin' Alive." Allow the chest to spring back after each push.
• If you haven't been trained in CPR , continue chest compressions until there are signs of movement or until emergency medical personnel take over. If you have been trained in CPR , go on to opening the airway and rescue breathing.

Airway: Open the airway

Breathing: breathe for the person.

Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or can't be opened. Current recommendations suggest performing rescue breathing using a bag-mask device with a high-efficiency particulate air (HEPA) filter.

• After opening the airway (using the head-tilt, chin-lift maneuver), pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal.
• Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and watch to see if the chest rises.
• If the chest rises, give a second breath.
• If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver and then give a second breath. Thirty chest compressions followed by two rescue breaths is considered one cycle. Be careful not to provide too many breaths or to breathe with too much force.
• Continue chest compressions to restore blood flow.
• As soon as an automated external defibrillator (AED) is available, apply it and follow the prompts. Give one shock, then continue chest compressions for two more minutes before giving a second shock. If you're not trained to use an AED , a 911 operator or another emergency medical operator may be able to give you instructions. If an AED isn't available, go to step 5 below.
• Continue CPR until there are signs of movement or emergency medical personnel take over.

To perform CPR on a child

The procedure for giving CPR to a child age 1 through puberty is essentially the same as that for an adult — follow the C-A-B steps. The American Heart Association says you should not delay CPR and offers this advice on how to perform CPR on a child:

If you are alone and didn't see the child collapse, start chest compressions for about two minutes. Then quickly call 911 or your local emergency number and get the AED if one is available.

If you're alone and you did see the child collapse, call 911 or your local emergency number first. Then get the AED , if available, and start CPR . If another person is with you, have that person call for help and get the AED while you start CPR .

• Place the child on their back on a firm surface.
• Kneel next to the child's neck and shoulders.
• Place two hands — or only one hand if the child is very small — on the lower half of the child's breastbone.
• Using the heel of one or both hands, press straight down on the chest about 2 inches (approximately 5 centimeters) but not greater than 2.4 inches (approximately 6 centimeters). Push hard and fast — 100 to 120 compressions a minute.
• If you haven't been trained in CPR , continue chest compressions until the child moves or until emergency medical personnel take over. If you have been trained in CPR , open the airway and start rescue breathing.

If you're trained in CPR and you've performed 30 chest compressions, open the child's airway using the head-tilt, chin-lift maneuver.

• Place your palm on the child's forehead and gently tilt their head back.
• With the other hand, gently lift the chin forward to open the airway.

Breathing: Breathe for the child

Follow these steps for mouth-to-mouth breathing for a child.

• After using the head-tilt, chin-lift maneuver to open the airway, pinch the child's nostrils shut. Cover the child's mouth with yours, making a seal.
• Breathe into the child's mouth for one second. Watch to see if the chest rises. If it rises, give a second breath. If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver first. Then give the second breath. Be careful not to provide too many breaths or to breathe with too much force.
• After the two breaths, immediately begin the next cycle of compressions and breaths. Note: If there are two people available to do CPR on the child, change rescuers every two minutes — or sooner if the rescuer is fatigued — and give one to two breaths every 15 compressions.
• As soon as an AED is available, apply it and follow the prompts. As soon as an AED is available, apply it and follow the prompts. Use pediatric pads for children older than 4 weeks old and up to age 8. If pediatric pads aren't available, use adult pads. Give one shock, then restart CPR — starting with chest compressions — for two more minutes before giving a second shock. If you're not trained to use an AED , a 911 operator or another emergency medical operator may be able to give you directions.

Continue until the child moves or help arrives.

To perform CPR on a baby 4 weeks old or older

Cardiac arrest in babies is usually due to a lack of oxygen, such as from choking. If you know that the baby has an airway blockage, perform first aid for choking. If you don't know why the baby isn't breathing, perform CPR .

First, evaluate the situation. Touch the baby and watch for a response, such as movement. Don't shake the baby.

If there's no response, call 911 or your local emergency number, then immediately start CPR .

Follow the compressions, airway and breathing method for a baby under age 1. Do not follow this procedure for newborns, which include babies up to 4 weeks old.

If you saw the baby collapse, get the AED , if one is available, before starting CPR . If another person is available, have that person call for help immediately and get the AED while you stay with the baby and perform CPR .

• Place the baby on their back on a firm, flat surface, such as a table or floor.
• Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest.
• Gently compress the chest about 1.5 inches, which is about 4 centimeters.
• Count aloud as you push in a fairly rapid rhythm. You should push at a rate of 100 to 120 compressions a minute, just as you would when giving an adult CPR .

After 30 compressions, gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand.

Breathing: Breathe for the baby

• Cover the baby's mouth and nose with your mouth.
• Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air, instead of deep breaths from your lungs. Gently puff a breath into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath.
• If the baby's chest still doesn't rise, continue chest compressions.
• Give two breaths after every 30 chest compressions. If two people are doing CPR , give one to two breaths after every 15 chest compressions.
• Continue CPR until you see signs of life or until medical personnel arrive.

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• Highlights of the 2020 AHA guidelines update for CPR and ECC. American Heart Association. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines. Accessed Jan. 18, 2022.
• Pozner CN. Adult basic life support (BLS) for health care providers. https://www.uptodate.com/contents/search. Accessed Jan. 18, 2022.
• FAQ: Hands-only CPR. American Heart Association. https://cpr.heart.org/en/cpr-courses-and-kits/hands-only-cpr/hands-only-cpr-resources. Accessed Jan. 18, 2022.
• Duff JP, et al. 2019 American Heart Association focused update on Pediatric Advanced Life Support: An update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2019; doi:10.1161/CIR.0000000000000731.
• Atkins DL, et al. 2019 American Heart Association focused update on pediatric basic life support: An update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2019; doi:10.1161/CIR.0000000000000736.
• Ralson ME. Pediatric basic life support (BLS) for health care providers. https://www.uptodate.com/contents/search. Accessed Jan. 18, 2022.
• Topjian AA, et al. Part 4: Pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; doi:10.1161/CIR.0000000000000901.
• Infant. Dorland's Medical Dictionary Online. https://www.dorlandsonline.com. Accessed March 1, 2021.
• Panchal AR, et al. Part 3: Adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; doi:10.1161/CIR.0000000000000916.
• Cetta Jr F (expert opinion). Mayo Clinic. April 21, 2021.
• Automated external defibrillators: Do you need an AED?
• Marathon CPR Saves Life

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Free first aid powerpoint presentations

Cardiopulmonary Resuscitation (CPR) CPR powerpoint

This basic first aid powerpoint covers how to perform Cardiopulmonary Resuscitation (CPR). We strongly recommend students have a chance to practice on CPR manikins.

Topics covered in this first aid powerpoint include:

• What is CPR?
• Patient assessment – DR ABC
• Managing someone’s airway using head tilt & chin lift
• Checking for breathing & agonal breathing
• Performing adult CPR – chest compressions and rescue breaths
• Real-life video examples

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What Is CPR? An Introduction to CPR and How It Saves Lives

Cardiopulmonary resuscitation (CPR) is an essential skill. Even if you don't work in the healthcare industry, learning how to perform CPR could potentially save someone's life. According to the American Heart Association (AHA), it can save up to 200,000 lives each year when performed correctly and early enough. So, what is CPR exactly?

The Basics of CPR

Even if you've heard of CPR, you might not know what it entitles. Basically, CPR is an emergency medical technique that involves chest compressions and/or mouth-to-mouth breathing. It's intended to promote blood flow through the person's body while simultaneously filling the person's lungs with air.

The AHA recommends using a ratio of 30:2 for compressions and mouth-to-mouth breathing. In other words, for every 30 chest compressions you perform on a person, you should breathe into his or her mouth twice.

How CPR Saves Lives

When a person experiences a medical emergency, time is of the essence. Waiting for an ambulance to arrive could be too late. Therefore, many 911 responders recommend CPR during a medical emergency if the individual performing it has proper training.

CPR is most commonly performed during cardiac arrest. Cardiac arrest is a catch-all term for when a person's heart stops beating. The heat muscle is responsible for pumping blood throughout the body. When it stops, the person may experience brain damage or lung damage. In some cases, death can occur. CPR can "kick-start" the person's heart during cardiac arrest, thereby saving his or her life.

In addition to cardiac arrest, CPR is often performed when a person stops breathing. Lifeguards, for instance, typically undergo CPR training. If a swimmer becomes unconscious while underwater, a lifeguard may pull him or her from the water, followed by performing CPR.

Is CPR Training Required in the Workplace?

The Occupational Safety and Health and Administration (OSHA) doesn't require CPR training in all workplaces. With that said, OSHA recommends CPR training as a part of a comprehensive first air program.

If you run your own business, you should consider offering CPR training for your employees. CPR training requires the completion of a hands-on course in which workers learn how to perform chest compressions and mouth-to-mouth breathing. With CPR training, workers will have the skills and knowledge to provide treatment during certain medical emergencies, including cardiac arrest.

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HLTH2210 Health, First Aid And Safety

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CARDIOPULMONARY RESUSCITATION (CPR) (Definition, Purpose, Equipment, General Instructions, Procedure, Method, Do’s and don’ts in CPR and Complications.

UPDATED 2024

Cardiopulmonary resuscitation is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone’s breathing or heartbeat has stopped. The American Heart Association recommends that everyone – untrained bystanders and medical personnel alike – begin CPR with chest compressions.

Resuscitation includes all measures that are applied to revive patients who have stopped breathing suddenly and unexpectedly due to either respiratory or cardiac failure.

Cardiac arrest is one of the common causes for cardio-respiratory failure. When a person stops breathing spontaneously, his heart also stops beating. Clinical death occurs within 4-6 minutes, the cells of the brain which is sensitivity to the paucity of oxygen begin to deteriorate. If the oxygen supply is not restored, the patient suffers irreversible brain damage and biological death occurs.

Artificial ventilation accompanied by cardiac massage to facilitate normal breathing and heart action in the event of cardiac arrest.

To re-establish effective ventilation and circulation

  EQUIPMENT

• Cardiac board
• Suction apparatus
• Oxygen supply
• Box containing Ambu bag
• Sterile endotracheal tube (2.5 – 5.5 mm)
• Extra-batteries
• Laryngoscope with 0, 1, 2 size tongue blades and stillet, Magill forceps, adhesive scissors, airway syringes 1, 2, 5, 10 cc
• Intracardiac needle 20 G, 22 G, 6-8 cm length
• Needles 23 G and 20 G
• Elastoplasts bandage
• Ventilation given with ambu-bag

GENERAL INSTRUCTIONS

• Identify “RED FLAG” signs of critically ill child-changes in level of consciousness, flaccid posturing, cyanosis severe chest retractions, grunting respiration, increased respiratory rate, shallow respiration, see saw respiration, i.e. abdominal protrusion with inhalation, irregular respirations with periodic deep sighs, apneas, absent pulse, absent heart rate, absent carotid pulse, dilated pupils, unrecordable blood pressure, cold clammy skin
• ACT quickly! As child can go into cerebral hypoxia within 3 to 4 minutes which will lead to permanent brain damage
• Assess child (look, listen, feel) and if not breathing call for help
• Immediately start cardiopulmonary resuscitation (CPR)
• Equipment for CPR to be always accessible and is functioning condition
• All CPR equipment to be checked at beginning of each shift
• All staff to be skillful at CPR
• Airway : establish patient airway by suctioning oropharynx with catheter, and deflate stomach by aspirating stomach contents

Ventilation by mouth to mouth:

• Breathing: establish breathing by artificial ventilation

Ambu bag on mouth and nose, and connect to 100% oxygen. Select ET tube using the formula:

Age in years + 4 /4

Calculate size of ET tube approximately as diameter of child’s little finger. The ET tube is inserted

• Circulation: initiate cardiac compression to a distance calculated using the formula (ET size multiply 3 cm)

Serial rhythmic compressions of chest that help circulate oxygen containing blood to vital organs

• Site: sternum compression – below level of infant’s nipples
• Width one finger breadth
• Depth 0.5 – 1 inch
• Rate 100 times per minute
• Site: lower margin of child’s rib cage to notch where ribs and sternum meet
• Avoid compression over notch
• Place heel of nurse’s hand over lower half of sternum (between nipple line and notch)
• Depth: 1-1.5 inches
• Rate: 100 times per minute

Ratio of Cardiac Compression to Ventilation (CPR)

• 2 persons – 5:1
• 1 person – 15:2

One Rescuer CPR

Shake shoulders and ask “are you okay”, shout for help. Open the airway: the most important action for successful resuscitation is immediate opening of the airway. Tilt the head by applying firm backward pressure on the victim’s forehead with palm of one hand. Place two or three fingers of the other hand under the bony part of the lower jaw near the chin and lift the chin

Check for breathing: please check close to victim’s mouth and nose. Look at chest to see if it rises and falls. Listen and feel for exhaled air (for at least 5 seconds)

External Cardiac Massage

Breathe : maintain an open airway. Pinch nose. Seal lips around victims mouth and deliver two full breathes watching chest to rise and fall with each breath

Check for circulation : feel for a carotid pulse. Again shout for help/activate EMS system. If pulse is present, continue to give artificial ventilation at the rate of 1 breath or 12 mm

Circulate : if pulse is absent, run fingers along the lower rib to notch in centre of the heart where ribs meet sternum. With middle finger in notch, place index finger on lower end of sternum. Place heel of other hand on lower ½ of sternum next to index finger. Put the heel of 1 st hand on top. With shoulders directly over sternum and elbows locked, compress straight up and down 15 minutes, at the rate of 80 – 100 times a minute, using the count “one and two and three and”, etc. return quickly to victims head to deliver two breaths. Compression depth should be 1.5 – 2 inches

Two-rescuer CPR : two medical professional arriving at same time – no

CPR in Progress

• First rescuer

Determine unresponsiveness

Opens the airway

Checks for breathing

Ventilates twice, watching chest movement

Checks for carotid pulse: give command to begin compressions if pulse is absent

• Second rescuer

Locates landmark and proper hand position on sternum

Begins chest compressions on command – at rate of 80-100 per minute, counting “one and two and three and four and five and”

Pauses after each fifth compression to allow for ventilation

Calls for a switch when fatigued. Give clear signal “change and two and three and four and five”

• Both rescuers change simultaneously

Compression moves to victim’s head. After checking for pulse, give breath and command to continue compressions

Ventilator moves to chest : finds landmark and properly positions hands, begins compressions on command pausing after each 5 th compression for breath

If CPR is in progress by lay person, rescue team enters after completion of cycle of 15 compressions and 2 ventilations and start with a reassessment

If CPR is in progress by a professional rescuer, the 2 nd professional rescuer takes over compressions at the end of a cycle and after 1 st rescuer reassesses pulse and gives another breath

DO’S AND DONOT’S IN CPR

• Reassure victim that help is on the way
• For major injuries call 9-1-1 immediately
• Check victim’s status regularly
• Use direct pressure to stop bleeding
• Check to see if victim’s airways are clear
• If no pulse or respiration, start CPR
• To prevent transmission of disease, use latex gloves
• Keep victims in shock warm (use blanket, etc)
• Assume spinal injury when blunt force trauma is present
• Raise head if bleeding in upper torso area
• Raise feet if bleeding in lower torso areas
• Flush all burns and chemical injuries with clean water
• Have MSDS sheets on the jobsite for 9-1-1 responders
• Call the Poison Control Center for chemical ingestion
• Do not move the victim unless absolutely necessary
• Always suspect “spinal injury” (and don’t move the victim)
• Do not set fractures and breaks (simply immobilize the victim)
• Do not apply a tourniquet (use “direct” pressure to stop bleeding)
• Do not remove items imbedded in the eye (cover with a Dixie cup)
• Do not use burn ointments
• Do not hesitate to call 9-1-1

COMPLICATIONS

Cardiopulmonary resuscitation, or CPR, is a technique used to support the circulation of blood and oxygen in the body of a victim who is not breathing and does not have a pulse. CPR is physically invasive for the victim and techniques used during CPR carry risks and the chance of complications. Ultimately, the risk of complications is small and should not deter the use of CPR for a victim in need

Broken bones

Rib fractures are the most common complication of CPR. Chest compressions administered during CPR are given quickly and with enough force to compress the chest about 1 inch in depth. This provides pressure to the ribs, which can be strong enough to cause ribs to fracture. Victims who are elderly, small in stature or children have the highest risk of developing rib fracture during chest compressions. Additionally, the chest bone, or sternum, also endures pressure and stress during chest compressions and can fracture as well

Internal Injuries

Internal organs lie within the area pressured by chest compressions. As the chest is compressed during CPR, ribs and chest bones can break, puncturing the lungs and liver. Additionally, internal bruising of the heart and liver can occur

Vomiting and Aspiration

As chest compressions are administered, pressure builds inside the body, which can force stomach contents up the esophagus and result in vomiting. This causes the risk of aspiration, or absorbing the vomit into the respiratory system. Aspiration is a serious complication which makes it difficult to provide the victim with adequate air and can ultimately damage lung tissue or result in infection, like pneumonia.

Body Fluid Exposure

CPR presents the risk of exposure to body fluids. It provides mouth-to-mouth rescue breathing to a victim without use of a mask results in saliva exposure between victim and rescuer. Blood and vomit may also be present during CPR, which carries the risk of communicable disease such as hepatitis and AIDS. The American Heart Association encourages the use of a barrier mask when administering rescue breathing during CPR for protection against contamination

Gastric Distention

Rescue breathing during CPR provides air directly into the lungs of the victim. If air is delivered too forcefully or for too long a time, the victim can accumulate air build-up in the stomach, called gastric distension. Gastric distension causes the stomach to swell and places pressure on the lungs. CPR efforts can become complicated if gastric distension occurs due to reduced ability to deliver adequate oxygen to the lungs, and can also result in vomiting and aspiration. Gastric distension can often be avoided by proper, careful administration of rescue breathing during CPR

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Cardiopulmonary resuscitation (CPR) training strategies in the times of COVID-19: a systematic literature review comparing different training methodologies

Daniyal mansoor ali.

1 Centre of Excellence Trauma and Emergencies, Aga Khan University, Karachi, Pakistan

Butool Hisam

Natasha shaukat.

2 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan

3 Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan

Marcus Eng Hock Ong

4 Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore

5 Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore

Jonathan L. Epstein

6 Emergency Care Safety Institute, Public Safety Group, Burlington, MA USA

Eric Goralnick

7 Department of Emergency Medicine, Harvard Medical School, Boston, MA USA

Paul D. Kivela

8 Department of Emergency Medicine, University of Alabama, Birmingham, USA

Bryan McNally

9 Department of Emergency Medicine, Emory University, Atlanta, GA USA

Junaid Razzak

10 Centre of Global Emergency Care, Johns Hopkins University, Baltimore, USA

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Traditional, instructor led, in-person training of CPR skills has become more challenging due to COVID-19 pandemic. We compared the learning outcomes of standard in-person CPR training (ST) with alternative methods of training such as hybrid or online-only training (AT) on CPR performance, quality, and knowledge among laypersons with no previous CPR training.

We searched PubMed and Google Scholar for relevant articles from January 1995 to May 2020. Covidence was used to review articles by two independent researchers. Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to assess quality of the manuscripts.

Of the 978 articles screened, twenty met the final inclusion criteria. All included studies had an experimental design and moderate to strong global quality rating. The trainees in ST group performed better on calling 911, time to initiate chest compressions, hand placement and chest compression depth. Trainees in AT group performed better in assessing scene safety, calling for help, response time including initiating first rescue breathing, adequate ventilation volume, compression rates, shorter hands-off time, confidence, willingness to perform CPR, ability to follow CPR algorithm, and equivalent or better knowledge retention than standard teaching methodology.

AT methods of CPR training provide an effective alternative to the standard in-person CPR for large scale public training.

Sudden Cardiac Death (SCD) refers to an unexpected death from cardiac arrest [ 1 ]. Worldwide, SCD is the most common cause of death accounting for 17 million deaths every year or 25% of all global mortality [ 1 ]. Out-of-hospital cardiac arrest (OHCA) is a global health issue with incidence reported as 40.6 per 100,000 person-years in Europe, 47.3 in North America, 45.9 in Asia, and 51.1 in Australia [ 2 – 5 ].

Decreasing the time to initiation of CPR is crucial for improving outcomes in cases of cardiac arrest [ 6 , 7 ]. This is where the role of the bystander – any layrescuer (non-medical professional) who witnesses a medical emergency – comes into play [ 8 ]. In fact, bystander CPR before arrival of EMS is independently associated with up to a threefold increase in survival [ 9 ]. Various attempts have been made to increase the number of people trained in CPR and therefore improve bystander CPR rates, including organization of mass CPR training events. These attempts, particularly when backed by effective legislation mandating CPR training, result in significantly more laypersons trained in CPR as demonstrated by efforts led in Norway [ 10 , 11 ], Singapore [ 12 ], and Denmark [ 13 ].

CPR has traditionally been taught face to face using a mannikin as a proxy for a patient. In 2015, the American Heart Association introduced the concept of blended learning that involved the use of online videos and simulated Voice Assisted Mannikins to replace instructors. CPR self-instruction through video- and/or computer-based modules paired with hands-on practice may be an effective alternative to instructor-led courses and such technologies can be utilized more easily to facilitate safe and effective learning [ 14 , 15 ]. This has become particularly relevant now that the COVID-19 pandemic, where wide spread restrictions on in-class training and potential risk of virus spread during face-to-face sessions, has caused organizations to reconsider how trainings are allowed to be conducted [ 16 , 17 ].

The aim of this systematic review is to compare the learning outcomes between standard instructor-led classroom-based CPR training with the alternative training methods among laypersons.

Study design

A research question was identified using the PICO strategy (Population (P): laypersons not trained in CPR, Intervention (I): alternative CPR training methodologies, Comparison (C): standard CPR training methodology, Outcome (O): CPR knowledge, quality, and skill performance). After establishing the research domain, inclusion and exclusion criteria were established to identify and select relevant articles. After assessing the quality of the studies included, data was extracted, organized, summarized, and charted accordingly. The results were analyzed and reported. The primary research question guiding this review is: “What are the differences in CPR knowledge, skill performance, and quality in laypersons receiving alternative CPR training when compared to standard training methodology?”

Search strategies

We searched PubMed or Medical Literature Analysis and Retrieval System Online (Medline), and Google Scholar for relevant articles from January 1995 to May 2020. Medical subject headings (MeSH) were searched using Boolean operators “ OR/AND ”. The search terms were: (“hands-only CPR” OR “cardiopulmonary resuscitation” OR “CPR”) AND (“teaching methodologies” OR “training methods”) AND (“medical students” OR “bystanders” OR “laypersons” OR “health-care workers” OR “school children” OR “physicians” OR “nurses” OR “paramedical staff” OR “technicians”).

Inclusion and exclusion criteria

We included studies which compared two or more CPR training methodologies targeting laypersons with no previous CPR training. Studies describing a single methodology with no comparison group were excluded as were the case reports, case series, and non-English articles.

Identification and selection of studies

The studies were selected after two stages of screening. Two researchers (DMA and BH) independently, extracted data. In stage 1, we screened the article titles and abstracts and those which matched the inclusion criteria were selected for full text review. In the final stage, we reviewed full texts of the articles and determined their inclusion in this review. Any conflicts between researchers during the article screening process was resolved by the senior researcher (JR). Data was organized using a simple database on Microsoft Excel. Figure  1 presents a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram showing the process of searching and selecting the research articles.

PRISMA Flow diagram for database search of studies

Data extraction from included studies

After article selection, we extracted and recorded data in a data extraction form in an excel spreadsheet. The domains in the data extraction form were: year and country of publication, intervention tested, study design, sample size, study population, presence of prior training, outcome measures, and key findings.

Quality assessment of studies

The quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool [ 18 ]. Two researchers (DMA and BH) reviewed each study using EPHPP. The results of the quality assessment are summarized in Table  2 . No studies were excluded on the basis of quality assessment, as this quantitative evidence synthesis aimed to include all articles relevant to our review question.

Results of quality assessment of included studies using the Effective Public Health Practice Project (EPHPP) tool

Summarizing the findings

We summarized our findings into the following research domains: standard instructor-led classroom-based CPR training, non-standard face to face CPR training, hybrid CPR training, and online CPR training.

Definition of terms

The definitions of commonly used terminologies in this article are detailed in Table  1 .

Definitions of training methodologies employed to train participants

Studies’ characteristics

A total of 978 articles were retrieved from PubMed and Google Scholar. Four hundred and twenty duplicate articles were excluded. Out of the remaining 558 articles, 537 articles were either not comparing different teaching methodologies, were case reports or case series, or were written in a language other than English, and no English translation was available and therefore were excluded. Among the remaining 21 articles, 1 articles did not have available full texts. Twenty full-text articles were reviewed and included in this study. Out of these twenty articles, ten had a moderate global rating, while ten had a strong global rating based on Effective Public Health Practice Project (EPHPP) Quality Assessment Tool (Table ​ (Table2 2 ) .

Research domains

Among the twenty studies included in this review, eleven compared online CPR training with the standard training, six studies compared non-standard face to face CPR training with the standard training, and three studies compared the standard CPR training with hybrid training methodologies. Among the included studies, fourteen studies were randomized controlled trials, two had an interventional study design, two were cluster randomized controlled trials, and two studies had a case-control study design. The study population comprised of school children, laypersons, medical students, and nursing students. The details of individual studies are summarized in Table  3 .

Summarized findings of included CPR training methodology research articles

Characteristics of different CPR training methodologies

The CPR training methodologies were divided into two broad categories including standard instructor-led classroom-based CPR training and alternative CPR training. The alternative CPR teaching methodology was further classified as non-standard face to face CPR training, hybrid CPR training, and online CPR training. The comparison of content, duration, mode of delivery, standard of content, and measured outcomes between different training methodologies are detailed in Fig.  2 and Table  4 . Significant difference was noted between the duration of the teaching methods. The studies reported a longer duration of standard CPR training (20 min to 6 h) when compared to non-standard face to face (45 min to 3 h), hybrid (4 min to 1.5 h), and online CPR training methods (1 min to 1.5 h). Moreover, variability was also noted in the standard of content taught between different training methods and within each training method as well. Although “Einlebenretten” (“save one life”) educational framework [ 20 ] and European Resuscitation Council (ERC) 2010 guidelines [ 21 , 34 ] were the two contents similar between standard and non-standard face to face CPR training, the standard training group also used contents from ERC 2005 guidelines [ 34 ], American Heart Association (AHA) Heartsaver Citizen CPR course [ 27 , 28 , 31 , 38 ], AHA 2010 guidelines [ 25 ], National Safety Council Adult CPR training program [ 29 ], HeartCode BLS course [ 33 ], Dutch Resuscitation Council course [ 37 ], and Danish Red Cross course [ 36 ]. Although the computer-based HeartCode BLS course [ 33 ] and National Center for Early Defibrillation course [ 27 ] were similar between hybrid and online CPR training methodology, the standard of content was also adopted from other sources in these instructional methods. The hybrid teaching methodology had contents from Japanese Red Cross Society [ 25 ] and AHA 2010 guidelines [ 25 ], while online training method adopted content from National Safety Council Adult CPR training program [ 29 ] and TrygFonden foundation [ 36 ]. The content (CPR, ventilation, and breathing) and outcomes measured (CPR performance, quality, knowledge, attitude, self-confidence, and willingness to perform CPR) were similar between the training methodologies.

Comparison of the mode of delivery of different CPR training methodologies

A comparison between the characteristics of different CPR training methodologies

a The content, skills taught, and outcomes measured were similar between standard and alternative CPR trainings

Comparison of outcomes between different training methodologies

The studies assessed three main outcomes after CPR training which included CPR skill performance, CPR quality, and CPR knowledge. The difference in each outcome was compared between the standard instructor-led classroom-based CPR training and alternative (non-standard face to face, hybrid, and online) CPR training methodologies. The detailed description of these differences is illustrated in Table  5 .

Comparison between standard CPR training versus non-standard face to face, hybrid, and online CPR teaching methodologies

Standard versus non-standard face to face CPR training

The non-standard face to face CPR training included simplified (hands-only) CPR, peer-based CPR training, Jigsaw model CPR training, flowchart-supplemented CPR training, and a multi-staged approach to CPR training. Out of the twenty studies, five randomized controlled trials and one prospective case-control study fell under this domain. Two studies compared CPR performance and one study compared CPR quality. More than one outcome was measured by three studies in which one study compared CPR performance and quality, one study compared CPR quality and knowledge, and one study compared CPR performance and knowledge between the instructional methods.

In CPR performance, no statistically significant difference was noted between the peer-led (41.0%, N  = 466), jigsaw model group, and the standard instructor-led group (40.3%, N  = 471) [ 20 , 21 ]. Moreover, willingness to perform CPR was also similar between the peer-led (64.7%) and standard instructor-led group (55.2%, p  = 0.202) [ 24 ]. However, flowchart supplemented group (7 ± 2) was more confident in performing CPR than the instructor-led group (7 ± 2 vs. 5 ± 2, p  = 0.0009) [ 22 ].

In CPR quality, the simplified CPR group performed better on CPR algorithm ( p  < 0.01), had higher number and adequate chest compressions ( p <  0.01), and shorter hands-off time ( p  < 0.001) when compared with the standard training group [ 19 ]. Although the flowchart-supplemented group showed shorter hands-off time (147 ± 30s vs. 169 ± 55 s, p  = 0.024), the time to chest compression was longer (60 ± 24 s vs. 23 ± 18 s, p  < 0.0001) as compared to the instructor-led group [ 22 ]. The staged CPR group had better “shout for help” ( p =  0.02 to p <  0.01) and more adequate compressions ( p  = 0.05 to p  = 0.04) when compared to standard training [ 23 ].

Although better CPR knowledge retention was seen in the multi-staged approach CPR training when compared to the standard group [ 23 ], no difference in retention was seen between peer-assisted (61.76 ± 17.80) and professional instructor groups (60.78 ± 39.77, p  = 0.848) [ 24 ].

Standard versus hybrid CPR training

The hybrid CPR training included a kiosk group, an interactive computer training group plus an instructor-led training group, and a video learning group followed by hands-on CPR training. Three studies fell under this domain. One study compared CPR quality, while one study compared CPR performance and quality and one study compared CPR performance and knowledge between the instructional methods.

In CPR performance, although the kiosk group outperformed the instructor-led group on hand placement (+ 4.9), they scored lower on compression depth (− 5.6) [ 26 ]. Moreover, for all outcome measures, mean scores were higher in the interactive-computer training group plus instructor-led practice group when compared to the instructor-led group [ 27 ].

In terms of CPR quality, no significant difference was noted in time to first chest compression (33 s vs. 31 s, U = 1171, p  = 0.73) and number of total chest compressions (101.5 vs. 104, U = 1083, p  = 0.75) between the instructor-led group and flipped learning group [ 25 ]. Furthermore, the kiosk group and the instructor-led group had similar total scores after training [ 26 ].

Lastly, use of a computer program resulted in higher knowledge retention (80%) as compared to the instructor-led group (75%) two days after training [ 27 ].

Standard versus online CPR training

The online CPR training methodology included video self-instruction, interactive computerized module with video, mobile phone video clips, a computer-based course with Voice Advisory Mannequin (VAM), and virtual reality CPR training. Eleven studies fell under this domain. Five studies compared CPR performance, two studies compared CPR quality, and one study compared CPR knowledge between the instructional methods. More than one outcome was compared by three studies in which, two studies compared CPR performance and knowledge while one study compared CPR quality and knowledge between instructional methods.

In CPR performance, video self-instruction group had superior overall performance scores with only 19% non-competent trainees as compared to 43% non-competent trainees in the instructor-led group [ 28 ]. Moreover, another study also reported similar findings in which, 40% of the video self-instruction group were competent when compared to only 16% competency in the instructor-led group [ 31 ]. The group which received video-based training also had more accurate airway opening ( p  < 0.001), breathing check ( p <  0.001), first rescue breathing ( p  = 0.004), hand positioning ( p =  0.004), and higher confidence and willingness to perform CPR at 3 months when compared to the instructor-led group [ 32 ]. Furthermore, another study showed that the video-based group performed better scene safety (95.2% vs. 76.1%, p <  0.05), call for help (97.6% vs. 76.1%, p <  0.05), and had shorter response to compression time (35 ± 9 s vs. 54 ± 14 s, p <  0.001) as compared to the standard instructor-based group [ 35 ]. A study in United States showed higher overall performance (60% vs. 42%), appropriate responsiveness assessment (90% vs. 72%), adequate ventilation volume (61% vs. 40%), and correct hand placement (80% vs. 68%) in the video group as compared to instructor-led training [ 38 ]. However, one study reported lower compression depth scores (− 9.9) [ 26 ] while another study had lower scores in calling 911 (71% vs. 82%) [ 38 ] in the video group as compared to the instructor-led group. Voice Advisory Mannequin (VAM) feedback was another methodology adopted for online training in one of the studies and those participants trained using this method had more correct hand position (73% vs. 37%, p  = 0.014) and better compression rate (124 vs 135, p  = 0.089) than the instructor-led group [ 34 ]. A study in Netherlands compared standard instructor-led training with Virtual Reality (VR) CPR teaching methodology. Although the VR group had better chest compression rates (114/min vs. 109/min) and proportion of compressions with full release (98% vs. 88%, p  = 0.002), the instructor-led group had higher overall scores (12 vs. 10, p <  0.001), better chest compression depth (57 mm vs. 49 mm), adequate chest compression fraction (67% vs. 61%, p <  0.001), higher proportion of participants fulfilling depth (75% vs. 51%, p <  0.001), and rate requirements (63% vs. 50%, p =  0.01) [ 37 ].

In CPR quality, the instructor-led training group had better quality of CPR compressions (location, rate, depth, and release) as compared to the computer-based training group [ 29 ]. Moreover, the chest compression depth was also better in the instructor-led group when compared to the group trained using brief videos [ 30 ]. Although the VAM feedback group showed similar compression rates, they had more compressions with adequate depth and hand placement, and had more ventilations with adequate volume than the instructor-led group [ 33 ].

Although some studies showed no significant difference in the CPR-related knowledge scores between the instructional methods [ 29 , 31 ], other studies highlighted significant differences. A study in Denmark highlighted that after 3 months, although the DVD-based group had better average inflation volume (844 ml vs. 524 ml, p  = 0.006) and chest compression depth (45 mm vs. 39 mm, p  = 0.005), the instructor-led group was superior in assessment of breathing (91% vs. 72%) [ 36 ]. At 2 months post-training, another study illustrated that although the video group had higher scores in overall performance (44% vs. 30%), assessing responsiveness (77% vs. 60%), ventilation volume (41% vs. 36%), and correct hand placement (64% vs. 59%), the instructor-led group scored higher in calling 911 (74% vs. 53%) [ 38 ].

This is a comprehensive systematic review that compares CPR performance, quality, and knowledge between different teaching methodologies including standard instructor-led, non-standard face to face, hybrid, and online CPR trainings. This review includes 20 studies and 5961 participants and illustrates significant differences in both the characteristics and the outcomes between the instructional methodologies.

All the included articles had an experimental study design and had a moderate or strong global rating based on our quality assessment tool. Our results suggested that the standard instructor-led CPR training had a longer duration (20 min to 6 h) as compared to alternative CPR trainings (1 min to 3 h). Moreover, the standard of content also varied significantly between the instructional methods. Interestingly, our review also showed variability in the content within the standard instructor-led CPR training methodology in which the teaching material was adopted from multiple sources including “Einlebenretten” (“save one life”) educational framework [ 20 ], European Resuscitation Council (ERC) 2005 and 2010 guidelines [ 21 , 34 ], American Heart Association (AHA) Heartsaver Citizen CPR course [ 27 , 28 , 31 , 38 ], AHA 2010 guidelines [ 25 ], National Safety Council Adult CPR training program [ 29 ], HeartCode BLS course [ 33 ], Dutch Resuscitation Council course [ 37 ], and Danish Red Cross course [ 36 ].

The instructional methods were compared on the basis of CPR performance, quality, and knowledge which were the three primary outcomes of the studies. In CPR performance, when compared to the standard instructor-led CPR training, the non-standard face to face CPR trained group were although more confident in performing CPR [ 22 ], similar performance was seen in the peer-led [ 20 , 24 ] and the jigsaw model groups [ 21 ]. Although the hybrid CPR training methodology led to higher overall performance scores including better hand placement, the instructor-led methodology outperformed on the chest compression depth scores [ 26 , 27 ]. When compared to standard CPR training, online instructional methodology not only resulted in a higher percentage of competent trainees [ 28 , 31 ], but it also resulted in more performance of scene safety, assessing responsiveness, calling for help, accurate airway opening, breathing check, first rescue breathing, adequate ventilation volume, shorter response to compression time, hand positioning, better compression rates, and higher confidence and willingness to perform CPR [ 32 , 34 , 35 , 38 ]. However, instructor-led trainings had higher compression depth scores and higher scores in calling 911 when compared to online CPR training [ 26 , 38 ]. With regards to CPR quality, the non-standard face to face CPR training methodology outperformed in the CPR algorithm, had higher “shout for help” rates, had better rate and quality of compressions, and had shorter hands-off time when compared with the standard training [ 19 , 22 , 23 ]. However, instructor-led groups took less time to start chest compressions [ 22 ]. The hybrid training groups and the instructor-led groups showed no statistically significant difference in the total obtained scores regarding CPR quality [ 25 , 26 ]. When compared to standard CPR training, online instructional methods showed better hand position, better chest compression rates, shorter hands-off time, and more frequency of calling for help [ 29 , 30 , 39 ]. However, correct hand placement and adequate depth of chest compression was better in the instructor-led group [ 26 , 30 ]. Lastly, when compared to standard CPR training, alternative instructional methods either had similar [ 24 , 29 , 31 ] or better knowledge retention [ 23 , 27 , 36 , 38 ].

The results of our study can be explained by certain determining factors. Due to access to better technology and readily available training material nowadays, numerous alternative training methodologies are being tested and compared with the standard training to assess their efficacy. This constant testing and repetition of training results in constant improvement in these alternate training methodologies resulting in better outcomes among participants. However, the quality of CPR, particularly the adequacy of chest compressions, is still better among instructor-led group as technology to effectively monitor chest compression depth remotely is not widely available currently.

Our systematic review has certain implications. First, since the studies included in this review had a moderate or strong global rating, comparisons made between standard and alternative CPR instructional methods can be used for future trainings. Secondly, standard CPR training is resource intensive driven by availability of instructors and therefore has limited scalability. This is especially true in low resource settings where creating an organizational structure and large cadre of instructors to deliver courses may take longer times and require more resources. Our study highlights the feasibility of utilizing instructional technologies and also recognizes the shortcomings of using technology-only solutions. Thirdly, “standard” CPR training had significant variability in both the duration and the standard of content among different studies. It is important to create standards so that future methodologies can be measured and further innovative solutions can be developed. Given the risk of infection spread due to pandemics such as COVID-19, we believe that alternative to face-to-face teaching methodologies have significant promise and can be implemented safely and effectively to increase the rate and effectiveness of bystander CPR and in turn save more lives by strengthening the first component of the chain of survival. Future alternatives to face-to-face instruction including possibly remote monitoring of students may improve correct hand placement and adequate depth of chest compression.

Limitations of the study

This article has some limitations. Most of the studies included in this review were conducted in developed countries and therefore, effective adaptability of alternate training methods in the local setting cannot be ascertained. Moreover, no study looked at CPR performance during an actual cardiac arrest event and none of the conducted studies measured the impact of different teaching methodologies on a population level. Furthermore, potential bias towards a particular CPR teaching methodology among trainers cannot be ruled out. Lastly, since no uniformity existed in the duration and content of standard CPR training, the outcomes cannot be compared with alternate training methods concretely enough.

This review outlines that alternative CPR training methodologies are as effective or even possibly better when compared to standard in-person classroom CPR training in CPR performance and knowledge acquisition. However, effective CPR quality still largely depends on some in-person training. Due to promising results seen in alternate training methodologies and non-uniformity seen in standard instructional techniques, these instructional methods can be adopted as an alternative, particularly during this time of the COVID-19 pandemic. Moreover, future research should aim to develop uniformity in standard CPR training methodology, which will make comparison with alternative CPR instructional techniques more plausible.

Acknowledgements

We thank Covidence systematic review software for its assistance in the research article screening process.

Abbreviations

Authors’ contributions.

DMA and BH contributed in the study design, data collection, data analysis, data interpretation, and writing of the manuscript. NS, NB, MO, JLE, EG, PK, and BM contributed in data analysis, data interpretation, and writing of the manuscript. JR contributed in the study design, data analysis, data interpretation, and writing of the manuscript and provided overall supervision. All authors read and approved the final manuscript.

Availability of data and materials

Declarations.

Not applicable.

The authors declare that they have no competing interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Daniyal Mansoor Ali, Email: [email protected] .

Butool Hisam, Email: [email protected] .

Natasha Shaukat, Email: [email protected] .

Noor Baig, Email: [email protected] .

Jonathan L. Epstein, Email: [email protected] .

Eric Goralnick, Email: UDE.DRAVRAH.HWB@KCINLAROGE .

Paul D. Kivela, Email: ude.cmbau@alevikp .

Bryan McNally, Email: ude.yrome@llancmb .

Junaid Razzak, Email: [email protected] .

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Role Assignment And Coordination In A Team-Based CPR Scenario

In a team-based CPR scenario, role assignment and coordination play a crucial role in ensuring effective and efficient resuscitation efforts. The successful outcome of such a scenario depends on the ability of team members to work together seamlessly, with each individual fulfilling their assigned roles and coordinating their actions.

One of the most critical aspects of role assignment in a team-based CPR scenario is the designation of a team leader. The team leader is responsible for overseeing the entire resuscitation process, making decisions, and coordinating the efforts of all team members. This individual should possess strong leadership skills, be knowledgeable about CPR protocols, and be able to remain calm under pressure.

The next important role in a team-based CPR scenario is that of the primary rescuer. This individual is responsible for initiating chest compressions and providing basic life support until additional help arrives or other team members take over. The primary rescuer should have received proper training in CPR techniques and be able to perform high-quality chest compressions consistently.

Another crucial role in this scenario is that of the airway manager. This person ensures that the victim’s airway remains open throughout the resuscitation process. They may need to perform tasks such as clearing obstructions from the airway or inserting an advanced airway device if necessary. The airway manager should have expertise in airway management techniques and be able to quickly assess and address any issues related to breathing difficulties.

Additionally, there may be individuals assigned to tasks such as obtaining necessary equipment or medications, documenting vital signs or interventions performed during resuscitation efforts, or providing emotional support to family members present at the scene. Each member’s specific roles will depend on their training level and expertise.

Once roles are assigned within a team-based CPR scenario, coordination becomes paramount. Effective communication among team members is essential for smooth coordination during resuscitation efforts. Clear communication helps ensure that everyone understands their roles, knows what actions to take, and can anticipate the needs of others.

Team members should use concise and direct language when communicating important information. They should also actively listen to one another, acknowledging and responding appropriately to any requests or updates. This open line of communication allows for quick adjustments in response to changing circumstances or new information.

Coordination also involves understanding the flow of tasks during a CPR scenario. Team members must be aware of the sequence in which interventions are performed and how they interact with each other’s actions. For example, chest compressions need to be paused briefly for ventilation, but this pause should be as short as possible to maintain blood flow.

Furthermore, coordination extends beyond individual team members; it includes coordination with emergency medical services (EMS) personnel who may arrive on the scene. Effective handover communication between the team and EMS is crucial for seamless continuation of care. The team leader should provide a concise summary of events, interventions performed, and any changes in the victim’s condition.

In conclusion, role assignment and coordination are vital components of a team-based CPR scenario. Assigning specific roles ensures that each team member knows their responsibilities and can focus on performing their tasks effectively. Coordination through clear communication and understanding of task flow allows for seamless teamwork during resuscitation efforts. By working together harmoniously, teams can maximize their chances of achieving successful outcomes in CPR scenarios.

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2018 Primetime Emmy & James Beard Award Winner

In Transit: Notes from the Underground

Jun 06 2018.

Spend some time in one of Moscow’s finest museums.

Subterranean commuting might not be anyone’s idea of a good time, but even in a city packing the war-games treasures and priceless bejeweled eggs of the Kremlin Armoury and the colossal Soviet pavilions of the VDNKh , the Metro holds up as one of Moscow’s finest museums. Just avoid rush hour.

The Metro is stunning and provides an unrivaled insight into the city’s psyche, past and present, but it also happens to be the best way to get around. Moscow has Uber, and the Russian version called Yandex Taxi , but also some nasty traffic. Metro trains come around every 90 seconds or so, at a more than 99 percent on-time rate. It’s also reasonably priced, with a single ride at 55 cents (and cheaper in bulk). From history to tickets to rules — official and not — here’s what you need to know to get started.

A Brief Introduction Buying Tickets Know Before You Go (Down) Rules An Easy Tour

A Brief Introduction

Moscow’s Metro was a long time coming. Plans for rapid transit to relieve the city’s beleaguered tram system date back to the Imperial era, but a couple of wars and a revolution held up its development. Stalin revived it as part of his grand plan to modernize the Soviet Union in the 1920s and 30s. The first lines and tunnels were constructed with help from engineers from the London Underground, although Stalin’s secret police decided that they had learned too much about Moscow’s layout and had them arrested on espionage charges and deported.

The beauty of its stations (if not its trains) is well-documented, and certainly no accident. In its illustrious first phases and particularly after the Second World War, the greatest architects of Soviet era were recruited to create gleaming temples celebrating the Revolution, the USSR, and the war triumph. No two stations are exactly alike, and each of the classic showpieces has a theme. There are world-famous shrines to Futurist architecture, a celebration of electricity, tributes to individuals and regions of the former Soviet Union. Each marble slab, mosaic tile, or light fixture was placed with intent, all in service to a station’s aesthetic; each element, f rom the smallest brass ear of corn to a large blood-spattered sword on a World War II mural, is an essential part of the whole.

The Metro is a monument to the Soviet propaganda project it was intended to be when it opened in 1935 with the slogan “Building a Palace for the People”. It brought the grand interiors of Imperial Russia to ordinary Muscovites, celebrated the Soviet Union’s past achievements while promising its citizens a bright Soviet future, and of course, it was a show-piece for the world to witness the might and sophistication of life in the Soviet Union.

It may be a museum, but it’s no relic. U p to nine million people use it daily, more than the London Underground and New York Subway combined. (Along with, at one time, about 20 stray dogs that learned to commute on the Metro.)

In its 80+ year history, the Metro has expanded in phases and fits and starts, in step with the fortunes of Moscow and Russia. Now, partly in preparation for the World Cup 2018, it’s also modernizing. New trains allow passengers to walk the entire length of the train without having to change carriages. The system is becoming more visitor-friendly. (There are helpful stickers on the floor marking out the best selfie spots .) But there’s a price to modernity: it’s phasing out one of its beloved institutions, the escalator attendants. Often they are middle-aged or elderly women—“ escalator grandmas ” in news accounts—who have held the post for decades, sitting in their tiny kiosks, scolding commuters for bad escalator etiquette or even bad posture, or telling jokes . They are slated to be replaced, when at all, by members of the escalator maintenance staff.

For all its achievements, the Metro lags behind Moscow’s above-ground growth, as Russia’s capital sprawls ever outwards, generating some of the world’s worst traffic jams . But since 2011, the Metro has been in the middle of an ambitious and long-overdue enlargement; 60 new stations are opening by 2020. If all goes to plan, the 2011-2020 period will have brought 125 miles of new tracks and over 100 new stations — a 40 percent increase — the fastest and largest expansion phase in any period in the Metro’s history.

Facts: 14 lines Opening hours: 5 a.m-1 a.m. Rush hour(s): 8-10 a.m, 4-8 p.m. Single ride: 55₽ (about 85 cents) Wi-Fi network-wide

Buying Tickets

• Ticket machines have a button to switch to English.
• You can buy specific numbers of rides: 1, 2, 5, 11, 20, or 60. Hold up fingers to show how many rides you want to buy.
• There is also a 90-minute ticket , which gets you 1 trip on the metro plus an unlimited number of transfers on other transport (bus, tram, etc) within 90 minutes.
• Or, you can buy day tickets with unlimited rides: one day (218₽/ US$4), three days (415₽/US$7) or seven days (830₽/US$15). Check the rates here to stay up-to-date.
• If you’re going to be using the Metro regularly over a few days, it’s worth getting a Troika card , a contactless, refillable card you can use on all public transport. Using the Metro is cheaper with one of these: a single ride is 36₽, not 55₽. Buy them and refill them in the Metro stations, and they’re valid for 5 years, so you can keep it for next time. Or, if you have a lot of cash left on it when you leave, you can get it refunded at the Metro Service Centers at Ulitsa 1905 Goda, 25 or at Staraya Basmannaya 20, Building 1.
• You can also buy silicone bracelets and keychains with built-in transport chips that you can use as a Troika card. (A Moscow Metro Fitbit!) So far, you can only get these at the Pushkinskaya metro station Live Helpdesk and souvenir shops in the Mayakovskaya and Trubnaya metro stations. The fare is the same as for the Troika card.
• You can also use Apple Pay and Samsung Pay.

Rules, spoken and unspoken

No smoking, no drinking, no filming, no littering. Photography is allowed, although it used to be banned.

Stand to the right on the escalator. Break this rule and you risk the wrath of the legendary escalator attendants. (No shenanigans on the escalators in general.)

Get out of the way. Find an empty corner to hide in when you get off a train and need to stare at your phone. Watch out getting out of the train in general; when your train doors open, people tend to appear from nowhere or from behind ornate marble columns, walking full-speed.

Always offer your seat to elderly ladies (what are you, a monster?).

An Easy Tour

This is no Metro Marathon ( 199 stations in 20 hours ). It’s an easy tour, taking in most—though not all—of the notable stations, the bulk of it going clockwise along the Circle line, with a couple of short detours. These stations are within minutes of one another, and the whole tour should take about 1-2 hours.

Start at Mayakovskaya Metro station , at the corner of Tverskaya and Garden Ring,  Triumfalnaya Square, Moskva, Russia, 125047.

1. Mayakovskaya.  Named for Russian Futurist Movement poet Vladimir Mayakovsky and an attempt to bring to life the future he imagined in his poems. (The Futurist Movement, natch, was all about a rejecting the past and celebrating all things speed, industry, modern machines, youth, modernity.) The result: an Art Deco masterpiece that won the National Grand Prix for architecture at the New York World’s Fair in 1939. It’s all smooth, rounded shine and light, and gentle arches supported by columns of dark pink marble and stainless aircraft steel. Each of its 34 ceiling niches has a mosaic. During World War II, the station was used as an air-raid shelter and, at one point, a bunker for Stalin. He gave a subdued but rousing speech here in Nov. 6, 1941 as the Nazis bombed the city above.

Take the 3/Green line one station to:

2. Belorusskaya. Opened in 1952, named after the connected Belarussky Rail Terminal, which runs trains between Moscow and Belarus. This is a light marble affair with a white, cake-like ceiling, lined with Belorussian patterns and 12 Florentine ceiling mosaics depicting life in Belarussia when it was built.

Transfer onto the 1/Brown line. Then, one stop (clockwise) t o:

3. Novoslobodskaya.  This station was designed around the stained-glass panels, which were made in Latvia, because Alexey Dushkin, the Soviet starchitect who dreamed it up (and also designed Mayakovskaya station) couldn’t find the glass and craft locally. The stained glass is the same used for Riga’s Cathedral, and the panels feature plants, flowers, members of the Soviet intelligentsia (musician, artist, architect) and geometric shapes.

Go two stops east on the 1/Circle line to:

4. Komsomolskaya. Named after the Komsomol, or the Young Communist League, this might just be peak Stalin Metro style. Underneath the hub for three regional railways, it was intended to be a grand gateway to Moscow and is today its busiest station. It has chandeliers; a yellow ceiling with Baroque embellishments; and in the main hall, a colossal red star overlaid on golden, shimmering tiles. Designer Alexey Shchusev designed it as an homage to the speech Stalin gave at Red Square on Nov. 7, 1941, in which he invoked Russia’s illustrious military leaders as a pep talk to Soviet soldiers through the first catastrophic year of the war.   The station’s eight large mosaics are of the leaders referenced in the speech, such as Alexander Nevsky, a 13th-century prince and military commander who bested German and Swedish invading armies.

One more stop clockwise to Kurskaya station,  and change onto the 3/Blue  line, and go one stop to:

5. Baumanskaya.   Opened in 1944. Named for the Bolshevik Revolutionary Nikolai Bauman , whose monument and namesake district are aboveground here. Though he seemed like a nasty piece of work (he apparently once publicly mocked a woman he had impregnated, who later hung herself), he became a Revolutionary martyr when he was killed in 1905 in a skirmish with a monarchist, who hit him on the head with part of a steel pipe. The station is in Art Deco style with atmospherically dim lighting, and a series of bronze sculptures of soldiers and homefront heroes during the War. At one end, there is a large mosaic portrait of Lenin.

Stay on that train direction one more east to:

6. Elektrozavodskaya. As you may have guessed from the name, this station is the Metro’s tribute to all thing electrical, built in 1944 and named after a nearby lightbulb factory. It has marble bas-relief sculptures of important figures in electrical engineering, and others illustrating the Soviet Union’s war-time struggles at home. The ceiling’s recurring rows of circular lamps give the station’s main tunnel a comforting glow, and a pleasing visual effect.

Double back two stops to Kurskaya station , and change back to the 1/Circle line. Sit tight for six stations to:

7. Kiyevskaya. This was the last station on the Circle line to be built, in 1954, completed under Nikita Khrushchev’ s guidance, as a tribute to his homeland, Ukraine. Its three large station halls feature images celebrating Ukraine’s contributions to the Soviet Union and Russo-Ukrainian unity, depicting musicians, textile-working, soldiers, farmers. (One hall has frescoes, one mosaics, and the third murals.) Shortly after it was completed, Khrushchev condemned the architectural excesses and unnecessary luxury of the Stalin era, which ushered in an epoch of more austere Metro stations. According to the legend at least, he timed the policy in part to ensure no Metro station built after could outshine Kiyevskaya.

Change to the 3/Blue line and go one stop west.

8. Park Pobedy. This is the deepest station on the Metro, with one of the world’s longest escalators, at 413 feet. If you stand still, the escalator ride to the surface takes about three minutes .) Opened in 2003 at Victory Park, the station celebrates two of Russia’s great military victories. Each end has a mural by Georgian artist Zurab Tsereteli, who also designed the “ Good Defeats Evil ” statue at the UN headquarters in New York. One mural depicts the Russian generals’ victory over the French in 1812 and the other, the German surrender of 1945. The latter is particularly striking; equal parts dramatic, triumphant, and gruesome. To the side, Red Army soldiers trample Nazi flags, and if you look closely there’s some blood spatter among the detail. Still, the biggest impressions here are the marble shine of the chessboard floor pattern and the pleasingly geometric effect if you view from one end to the other.

Keep going one more stop west to:

9. Slavyansky Bulvar.  One of the Metro’s youngest stations, it opened in 2008. With far higher ceilings than many other stations—which tend to have covered central tunnels on the platforms—it has an “open-air” feel (or as close to it as you can get, one hundred feet under). It’s an homage to French architect Hector Guimard, he of the Art Nouveau entrances for the Paris M é tro, and that’s precisely what this looks like: A Moscow homage to the Paris M é tro, with an additional forest theme. A Cyrillic twist on Guimard’s Metro-style lettering over the benches, furnished with t rees and branch motifs, including creeping vines as towering lamp-posts.

Stay on the 3/Blue line and double back four stations to:

10. Arbatskaya. Its first iteration, Arbatskaya-Smolenskaya station, was damaged by German bombs in 1941. It was rebuilt in 1953, and designed to double as a bomb shelter in the event of nuclear war, although unusually for stations built in the post-war phase, this one doesn’t have a war theme. It may also be one of the system’s most elegant: Baroque, but toned down a little, with red marble floors and white ceilings with gilded bronze c handeliers.

Jump back on the 3/Blue line  in the same direction and take it one more stop:

11. Ploshchad Revolyutsii (Revolution Square). Opened in 1938, and serving Red Square and the Kremlin . Its renowned central hall has marble columns flanked by 76 bronze statues of Soviet heroes: soldiers, students, farmers, athletes, writers, parents. Some of these statues’ appendages have a yellow sheen from decades of Moscow’s commuters rubbing them for good luck. Among the most popular for a superstitious walk-by rub: the snout of a frontier guard’s dog, a soldier’s gun (where the touch of millions of human hands have tapered the gun barrel into a fine, pointy blade), a baby’s foot, and a woman’s knee. (A brass rooster also sports the telltale gold sheen, though I am told that rubbing the rooster is thought to bring bad luck. )

Now take the escalator up, and get some fresh air.

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