When performing CPR or first aid, several special circumstances change how a rescuer should respond. Standard protocols work for most cardiac arrest situations, but factors like drowning, pregnancy, hypothermia, suspected spinal injury, opioid overdose, and the victim’s age or body type all require specific adjustments. Knowing these differences can directly affect whether a victim survives.
Drowning: Rescue Breaths Are Essential
Standard CPR guidance for bystanders often emphasizes hands-only CPR (chest compressions without mouth-to-mouth breathing). Drowning is a major exception. The American Heart Association specifically recommends that all drowning victims in cardiac arrest receive CPR with both rescue breaths and chest compressions after being removed from the water.
The reason is straightforward: drowning causes cardiac arrest because the body runs out of oxygen, not because the heart malfunctions on its own. Multiple large studies show that more drowning victims survive when CPR includes rescue breaths compared to chest compressions alone. If you’re untrained or unable to give breaths, compressions alone are still better than doing nothing, but breaths significantly improve the odds.
Pregnancy: Shifting the Uterus
When a pregnant person goes into cardiac arrest, the weight of the uterus can compress major blood vessels and reduce blood flow back to the heart, making standard chest compressions less effective. The key adjustment is called left lateral uterine displacement. If the top of the uterus reaches or rises above the belly button (typically around 20 weeks of pregnancy), a second rescuer should manually push the uterus to the left side while compressions continue. This shifts the weight off the large vein that returns blood to the heart, giving compressions a better chance of circulating blood.
Chest compressions themselves are performed in the same location as for any adult. The critical difference is having someone maintain that leftward pressure on the abdomen throughout resuscitation.
Suspected Spinal Injury: Protecting the Neck
If there’s any reason to suspect a neck or spinal injury, such as a fall, car crash, or diving accident, a rescuer needs to open the airway without tilting the head back. The standard head-tilt, chin-lift technique can worsen a cervical spine injury.
Instead, use the jaw-thrust maneuver. Place your fingers behind the angles of the jaw on both sides and push the lower jaw forward. This lifts the tongue away from the back of the throat and clears the airway without moving the neck. It takes a bit more effort than a simple head tilt, but it protects the spine while still allowing air to pass. If the jaw thrust alone doesn’t open the airway, a careful head tilt may still be necessary, because an open airway always takes priority over a potential spinal injury.
Hypothermia: Handle Gently, Rewarm First
Severe hypothermia makes the heart extremely irritable. Research going back decades has shown that rough or sudden movement of a hypothermic victim can trigger fatal heart rhythms like ventricular fibrillation. This means a rescuer should move the person as gently as possible, keeping them horizontal and avoiding jerky motions.
Checking for a pulse in a hypothermic person takes longer than usual because the heart rate may be extremely slow and faint. Experts recommend taking up to 60 seconds to check for signs of life before starting compressions. The body’s reduced temperature also slows metabolism dramatically, which can actually protect the brain. People have survived prolonged cardiac arrest in cold water with good neurological outcomes, so resuscitation efforts should continue until the victim can be rewarmed by medical professionals. The general principle: a hypothermic person isn’t dead until they’re warm and dead.
Opioid Overdose: Naloxone Plus CPR
If someone collapses and you suspect an opioid overdose (look for tiny “pinpoint” pupils, slow or absent breathing, and nearby drug paraphernalia), the current guidelines call for administering naloxone if it’s available. Naloxone is a nasal spray or injection that reverses opioid effects, and it’s increasingly carried by first responders and available over the counter in pharmacies.
If the person still has a pulse but is breathing abnormally, give naloxone and support their breathing. If there’s no pulse and no breathing, start full CPR and give naloxone as well. Naloxone alone isn’t a substitute for CPR when the heart has stopped. Like drowning, opioid overdose causes cardiac arrest through oxygen deprivation, so rescue breaths combined with compressions give the best chance of survival.
Infants and Children: Smaller Bodies, Different Depths
CPR on children and infants requires less force than on adults, but the compressions still need to be deep enough to circulate blood. For children, effective compressions reach a depth of about 2 inches (5 cm), which is roughly one-third the depth of the chest. Research has confirmed that reaching this depth improves rates of return of spontaneous circulation and 24-hour survival in children.
For infants, use two fingers or two thumbs on the lower half of the breastbone rather than the heel of your hand. The compression-to-breath ratio also differs: a single rescuer uses 30 compressions to 2 breaths (same as adults), but two trained rescuers working together on a child or infant switch to 15 compressions to 2 breaths to deliver more oxygen to a smaller body that depends heavily on adequate ventilation.
Choking in Pregnant or Obese Individuals
The standard Heimlich maneuver involves wrapping your arms around the victim’s waist and delivering upward abdominal thrusts. This doesn’t work well if the person is pregnant or if you physically can’t reach around their abdomen. In these cases, switch to chest thrusts. Position your hands at the base of the breastbone, just above where the lowest ribs meet, and press hard into the chest with quick, firm thrusts. The motion is similar to the Heimlich but applied to the chest instead of the abdomen. Repeat until the object is dislodged or the person becomes unresponsive.
Medication Patches and Implanted Devices
Before using an AED (automated external defibrillator), check the victim’s chest for transdermal medication patches, such as nitroglycerin or pain patches. These patches can block the electrical contact between the AED pad and the skin, causing arcing and even burns during a shock. Remove any patches you see and wipe the area clean before placing the AED pads.
If you notice a lump under the skin near the collarbone, that’s likely a pacemaker or implantable defibrillator. Place the AED pad at least 8 centimeters (about 3 inches) away from the device, or use an alternative pad position such as one pad on the front of the chest and one on the back. Placing a pad directly over an implanted device can damage it and reduce the effectiveness of the shock.
Wet Chest or Excessive Hair
Two other common situations affect AED use. If the victim’s chest is wet from sweat, rain, or water rescue, dry it quickly before applying the pads. Water can conduct the electrical shock across the skin’s surface rather than through the heart. Most AED kits include a small towel for this purpose. If the victim has a very hairy chest and the pads won’t stick, press them down firmly and try to get a seal. Some AED kits include a razor for shaving the area if needed. A poor connection will prompt the AED to display a “check pads” warning, which delays treatment.