During cardiac arrest, if the patient vomits, should chest compressions be briefly paused to clear the airway or continued uninterrupted according to the latest AHA guidelines?

Management of Vomiting During CPR

If a patient vomits during CPR, briefly pause compressions only long enough to turn the patient to the side, quickly clear the airway, and immediately resume high-quality chest compressions—minimizing interruptions is critical for survival. 1

Evidence-Based Approach to Airway Management During Vomiting

When Vomiting Occurs

• Turn the patient to the side and remove vomitus using your finger, a cloth, or suction 1
• If spinal cord injury is suspected, the victim should be logrolled so that the head, neck, and torso are turned as a unit to protect the cervical spine 1
• Immediately return to chest compressions once the airway is cleared 1

Critical Principle: Minimize All Interruptions

The 2020 AHA Guidelines emphasize that total pauses in chest compressions should be as short as possible (Class I, LOE C-LD) 1. This applies to all interruptions, including airway management for vomiting:

• All interruptions should be kept under 10 seconds whenever feasible 1
• The target chest compression fraction should be at least 60%, meaning compressions should occupy at least 60% of total resuscitation time 1
• For patients without an advanced airway, it is reasonable to pause compressions for less than 10 seconds to deliver 2 breaths 1

Context: Vomiting is Common During CPR

• In a 10-year Australian study, two-thirds of victims who received rescue breathing vomited, and 86% of those requiring compressions and ventilations vomited 1
• This high incidence makes it essential to have a clear, efficient protocol for managing vomiting without compromising compression quality 1

Practical Algorithm for Managing Vomiting During CPR

1. Recognize vomiting immediately during compressions or ventilations
2. Pause compressions briefly (goal: <10 seconds total)
3. Turn patient to side (logroll if spinal injury suspected) 1
4. Rapidly clear airway using finger sweep, cloth, or suction
5. Return patient to supine position
6. Resume high-quality compressions immediately 1
7. Continue CPR with minimal further interruptions

Key Pitfalls to Avoid

• Do NOT use abdominal thrusts or the Heimlich maneuver for vomiting during CPR—these are unnecessary and potentially dangerous 1
• Do NOT perform prolonged airway clearance that extends interruption time beyond what is absolutely necessary 1
• Do NOT check for pulse or rhythm during the vomiting episode—focus solely on clearing the airway and resuming compressions 1
• Do NOT apply spinal immobilization devices if spinal injury is suspected, as these can worsen airway management; use manual stabilization only 1

Physiological Rationale

• Chest compressions generate critical blood flow to the heart and brain during cardiac arrest 2
• Any interruption in compressions causes immediate cessation of this blood flow 3, 4
• Prolonged pauses (>10 seconds) are associated with decreased survival to hospital discharge 4
• Studies show that preshock pauses exceeding 10 seconds significantly reduce survival, with an OR of 1.86 (95% CI, 1.10-3.15) for every 5-second reduction in pause time 1

Special Considerations

With Advanced Airway in Place

• If an endotracheal tube or supraglottic airway is already placed, vomiting is less likely to compromise the airway 5
• Continue compressions while suctioning around the advanced airway device 5
• Do not remove a properly placed advanced airway unless it becomes completely obstructed 5

Team Coordination

• Designate one team member to manage airway clearance while another maintains readiness to resume compressions 3
• The compressor should not be the person clearing the airway—this allows for immediate resumption of compressions 3
• Aggressive rotation of compressors every 2 minutes prevents fatigue-related decline in compression quality 1