Two-Rescuer Adult CPR With a Reluctant Ventilator
You and a colleague are doing two-rescuer CPR on a 70-year-old woman in cardiac arrest in an office hallway. You have a bag-mask device but no oropharyngeal airway. Your colleague has never used a bag-mask and is squeezing it too fast and too hard, and you can hear air escaping around the mask. After 4 minutes of cycles, your compressions are noticeably shallower and your rate has crept up. The patient has dentures that are loose, and there is vomit in her mouth from the last cycle.
1. Prioritize the problems you observed and state the correct adult two-rescuer compression-to-ventilation ratio and the quality targets you are missing.
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Priorities, in order of immediate harm:
- Airway/ventilation failure - audible leak means the mask seal is inadequate; over-fast, over-hard squeezes risk gastric inflation and regurgitation (already occurred). Correct technique: head-tilt/chin-lift, firm mask seal with two hands (E-C clamp), squeeze over ~1 second just enough for visible chest rise, 2 breaths per cycle, avoiding excessive volume.
- Compression quality - rate has drifted above target and depth is falling. Targets: 100–120/min, at least 5 cm (2 in) deep, full chest recoil, minimal interruptions (<10 s), and 30:2 for two-rescuer adult (the same 30:2 as single-rescuer for adults without an advanced airway).
- Swap compressors about every 2 minutes (or sooner if quality falls) - your fatigue is the direct cause of the shallow compressions, so the fix is a role switch, not 'trying harder.' Judgment point: you do not abandon compressions to coach at length - you correct the seal with brief, specific cues and switch roles at the next cycle boundary.
2. Address the loose dentures and the vomit. What do you do, and what do you NOT do?
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Vomit: suction or clear it - turn the head, use finger sweeps only for visible solid material, and if no suction device is available, log-roll briefly or wipe with a cloth, then resume. Vomit in the airway defeats every ventilation you attempt and raises aspiration risk. Do not perform blind finger sweeps. Loose dentures: leave well-fitting dentures in place - they help maintain facial contours and improve the mask seal. Remove only dentures that are loose enough to obstruct the airway or fall into it. Here they are described as loose, so if they are dislodging into the airway, remove them; otherwise leave them. Judgment point: the reflex 'take the dentures out' is wrong when they fit, and blind sweeping for vomit is wrong in all cases. After any airway event, resume compressions promptly - airway cleanup should cost seconds, not a prolonged pause.
3. A third rescuer arrives with an AED and an oropharyngeal airway. How does your technique change, and how do you integrate the OPA?
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With three rescuers you can run continuous compressions with asynchronous ventilation once an advanced airway is in place - but an OPA is not an advanced airway. Until a supraglottic device or endotracheal tube is placed, you keep the 30:2 ratio. The OPA improves ventilation by holding the tongue off the posterior pharynx; size it corner-of-mouth to angle of jaw, insert with the tip toward the palate and rotate, or use a tongue blade. Confirm it is not too long (which can push the epiglottis down and obstruct). AED integration: apply pads, pause compressions only for analysis/shock, resume immediately after the shock, and keep total peri-shock pause under ~10 seconds. Assign clear roles: compressor, ventilator, AED/monitor - and rotate the compressor at each 2-minute rhythm check. Judgment point: an OPA does not license dropping to continuous compressions; that change requires an advanced airway.