Melanie Cole, MS (Host): In October, 2025, the American Heart Association issued updated CPR guidelines, the first full revision of Life-Saving Resuscitation guidelines since 2020. We're talking about that here today on It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole and joining me is Tamar Avakian. She's the Cardiology Nurse Practitioner Coordinator at Henry Mayo Newhall Hospital.

Tamar, thank you so much for joining us today. So I'd like you to start by explaining to our listeners a little bit about CPR. We've all heard the term, they're not quite sure. You know, it's been around a very long time, but it's changed quite a few times. Can you give us a little evolution explanation of it?

Tamar Avakian, NP: Yeah, absolutely. And first, I just wanted to say thank you for having me on. I'm happy to join you guys today. So, yeah, CPR, it's something we've all heard. Technically what it stands for is cardiopulmonary resuscitation, so it's a bit of a mouthful. And essentially what CPR means, Cardiopulmonary resuscitation, basically it means two primary things.

It's one is helping someone breathe, what we call rescue breathing, and also performing chest compressions, pushing down on the chest. This is a situation where there has been cardiac arrest, or respiratory arrest, meaning a person has either stopped breathing and or their heart has stopped pumping.

Host: Well, thank you for that. I mean, like we said, it's been around a long time and we've had what we all have learned when we use the Debbie Doll or whichever one, you know, the basic CPR. I'd like you to explain, first of all, before we get into the new guidance, kind of what was the standard? What were we doing with chest compressions and we were doing rescue breathing, but some of this has changed now.

Can you tell us a little bit about what we were doing, what everybody kind of thinks of, and then you can tell us what has changed and why.

Tamar Avakian, NP: Yeah. The essentials of what we're doing has actually not changed. The core essentials of CPR as I mentioned, is number one, chest compressions, and number two is rescue breathing. Those core essentials are unchanged, and those remain the gold standard. And I can talk about what some of the newer updates are.

It has to do with, in other areas and other situations that could potentially be life-threatening. So things like, asphyxia or meaning, uh, choking, for an object obstruction in the airway that blocks breathing and also overdose situations. So other life threatening situations. The reason that guidelines are updated periodically is the American Heart Association who publishes these guidelines, for decades that have been working on these kinds of lifesaving situations and trying to find what is a optimal way to enhance survival, in these critical situations, in these critical moments.

So they're always looking at the science, looking at the evidence, and trying to improve in any way that they can.

Host: Okay, so then let's start with the standard CPR, because I do want to get into overdose and choking as well. What's changed? What's new?

Tamar Avakian, NP: Yeah. So in terms of the, the core elements of CPR, that has not changed. The foundation is what we call, high quality, chest compression. So that's where you kind of put the hands over the middle of the chest, over the breastbone and you have to do chest compressions at a rate of about 100 per minute.

 And that is an effort to mimic what the heart would do, you push down on the chest to try to have the heart pump blood and to provide that circulation. Because that's what's happened in the cardiac arrest situation, is that the heart has stopped pumping and within minutes, if there's no restoration of blood circulation to the body, that can lead to death, and all of the cells in the body need oxygen to survive, and it's estimated that within four minutes the oxygen starts to deplete. You can start having brain damage after four minutes. And then obviously if circulation's not restored, then it's, it's going to be you know, game over. So that's the whole essence of CPR is to provide those chest compressions to provide that circulation, until there can be emergency, advanced, resuscitation capabilities. And the second component of that is a breathing component. So you alternate chest compressions with rescue breathing.

 But some of the updates in the past decade has been especially for community members, uh, lay people to, to not worry so much about the breathing component and primarily to focus on three key highlighted things. Number one is to activate the emergency response, calling 911. Number two, doing the high quality chest compressions, what I talked about. And then the third piece is to do a defibrillation. So that's when, because many, many cardiac arrests are as a, are a result of a cardiac arrhythmia, abnormal heart rhythm. So in a lot of public places now, there are these, what they call AEDs, automatic external defibrillators, where that can deliver a shock to try to bring someone heart rhythm back to a regular beating. So those are the three essential components of standard CPR.

Host: So we're looking at a hundred compressions a minute. We used to say, sing, stayin alive. Or something of that nature for somebody who isn't quite sure about how many a hundred really is. I'm an exercise physiologist, so I mean, I could take heart rate and I can generally approximate, but not everybody could do that.

So how can they know that they're doing it at the right speed?

Tamar Avakian, NP: That's a great question, Melanie. Yeah, that song Staying Alive, hopefully most people know that song. That's a great way to try to keep the rhythm. It's a fairly rapid rate. And so, you put your arms down on the breastbone, right in between the nipples, and you want to go at a rate of about a hundred a minute.

So it's quite fast. For someone who performs CPR for more than a couple minutes, you'll get pretty winded. It's a bit of a workout and you want to compress to a depth of about an inch and a half to two inches. Again, these are kind of hard things to, just explain and describe verbally.

That's why when we talk about CPR education, it's something that there could be some great online tools and videos and resources, but it's something that you really just need to try and practice, in real life, to be able to really kind of get a sense of how to do it appropriately.

Host: Now let's talk about choking, because that is one of my fears and everybody's fears and they used to say, throw yourself over a chair. I've seen some products on the market that are like little suction things you put on your mouth and pull. Tell us, what is the now standard for choking, both if you see someone and if it's you.

Tamar Avakian, NP: So let me just back up just briefly. So, this area of choking guidance is actually one of the new updates to these 2025 guidelines that just came out last month. In the previous versions back in 2020, they didn't really address choking, especially in adults. It wasn't really, it's something that we, in healthcare field, we kind of learn when we do our CPR certification, but it wasn't really kind of formally addressed.

So in these new guidelines, 2025, that's something that they have kind of now formalized and so essentially what the new guidelines state, and this is both for adults and children. The key recommendation now is what they call five back blows, where you just kind of forcefully hit someone in the back between the shoulder blades, you do five back blows.

Then you turn around and then do five, what we call abdominal thrusts or kind of old term Heimlich maneuver for some people who have heard of that term. And that's, again, it's a little bit hard to describe, just through audio, but essentially if you see someone choking, whether it's an adult or a child, you want to come up to them and, after you verify

And one of the things, the ways that you'll know that they have an airway obstruction is they will not be able to, talk, to speak. They won't be able to make a voice because of that, obstruction in their airway. So once you confirm that yes, they are choking, you want to start with the five back blows.

So you give them really hard pats on the back. Big five blows, and see if that might expel the foreign object. If that doesn't work after five back blows, then you come and you stand behind them and you wrap your two arms around them and you make a fist with one hand and put your other arm over that fist and you place it kind of right where their stomach area is below their breastbone now.

And you want to pull your arms in towards yourself, like so kind of upwards and inwards at a 45 degree angle. So that's what we refer to as abdominal thrust. Again, it's easier to demonstrate and to practice than to just kind of talk about on a podcast, but that's essentially the idea, for both adults and children and you continue that until they're hopefully at some point they will be able to expel that foreign object that's blocking the airway.

Host: Well, that was an excellent description. And so, you know, maybe you and I do this again and we do a video and you really demonstrate for us, but I think you gave an excellent description of what that Heimlich is as we're calling it, but those thrusts and it's so important to learn. Now what about if you are alone?

Tamar Avakian, NP: Yeah, if you're alone, obviously that's going to be a lot more difficult. And so there have been instances and description. Now this is nothing official, this is not part of the guidelines just to be clear, but, essentially you want to try to mimic those abdominal thrusts. Obviously you can't really hit yourself on the back.

That's not really possible. But all you have is, to kind of mimic the abdominal thrust of what I just described a moment ago. And so the most feasible way to do that is to come up to a chair that's below your chest, kind of right at your stomach, abdominal area, and you kind of just have to kind of push yourself into that chair. Or another alternative could be to give yourself the abdominal thrust of what I just described. That might be easier actually now that I'm thinking about it, is you make that fist, with the one hand and you put your hand over that fist, and then you just press right into where your stomach is.

And you don't want to press right in like straight into your abdomen. You want to kind of go in and up. So like at a, kind of think of it as a more 45 degree angle. You keep, giving those abdominal thrusts to yourself, until you're able to cough that piece out, whatever is blocking the airway.

Host: And then calling 911 is always a good idea if you can. And hopefully there's people around. Okay, so now we also mentioned overdose and with the advent of Narcan, certainly kids in college and places where this might be something that is prevalent. It's a great idea. I mean, when my daughter was away at school in the dorms, she had some with her.

Tamar Avakian, NP: And you're right. This is another big piece of the new updated guidelines. This is actually something brand new, so it's not changed or revised or updated. It's brand new, versus the 2020 version of the guidelines. And essentially, yes, they are kind of shining a spotlight on the need to address overdose and in particular opiate overdose, that accounts for, roughly 80% of all overdoses are from drugs called opiates.

And these are drugs, typically painkillers. The most common one, the biggest culprit in this is, is what's called fentanyl. That's a medication that we use a lot in the hospital for anesthesia and things like that. But unfortunately, it is used illegally and, it's the number one leading cause of deaths and the problem with these opiate drugs, other ones include things like oxycodone, morphine, things like that. Some prescription. These are very strong pain medications. That's typically what they're used for. Fentanyl of course, is not used at all outside of a hospital. Sure. Shouldn't be used. In any case, these drugs, the reason that they are such a leading cause of overdose deaths is they work in the brain and they suppress the area of the brain that controls your breathing response. And so it suppresses that region of the brain. And so your breathing becomes less and less and shallower. And shallower. And until eventually, you could stop breathing completely.

And that's kind of how this happens. And so what these new guidelines do is they really especially aim it from a kind of a policy perspective, for communities or local governments or whatnot, to find any ways to make a reversal agent that you just referenced Narcan, or technically also called naloxone, or Narcan is the, uh, brand name.

And they focus on having policies were these can become more publicly available. And that's kind of started already, as you just mentioned, you said your daughter had, knew about access to it in college. So it is starting to happen. And so that's just the, the recommendations are that to continue to increase that awareness.

 And Narcan is a medication, it's basically a reversal agent, for opiate drugs. It doesn't work on every kind of drug, only on this opiate class. But again, these opiate category of drugs are responsible for about 80% of overdose deaths. And so that's why having this medication that is so effective, it essentially blocks the action of those opiate drugs in the brain.

What I was just describing. And they come in two forms. It's most readily available and easily used as what's called intranasal, meaning that, you get squirted into the nostrils. And these are available everywhere, over the counter, no prescription needed. You get it on Amazon or CVS, Walmart, any of the pharmacies, almost all of them should have them.

And so, especially this is helpful in cases where there is a family member or friend or someone who's known to struggle with addiction to these drugs. It's very helpful to have and it's a really good idea, recommendation to have Narcan available on hand. Hopefully it would never need to be used, but if in that need, it's a great, rescue medication.

 So that's the other big change in the new 2025 guidelines.

Host: So with Narcan specifically, explain just a little bit to the listeners that it is not harmful if it's not an opiate overdose. So if it's alcohol or something that's not an opioid, it still doesn't hurt to try it if you don't know.

Tamar Avakian, NP: That's a great point, Melanie. Yes, that is a great point. Narcan is a very safe drug. It's not going to have any side effects. It's not going to cause any harm because you're right. You may or may not know, what that person, has taken. So it's definitely worth a shot. Again, like I said, the vast majority of time it is opiates, and so, the vast majority of time it is going to work.

The instructions for use is, you give one squirt into the nostril and after a few minutes, three, four minutes, if there's no response, no effect, you can administer it again two or three times total.

And again, it will not cause any harmful side effects.

 I think it's also important, for everyone to be able to recognize the signs of overdose, to even know what to look for. So the first thing that you'll notice is that the person is, unresponsive, loss of consciousness. Or if they are still somewhat responsive, they're still conscious. They're extremely, extremely sluggish and lethargic and barely responsive. So that's the first sign. The other thing is that, if you may come to someone who is on the ground and unconscious, not responding, the other thing you're going to see is that there's either very, very shallow breathing or what we call agonal respirations, like kind of choking or gurgling sounds or no breathing at all. And so they may have a pulse still. Hopefully they have a pulse. If they do have a pulse, then that's when you can give them Narcan.

If you come and find someone who's unresponsive, not breathing and has no pulse, that's when we need to initiate CPR. So you call 911 and then you immediately start chest compressions. In the case where there's no heartbeat, there's no point in giving the Narcan. The only priority is to, to do CPR to activate emergency response and do CPR and one other symptom too that you typically will see in an opiate overdose is, pinpoint pupils. Small, tiny little. You know, you'll see that the pupils become really, really small and tiny. That's another clue that it could be an opiate, that's a side effect of opiate drugs.

And also if you see their skin color's very blue, gray, ashen, kind of, there's just no color. These are all signs of inadequate oxygen, breathing, you know, circulation, things like that.

Host: This is so educational. Tamar, what are some of the common mistakes that you've seen people do when trying to perform CPR?

Tamar Avakian, NP: Yeah, that's a great question. I would say the most common one has to do with the chest compressions. And that's why the emphasis from AHA for many, many years now, has known what they refer to as quote, high quality chest compressions. And so earlier we were talking about, at the beginning of our call, make sure that the chest compressions are fast enough and deep enough, you need to try to get as close to that rate of a hundred as possible.

And also you have to go kind of pretty deep. Almost two inches, which is, you have to apply quite a bit of force because if it's just these kind of little taps, well unfortunately it's not going to be really effective. And so yeah, that would be the number one area, is performing the chest compressions correctly. And the two key areas are rate and depth, how fast you're going and how deep you're pushing on the chest.

Host: So important this information. As we get ready to wrap up, what's the best way to learn CPR? Tell us about learning it at Henry Mayo Newhall Hospital.

Tamar Avakian, NP: Yeah, absolutely. Um, as I had mentioned earlier, it's fine to try to describe these things and there's great online tools and in fact, in one of the other kind of minor guideline updates that AHA made is, you know, recognizing the role of social media and trying to do these campaigns and things for education.

Those are all excellent tools, but really in this particular skill of chest compressions and CPR, this is really an area where you do need to kind of just practice live. And by that I mean like in person, not on a live person, you're going to practice them on, on mannequins or dummies.

So yeah, this is something where we really do recommend that you take classes just so you get a feel for what it's like to push down and how fast and how deep and, you know, and all the other little details and what to look for. So, here at Henry Mayo Newhall Hospital, we do offer a community education class.

We offer these classes once a month. They're typically held on the third Tuesday of every month, in the evening from five to 8:00 PM it's a $20 fee to attend. And this is for official certification as well. So, yeah, these classes are offered monthly and people can register on the website, henry mayo.com.

If you go to henry mayo.com and then you navigate to where it says classes and events, folks can register and sign up there for classes.

Host: $20 is so reasonable for what you learn and how important it is, and then you get your certification right then and there, don't ya.

Tamar Avakian, NP: Yes. Right on. Yep.

Host: So your best advice now, Tamar, you've given us such great information, and you may not believe it with audio, but you described everything so thoroughly and so well that you really gave us a whole overview of how important these guideline changes are.

So wrap it up with your best advice, what you want people to know about learning CPR and the importance of it.

Tamar Avakian, NP: Yeah. My best advice is I would just encourage people to learn it. It's never something that we ever want to think about, something that we would hope we would never have to use. But unfortunately, you never know what kind of situation you may find yourself. It could be with a loved one, friends or you could be out in the community.

Here in the hospital, we, unfortunately, we see these cases almost every day. And, not everybody has had what we call bystander CPR. It's kind of 50/50. So the more of our community members, are aware and know what to look for the signs and know how to respond in these emergency life-threatening situations.

We just highly recommend and we do whatever we can in the community to help kind of spread that word. So.

Host: Yeah. And you just did that here today, and I thank you so much, Tamar, for joining us today. And CPR classes are taught at Henry Mayo Newhall Hospital every month, as Tamar said, so to sign up or to learn more, go to henry mayo.com/classes and click on the special topics link.

You can also visit the free Henry Mayo Newhall Hospital online health information library@library.henrymayo.com. That concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. Thanks so much for joining us for this very important episode today.