Part 5: Adult Basic Life Support : 2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Robert A. Berg, Robin Hemphill, Benjamin S. Abella, Tom P. Aufderheide, Diana M. Cave,
Mary Fran Hazinski, E. Brooke Lerner, Thomas D. Rea, Michael R. Sayre and Robert A. Swor

Circulation. 2010;122:S685-S705
doi: 10.1161/CIRCULATIONAHA.110.970939
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Copyright © 2010 American Heart Association, Inc. All rights reserved.
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Part 5: Adult Basic Life Support
2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
Robert A. Berg, Chair; Robin Hemphill; Benjamin S. Abella; Tom P. Aufderheide; Diana M. Cave;
Mary Fran Hazinski; E. Brooke Lerner; Thomas D. Rea; Michael R. Sayre; Robert A. Swor

B asic life support (BLS) is the foundation for saving lives
following cardiac arrest. Fundamental aspects of BLS
include immediate recognition of sudden cardiac arrest
SCA has many etiologies (ie, cardiac or noncardiac causes),
circumstances (eg, witnessed or unwitnessed), and settings
(eg, out-of-hospital or in-hospital). This heterogeneity sug-
(SCA) and activation of the emergency response system, gests that a single approach to resuscitation is not practical,
early cardiopulmonary resuscitation (CPR), and rapid de- but a core set of actions provides a universal strategy for
fibrillation with an automated external defibrillator (AED). achieving successful resuscitation. These actions are termed
Initial recognition and response to heart attack and stroke are the links in the “Chain of Survival.” For adults they include
also considered part of BLS. This section presents the 2010
● Immediate recognition of cardiac arrest and activation of
adult BLS guidelines for lay rescuers and healthcare provid-
ers. Key changes and continued points of emphasis from the the emergency response system
● Early CPR that emphasizes chest compressions
2005 BLS Guidelines include the following:
● Rapid defibrillation if indicated
● Immediate recognition of SCA based on assessing unre- ● Effective advanced life support
sponsiveness and absence of normal breathing (ie, the ● Integrated post– cardiac arrest care
victim is not breathing or only gasping)
● “Look, Listen, and Feel” removed from the BLS algorithm When these links are implemented in an effective way,
● Encouraging Hands-Only (chest compression only) CPR survival rates can approach 50% following witnessed out-of-
(ie, continuous chest compression over the middle of the hospital ventricular fibrillation (VF) arrest.2 Unfortunately
chest) for the untrained lay-rescuer survival rates in many out-of-hospital and in-hospital settings
● Sequence change to chest compressions before rescue fall far short of this figure. For example, survival rates
breaths (CAB rather than ABC) following cardiac arrest due to VF vary from approximately
● Health care providers continue effective chest compres- 5% to 50% in both out-of-hospital and in-hospital settings.3,4
sions/CPR until return of spontaneous circulation (ROSC) This variation in outcome underscores the opportunity for
or termination of resuscitative efforts improvement in many settings.
● Increased focus on methods to ensure that high-quality Recognition of cardiac arrest is not always straightforward,
CPR (compressions of adequate rate and depth, allowing especially for laypersons. Any confusion on the part of a rescuer
full chest recoil between compressions, minimizing inter- can result in a delay or failure to activate the emergency response
ruptions in chest compressions and avoiding excessive system or to start CPR. Precious time is lost if bystanders are too
ventilation) is performed confused to act. Therefore, these adult BLS Guidelines focus on
● Continued de-emphasis on pulse check for health care recognition of cardiac arrest with an appropriate set of rescuer
providers actions. Once the lay bystander recognizes that the victim is
● A simplified adult BLS algorithm is introduced with the unresponsive, that bystander must immediately activate (or send
revised traditional algorithm someone to activate) the emergency response system. Once the
● Recommendation of a simultaneous, choreographed ap- healthcare provider recognizes that the victim is unresponsive
proach for chest compressions, airway management, rescue with no breathing or no normal breathing (ie, only gasping) the
breathing, rhythm detection, and shocks (if appropriate) by healthcare provider will activate the emergency response sys-
an integrated team of highly-trained rescuers in appropriate tem. After activation, rescuers should immediately begin CPR.
settings Early CPR can improve the likelihood of survival, and yet
CPR is often not provided until the arrival of professional
Despite important advances in prevention, SCA continues emergency responders.5 Chest compressions are an especially
to be a leading cause of death in many parts of the world.1 critical component of CPR because perfusion during CPR

The American Heart Association requests that this document be cited as follows: Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM,
Hazinski MF, Lerner EB, Rea TD, Sayre MR, Swor RA. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S685–S705.
(Circulation. 2010;122[suppl ]:S685–S705.)
© 2010 American Heart Association, Inc.
Circulation is available at DOI: 10.1161/CIRCULATIONAHA.110.970939

Downloaded from
S685 by guest on May 1, 2013

bystanders often misinterpret agonal gasps or rescuer should check for a response by tapping the victim on abnormal breathing as normal breathing. and a third either provides ventilations or retrieves EMS response. Thus. This Dispatchers should include rescue breathing in their tele- section updates the adult BLS guidelines with the goal of phone CPR instructions to bystanders treating adult and incorporating new scientific information while acknowledg. the last section focuses on the However.30 gardless of training or experience. The “Special the steps of BLS in a logical and concise manner that is easy Resuscitation Situations” section addresses acute coronary for all types of rescuers to learn. drowning). 2010 depends on these compressions.26.19. no move- telephone CPR instructions (Class I. The “Adult BLS Skills” section provides greater and by guest on May 1. adult BLS sequence. pediatric victims with a high likelihood of an asphyxial cause ing the challenges of real-world application.14 Bystanders (lay responders) should immedi. all dispatchers should be appropriately trained to provide If a lone rescuer finds an unresponsive adult (ie.ahajournals. This erroneous the shoulder and shouting at the victim.31–33 BLS skills. stroke. High-quality CPR quality of breathing (normal versus not normal). Defibrillation and advanced care should be breathing in order to improve recognition of gasping and interfaced in a way that minimizes any interruption in CPR.9 –12 One of these strategies is the use of the patient is conscious and breathing normally in order to an AED. including lifesaving rescuer. dispatchers phrase “push hard and push fast” emphasizes some of these should inquire about a victim’s absence of consciousness and critical components of chest compression. and foreign body airway These actions have traditionally been presented as a sequence obstruction.8. lives. ensuring the quality of CPR.13 Because it is easier for rescuers receiving telephone CPR Immediate recognition and activation. the is present.15–21 ment or response to stimulation) or witnesses an adult who When dispatchers ask bystanders to determine if breathing suddenly collapses. the bag-mask for rescue breathing. after ensuring that the scene is safe. Therefore. Everyone. nontraditional first responders. early CPR. can potentially be a The EMS system quality improvement process. Dispatchers is important not only at the onset but throughout the course of should be specifically educated in recognition of abnormal resuscitation. the dis- police. The trained or Downloaded from http://circ. enabling identify patients with possible cardiac arrest. and instructions to perform Hands-Only (compression-only) CPR rapid defibrillation (when appropriate) are the first three than conventional CPR (compressions plus rescue breathing). The AED correctly assesses heart rhythm. and the quality of BLS.S686 Circulation November 2. re. Because of increasing interest in monitoring and of distinct steps to help a single rescuer prioritize actions. use of an AED. Immediate Recognition and Activation of the stander CPR performance and improve survival from cardiac Emergency Response System arrest. LOE B). resuscitations involve teams of providers who should perform several actions simultaneously (eg. BLS care in the dispatchers should instruct untrained lay rescuers to provide out-of-hospital setting is often provided by laypersons who Hands-Only CPR for adults with SCA (Class I.22–26 starting CPR in the adult victim of sudden cardiac arrest. of serious injury from chest compressions in the nonarrest lation may be achieved by a variety of strategies that include group is very low (Class I. The intent of the algorithm is to present about Hands-Only (compression-only) CPR.8 Efforts to reduce the manifestation of cardiac arrest. Notably. information can result in failure by 911 dispatchers to instruct sions should be the highest priority and the initial action when bystanders to initiate CPR for a victim of cardiac arrest. The To help bystanders recognize cardiac arrest. skills to real-world circumstances presents a challenge.6 cardiac arrest (Class I. ommend CPR for unresponsive victims who are not breathing prove survival in both out-of-hospital and in-hospital settings.7. LOE B). LOE B). one rescuer activates the Activating the Emergency Response System emergency response system while another begins chest com- Emergency medical dispatch is an integral component of the pressions. 2013 .9 normally because most are in cardiac arrest and the frequency Depending on the setting and circumstances.27 Dispatchers should rec- interval from collapse to defibrillation can potentially im. review of the quality of dispatcher CPR instructions provided The rest of this chapter is organized in sections that address to specific callers. LOE B).28 In summary. and patcher should ask straightforward questions about whether hospital professionals. hypothermia. dispatchers should Rapid defibrillation is a powerful predictor of successful be aware that brief generalized seizures may be the first resuscitation following VF SCA. chest compres. remember and perform.29 may be involved in a resuscitation attempt only once in their While Hands-Only CPR instructions have broad applicability. emergency medical services (EMS) professionals. of SCA. The dispatcher a rescuer who is not trained in heart rhythm interpretation to should also provide CPR instructions to help bystanders accurately provide a potentially lifesaving shock to a victim initiate CPR when cardiac arrest is suspected. anytime they find an unresponsive victim. many workplaces and most EMS and in-hospital quality of BLS. BLS links in the adult Chain of Survival. The “Adult BLS Sequence” section Adult BLS Sequence provides an overview and an abridged version of the BLS The steps of BLS consist of a series of sequential assessments sequence. of arrest (eg. LOE B). syndromes. adult high-quality lifesaving program (Class IIa. and a fourth retrieves and ately call their local emergency number to initiate a response sets up a defibrillator). Because dispatcher CPR instructions substantially increase the likelihood of by. earlier defibril. in addition rescuers who are laypersons. to activating professional emergency responders. special resuscitation situations. which are illustrated in the new simplified BLS detail regarding individual CPR skills and more information algorithm (Figure 1). creating an effective strategy to translate BLS instances remain when rescue breaths are critically important. is considered an important component of a the emergency response system.

24. call that providers have difficulty detecting a pulse. The healthcare provider can check for response and seconds to check for a pulse and.38. the rescuer should assume the victim is in cardiac arrest (Class I. also be prepared to follow the dispatcher’s instructions.19. rescuer through the check for breathing and the steps of CPR. or if in Studies have shown that both lay rescuers and healthcare an institution with an emergency response system. LOE C). These incident.45. If rescuers pressure and directly compressing the heart. the events of the incident. For this reason all patients in Downloaded from http://circ. Simplified adult BLS algorithm.41 absent or abnormal breathing (ie. they should blood flow and oxygen delivery to the myocardium and brain. and the type of aid by guest on May 1. call 911. Berg et al Part 5: Adult Basic Life Support S687 Figure 1. blood flow during CPR.46 gency response system.35– 44 Healthcare facility’s emergency response number). If the victim also has providers also may take too long to check for a pulse. all rescuers should immediately begin CPR Early CPR (see steps below) for adult victims who are unresponsive with no breathing or no normal breathing (only gasping). Chest Compressions When phoning 911 for help.34 The lay rescuer should phone the emergency assume that cardiac arrest is present if an adult suddenly response system once the rescuer finds that the victim is collapses or an unresponsive victim is not breathing unresponsive—the dispatcher should be able to guide the lay normally. ● The healthcare provider should take no more than 10 if needed. untrained bystander should—at a minimum—activate the Pulse Check community emergency response system (eg. Finally the rescuer making the phone call should hang up ● Effective chest compressions are essential for providing only when instructed to do so by the dispatcher. After activation of the emergency response system. only definitely feel a pulse within that time period. if the rescuer does not look for no breathing or no normal breathing (ie. the number and condition compressions create blood flow by increasing intrathoracic of the victim(s).ahajournals. the rescuer should be prepared Chest compressions consist of forceful rhythmic applications to answer the dispatcher’s questions about the location of the of pressure over the lower half of the sternum. the rescuer gasping) almost simultaneously before activating the emer- should start chest compressions (Class IIa. only gasping). 2013 . This generates never learned or have forgotten how to do CPR. ● The lay rescuer should not check for a pulse and should LOE C).

It is reasonable for laypersons and healthcare that should be performed by 3 prototypical rescuers after they providers to compress the adult chest at a rate of at least activate the emergency response system. CPR and AED use) are deter- LOE B). While no published human or animal evidence demon. chest compressions should be minimized of the victim (Class I.” or follow the directions of number of compressions delivered per minute (Class IIa. to allow the heart to fill Untrained Lay Rescuer completely before the next compression (Class IIa. Optimally all healthcare providers should be trained in BLS. it is clear that blood should add rescue breaths in a ratio of 30 compressions to 2 flow depends on chest compressions. (Class IIb. then the bystander should ● Rescuers should attempt to minimize the frequency and provide Hands-Only (chest compression only) CPR. ● Give a sufficient tidal volume to produce visible chest rise or ventilating with. It is reasonable for healthcare providers to tailor the sequence pressions to 2 ventilations. an advanced airway. This should be performed in cycles of 30 compres- Once chest compressions have been started. he or she ventilations leads to improved outcomes. 2013 . conventional compression depth of at least 2 inches/5 cm (Class IIa. with an duration of interruptions in compressions to maximize the emphasis on “push hard and fast. achieving a seal for mouth-to-mouth rescue breath.52–54 LOE B).org/ by guest on May 1. chest after each compression.47–51 All Together ● To provide effective chest compressions. The sequence of BLS skills for the healthcare provider is Defibrillation Sequence depicted in the BLS Healthcare Provider Algorithm (see Figure 2). A compression-ventilation ratio of 30:2 is recommended tinue Hands-Only CPR until an AED arrives and is ready for (Class IIa. the healthcare provider may give about 5 cycles begin chest compressions while a second rescuer activates the (approximately 2 minutes) of CPR before activating the emer- emergency response system and gets the AED (or a manual gency response system (Class IIa. In addition. the provider may assume that the victim has suffered a After activating the emergency response system the lone sudden cardiac arrest and call for help (phone 911 or the rescuer should next retrieve an AED (if nearby and easily emergency response number). Recognition of Arrest (Box 1) ● Resume chest compressions immediately after the shock The necessary first step in the treatment of cardiac arrest is (minimize interruptions). Moreover. delays in. LOE the emergency medical dispatcher. defibrillator in most hospitals) (Class IIa. LOE B).55 sive ventilation should be avoided. ● Use a compression to ventilation ratio of 30 chest com. Bystanders may witness the sudden Downloaded from http://circ.ahajournals. Beginning CPR with 30 compressions rather than in-hospital professional rescuers to provide chest compres- 2 ventilations leads to a shorter delay to first compression sions and rescue breaths for cardiac arrest victims (Class IIa. at a minimum. Therefore. chest compres- sions can be started almost immediately. push hard and This section summarizes the sequence of CPR interventions push fast.S688 Circulation November 2. CPR. as follows: of 1 breath every 6 to 8 seconds (8 to 10 ventilations per minute) should be performed. rescuer should deliver rescue breaths by mouth-to-mouth or then continuous chest compressions with ventilations at a rate bag-mask to provide oxygenation and ventilation. get an AED (if nearby). ● Turn the AED on. one rescuer should or a victim of foreign body airway obstruction who becomes unconscious. throughout the entire resuscitation. In addition. Rescue Breaths A change in the 2010 AHA Guidelines for CPR and ECC is Trained Lay Rescuer to recommend the initiation of compressions before ventila. pressions for victims of cardiac arrest. If a bystander is not trained in CPR. CPR with rescue breathing. immediate recognition. exces- (Class IIa. if a lone healthcare provider sees an adolescent suddenly Early Defibrillation With an AED collapse. The rescuer should continue CPR until an AED arrives and is ready for use or EMS providers take over care and interruptions of. All lay rescuers should. LOE C). LOE B). of rescue actions to the most likely cause of arrest. 2010 cardiac arrest should receive chest compressions (Class I. For example. minimize interruptions in chest compressions when placing. and accessible) and then return to the victim to attach and use the return to the victim to attach and use the AED and then provide AED. Rescuers should allow complete recoil of the mined by the rescuer’s level of training. a trained sions to 2 ventilations until an advanced airway is placed. The rescuer should con- B). LOE C). LOE B). Rescuer Specific CPR Strategies: Putting It LOE B). ● Follow the AED prompts. Care should be taken to ● Deliver each rescue breath over 1 second (Class IIa. provide chest com- tions. and getting a bag-mask apparatus for rescue breathing all In this trained population it is reasonable for both EMS and take time. use or healthcare providers take over care of the victim (Class IIa. if the strates that starting CPR with 30 compressions rather than 2 trained lay rescuer is able to perform rescue breaths. breaths. ing. LOE C). If a lone healthcare provider aids an adult drowning victim When 2 or more rescuers are present. LOE B). while positioning Healthcare Provider the head. LOE C). LOE B) with a that rescuers should take (Hands-Only CPR. The specific steps 100 compressions per minute (Class IIa. LOE C). The rescuer should then provide high-quality CPR. The AED should be used as rapidly as possible and both rescuers should Adult BLS Skills provide CPR with chest compressions and ventilations.

tap the victim on the LOE B). Professional as well as lay or absent. only gasping). Healthcare providers may take too long to check for a These 2010 AHA Guidelines for CPR and ECC deempha- pulse38. place “just in time” training such as that given through a dispatch the victim on a firm surface when possible. Occasional gasps do not necessarily result in rescuer should start chest compressions (Class IIa. collapse of a victim or find someone who appears lifeless. 2013 . BLS healthcare provider algorithm. or moan. both formal classroom training and To maximize the effectiveness of chest compressions. should emphasize how to recognize occasional gasps that time several steps should be by guest on May 1. the healthcare provider should take no victim has occasional gasps.24. the rescuer should arrest is present and should begin CPR if an adult suddenly assume the victim is in cardiac arrest and immediately activate collapses or an unresponsive victim is not breathing or not the emergency response system (Class I. however. Technique: Chest Compressions (Box 4) LOE C). if the health.41 and have difficulty determining if a pulse is present size checking for breathing. To do this.35– 44 should also check for no breathing or no normal breathing (ie. shoulder and shout.41. the lay rescuer should activate cardiac arrest. CPR training. and should instruct rescuers to provide CPR even when the ing a victim. move. The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class I. or movement is superior for detec- or absence of adequate or normal breathing in unresponsive tion of circulation. rescuers several years ago. and is deemphasized in training for care provider finds the victim is unresponsive with no breathing healthcare providers. LOE C19.58 Because delays in chest compressions victims35. in a supine Downloaded from http://circ. If the deemphasize the pulse check as a mechanism to identify victim remains unresponsive. then check for response. which can occur in the first more than 10 seconds to check for a pulse.46).38.34). adequate ventilation. that checking rescuers may be unable to accurately determine the presence for breathing. For this reason pulse check was deleted from training for lay only gasping) while checking for responsiveness.45 There is no evidence. “Are you all right?” If the victim is These 2010 AHA Guidelines for CPR and ECC also responsive he or she will answer. coughing. breathing normally (ie.ahajournals. only gasping). Studies have shown that both laypersons and the emergency response system. and if the rescuer minutes after SCA and may be confused with adequate does not definitely feel a pulse within that time period the breathing.56 because the airway is not open57 or because the should be minimized. Berg et al Part 5: Adult Basic Life Support S689 Figure 2. The health care provider healthcare providers have difficulty detecting a pulse. the rescuer must ensure that the scene is safe and unresponsive victim demonstrates occasional gasps (Class I. Before approach. The lay rescuer should assume that cardiac or no normal breathing (ie. LOE C45. At center.

98 or by EMS providers using a higher blood flow. ing the effectiveness of these interventions in “the real Correct performance of chest compressions requires sev.103 eral essential skills.6.87–90 a duty cycle of 50% is recommended because insufficient evidence for or against the use of backboards it is easy to achieve with practice (Class IIb. Extrapolation of data from an out-of-hospital obser. any intervention associated with appropriate interruptions in vational study6 showed improved survival to hospital dis. in. circulation (ROSC) can compromise vital organ perfu- The term “duty cycle” refers to the time spent compressing sion.95 suggests that lim- The rescuer should place the heel of one hand on the center iting the frequency and duration of interruptions in chest (middle) of the victim’s chest (which is the lower half of the compressions may improve clinically meaningful outcomes sternum) and the heel of the other hand on top of the first so that in cardiac arrest patients.80 Manikin studies suggest that lifting some point during the EMS resuscitation. world.96 Notably. coronary perfusion is associated with a duty cycle of ⬎50%) hospital). mattresses should be deflated when performing CPR.65 The preponderance of efficacy data94. in each of incidence of incomplete chest wall recoil can be reduced these studies.77. The adult sternum should be depressed at it is reasonable for rescuers to minimize interruption of chest least 2 inches (5 cm) (Class IIa. the compression-to-ventilation ratio (50:2).81 Incomplete ized studies suggesting that survival from out-of-hospital recoil during BLS CPR is associated with higher intrathoracic cardiac arrest may be improved by the initial EMS provider pressures and significantly decreased hemodynamics.78 – 80 incomplete chest wall recoil was common. LOE C75).84 The number of chest compressions delivered per 2 or more rescuers are available it is reasonable to switch minute is an important determinant of return of spontaneous chest compressors approximately every 2 minutes (or after circulation (ROSC) and neurologically intact survival. myocardial assisted ventilations. analyzing rhythm.75). the airway was opened. and assisted ventilation was recommended at vide real-time feedback. In shock is delivered (Class IIa. human studies of CPR in out-of-hospital81 and in-hospital Additional evidence of the importance of minimizing settings. with chest compressions for checking the pulse. averaging in CPR.2.104 –106 Significant fatigue and shallow compressions compressions and the number and duration of interruptions to are common after 1 minute of CPR.83.99 At this time there is without interruption.94 –99 Accordingly lay rescuers should not interrupt the chest as a proportion of the time between the start of 1 chest compressions to palpate pulses or check for ROSC cycle of compression and the start of the next. The compression rate refers to the speed insufficient evidence to support the removal of ventilations of compressions. LOE C74. The actual number of chest compres. It is therefore reasonable for lay rescuers and “working compressor” every 2 minutes. interruptions in chest compressions comes from nonrandom- particularly when rescuers were fatigued. to minimize interruptions interruptions of chest compressions were common. taneous pulse or to otherwise check for return of spontaneous LOE B). includ- delivery of continuous chest compressions without initial ing decreased coronary perfusion. oxygen insufflations during CPR by using electronic recording devices that pro- were provided.86 Although duty cycles ranging between 20% mattress displacement rather than chest compression. LOE B76 – 80).61 Air-filled 24% to 57%85. 2013 . off the chest can have noted significant improvement in survival from out-of- improve chest recoil.78. LOE B). delivered per minute. out-of-hospital) or standing beside the bed (eg. not the actual number of compressions from CPR provided by EMS professionals. Coronary (Class IIa.85 about 5 cycles of compressions and ventilations at a ratio of One study of in-hospital cardiac arrest patients85 showed that 30:2) to prevent decreases in the quality of compressions delivery of ⬎80 compressions/min was associated with (Class IIa.81 hospital arrest with use of compressions-plus-ventilations The total number of chest compressions delivered to the with emphases on improved quality of compressions and victim is a function of the chest compression rate and the proportion of time that chest compressions are delivered minimization of hands-off time.59 Because hospital beds are typically not firm and and partly by how fully the chest is relaxed at the end of each some of the force intended to compress the chest results in compression. although rescuers may open the airway.105 When analysis.82 Importantly. LOE B70 –73). and to avoid line/tube displacement. particularly in the period immediately before and after a recoil after each compression (Class IIa.ahajournals. the study also demonstrated that improved seconds. or compression and chest recoil/relaxation times approximately performing other activities throughout the entire resuscita- equal (Class IIb. cardiac by guest on May 1. 1 rescuer will be ready and waiting to relieve the 120/min. Rescuer fatigue may lead to inadequate compression rates sions delivered per minute is determined by the rate of chest or depth. care should be taken In 2005 3 human observational studies91–93 showed that to avoid delays in initiation of CPR. we have and 50% can result in adequate coronary and cerebral traditionally recommended the use of a backboard despite perfusion.64.97.2.”2. 2010 position with the rescuer kneeling beside the victim’s chest blood flow is determined partly by the duty cycle (reduced (eg. during CPR. charge when at least 68 to 89 chest compressions per minute Every effort should be made to accomplish this switch in ⬍5 were delivered. Consider switching compressors during ROSC.91–93 of the total arrest time.60 – 63 If a backboard is used. healthcare providers to perform chest compressions for adults Interruptions of chest compressions to palpate for a spon- at a rate of at least 100 compressions per minute (Class IIa. deliver rescue breaths. Other EMS systems the heel of the hand slightly. and cerebral perfusion. Allow the chest to completely tion. LOE C). LOE B66 – 69). Data are now accumulating regard- the hands are overlapped and parallel (Class IIa. and allow AED not recognize that fatigue is present for ⱖ5 minutes. but completely.S690 Circulation November 2. LOE B94 –98). despite some data to the contrary. chest compressions (eg. In addition lay rescuers should continue Downloaded from http://circ.96 –102 Therefore. when an AED is delivering a shock). If the 2 rescuers are positioned on either side of the survival occurred with chest compression rates as high as patient.

rescue breaths are head or neck trauma. drug overdose) and from prolonged cardiac arrests. Instead.117 airway using a head tilt– chin lift maneuver (Class IIa.127–129). and to define the best compression-ventilation ratio in terms of survival and neurologic outcome in patients with or Managing the Airway without an advanced airway in place. LOE B). This 30:2 ratio in adults is based on a drowning. A recent large study of out-of-hospital pediatric resuscitation should generally be conducted where the patient cardiac arrests showed that survival was better when conven- is found (Class IIa. Because of difficulties with pulse pressions (either Hands-Only or conventional CPR.107–111).7% of victims with blunt trauma have elimination.110.111.ahajournals. LOE C). pressed. however. LOE B). LOE B).110. supplementary oxygen Healthcare providers should interrupt chest compressions with assisted ventilation is necessary.48 –51 Observational studies of resuscitation of an adult. LOE B). at personnel take over CPR (Class IIa.132 and a case victims exhibit gasping or agonal gasps. some time during prolonged CPR. but further validation of this guideline is needed (Class asphyxial cardiac arrests in both adults and children (eg. Only CPR was provided for children in cardiac arrest due to noncardiac causes. indicate that reluctance to perform mouth-to-mouth ventila- For the rescuer providing Hands-Only CPR. 2 rescuers no longer is to recommend the initiation of chest compressions before need to pause chest compressions for ventilations. many cardiac arrest arrest. clinical130 and radiographic evidence131. interruptions in chest compressions for a pulse rescue breaths) for anyone with a presumed cardiac arrest check should be minimized during the resuscitation. IIb. Berg et al Part 5: Adult Basic Life Support S691 CPR until an AED arrives. consensus among experts and on published case series.2. The rescuer delivering The ABC mindset may reinforce the idea that compressions ventilation can provide a breath every 6 to 8 seconds (which should wait until ventilations have begun. As previously stated. allows for some oxygenation and carbon dioxide (CO2) Between 0.113 Hands-Only airway maneuvers should be performed quickly and effi- (compression-only) bystander CPR substantially improves ciently so that interruptions in chest compressions are mini- survival following adult out-of-hospital cardiac arrests com.123. This mindset can yields 8 to 10 breaths per minute).112. No prospective study of adult cardiac arrest determine if ROSC has occurred. adults with cardiac arrest treated by lay rescuers showed Open the Airway: Lay Rescuer similar survival rates among victims receiving Hands-Only The trained lay rescuer who feels confident that he or she can CPR versus conventional CPR with rescue breaths.134 –136 and the risk of spinal injury is increased recoil during the relaxation phase of chest compressions can if the victim has a craniofacial injury.118 The simpler Hands-Only Open the Airway: Healthcare Provider technique may help overcome panic and hesitation to act. passive chest a spinal injury. LOE B83.119 –122 However.30 Because rescue breathing is an important Compression-Ventilation Ratio (Box 4) component for successful resuscitation from pediatric arrests A compression-ventilation ratio of 30:2 is reasonable in (other than sudden. from adults.110. even to (Class I. and gas exchange series133 have shown it to be effective (Class by guest on May 1. This change reflects the the compressing rescuer should give continuous chest com- growing evidence of the importance of chest compressions pressions at a rate of at least 100 per minute without pauses and the reality that setting up airway equipment takes time. for ventilation (Class IIa. or EMS also provide some air exchange. such reluctance was not ex- ventilation).29.99 –102 conventional CPR with rescue breathing is recommended for Further studies are needed to define the best method for all trained rescuers (both in hospital and out of hospital) for coordinating chest compressions and ventilations during CPR those specific situations (Class IIa. When actual bystanders airway (such as hyperextending the neck to allow passive were interviewed. The precise interval for as infrequently as possible and try to limit interruptions to no which the performance of Hands-Only CPR is acceptable is longer than 10 seconds. paralyzed adult level in the blood remains adequate for the first several volunteers and has not been studied in victims with cardiac minutes after cardiac arrest. LOE B). ventilations (CAB rather than ABC). some healthcare providers114 –116 and laypersons116.19.48 –51. mized and chest compressions should take priority in the pared with no bystander CPR.137. a significant change in these Guidelines Once an advanced airway is in place. witnessed collapse of adolescents). LOE C109.138 a Glasgow Coma Downloaded from http://circ. occur even when more than 1 rescuer is present because Hands-Only CPR “airway and breathing before ventilations” is so ingrained in Only about 20% to 30% of adults with out-of-hospital cardiac many rescuers. has demonstrated that layperson conventional CPR provides Because of the difficulty in providing effective chest better outcomes than Hands-Only CPR when provided before compressions while moving the patient during CPR. the EMS arrival. A healthcare provider should use the head tilt– chin lift How can bystander CPR be effective without rescue maneuver to open the airway of a victim with no evidence of breathing? Initially during SCA with VF. This may not be possible if the tional CPR (including rescue breaths) as opposed to Hands- environment is dangerous.48 –51 Of perform both compressions and ventilations should open the note. This new emphasis on CAB helps clarify that arrests receive any bystander CPR.111. In addition. the victim wakes up. LOE C).119 If the airway is open.12 and 3. 2013 .119. except for specific interventions such not known at this time.29. there is insuffi- tion for victims of cardiac arrest is a theoretical and potential cient evidence to recommend the use of any specific passive barrier to performing bystander CPR. panic was cited as the major obstacle to laypersons performance of bystander CPR. Although the head tilt– chin lift tech- not as important as chest compressions because the oxygen nique was developed using unconscious.29. including assessments.123–126 as insertion of an advanced airway or use of a defibrillator Laypersons should be encouraged to provide chest com- (Class IIa.

normal tidal volume and respiratory rate) can maintain If an adult victim with spontaneous circulation (ie. starting with Chest Compressions Rescue Breathing (Box 3A. because they ● Use a compression to ventilation ratio of 30 chest com. Combi- Mouth-to-mouth rescue breathing provides oxygen and ven- tube. Mouth-to-nose ventilation is recommended if ventilation and diminishes cardiac output and survival. LOE C). in water.55 arrest.153 because the maintain spinal alignment during transport. rescuers should initially use manual to maintain adequate oxygenation. As a result. As noted above. strong effective oxygenation and ventilation. Each breath should be given visible chest rise.154 These does not adequately open the airway. so oxygen uptake if the victim’s chest does not rise with the first rescue breath. In addition.148 Ensure that the bag-mask device to use a barrier device. a low minute ventilation (lower than and then give the second rescue breath.145–147 This is consistent with a tidal volume that produces per minute (Class IIb. 2010 Scale score of ⬍8. issues support the CAB approach of the 2010 AHA Guide- lines for CPR and ECC (ie. and it is reasonable to pressures. delivery of ventilations (Class IIb. When Excessive ventilation is unnecessary and can cause gastric using a barrier device the rescuer should not delay chest inflation and its resultant complications. LOE C). then continues to be adequate during the first several minutes sion (Class IIb. Spinal immobilization those purposes are not known. during the devices may interfere with maintaining a patent airway. over 1 second. open the victim’s airway.109 pressions to 2 ventilations.139. such as regurgitation compressions while setting up the by guest on May 1.57 so cardiac output is ⬇25% to 33% of normal. (although the precise time course is unknown). of ventilation difficulty is an improperly opened airway.30. give 1 breath every 6 to 8 seconds without breaths. During CPR. LOE C). use the head tilt– chin lift maneuver if the jaw thrust may delay the initiation of chest compressions.55. the mouth cannot be opened. LOE C). the optimal inspired oxygen the patient’s head to hold it still) rather than immobilization concentration. 2013 .152 In summary. oxygen content in the noncirculating arterial blood remains If healthcare providers suspect a cervical spine injury. pinch the victim’s nose. tidal volume and respiratory rate to achieve devices (Class IIb. A pressure-relief valve on a resuscita- Some healthcare providers114 –116 and lay rescuers state that they tion bag-mask may prevent the delivery of a sufficient tidal may hesitate to give mouth-to-mouth rescue breathing and prefer volume in these patients.111. The risk of disease transmission through allows you to bypass the pressure-relief valve and use high mouth to mouth ventilation is very low. LOE B). Taking a regular rather than a deep breath prevents the Studies in anesthetized adults (with normal perfusion) rescuer from getting dizzy or lightheaded and prevents suggest that a tidal volume of 8 to 10 mL/kg maintains overinflation of the victim’s lungs.140 or both. rescue breaths are but ultimately the use of such a device may be necessary to not as important as chest compressions29. Each breath should cause visible chest rise. may require high pressures to be properly ventilated (to make Mouth-to–Barrier Device Breathing the chest visibly rise). attempting to synchronize breaths between compressions and create an airtight mouth-to-mouth seal.108. Because maintaining a patent airway of CPR. over 1 second regardless of whether an advanced airway is in Patients with airway obstruction or poor lung compliance place. rescue breaths (or to access and set up airway equipment) LOE C). the mouth is rescuers should avoid excessive ventilation (too many breaths seriously injured). Give 1 breath (this will result in delivery of 8 to 10 breaths/minute). LOE C141. LOE C). are hypoxemic at the time of cardiac arrest.149 initiate rescue breathing with or without a barrier device. decreases venous return to the heart. or a mouth-to-mouth seal is difficult to achieve Downloaded from http://circ. such as children and drowning victims. they unchanged until CPR is started.ahajournals. However.144 first minutes of sudden VF cardiac arrest. through the victim’s mouth is impossible (eg. LOE B150 –152). LOE about 1 breath every 5 to 6 seconds. excessive ventilation can be harmful because it increases Mouth-to-Nose and Mouth-to-Stoma Ventilation intrathoracic pressure.119 For that and easily palpable pulses) requires support of ventilation. the blood oxygen content should open the airway using a jaw thrust without head exten. and aspiration (Class III.143. 4) prior to Airway and Breathing). attempts to open the airway and give and providing adequate ventilation are priorities in CPR (Class I. the reason during adult CPR tidal volumes of approximately 500 healthcare provider should give rescue breaths at a rate of to 600 mL (6 to 7 mL/kg) should suffice (Class IIa. and give There should be no pause in chest compressions for a second rescue breath over 1 second (Class IIb. More important. ● Mouth-to-Mouth Rescue Breathing When an advanced airway (ie. placing 1 hand on either side of to eliminate CO2.155 To provide mouth-to-mouth rescue 2-person CPR. The most common cause normal oxygenation and elimination of CO2. from the lungs and CO2 delivery to the lungs are also reposition the head by performing the head tilt– chin lift again reduced. endotracheal tube. or laryngeal mask airway [LMA]) is in place during tilation to the victim. the secondary purpose is spinal motion restriction (eg.142). Ventilations ● Give a sufficient tidal volume to produce visible chest rise and compressions are also important for victims of asphyxial (Class IIa.S692 Circulation November 2.139 For victims with During CPR the primary purpose of assisted ventilation is suspected spinal injury. to achieve visible chest expansion. The 2010 AHA Guidelines for CPR and ECC make many of For victims of prolonged cardiac arrest both ventilations the same recommendations regarding rescue breathing as in and compressions are important because over time oxygen in 2005: the blood is consumed and oxygen in the lungs is depleted ● Deliver each rescue breath over 1 second (Class IIa. if necessary. LOE C133).138. take a “regular” (not a deep) breath. or about 10 to 12 breaths B).110. the victim is or too large a volume) during CPR (Class III.

The protocol included insertion of an a standard 15-mm/22-mm connector. Seven randomized. These studies did not demonstrate a significant Bag-mask ventilation is a challenging skill that requires overall improvement in outcome measures. effectiveness. One study of patients with less complicated to use than a bag and mask. lone rescuer during CPR. 2013 . and ventilations are delivered at the rate of 1 valve that can be bypassed. A reasonable acceptable alternative to bag-mask ventilation for well-trained alternative is to create a tight seal over the stoma with a healthcare providers who have sufficient experience to use the round. safe. LOE C). Cricoid pressure available. However. Instead. Masks passive ventilation airway techniques during cardiac arrest should be fitted with an oxygen (insufflation) inlet and have used the same protocol.162 The rescuer should use an adult (1 to 2 L) bag to deliver Cricoid Pressure approximately 600 mL tidal volume163–165 for adult victims. is not recommended (Class III. published evidence on the safety. Give mouth-to-stoma rescue breaths to a victim with a Ventilation with a bag through these devices provides an tracheal stoma who requires rescue breathing. approximately 8 to 10 breaths per minute). Both rescuers watch for visible chest rise. The healthcare Neither expert nor nonexpert rescuers demonstrated mastery provider should use supplementary oxygen (O2 concentration of the technique. the routine use of cricoid pressure in adult cardiac arrest esophageal-tracheal combitube and the King airway device. coid pressure can prevent gastric inflation and reduce the risk tight seal is established between face and mask. these studies infrequently address additional tech- Masks should be made of transparent material to allow niques to improve ventilation or oxygenation.160. the rescuers should deliver cycles of 30 that aspiration can occur despite application of pressure. thirds of its volume or a 2-L adult bag about one third of its controlled studies demonstrated that cricoid pressure can volume. It is most effective when provided For layperson Hands-Only CPR. LOE C). this volume of regurgitation and aspiration during bag-mask ventilation. These devices are discussed in greater Ventilation With Bag and Mask detail in Part 8.156 regions (with specific authorization from medical control). breath about every 6 to 8 seconds (which will deliver an oxygen reservoir to allow delivery of high oxygen con. might be used in a few special circumstances (eg. with interposed ventilations versus passive insufflation of oxygen during minimally interrupted chest Bag-Mask Ventilation compressions. LOE B). Cri- (Class IIa. they no longer interrupt compressions to The Bag-Mask Device deliver 2 breaths). A case series suggests that mouth-to-nose are currently within the scope of BLS practice in a number of ventilation in adults is feasible. LOE C).172 and 2 post hoc analysis studies98. and the capability to function During CPR Although many studies describe outcomes after compression- satisfactorily under common environmental conditions and extremes of temperature. to aid in Ventilation With a Supraglottic Airway viewing the vocal cords during tracheal intubation). LOE C145–147). the bag.173 of a tight seal on the face. therefore a bag-mask CPR. only CPR. They should be capable of creating ative studies97. rescuers no longer deliver cycles of 30 compressions device may produce gastric inflation and its complications. Rescuers can provide bag-mask ventilation with room air or Ventilation With an Advanced Airway oxygen. or feasibility LOE B166 –171). breather by guest on May 1. group analysis showed better survival with passive oxygen lation is not the recommended method of ventilation for a insufflation among patients with witnessed VF cardiac arrest. sub- considerable practice for competency.161 Bag-mask venti. a nonrebreathing outlet valve that cannot be obstructed by foreign material and will not jam with an Passive Oxygen Versus Positive-Pressure Oxygen oxygen flow of 30 L/min. and effective. breath over 1 second (Class IIa. A bag-mask device provides positive-pressure ven. at a minimum flow rate of 10 to 12 L/min) when inconsistent and outside of effective limits. Berg et al Part 5: Adult Basic Life Support S693 (Class IIa. Two compar- detection of regurgitation.1 of these Guidelines. The rescuer delivers Additional manikin studies181–194 found training in the ma- ventilations during pauses in compressions and delivers each neuver to be difficult for both expert and nonexpert rescuers.157 of the advanced airways. continuous chest compressions are A bag-mask device should have the following158: a nonjam performed at a rate of at least 100 per minute without pauses inlet valve. evidence is insufficient to by 2 trained and experienced rescuers. As long as the patient does not have an advanced delay or prevent the placement of an advanced airway and airway in place. and the applied pressure was frequently ⬎40%. either no pressure relief valve or a pressure relief for ventilation. training is needed laryngectomies showed that a pediatric face mask created a for safe and effective use of both the bag-mask device and each better peristomal seal than a standard ventilation mask. Cricoid pressure is a technique of applying pressure to the This amount is usually sufficient to produce visible chest rise victim’s cricoid cartilage to push the trachea posteriorly and and maintain oxygenation and normocarbia in apneic patients compress the esophagus against the cervical vertebrae. standard 15-mm/22-mm fittings. How- Supraglottic airway devices such as the LMA. the ever. One rescuer opens the support recommending the use of any specific passive airway airway and seals the mask to the face while the other squeezes or ventilation technique. covering both mouth and nose. pediatric face mask (Class IIb. can be delivered by squeezing a 1-L adult bag about two but it may also impede ventilation. When the victim has an advanced airway in place during tilation without an advanced airway. If the airway is open and a good. There is no devices for airway management during cardiac arrest (Class IIa.ahajournals. It is not clear that these devices are any more or of mouth-to-stoma ventilation. and 2 breaths (ie.160. Downloaded from http://circ. centrations.174 –180 compressions and 2 breaths during CPR.159 They should be oral airway and administration of oxygen with a nonre- available in one adult and several pediatric sizes.

above the head and rolling the head onto the arm. discomfort in other areas of the upper body. hours after the onset of symptoms. Atypical symptoms of ACS may be more common no overall differences in outcomes. or based on regional EMS protocols (Class normal volunteers206 show that extending the lower arm IIa. or if the EMS rescuer To improve ACS outcome. providing the patient has no history of aspirin system and retrieves the defibrillator. nausea. a period The classic symptoms associated with ACS are chest of 1 1⁄2 to 3 minutes of CPR by EMS before defibrillation did discomfort. may be feasible for victims with known or oxygen during the initial assessment of patients with sus- suspected spinal injury. 6) Special Resuscitation Situations All BLS providers should be trained to provide defibrillation Acute Coronary Syndromes because VF is a common and treatable initial rhythm in adults In the United States coronary heart disease was responsible with witnessed cardiac arrest. cardiac biomarkers.235–237 If the patient has a STEMI on ECG and if PCI is the of the body. sweating.208 Approxi- of choice for VF of short duration.S694 Circulation November 2. all dispatchers and EMS witnesses the collapse. However.205 The position should be stable.209 In swine. and diabetic patients. LOE C).196.208. Defibrillation is dis. In settings in or rule out ACS in prehospital or emergency department with lay rescuer AED programs (AED onsite and available) (ED) settings. determine Recovery Position onset of ACS symptoms.199 care by contacting family. microvascular blood flow is markedly reduced Early recognition. rather than delaying chest compressions before defibrillation may be beneficial. LOE C). 2013 .210 but restore some of the diminished microvascular blood flow treatment is most effective if provided within a few hours of within 1 minute. in two of these in the elderly. hospital VF/pulseless ventricular tachycardia (VT).198 Performing chest compressions while the onset of symptoms. LOE C). not improve ROSC or survival rates regardless of EMS shortness of breath. and transport times are relatively short (ie.207 pected ACS. or driving In 2 randomized controlled trials in adults with out-of. LOE A).195 For victims with VF. and lightheadedness. women.211 Patients at risk for acute coronary another rescuer retrieves and charges a defibrillator improves syndromes (ACS) and their families should be taught to the probability of survival.6 After about 3 to 5 minutes of recognize the symptoms of ACS and to immediately activate untreated VF. 785 000 Americans will have a new coronary of collapse.234 Clinical trials have shown who clearly have normal breathing and effective circulation. There is insufficient evidence to recommend for or against Numerous studies do not support the use of any clinical signs and symptoms independent of electrocardiograph (ECG) delaying defibrillation to provide a period of CPR for patients tracings. but any patient studies subgroups of patients with the EMS response interval may present with atypical signs and symptoms. response interval. less chest to impair breathing (Class IIa. LOE B).229 –233 EMS providers should obtain a 12-lead ECG.215–228 and for in-hospital environments.5. sur.11. the rescuer should use the defibrillator providers must be trained to recognize ACS symptoms. bypassing closer emergency with its own advantages. 2010 AED Defibrillation (Box 5. chest compressions improve outcome by limiting damage to the heart. some animal models suggest that a period of the EMS system when symptoms appear.200. Studies in than 30 minutes).229. in systems where time intervals victims. chosen method of reperfusion. However.197 Rapid defibrillation is the treatment attack and 470 000 will have a recurrent attack. No single position is perfect for all departments as necessary. improved outcomes in ST-segment elevation myocardial This position is designed to maintain a patent airway and infarction (STEMI) patients transported by EMS directly to a reduce the risk of airway obstruction and aspiration. 203 35% to 92% and specificity ranges from 28% of 91%. such as for victims of mately 70% of deaths from acute myocardial infarction witnessed out-of-hospital cardiac arrest or for hospitalized (AMI) occur outside of the hospital.204. and treatment of AMI can within 30 seconds of the onset of VF.” bleeding (Class IIa. for 1 of every 6 hospital admissions in 2005 and 1 in every 6 vival rates are highest when immediate bystander CPR is deaths in 2006.202. When more than if atypical. one rescuer should provide chest with potential cardiac symptoms to chew an aspirin (160 to compressions while another activates the emergency response 325 mg). while Common practice has been for basic EMT’s to administer bending both legs. allergy and no signs of active or recent gastrointestinal cussed in further detail in Part 6: “Electrical Therapies. most within the first 4 patients whose heart rhythm is monitored (Class I. there is insufficient evidence to Downloaded from http://circ. it is reasonable to transport the There are several variations of the recovery position.201 A third randomized controlled trial202 The symptoms of AMI characteristically last more than 15 and a cohort clinical trial with historic controls203 also found minutes. or other diagnostic tests to rule in VF/pulseless VT out-of-hospital cardiac arrest.208 The American Heart Association estimates provided and defibrillation occurs within 3 to 5 minutes that in 2010. themselves to the hospital.ahajournals. with the head dependent and with no pressure on the 90 by guest on May 1. It is reasonable for dispatchers to advise patients one rescuer is available. calling a physician. even as soon as it is available (Class IIa.212–214 Signs intervals longer than 4 to 5 minutes showed increased and symptoms cannot be used to confirm or exclude the survival to hospital discharge with a period of CPR prior to diagnosis of ACS because reported sensitivity ranges from defibrillation. diagnosis. near a true lateral between first medical contact and balloon times are less than position. and provide prearrival notification The recovery position is used for unresponsive adult victims to the destination hospital. The percutaneous coronary intervention (PCI)– capable hospi- victim is placed on his or her side with the lower arm in front tal. each patient directly to a PCI facility.4.10.

tension intervention in the prehospital environment. providers sudden numbness or weakness of the face. insufficient onset when possible. trouble speaking or lowest administered oxygen concentration that will maintain understanding.266 Over the last 25 years.252. sudden trouble seeing in one or both eyes. and stroke is a leading cause of severe. dizziness. has obvious signs of heart present (Class I. it is reasonable for the lone ischemic stroke.241–243 Nitrates in protocols that address triaging the patient when possible all forms are contraindicated in patients with initial systolic directly to a stroke center (Class I. patients (Class 1.2 in 2006. their family members.266 The Stroke duration and severity of hypoxia sustained as a result of Almost 800 000 people suffer stroke each year in the United drowning is the single most important determinant of out- States.” angina (UA)/NSTEMI due to an association with increased mortality in a large registry. Effective therapy requires early detection of before leaving the victim to activate the EMS system. Nitrates are contraindicated when hospital medical personnel should administer supplementary patients have taken a phosphodiesterase-5 (PDE-5) inhibitor oxygen to hypoxemic (ie. and sudden severe headache with no known cause. the incidence “Acute Coronary Syndromes. EMS personnel with chest discomfort and suspected ACS. arm. Berg et al Part 5: Adult Basic Life Support S695 ‘support or refute oxygen use in uncomplicated ACS.234. prearrival notification.264). LOE C). the signs of stroke. When rescuing a injury and improves outcome in selected patients with acute drowning victim of any age. hypoxemic. The signs and symptoms of stroke are by guest on May 1.238 If sudden trouble walking. and are not necessary and they can cause injury.8 deaths per 100 000 population in 1970 to 1.265 Both out-of-hospital and in- adequate RV preload. however. LOE B261.268 Rescuers should provide CPR. prehospital intervention for blood pressure is administering intravenous morphine for undifferentiated not recommended (Class III.267. long-term come. and evidence exists to support or refute the routine administration notify the receiving hospital that a patient with possible of nitroglycerin in the ED or prehospital setting in patients stroke is being transported. to patients with inferior STEMI and hypoxemia will exacerbate and extend ischemic brain injury suspected RV involvement because these patients require leading to worse outcomes. loss of balance or coordina- the patient has not taken aspirin and has no history of aspirin tion.254 –256 (160 to 325 mg) to chew (Class I. Maneuvers to management of acute ischemic stroke and Part 11: “Adult relieve foreign-body airway obstruction (FBAO) are not Stroke. There is no evidence that AHA/American Stroke Association (ASA) Guidelines for the water acts as an obstructive foreign body. when administered by a trained rescuer (Class IIb. LOE B257–259). LOE C) or those with unknown oxygen For patients diagnosed with STEMI in the prehospital saturation. Unless gesics. LOE C). appropriate triage to a stroke center. BLS providers should learn to recognize the signs and symptoms aspiration.253 allergy and no evidence of recent gastrointestinal bleeding. see the both the rescuer and the victim. oxygen saturation ⬍94%) stroke within 24 hours (48 hours for tadalafil). about the assessment of stroke using stroke scales and the However. For additional information about these steps. if at all. such as intravenous morphine. rapid triage. and delay of CPR.251 recommended for drowning victims because such maneuvers Patients at high risk for stroke. It may be blood pressure ⬍90 mm Hg or ⱖ30 mm Hg below baseline important for a family member to accompany the patient and in patients with right ventricular infarction (see Part 10).”250.263. EMS providers may consider ⬍90 mm Hg).246 –249 The window of opportunity is extremely healthcare provider to give 5 cycles (about 2 minutes) of CPR limited. EMS providers should administer appropriate anal.239. establish the time of symptom erin in select hemodynamically stable patients. and the combination of poor perfusion and extreme caution. Administer nitrates with compromise. LOE C). LOE C). vomiting. they in the ED. especially should administer oxygen and titrate therapy to provide the on one side of the body. LOE B). LOE C269). Although it is should be able to perform an out-of-hospital stroke assess- reasonable to consider the early administration of nitroglyc. sudden confusion. during transport to verify the time of symptom onset and Caution is advised in patients with known inferior wall provide consent for interventional therapy. STEMI.ahajournals. Community and professional education is essential to improve EMS providers should give the patient nonenteric aspirin stroke recognition and early EMS activation. and management Chest compressions are difficult to perform in water. and a right-sided ECG should be performed to Patients with acute stroke are at risk for respiratory evaluate right ventricular infarction. ment (Class I. and rapid delivery of fibrinolytic therapy to eligible may not be effective and they could potentially cause harm to patients. 2013 . or leg. prompt activation of the EMS system and Mouth-to-mouth ventilation in the water may be helpful dispatch of EMS personnel. as soon as an unresponsive submersion victim is the first hours of the onset of symptoms limits neurological removed from the water (Class I. LOE C). the oxyhemoglobin saturation ⱖ94% (Class I. Additional information chest pain unresponsive to nitroglycerin (Class IIb. or an oxyhemoglobin saturation ⬍94%. particularly rescue disability and death. LOE C). evaluation. provide cardiopulmonary support. There are no data to support initiation of hyper- setting. for persistent chest the patient is hypotensive (systolic blood pressure pain (Class IIa.240 EMS dispatchers should be trained to suspect stroke and EMS providers can administer nitroglycerin for patients rapidly dispatch emergency responders. morphine should be used with caution in unstable management of stroke is included in Part 11: “Adult Stroke.260 –262 EMS systems should have with a suspected ACS (Class IIb. LOE C). Drowning Additional information about the assessment and treatment Drowning is a preventable cause of death for more than 3500 of the patient with ACS and STEMI is included in Part 10: Americans annually.270 Downloaded from http://circ.245 Fibrinolytic therapy administered within breathing.” of fatal drowning has declined significantly from 3. If the of stroke and to call EMS as soon as any signs of stroke are patient is dyspneic.

The few patients with persistent obstruction from wind. Quickly ask.276. the rescuer Most reported cases of FBAO occur in adults while they are should use chest thrusts instead of abdominal thrusts. and breathing may be very slow. or cold. that abdominal thrusts are not recommended for infants ⬍1 year ing can be used until active warming is available. Less than 4% died. humidified oxygen. The recommendation to use the finger sweep in the victim has severe airway obstruction.272 tory difficulty increases and is accompanied by stridor. pressures can be generated using the chest thrust rather than Foreign bodies may cause either mild or severe airway the abdominal by guest on May 1. demonstrating the universal choking No studies have evaluated the routine use of the finger sign. and health care ing efforts. heat.279.274 Most reported episodes of choking in infants and If the adult victim with FBAO becomes unresponsive.275 approximately start CPR if a pulse is not definitely felt within 10 seconds. the rescuer may resuscitative efforts until the patient is evaluated by advanced consider chest thrusts (Class IIb. Simply looking into the mouth poor air exchange and increased breathing difficulty.ahajournals. and commonly witnessed. emergency feasible and effective for relieving severe FBAO in conscious personnel should deliver shocks using the same protocols (responsive) adults and children ⱖ1 year of age. rapid sequence until the obstruction is relieved (Class IIb. eating. this will verify that obstruction. A randomized trial of maneuvers to open the it is important to distinguish this emergency from fainting. It is important to note care providers. If mild drowning victims. 2013 . For If the victim is unresponsive with no normal breathing. only and chest thrusts. The rescuer should intervene if the choking victim CPR. assessments of rescuer is present.273 choking victim is in the late stages of pregnancy. ventilate the victim usually responded to suction or the use of Magill forceps. Do 50% of the episodes of airway obstruction were relieved prior not wait to check the victim’s temperature and do not wait until to arrival of EMS.281 In 1 case series of 513 choking gasping). healthcare providers can check for a pulse. The healthcare provider should carefully while the victim is still responsive. Spinal cord injury is rare among fatal rescuers must act quickly to relieve the obstruction. If the adult victim is back blows or “slaps. seizure. depending on the degree of The clinical data about effectiveness of maneuvers to hypothermia.280 unresponsive with no breathing or no normal breathing (ie. sponse system. Recognition of Foreign-Body Airway Obstruction the healthcare provider should activate the emergency re- Because recognition of FBAO is the key to successful outcome. After 2 minutes. EMS intervention with abdominal thrusts the victim is rewarmed to start CPR. or loss of consciousness. the children occur during eating or play when parents or child. past guidelines was based on anecdotal reports that suggested Downloaded from http://circ. Chest thrusts should be used for obese patients if the Foreign-Body Airway Obstruction (Choking) rescuer is unable to encircle the victim’s abdomen. and the rescuer usually intervenes then begin CPR. Treatment is usually lower the victim to the ground. “Are you choking?” If the victim indicates sweep to clear an airway in the absence of visible airway “yes” by nodding his head without speaking. remove it. successfully relieved the obstruction in more than 85% of the remove wet clothes from the victim.275 Avoid rough movement. care providers are present.271 Victims with obvious clinical signs of obstruction is present and the victim is coughing forcefully. If VF is detected. such as a should not significantly increase the time needed to attempt silent cough. and transport the victim to a Although chest thrusts. cyanosis. continue B). the rescuer should look for an object in the victim’s shows signs of severe airway obstruction. alcohol intoxication. do injury. Attempt to relieve the obstruction only if signs of providers may consider stabilization and possible immobiliza. To prevent further heat loss. insulate or shield the victim remaining cases. but preventable. or inability to speak or breathe. Activate the EMS system quickly Hypothermia if the patient is having difficulty breathing. and abdominal thrusts are hospital as soon as possible. If the FBAO is an uncommon.283 showed that higher sustained airway respiratory distress. send someone to activate the successful.S696 Circulation November 2. and if possible. The choking event is therefore immediately activate (or send someone to activate) EMS. If abdominal thrusts are not effective. and survival rates can exceed 95%.275–277. In the out-of-hospital setting. or the victim becomes unresponsive. relieve FBAO are largely retrospective and anecdotal. LOE B). victim may clutch the neck. respira- tion of the cervical and thoracic spine for these victims. passive warm. lay responsive adults and children ⬎1 year of age with severe rescuers should begin chest compressions immediately (see Part FBAO. case reports show the feasibility and effectiveness of 12: “Cardiac Arrest in Special Situations”). The the ventilations and proceed to the 30 chest compressions. of age because thrusts may cause injuries. severe obstruction develop: the cough becomes silent. but should episodes for which EMS was summoned. with warm. or a history of diving into shallow not interfere with the patient’s spontaneous coughing and breath- water are at a higher risk of spinal cord injury.”276 –278 abdominal thrusts. LOE For the hypothermic patient in cardiac arrest. 2010 Rescuers should remove drowning victims from the water by Relief of Foreign-Body Airway Obstruction the fastest means available and should begin resuscitation as When FBAO produces signs of severe airway obstruction. rescuer should carefully support the patient to the ground. heart airway in cadavers282 and 2 prospective studies in anesthe- attack. cause of death. or other conditions that may cause sudden tized volunteers281. back slaps. If more than one In an unresponsive victim with hypothermia.275 emergency response system and begin CPR (without a pulse check). quickly as possible. if someone has not already done so. one rescuer should phone 911 while the other breathing and pulse are particularly difficult because heart rate rescuer attends to the choking victim. Each time the airway is opened during obstruction. cyanosis. These include signs of mouth and if found. for simplicity in used for the normothermic cardiac arrest victim (see Part 12: training it is recommended that abdominal thrusts be applied in “Cardiac Arrest in Special Situations”).

284 However.288 –293 However. no trial grant-research grant for study of CPR cardiac arrest appearances training in the community Doris Duke Foundation-research grant for study of post resuscitation injury after cardiac arrest Tom P. depth. whoever is nearby improvement in chest compression rate.-Supplied AEDs *EMS Today. They should also avoid compression of the chest.80. prompt and effective provision of these actions. MSN.ahajournals. Portland Com. University of †Philips Healthcare-research grant for *Laerdal Medical Corp-inkind support *CME lectures on None None *legal review of two Abella Pennsylvania–Assistant study of CPR during inhospital cardiac of equipment for CPR research topics of CPR and cardiac arrest Professor arrest AHA Clinical Research Program hypothermia after cases. chest compressions compressions are performed on a soft surface such as a mattress should be of adequate rate and depth). Emanuel Hospital is a Level I Trauma Center.277. $2. None None None None None None Emanuel Hospital. Inc.285.)-PI of Oshkosh study Systems. If and when available. Cave Legacy Health System. In Kind Consortium Medtronics-Consultant JoLife-Consultant Take Heart America-Board Member Diana M. and indicators of blood flow such as end-tidal pressions (regardless of training). Contrary to the belief of too many in no studies to date that demonstrate a significant improvement in this situation. Berg University of None None None None None None Pennsylvania–Professor of Anesthesiology and Critical Care Medicine. Summary tion. Rescuers should allow because the depth of sternal movement may be partly due to complete chest recoil after each compression and minimize movement of the mattress rather than anterior-posterior (AP) interruptions in chest compressions. AHA ECC Product Development–Senior Science Editor †Significant compensation from the AHA to write and edit the AHA Guidelines and resuscitation statements and training materials (Continued) Downloaded from http://circ.276. Other CPR feedback devices critical. With prompting devices can improve the quality of CPR (Class IIa. Institute for Health Professionals–Faculty/ Instructor Mary Fran Vanderbilt University School of None None None None None None Hazinski Nursing—Professor. should activate the emergency system and begin chest com- ventilation rate. case reports have also documented The critical lifesaving steps of BLS are harm to the victim236. Inaction is harmful and patient survival related to the use of CPR feedback devices CPR can be by guest on May 1. Berg et al Part 5: Adult Basic Life Support S697 that it was helpful for relieving an airway obstruc. Dept.72. Inc. Division Chief. Emergency Services: Not-for-profit health system consists of 5 hospitals in the Portland.73. chest recoil. and methods should ● Rapid Defibrillation for VF be developed to improve the quality of CPR delivered to victims of cardiac arrest. However.62. CPR is not harmful. In Kind NHLBI Trial-PI for threshold devices for ROC Milwaukee site.-Supplied impedance *JoLife-Consultant site.294 Nevertheless. Oregon metro area.000 Member *ResQTrial (Advanced Circulatory Consortium Advanced Circulatory *Medtronic-Consultant Systems.287 Several studies have demonstrated When an adult suddenly collapses. Medical College of †NIH-ROC Consortium-PI of *Zoll Medical Corp. the quality of CPR is during actual cardiac arrest events.286 or rescuer. ● Immediate Recognition and Activation of the emergency The Quality of BLS response system The quality of unprompted CPR in both in-hospital and out-of– ● Early CPR and hospital cardiac arrest events is often poor. College. None *Take Heart None Aufderheide Wisconsin–Professor of Milwaukee site NETT-PI of Milwaukee and software capturing CPR Compensated *America-Board Emergency Medicine site performance data for ROC speaker. of None None None None None None Emergency Medicine– Associate Professor *Paid writer for AHA guidelines Benjamin S.91–93. an AED should prompting and feedback technology such as visual and auditory be applied and used without delaying chest compressions.– RN. real-time CPR excessive ventilation. lives are saved LOE B). 2013 . Disclosures Guidelines Part 5: Adult Basic Life Support: Writing Group Disclosures Writing Group Speakers’ Consultant/Advisory Member Employment Research Grant Other Research Support Bureau/Honoraria Ownership Interest Board Other Robert A. every day. Pediatric Critical Care Robin Hemphill Emory University. Trained lay rescuers who CO2 (PETCO2) when real-time feedback or prompt devices are are able and healthcare providers should provide compres- used to guide CPR performance. Chest compressions should be delivered by pushing with accelerometers may overestimate compression depth when hard and fast in the center of the chest (ie. there are sions and ventilations.73.

Wylie-Rosett J. Cretin S. *Modest.000 (funding is received by my employer to support my time on this trial. Ensuring the effectiveness of community-wide Regional variation in out-of-hospital cardiac arrest incidence and emergency cardiac care. Nichol G. 2008. Kellermann AL. Christenson J. Ventricular fibrillation report from the American Heart Association. emergency medical dispatchers? Resuscitation. Predictors of survival acute myocardial infarction.96:3308 –3313. 2010 Guidelines Part 5: Adult Basic Life Support: Writing Group Disclosures.300:1423–1431.D. Ann Emerg Med. Rho RW. Am J Emerg Med. Arch Intern Med. Travers A. Kudenchuk P. JAMA. Schron EB. Downloaded from http://circ. Christenson J. Short F. Rea T. Treatment of ventricular fibrillation: emergency medical technician defi- hospital ventricular fibrillation arrest: survival implications of guideline brillation and paramedic services. Beekhuis F. 19. Idris A. Ford E. Delayed time to Importance of the first link: description and recognition of an out-of- defibrillation after in-hospital cardiac arrest. access defibrillation and survival after out-of-hospital cardiac arrest. Rosamond W. None None Lerner Wisconsin– Associate Care Trial Source: Zoll Medical Pfizer. M. Cloyd D. hospital cardiac arrest in an emergency call. Valenzuela TD. Page RL. Bishop D. N Engl J Med. Roger VL. Howard V. Aufderheide Electrophysiol.119: 358:9 –17.S698 Circulation November 2. Everson-Stewart S. Hardman RG. 2000. 1997. Becker LB. Adams RJ. Spaite DW. 2000. or (b) the person owns 5% or more of the voting stock or share of the entity. Clark JJ. National Heart Attack Alert Program Coor- from out-of-hospital cardiac arrest: a systematic review and meta- dinating Committee Access to Care Subcommittee. Meigs J. These studies are supported by the NIH primarily and I receive no support from Philips or the company that makes the impedance threshold device. References 9. Helbock M.120:1241–1247. Krumholz HM. Nallamothu BK. Minnesota: experience over 18 years. Stiell I. Stouffer JA.35:213–218. or 5% or more of the person’s gross income. Andrusiek D. Callaway CW. 8. survival model. Haase N. Brown T. Dates: 12/2006–8/2010 Total Funding to MCW: $345. Perry S. My institution receives support for 20% of my time and the remaining funds are used for other members of our staff and supplies. Hallstrom AP. Sacco R. Hallstrom A. 2006. 2010. 948 –954. 2009. N Engl J Med. Proschan M. Buylaert WA. 2013 . Circ Cardiovasc Qual Outcomes. Wong ND. Marelli A. White RD. Callaway CW. Circulation. Eisenberg MS. Valenzuela TD. Circulation. 10. I care. Furie K. Dai S. Gillespie C. Spaite DW. analysis. 1984.343:1206 –1209. Thomas E. 14. Johnson E. Kissela B. Powell JL. 1. Hostler D. Rogers MA. De Simone McBurnie MA. Zalenski R. Estimating telephone CPR: common delays and time standards for delivery. Emergency medical dispatching: rapid identification and treatment of 5.121: in Rochester. Pierce J. I have received unrestricted *We conducted an AED training None None None *I serve on a DSMB Rea Physician–Associate (modest) grant support from Philips Inc study that recently completed where for a trial sponsored Professor of Medicine. Circulation. †Significant. Lackland N Engl J Med. Weisfeldt M. The Ohio State University. 2008. Carnethon M. The automated external defibrillator. 18. I did not evaluate quantitative Services Division of Public generally (changing resuscitation receive any of this equipment VF waveform Health-Seattle & King protocols) and not specific to algorhithm to guide County–Program Medical proprietary information or equipment. Nichol G. and PhysioControl. Davis D. Copass M. Mozaffarian D. Tijssen JG. changes. Rea TD. I am directly involved in effort in order to the Feedback Trial to evaluate dynamic minimize (eliminate) fdbk available on the Philips MRX. I receive less than 5% salary support Michael R. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. The any conflict ROC is also evaluating the impedance threshold device. Do victims of an 4. Larsen MP. 2007. 1997. Resuscitation. 22(pt 2):354 –365. 2009. JAMA. 17. Lagaert L. Chan PS. Sasson C. Garcia M. Mussolino M. My role is to advise them on human subject protection issues and to assist with data management and report generation for the trial) Thomas D. 13. Brooke Medical College of None †Title: Circulation Improving Resuscitation None *Stockholder in Medtronic. Thom T. Krumholz HM.351:637– 646. Vanhaute O. Nichol G. Lowe R. Eisenberg MS. McDermott MM. 2004.ahajournals. 15. I am participating in a trial of chest compression only vs chest compression plus ventilation for dispatch-assisted CPR-supported in part by Laerdal Foundation. Cardiopulmonary resus- derheide TP. out-of-hospital cardiac arrest benefit from a training program for Hospital variation in time to defibrillation after in-hospital cardiac arrest. Vaillancourt C. 1993.3:63– 81. 2009. Chest compression citation by chest compression alone or with mouth-to-mouth ventilation. D.114:2760 –2765. Culley LL. Roe DJ. Ferguson TB. Brown TM. Hedges J. 16. Clark LL. Zwinderman AH. The topics were Philips and PhysioControl contributed by Philips to Emergency Medical related to improving resuscitation equipment for the research. Continued Writing Group Speakers’ Consultant/Advisory Member Employment Research Grant Other Research Support Bureau/Honoraria Ownership Interest Board Other E. Agarwal DA.18:896 – 899.20:362–366. 2. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period. or owns $10 000 or more of the fair market value of the entity. Swor Beaumont Hospital–Director None None None None None None EMS Programs This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire. in casinos. Cobb L. Hailpern S. Becker L. 2096 –2102.13:67–73. Idris A. 2009. Auf. Ann effectiveness of cardiac arrest interventions: a logistic regression Emerg Med. Public- G. fraction determines survival in patients with out-of-hospital ventricular N Engl J Med. 2010. and General Professor Corporation Role: Consultant Principal Electric Investigator: Lars Wik.169:1265–1273. Nallamothu BK. Nichol G. 80:1253–1258. Outcomes of rapid defibrillation by security officers after cardiac arrest Stafford R. Larsen MP. Hallstrom AP. Circulation. TP. Koster RW. Ornato JP. Atkinson EJ.251:1723–1726. outcome. Hess EP. University of Washington: *In the past. Chan PS. Dahl J. Spertus JA. Dispatcher-assisted 7. Greenlund K. Powell J. Stiell I.342:1546 –1553. None None None None None None Sayre Associate Professor Robert A. Bergner L. Lloyd-Jones D. Executive summary: heart disease and stroke statistics–2010 update: a 11. 1995. Becker LB. Ho PM. Go A. Eisenberg 12. M. Berg R. J Cardiovasc 3. Davis D. Pepe PE. Calle PA. Sorlie P. I receive no Director am currently an investigator in the ROC. by guest on May 1. Berdowski J. 6. 1991. Increasing use of cardiopulmonary resuscitation during out-of. support for this As part of this. Wasserthiel-Smoller S. Roe DJ. fibrillation. Copass MK. Kittner S. Lisabeth L. which all members of the writing group are required to complete and submit. Dreyer J. Nichol G.

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. Correction In the article by Berg et al. Circulation is available at http://circ. 2013 . a correction was needed.ahajournals.ahajournals. . On page S696. and appeared with the November 2.1161/CIR.122[suppl 3]:S685–S705). “After 2 minutes . activate the emergency response system. which is available at http://circ. activate the emeregency response system. . 2011.” It has been changed to read.124:e402.) © 2011 American Heart Association. . line 8 in the fifth paragraph under “Relief of Foreign-Body Airway Obstruction” read “After 2 minutes . 2010.0b013e318235d003 (Circulation. “Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. e402 by guest on May 1. right column.” which published ahead of print on October 18.ahajournals.” This correction has been made to the current online version of the Downloaded from issue of the journal Circulation (2010. Inc. DOI: 10.