High Quality CPR: Beating Anoxic Brain Injury

Damar Hamlin: A Success Story of High Quality CPR

You don’t have to be a fan of football or the Buffalo Bills to experience the chills associated with Damar Hamilin’s story; I just happen to be a fan of both! Hamlin is a 25 year-old who plays for the Buffalo Bills as a safety. Just moments into a Monday night game on January 2nd 2023, Hamlin collapsed on the field after making a tackle; causing the stadium to fall silent and viewers at home to move to the edge of their seats. The young player went into cardiac arrest and required medical staff on the field to perform high quality CPR to restore his heartbeat. From there, began the road of recovery that would eventually land Hamlin cleared to return to football with no residual complications post cardiac arrest.

How did he defy the odds and escape catastrophe? Well, for that we can thank the trained medical professionals who performed high quality CPR right there on the field. Damar Hamlin’s story will remain one of the most well-known success stories of CPR and serves to remind us all how important CPR is, not only to save a life, but for minimizing the possible deficits after a cardiac arrest event. Without the valiant work done by the Buffalo Bills training staff, things could have gone much differently for Damar Hamilin… Keep Damar in the back of your mind as you continue reading and think about just how lucky he is to not only survive this event, but also to be returning to the football field.

Hallmarks of High Quality CPR

Cardiopulmonary Resuscitation (CPR) should begin within 2 minutes of cardiac arrest for best outcomes. The American Heart Association emphasizes the importance of providing high quality CPR after cardiac arrest and uses these metrics to describe the performance of high quality CPR…

  • 100-120 compressions per minute
  • >80% compression fraction 
  • Compression depth of at least 2in in adults 
  • Avoid excessive ventilation 

Not all heroes wear capes, some carry around a CPR certification card. Sign up for an AHA training class to learn valuable skills and become certified in CPR- remember it not only can it prevent significant lasting physical impairment but it can save a life!!

Anoxic Brain Injury: Role of the Heart

Cardiac arrest occurs when the heart suddenly stops functioning properly and usually results in unconsciousness. This event is typically the hallmark of an electrical disturbance within the heart however, it is NOT the same as a heart attack. Anoxic Brain Injury occurs when brain cells are deprived of oxygen and this causes cell death. Anoxic Brain Injury can occur as a secondary injury in the cascade of events after a cardiac arrest due to disrupted blood flow and oxygenation to the brain. Let’s pump the breaks and take a closer look at why/how this occurs.

Post Cardiac Arrest Brain Injury (PCABI) is caused by inadequate blood flow, or ischemia, to the brain. Reperfusion can cause secondary injury as the body attempts to restore blood flow to the brain.

Early signs of Anoxic Brain Injury include: 

  • Loss of consciousness
  • Nausea or vomiting 
  • Intense headache 
  • Confusion 
  • Seizures 
  • Sensory changes – commonly in the extremities 

Physiological Damage: 

  • Blood carries nutrients to brain tissue and without it, cells begin to malfunction and are at risk for cell death.
  • 1 minute: cells begin to die; 3 minutes: damage to neurons and lasting brain damage; 5+ minutes: coma and death
  • Temporal lobe is amongst the most susceptible to damage due to lack of oxygen and this area is big on memory → the hippocampus which resides in the temporal lobes, is most susceptible

Other Considerations

  • There is such a thing as TOO much oxygen (hyperoxia) and over ventilation that can impair blood flow following a PCABI. Current recommendations for post-resuscitation care hold that pulse ox should maintain within the 94-98% range.
  • Coma: 80% resuscitated from cardiac arrest are comatosed due to PCABI 
  • Seizures: associated with poor outcomes for neurological function post cardiac arrest 

Physical and Cognitive Deficits Post Anoxic Brain Injury

  • Spasticity
  • Motor coordination impairments
  • Hemiplegia
  • Gait/balance deficits
  • Behavioral changes
  • Memory loss
  • Agitation
  • Vision changes
  • Swallowing difficulty/dysphagia 

Rehab Impact

For those who experience an Anoxic Brain Injury, and do not end up in a comatose state, the above deficits as well as others will need to be addressed in a rehab setting by the interdisciplinary team to maximize client outcomes. Let’s talk about how this is going to impact your treatment sessions and the importance of education… 

Memory Impairments

It is likely that if these clients are aware/alert they will have both long and short term memory deficits. These deficits can impact the rehab process all together but luckily there are some strategies clinicians can implement into therapy sessions to address memory impairments:

  • Visual cues: These can involve photos of family members around the client’s room, using color coding or numbering (sticky notes, stickers etc.) on objects that are associated with particular ADLs to help with sequencing, or arrows on the wall to help with functional mobility/navigation within a setting.
  • Repetition: It’s a good idea to start and/or carryout each session similarly so the client can develop expectations for his/her time spent with their team members. For example: starting the session with introducing yourself, your role, and the goals for the day. 
  • Working memory: Developing interventions that target the use of working memory (just right challenge- discussed below) in order to initiate the storage of information into short and long term memory. 

Behavioral Changes

After sustaining any form of brain injury, clients are susceptible to changes in demeanor and personality that can present as “challenging behaviors”. Not only must we as practitioners provide this education to the family but we also must be prepared to navigate these disturbances during our treatment sessions.

  • Redirection: if the client is becoming increasingly agitated it can be helpful to distract them with a new thought but remember to present information slowly and allow time for them to process what you are telling or asking of them to prevent further frustration!
  • Just right challenge: When presenting a task, old or new, it is important that it is challenging enough to be beneficial to their rehab process but not TOO difficult to the point it becomes frustrating. This will likely require clinical judgment and trial and error to determine an appropriate difficulty level.
  • De-escalation: In moments of increased agitation, the rehab team as well as family members must be prepared to diffuse the situation. Some strategies to achieve this include teaching self-regulation techniques like: counting to 10 before responding, diaphragmatic breathing, and using “I” statements for successful communication.

Interdisciplinary Team Approach

Each member of the team brings a unique set of skill sets that will be instrumental to the rehab process. If there is a member of the team that has formed a stronger relationship in terms of communicating effectively, it might be a good idea to include them during times of conflict or uncomfortable conversations. It is also a good idea to meet with the team on a regular basis to discuss progress and what deficits remain in order to determine a plan of action to address them. 


We must remember that both the client and their families require education when navigating the rehab process post PCABI.

  • We can suggest additional resources such as peer support groups (for both caregivers & the client) to help both parties feel supported and make connections with individuals experiencing similar challenges.
  • Family meetings are necessary in the early stages of the rehab process to bring awareness to the possible changes not only in temperament but in physical & cognitive function to allow families/friends/caregivers to be aware of what they might expect during the rehab process. 
  • Counseling techniques such as motivational interviewing to grant autonomy, their values, and create a sense of teamwork. Other techniques such as cognitive behavioral therapy are used to change negative thought processes and exchange them for positive thoughts. Check out this great source that explains how to implement these techniques and others into your day-to-day sessions!

Educational Opportunity

The link between Anoxic Brain Injury and cardiac arrest is not always recognized by clinicians, clients, or their families. Increasing education for all parties involved will serve as a stepping stone to positive client outcomes and an overall better rehab process. Another IMPORTANT way to address this is for clinicians to remain up-to-date on brain injury – check out ARC’s CBIS course here to increase your knowledge base and skill sets as a clinician to feel empowered when treating those with brain injury.

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