Editing Cardiopulmonary resuscitation (section)

== Methods ==
[[File:CPR training-03.jpg|thumb|upright=1.25|CPR training: CPR is being administered while a second rescuer prepares for [[defibrillation]].]]
In 2010, the AHA and [[International Liaison Committee on Resuscitation]] updated their CPR guidelines.<ref name="CircEx10">{{cite journal | vauthors = Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, Samson RA, Kattwinkel J, Berg RA, Bhanji F, Cave DM, Jauch EC, Kudenchuk PJ, Neumar RW, Peberdy MA, Perlman JM, Sinz E, Travers AH, Berg MD, Billi JE, Eigel B, Hickey RW, Kleinman ME, Link MS, Morrison LJ, O'Connor RE, Shuster M, Callaway CW, Cucchiara B, Ferguson JD, Rea TD, Vanden Hoek TL | title = Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S640–S656 | date = November 2010 | pmid = 20956217 | doi = 10.1161/CIRCULATIONAHA.110.970889 | doi-access = free }}</ref>{{rp|S640}}<ref>{{cite journal | vauthors = Hazinski MF, Nolan JP, Billi JE, Böttiger BW, Bossaert L, de Caen AR, Deakin CD, Drajer S, Eigel B, Hickey RW, Jacobs I, Kleinman ME, Kloeck W, Koster RW, Lim SH, Mancini ME, Montgomery WH, Morley PT, Morrison LJ, Nadkarni VM, O'Connor RE, Okada K, Perlman JM, Sayre MR, Shuster M, Soar J, Sunde K, Travers AH, Wyllie J, Zideman D | title = Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations | journal = Circulation | volume = 122 | issue = 16 Suppl 2 | pages = S250–S275 | date = October 2010 | pmid = 20956249 | doi = 10.1161/CIRCULATIONAHA.110.970897 | doi-access = free }}</ref> The importance of high quality CPR (sufficient rate and depth without excessively ventilating) was emphasized.<ref name="CircEx10" />{{rp|S640}} The order of interventions was changed for all age groups except [[newborns]] from [[ABC (medicine)|airway, breathing, chest compressions (ABC)]] to chest compressions, airway, breathing (CAB).<ref name="CircEx10" />{{rp|S642}} An exception to this recommendation is for those believed to be in a [[respiratory arrest]] (airway obstruction, drug overdose, etc.).<ref name="CircEx10" />{{rp|S642}}

The most important aspects of CPR are: few interruptions of chest compressions, sufficient speed and depth of compressions, completely relaxing pressure between compressions, and not ventilating too much.<ref>{{cite journal | vauthors = Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, Aufderheide TP, Menon V, Leary M | title = Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association | journal = Circulation | volume = 128 | issue = 4 | pages = 417–435 | date = July 2013 | pmid = 23801105 | doi = 10.1161/CIR.0b013e31829d8654 | doi-access = free }}</ref> It is unclear if a few minutes of CPR before defibrillation results in different outcomes than immediate defibrillation.<ref name="Cardiopulmonary resuscitation CPR">{{cite journal | vauthors = Huang Y, He Q, Yang LJ, Liu GJ, Jones A | title = Cardiopulmonary resuscitation (CPR) plus delayed defibrillation versus immediate defibrillation for out-of-hospital cardiac arrest | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 9 | pages = CD009803 | date = September 2014 | pmid = 25212112 | pmc = 6516832 | doi = 10.1002/14651858.CD009803.pub2 }}</ref> 

=== Compressions with rescue breaths ===
A normal CPR procedure uses chest compressions and ventilations (rescue breaths, usually mouth-to-mouth) for any victim of cardiac arrest, who would be unresponsive (usually unconscious or approximately unconscious), not breathing, or only gasping because of the lack of heartbeats.<ref>{{Cite book |title=Guidelines for CPR and ECC |date=2016 |publisher=American Heart Association (AHA)}}</ref> But the ventilations could be omitted<ref name="Ali_2019" /> for untrained rescuers aiding adults who suffer a cardiac arrest (if it is not an asphyxial cardiac arrest, as by drowning, which needs ventilations).<ref name="AHAHighlights5" />[[File:Chest compressions.gif|thumb|Chest compressions performed at 100 per minute (proper rhythm)]]The patient's head is commonly tilted back (a head-tilt and chin-lift position) for improving the airflow if ventilations can be used. However, when a patient seems to have a possible serious injury in the spinal cord (in the backbone, either at the neck part or the back part), the head must not be moved except if that is completely necessary, and always very carefully, which avoids further damages for the patient's mobility in the future.<ref name=":0" /> And, in the case of babies, the head is left straight, looking forward, which is necessary for the ventilations, because of the size of the baby's neck.<ref name=":4">{{Cite web |date=2024-03-02 |title=How to Perform Child and Baby CPR {{!}} Red Cross |url=http://redcross.org/take-a-class/cpr/performing-cpr/child-baby-cpr |access-date=2024-06-29 |page=1, 3.3|archive-url=https://web.archive.org/web/20240302035229/http://redcross.org/take-a-class/cpr/performing-cpr/child-baby-cpr |archive-date=2024-03-02 }}</ref>[[File:Insulfation2.jpg|thumb|[[Mouth-to-mouth resuscitation|Mouth-to-mouth ventilations]] (mouth-to-mouth rescue breaths)

]]In CPR, the chest compressions push on the lower half of the [[sternum]] —the bone that is along the middle of the chest from the neck to the belly— and leave it to rise up until recovering its normal position. The rescue breaths are made by pinching the victim's nose and blowing air mouth-to-mouth. This fills the lungs, which makes the chest rise up, and increases the pressure into the thoracic cavity. If the victim is a baby, the rescuer would compress the chest with only 2 fingers and would make the ventilations using their own mouth to cover the baby's mouth and nose at the same time. The recommended compression-to-ventilation ratio, for all victims of any age, is 30:2 (a cycle that alternates continually 30 rhythmic chest compressions series and 2 rescue breaths series).<ref name="AHAHighlights2">{{cite web |title=Highlights of the 2010 American Heart Association Guidelines for CPR and ECC |url=http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf |url-status=live |archive-url=https://web.archive.org/web/20101121152639/http://www.heart.org/idc/groups/heart-public/%40wcm/%40ecc/documents/downloadable/ucm_317350.pdf |archive-date=2010-11-21 |work=American Heart Association}}</ref>{{rp|8}} Victims of drowning receive an initial series of 2 rescue breaths before that cycle begins.<ref name=":5">{{Cite book |last=Red Cross |title=CPR/AED for Professional Rescuers |year=2016 |page=133}}</ref>

As an exception for the normal compression-to-ventilation ratio of 30:2, if at least two trained rescuers are present and the victim is a child, the preferred ratio is 15:2.<ref name="AHAHighlights3">{{cite web |title=Highlights of the 2010 American Heart Association Guidelines for CPR and ECC |url=http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf |url-status=live |archive-url=https://web.archive.org/web/20101121152639/http://www.heart.org/idc/groups/heart-public/%40wcm/%40ecc/documents/downloadable/ucm_317350.pdf |archive-date=2010-11-21 |work=American Heart Association}}</ref>{{rp|8}} Equally, in newborns, the ratio is 30:2 if one rescuer is present, and 15:2 if two rescuers are present (according to the AHA 2015 Guidelines).<ref name="CircEx10" />{{rp|S647}} In an advanced airway treatment, such as an [[endotracheal tube]] or [[laryngeal mask airway]], the artificial ventilation should occur without pauses in compressions at a rate of 1 breath every 6 to 8 seconds (8–10 ventilations per minute).

In all victims, the compression speed is at least 100 compressions per minute.<ref name="AHAHighlights4">{{cite web |title=Highlights of the 2010 American Heart Association Guidelines for CPR and ECC |url=http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf |url-status=live |archive-url=https://web.archive.org/web/20101121152639/http://www.heart.org/idc/groups/heart-public/%40wcm/%40ecc/documents/downloadable/ucm_317350.pdf |archive-date=2010-11-21 |work=American Heart Association}}</ref>{{rp|8}} Recommended compression depth in adults and children is of 5&nbsp;cm (2 inches), and in infants it is 4&nbsp;cm (1.6 inches).<ref name="AHAHighlights4" />{{rp|8}} In adults, rescuers should use two hands for the chest compressions (one on top of the other), while in children one hand could be enough (or two, adapting the compressions to the child's constitution), and with babies the rescuer must use only two fingers.<ref>{{cite book | vauthors = Autin M, Crawford R, Klaassen D |title=First Aid Manual |publisher=St. John Ambulance; St. Andrew's First Aid; British Red Cross Society }}</ref>

There exist some plastic shields and respirators that can be used in the rescue breaths between the mouths of the rescuer and the victim, with the purposes of sealing a better vacuum and avoiding infections.<ref>{{Cite web | author = Department of Health & Human Services | title=Cardiopulmonary resuscitation (CPR) |url=http://betterhealth.vic.gov.au/health/conditionsandtreatments/cardiopulmonary-resuscitation-cpr |access-date=2022-10-20 |website=www.betterhealth.vic.gov.au |language=en}}</ref>

In some cases, the problem is one of the failures in the rhythm of the heart (ventricular fibrillation and ventricular tachycardia) that can be corrected with the electric shock of a [[Cardiopulmonary resuscitation#Defibrillators|defibrillator]]. So, if a victim is suffering a cardiac arrest, it is important that someone asks for a defibrillator nearby, to try with it a [[Cardiopulmonary resuscitation#Defibrillators|defibrillation process]] when the victim is already unconscious. The common model of a defibrillator (the AED) is an automatic portable machine that guides the user with recorded voice instructions along the process, analyzes the victim, and applies the correct shocks if they are needed.

The time in which a cardiopulmonary resuscitation can still work is unclear, and it depends on many factors. Many official guides recommend continuing cardiopulmonary resuscitation until emergency medical services arrive (for trying to keep the patient alive, at least).<ref name=":0">{{Cite book |last=American Red Cross |title=CPR/AED for Professional Rescuers}}</ref> The same guides also indicate asking for any emergency defibrillator (AED) near, to try an automatic defibrillation as soon as possible before considering that the patient has died.<ref name=":0" />

A normal cardiopulmonary resuscitation has a recommended order named 'CAB': first 'Chest' (chest compressions), followed by 'Airway' (attempt to open the airway by performing a head tilt and a chin lift), and 'Breathing' (rescue breaths).<ref name="CircEx10" />{{rp|S642}} As of 2010, the [[Resuscitation Council (UK)]] was still recommending an 'ABC' order, with the 'C' standing for 'Circulation' (check for a pulse), if the victim is a child.<ref>{{cite web |title=Resuscitation Council UK Paediatric Advanced Life Support Guidelines |url=http://www.resus.org.uk/pages/pals.pdf |url-status=live |archive-url=https://web.archive.org/web/20110527145122/http://www.resus.org.uk/pages/pals.pdf |archive-date=2011-05-27 |access-date=2010-10-24}}</ref> It can be difficult to determine the presence or absence of a pulse, so the pulse check has been removed for common providers and should not be performed for more than 10 seconds by healthcare providers.<ref name="AHAHighlights5">{{cite web |title=Highlights of the 2010 American Heart Association Guidelines for CPR and ECC |url=http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf |url-status=live |archive-url=https://web.archive.org/web/20101121152639/http://www.heart.org/idc/groups/heart-public/%40wcm/%40ecc/documents/downloadable/ucm_317350.pdf |archive-date=2010-11-21 |work=American Heart Association}}</ref>{{rp|8}}

=== Compression only ===
For untrained rescuers helping adult victims of cardiac arrest, it is recommended to perform compression-only CPR (chest compressions hands-only or cardiocerebral resuscitation, without [[artificial ventilation]]), as it is easier to perform and instructions are easier to give over a phone.<ref name="Ali_2019">{{cite journal | vauthors = Ali S, Athar M, Ahmed SM | title = A randomised controlled comparison of video versus instructor-based compression only life support training | journal = Indian Journal of Anaesthesia | volume = 63 | issue = 3 | pages = 188–193 | date = March 2019 | pmid = 30988532 | pmc = 6423949 | doi = 10.4103/ija.IJA_737_18 | doi-access = free }}</ref><ref name="CircEx10" />{{rp|S643}}<ref name="CircEx10" />{{rp|S643}}<ref name="AHAHighlights">{{cite web |title=Highlights of the 2010 American Heart Association Guidelines for CPR and ECC |url=http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf |url-status=live |archive-url=https://web.archive.org/web/20101121152639/http://www.heart.org/idc/groups/heart-public/%40wcm/%40ecc/documents/downloadable/ucm_317350.pdf |archive-date=2010-11-21 |work=American Heart Association}}</ref>{{rp|8}}<ref name="Lancet2010">{{cite journal | vauthors = Hüpfl M, Selig HF, Nagele P | title = Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis | journal = Lancet | volume = 376 | issue = 9752 | pages = 1552–1557 | date = November 2010 | pmid = 20951422 | pmc = 2987687 | doi = 10.1016/S0140-6736(10)61454-7 }}</ref> In adults with out-of-hospital [[cardiac arrest]], compression-only CPR by the average person has an equal or higher success rate than standard CPR.<ref name="Lancet2010" /><ref name="AHA2015 2">{{cite web |url=https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf |title=Highlights of the 2015 American Heart Association: Guidelines Update for CPR and ECC |url-status=dead |archive-url=https://web.archive.org/web/20160313233123/http://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf |archive-date=2016-03-13 | vauthors = Hazinski MF, Shuster M, Donnino MW, etal | date = 2015 }} "The ''2015 AHA Guidelines Update for CPR and ECC'' is based on an international evidence evaluation process that involved 250 evidence reviewers from 39 countries."</ref><ref name="EMS37-6">{{cite journal| vauthors = Ewy GA |date=June 2008 |title=Cardiocerebral Resuscitation: Could this new model of CPR hold promise for better rates of neurologically intact survival?|access-date=2008-08-02|url=http://emsresponder.com/print/Emergency--Medical-Services/CARDIOCEREBRAL-Resuscitation/1$7857|journal=EMS Magazine|volume=37|issue=6|pages=41–49|url-status=dead|archive-url=https://web.archive.org/web/20080803153326/http://www.emsresponder.com/print/Emergency--Medical-Services/CARDIOCEREBRAL-Resuscitation/1%247857|archive-date=2008-08-03}}</ref>[[File:2002 CPR Technique.jpg|thumb|upright=1.25|CPR technique as demonstrated on a dummy]]

The CPR 'compressions only' procedure consists only of chest compressions that push on the lower half of the bone that is in the middle of the chest (the [[sternum]]).

Compression-only CPR is not as good for children who are more likely to have cardiac arrest from respiratory causes. Two reviews have found that compression-only CPR had no more success than no CPR whatsoever.<ref name="AHA2015 2" /><ref name="CircEx10" />{{rp|S646}} Rescue breaths for children and especially for babies should be relatively gentle.<ref name="AHA2015 2" /> Either a ratio of compressions to breaths of 30:2 or 15:2 was found to have better results for children.<ref>{{cite journal | vauthors = Ashoor HM, Lillie E, Zarin W, Pham B, Khan PA, Nincic V, Yazdi F, Ghassemi M, Ivory J, Cardoso R, Perkins GD, de Caen AR, Tricco AC | title = Effectiveness of different compression-to-ventilation methods for cardiopulmonary resuscitation: A systematic review | journal = Resuscitation | volume = 118 | pages = 112–125 | date = September 2017 | pmid = 28583860 | doi = 10.1016/j.resuscitation.2017.05.032 | s2cid = 207518670 | url = http://wrap.warwick.ac.uk/89631/1/WRAP-effectiveness-different-compression-to-ventilation-methods-Perkins-2017.pdf }}</ref> Both children and adults should receive 100 chest compressions per minute. Other exceptions besides children include cases of [[drowning]]s and [[drug overdose]]; in both these cases, compressions, and rescue breaths are recommended if the bystander is trained and is willing to do so.<ref>{{Cite web | vauthors = Steinson B |date=2023-08-29 |title=Compression-Only CPR vs. CPR with Rescue Breaths |url=https://fundamentalfirstaid.ca/first-aid-blog/compression-only-cpr-rescue-breaths/ |access-date=2023-08-29 |website=Fundamental First Aid Ltd. |language=en-CA}}</ref>

As per the AHA, the beat of the [[Bee Gees]] song "[[Stayin' Alive]]" provides an ideal rhythm in terms of beats per minute to use for hands-only CPR, which is 104 beats-per-minute.<ref>{{Cite web | author = Blendist LLC |title=BPM for Stayin' Alive by Bee Gees|url=https://songbpm.com/@bee-gees/stayin-alive|access-date=2020-12-31|website=SONG BPM|language=en}}</ref> One can also hum [[Queen (band)|Queen]]'s "[[Another One Bites the Dust]]", which is 110 beats-per-minute<ref>{{Cite web |url=https://www.beatdetect.com/song/another-one-bites-the-dust-by-queen/5Lsg8jlCoTyxRch9LvJo3E |title=Another One Bites The Dust by Queen | access-date=2024-01-24|website=beatdetect.com|language=en}}</ref><ref>{{Cite web | author = Blendist LLC |title=BPM for Another One Bites The Dust by Queen|url=https://songbpm.com/@queen/another-one-bites-the-dust|access-date=2020-12-31|website=SONG BPM|language=en}}</ref> and contains a repeating drum pattern.<ref name="CommonHealth">{{cite news |title=From Queen, The Best Song For CPR – Except For The Lyrics |access-date=2012-05-29 |url=http://commonhealth.wbur.org/2010/12/cpr-song |archive-url=https://web.archive.org/web/20131102063841/http://commonhealth.wbur.org/2010/12/cpr-song |archive-date=November 2, 2013 |url-status=live }}</ref> For those in cardiac arrest due to non-heart related causes and in people less than 20 years of age, standard CPR is superior to compression-only CPR.<ref>{{cite journal | vauthors = Ogawa T, Akahane M, Koike S, Tanabe S, Mizoguchi T, Imamura T | title = Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: nationwide population based observational study | journal = BMJ | volume = 342 | pages = c7106 | date = January 2011 | pmid = 21273279 | doi = 10.1136/bmj.c7106 | hdl-access = free | doi-access = free | hdl = 10564/1584 }}</ref><ref>{{cite journal | vauthors = Koenig KL |title=Compression-Only CPR Is Less Effective Than Conventional CPR in Some Patients |journal=JW Emerg Med |date=March 4, 2011 |url=http://emergency-medicine.jwatch.org/cgi/content/full/2011/304/1?q=etoc_jwem |volume=2011 |issue=304 |page=1 |url-status=dead |archive-url=https://web.archive.org/web/20110724151702/http://emergency-medicine.jwatch.org/cgi/content/full/2011/304/1?q=etoc_jwem |archive-date=2011-07-24 |access-date=2018-12-07 }}</ref>

=== Prone CPR ===
[[File:Supine and prone diagrams-en.svg|thumb|Supine and prone positions]]Standard CPR is performed with the victim in [[supine position]]. Prone CPR, or reverse CPR, is performed on a victim in [[prone position]], lying on the chest. This is achieved by turning the head to the side and compressing the back. Due to the head being turned, the risk of vomiting and complications caused by [[aspiration pneumonia]] may be reduced.<ref>{{cite journal | vauthors = Wei J, Tung D, Sue SH, Wu SV, Chuang YC, Chang CY | title = Cardiopulmonary resuscitation in prone position: a simplified method for outpatients | journal = Journal of the Chinese Medical Association | volume = 69 | issue = 5 | pages = 202–206 | date = May 2006 | pmid = 16835981 | doi = 10.1016/S1726-4901(09)70219-9 | s2cid = 43391072 | doi-access = free | publication-date = May 2006 }}</ref>

The American Heart Association's current guidelines recommend performing CPR in the [[supine position]] and limiting prone CPR to situations where the patient cannot be turned.<ref>{{cite journal | vauthors = Cave DM, Gazmuri RJ, Otto CW, Nadkarni VM, Cheng A, Brooks SC, Daya M, Sutton RM, Branson R, Hazinski MF | title = Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S720–S728 | date = November 2010 | pmid = 20956223 | pmc = 3741663 | doi = 10.1161/CIRCULATIONAHA.110.970970 | quote = When the patient cannot be placed in the supine position, it may be reasonable for rescuers to provide CPR with the patient in the prone position, particularly in hospitalized patients with an advanced airway in place (Class IIb, LOE C). }}</ref>

===Pregnancy===
During [[pregnancy]] when a woman is lying on her back, the [[uterus]] may compress the [[inferior vena cava]] and thus decrease venous return.<ref name=AHAPart12/> It is therefore recommended that the uterus be pushed to the woman's left. This can be done by placing a pillow or towel under her right hip so that she is on an angle of 15–30 degrees, and making sure their shoulders are flat to the ground. If this is not effective, healthcare professionals should consider emergency [[resuscitative hysterotomy]].<ref name=AHAPart12/>

===Family presence===
Evidence generally supports family being present during CPR.<ref>{{cite journal | vauthors = Flanders SA, Strasen JH | title = Review of evidence about family presence during resuscitation | journal = Critical Care Nursing Clinics of North America | volume = 26 | issue = 4 | pages = 533–550 | date = December 2014 | pmid = 25438895 | doi = 10.1016/j.ccell.2014.08.010 }}</ref> This includes in CPR for children.<ref>{{cite journal | vauthors = McAlvin SS, Carew-Lyons A | title = Family presence during resuscitation and invasive procedures in pediatric critical care: a systematic review | journal = American Journal of Critical Care | volume = 23 | issue = 6 | pages = 477–84; quiz 485 | date = November 2014 | pmid = 25362671 | doi = 10.4037/ajcc2014922 }}</ref>

===Other===
Interposed abdominal compressions may be beneficial in the hospital environment.<ref name=CircP7>{{cite journal | vauthors = Cave DM, Gazmuri RJ, Otto CW, Nadkarni VM, Cheng A, Brooks SC, Daya M, Sutton RM, Branson R, Hazinski MF | title = Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S720–S728 | date = November 2010 | pmid = 20956223 | pmc = 3741663 | doi = 10.1161/CIRCULATIONAHA.110.970970 }}</ref> There is no evidence of benefit pre-hospital or in children.<ref name=CircP7/>

Cooling during CPR is being studied as currently, results are unclear whether or not it improves outcomes.<ref>{{cite journal | vauthors = Dell'anna AM, Scolletta S, Donadello K, Taccone FS | title = Early neuroprotection after cardiac arrest | journal = Current Opinion in Critical Care | volume = 20 | issue = 3 | pages = 250–258 | date = June 2014 | pmid = 24717694 | doi = 10.1097/mcc.0000000000000086 | s2cid = 10088805 }}</ref>

Internal cardiac massage is the manual squeezing of the exposed heart itself carried out through a [[surgical incision]] into the [[chest cavity]], usually when the chest is already open for cardiac surgery.

Active compression-decompression methods using mechanical decompression of the chest have not been shown to improve outcomes in cardiac arrest.<ref>{{cite journal | vauthors = Lafuente-Lafuente C, Melero-Bascones M | title = Active chest compression-decompression for cardiopulmonary resuscitation | journal = The Cochrane Database of Systematic Reviews | volume = 2013 | issue = 9 | pages = CD002751 | date = September 2013 | pmid = 24052483 | pmc = 7100575 | doi = 10.1002/14651858.CD002751.pub3 }}</ref>