Correct Hand Placement for Chest Compressions During CPR
Place the heel of one hand on the center (middle) of the victim's chest, which is the lower half of the sternum, and place the heel of the other hand on top of the first so that the hands are overlapped and parallel. 1
Precise Hand Positioning Technique
Primary Landmark
- The compression point should be on the lower half of the sternum (the breastbone), which corresponds to the center of the chest 1
- This location is anatomically positioned over the left ventricle, which is typically located inferior to the internipple line 1
Step-by-Step Hand Placement Method
- Kneel beside the victim's chest (out-of-hospital) or stand beside the bed (in-hospital) 1
- Locate the lower half of the sternum by running the index and middle fingers of one hand up the lower margin of the ribcage to find the notch where the ribs join 1
- Place the middle finger into this notch and the index finger onto the sternum above 1
- Slide the heel of the second hand down the sternum until it reaches the index finger—the heel will then be in the middle of the lower half of the sternum 1
- Place the heel of the first hand on top of the second hand with fingers interlocked and parallel 1
Critical Positioning Considerations
Surface and Patient Position
- Perform CPR on a firm surface whenever feasible to maximize compression effectiveness 1
- Place the victim in the supine position (lying flat on their back) when possible 1
- If using a hospital bed, consider deflating air-filled mattresses, as soft surfaces reduce compression effectiveness 1
Hand Mechanics and Force Distribution
- The hypothenar (ulnar) part of the heel of the hand exerts significantly higher force compared to the thenar (thumb) part during compressions 2
- The total breadth of the heel in contact with the sternum is approximately 9.2 cm 2
- Use the right hand in direct contact with the sternum if kneeling on the right side of the patient, and vice versa, to reduce the risk of sternal fractures from compressions applied too far cephalad 2
Anatomical Rationale and Evidence Nuances
Why the Lower Half of the Sternum?
- Radiographic studies demonstrate that the left ventricle is typically located inferior to the internipple line, corresponding with the lower half of the sternum 1
- A 2020 systematic review found better physiological parameters (peak arterial pressure, mean arterial pressure, end-tidal CO2) when compression was performed over the lower third of the sternum compared with the middle 1
- CT scan analysis in adults who were successfully resuscitated showed the widest left ventricular area was most frequently observed at the sternoxiphoid junction (78% of cases), suggesting compression at this lower location might be more effective 3
Important Caveat About Xiphoid Process
- While evidence suggests more caudal (lower) compression may be more effective, hand placement inferior to the internipple line may result in compression over the xiphoid process, which can cause injury 1
- The current guideline recommendation of the "lower half of the sternum" represents a balance between maximizing ventricular compression and minimizing risk of xiphoid injury 1
Common Pitfalls to Avoid
- Do not compress too high on the sternum (at or above the internipple line), as this misses the left ventricle and reduces hemodynamic effectiveness 1, 3
- Do not compress directly over the xiphoid process, as this can cause abdominal organ injury 1
- Do not place fingers on the ribs during compression—only the heel of the hand should contact the chest to avoid rib fractures 1
- Do not allow hands to separate or become unparallel during compressions, as this reduces force transmission 1
Integration with Other CPR Quality Metrics
Hand placement is only one component of high-quality CPR. Once properly positioned: