Sequence to Follow in Case of Vomiting During CPR

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It has come to our attention that there seems to be some misunderstanding regarding the sequence to follow in case of vomiting during cardiopulmonary resuscitation (CPR). We would like to provide some guidance to address this recurring question.

For several years now, it has been recognized that vomiting during resuscitation is a passive phenomenon caused by air being introduced into the stomach during ventilations using a pocket mask. Such vomiting should not be considered a change in the victim's condition requiring a reassessment of the ABCs. The correct response is to turn the victim onto their side, perform a finger sweep to remove any solid vomitus obstructing the airway if necessary, return the victim to their back, and "continue resuscitation." However, this phrase appears to leave room for interpretation, leading some to question the best approach.

To our knowledge, there is no specific scientific study addressing this question. However, we can rely on some key CPR principles to provide guidance.

Minimizing Interruptions: First, it’s important to remember that interruptions during CPR are associated with lower survival rates. To achieve high-quality resuscitation, chest compressions should be performed for more than 80% of the total resuscitation time. This measure, known as the Chest Compression Fraction, is directly linked to improved survival in cases of cardiac arrest.

Maintaining Circulatory Pressure: Second, the first compressions in a new cycle serve to rebuild the necessary pressure to circulate blood through the arterial network. Changes in the compression-to-ventilation ratio over the years—from 15 compressions for 2 ventilations to 30 compressions for 2 ventilations—are partly attributed to this discovery.

Simplifying the Approach: Finally, CPR is a high-stress situation. In such scenarios, rigorous and simplified training facilitates the execution of critical actions. The appropriate approach to vomiting during CPR should minimize interruptions to chest compressions, ensure a full resuscitation cycle to optimize compression effectiveness, and adopt a standardized approach to limit decision-making in stressful situations.

Recommended Procedure: “For these reasons, we believe it is appropriate to recommend the following: in case of vomiting, turn the victim onto their side, perform a finger sweep if needed, return the victim to their back, and restart CPR with chest compressions, beginning a new cycle regardless of the number of compressions performed before the vomiting occurred. Note that we consider it unnecessary to test candidates on whether to proceed with compressions or ventilations after managing a vomiting situation, as both approaches could be acceptable if the principles outlined above are respected.”

This position aims to provide instructors with a reference for teaching purposes.

We believe that other aspects of high-quality CPR are far more critical to assess, such as the rapid recognition of cardiac arrest, the speed and depth of compressions, and the swift identification of complications during resuscitation.

(Published: January 2023)