Bystander CPR: The Biggest Links in the Chain of Survival

Arthur Hsieh // June 1, 2011

The release of the American Heart Association 2010 Emergency Cardiac Care Guidelines marks the 50th anniversary of CPR. It is perhaps with some irony that some of the biggest changes in the resuscitation guidelines have occurred at the most basic level of care – public participation in managing sudden cardiac arrest (SCA). It may be that the greatest opportunity for EMS providers to improve patient survival from SCA is in the encouragement and support of the lay person to recognize cardiac arrest, activate the emergency response system, and perform effective chest compressions and defibrillation.

Scope of the problem
Approximately 350,000 people each year in the United States and Canada experience SCA and undergo resuscitation efforts1. Approximately half occur outside of the hospital. Despite 50 years of understanding the causes of sudden death and developing techniques to reverse it, out-of-hospital survival rates remain low, ranging from 3 to 16 percent in one multi-system study2. In another words, survival from out-of-hospital cardiac arrest has not improved significantly in decades.

Professional resuscitation comes of age
It has become apparent that the "professional" side of cardiac resuscitation has come of age. The number of medications that are routinely recommended for cardiac arrest management has been reduced, and advanced medical procedures such as endotracheal intubation has not been shown to reliably improve survival outcome.

This evolution is reflected in the 2010 Advanced Cardiac Life Support Guidelines; there have been relatively few changes in the recommended care provided by the advanced healthcare provider. The AHA has clearly organized its resuscitation guidelines around the delivery of high quality chest compressions to increase perfusion through the coronary arteries and the need to defibrillate early in cases of ventricular fibrillation. This makes sense – there is no reason to believe that the ALS "house" would stand if the BLS "foundation" is weak.

The effect of bystander participation
If the above statement is to be believed, then the greatest opportunity to improve survival is to turn to the first three links in the chain of survival: early recognition and activation, early CPR, and early defibrillation. In its executive summary of the 2010 Guidelines, the AHA states that, for the management of cardiac arrest "no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act."3 Recent studies show that the sooner the CPR begins during cardiac arrest, the better the outcome.4,5

Where EMS plays a role
Prehospital care providers own the fourth link in the chain of survival in the out-of-hospital cardiac arrest. We are portrayed as heroes in television shows, movies, and newspaper reports when someone survives after a cardiac arrest. It is critical that the profession plays its part in getting the public to participate in the saving of a life.

While providing certification courses in CPR, AED and First Aid is helpful, there are additional ways to increase public knowledge of CPR. The AHA has endorsed the concept of "hands only" CPR, where recognition of cardiac arrest, activation of the emergency response system, and high quality chest compressions are the key knowledge points.

A casebook example of public participation would be the San Francisco Paramedic Association sponsorship of "sidewalk CPR," which began two years ago. During National CPR & AED Awareness week, volunteer instructors coaxed and cajoled people passing by the SFPA’s building during rush hour, and encouraged them to spend less than 5 minutes practicing hands only CPR on manikins that were laid out on the sidewalk.

Music such as the Bee Gee’s "Staying Alive," "Quit Playing Games with my Heart" by the Back Street Boys, and "Rock It" by Master P provided a soundtrack that allowed participants to practice a rate of about 100 beats per minute. Over the course of two hours, more than 50 individuals stopped and practiced CPR. The cost was low, and the fun factor was high. Last year the event expanded to San Francisco City Hall, where more than one hundred individuals trained during a short period.

EMS providers play a pivotal role in educating and encouraging their community in the management of cardiac arrest management. The level of respect and expectation from the public places us in a unique position to provide the leadership necessary to improve survival from cardiac arrest.


1. Lloyd-Jones D et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation. 2010;121:e46–e215.

2. Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, Rea T, Lowe R, Brown T, Dreyer J, Davis D, Idris A, Stiell I. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300:1423–1431.

3. Field, et al. Part 1: Executive Summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122;S640-S656.

4. Yoneomoto N. The Effect of Time to Bystander Cardiopulmonary Resuscitation on Survival From Out-of-hospital Cardiac Arrest From All-Japan Utstein Registry Data: A Validation of 3-Phase Sensitive Model. Circulation 2010;122:A260.

5. Bobrow B et al. Chest Compression–Only CPR by Lay Rescuers and Survival From Out-of-Hospital Cardiac Arrest. JAMA 2010;304(13):1447-1454.


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