The xiphoid process is a bone shaped somewhat like an arrowhead. It is
located at the bottom of the sternum. Force is never applied directly to the
(5) Place the heel of your other hand so that the thumb side is next to your
index finger (figure 4-2C). The heel is now over the lower half of the sternum and
covers the compression site. Having the long axis of the heel of your hand placed along
the long axis of the sternum keeps the main line of the force of compression on the
sternum only rather than on the sternum and the ribs together. This decreases the
chance of fracturing a rib during chest compressions. This hand position also ensures
that the heel of the hand is not over the xiphoid process. A fractured rib or a xiphoid
process that has broken free of the sternum can result in damage to the heart, lungs,
and/or major blood vessels. It is common, even with proper CPR, to fracture a rib or
ribs in the process of good resuscitation. The 2005 AHA guidelines state that it is
extremely important to ensure proper force and depth of compressions and that this
outweighs the risk associated with fracturing ribs.
e. Position Hands for Compression. Lift your hand that is closest to the
casualty's feet (the one you ran along the bottom of the casualty's rib cage) and place
the heel of that hand on top of the hand that is on the compression site. The long axis
of both heels should be parallel with the long axis of the sternum with the fingers of both
hands pointing away from you. Either extend the fingers of both hands so that the
fingers are straight or interlace your fingers. (Figure 4-3 shows the fingers interlaced.)
Keep your fingers and palms off the casualty's chest.
f. Position Your Body to Deliver Compressions. To be efficient and effective
(the best heart compression for the least amount of energy expended), the thrust must
be straight down. If the thrust is not straight down, the casualty's body will tend to roll.
Such a rolling motion will decrease the force of the compression, lead to early fatigue on
your part, and could cause fractured ribs or a fractured xiphoid process.
(1) Lock elbows. Straighten your arms and lock your elbows. If your
elbows are not locked, your arms will bend somewhat when you deliver the
compression and your compression will not be as effective.
(2) Position shoulders over hands. Move your shoulders so that they are
directly over your hands and directly above the casualty's sternum. You will probably be
at a point of imbalance when you assume this position. That is, you will feel that you
would fall forward if you were not being supported by your hands on the casualty's
chest. This imbalance actually helps in performing external chest compressions since
your weight is added to the force of the compressions.