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
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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
Basic life support (BLS) is the foundation for saving lives SCA has many etiologies (ie, cardiac or noncardiac causes),
following cardiac arrest. Fundamental aspects of BLS
circumstances (eg, witnessed or unwitnessed), and settings
include immediate recognition
of sudden cardiac arrest
(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
), and rapid de-
but a core set of actions provides a universal strategy for
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
adult BLS guidelines for lay rescuers and healthcare provid-
Immediate recognition of cardiac arrest and activation of
ers. Key changes and continued points of emphasis from the
the emergency response system
2005 BLS Guidelines include the following:
Early CPR that emphasizes chest compressions
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
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.
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 forCardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation
. 2010;122(suppl 3):S685–S705.
(Circulation. 2010;122[suppl 3]:S685–S705.)
2010 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
November 2, 2010
depends on these compressions. Therefore, chest compres-
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.19,22–26
starting CPR in the adult victim of sudden cardiac arrest. The
To help bystanders recognize cardiac arrest, 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. High-quality CPR
quality of breathing (normal versus not normal). Dispatchers
is important not only at the onset but throughout the course of
should be specifically educated in recognition of abnormal
resuscitation. 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.6
cardiac arrest (Class I, LOE B). Notably, dispatchers should
Rapid defibrillation is a powerful predictor of successful
be aware that brief generalized seizures may be the first
resuscitation following VF SCA.7,8 Efforts to reduce the
manifestation of cardiac arrest.26,27 Dispatchers should rec-
interval from collapse to defibrillation can potentially im-
ommend CPR for unresponsive victims who are not breathing
prove survival in both out-of-hospital and in-hospital settings.8,9
normally because most are in cardiac arrest and the frequency
Depending on the setting and circumstances, earlier defibril-
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, LOE B).28 In summary, in addition
rescuers who are laypersons, nontraditional first responders,
to activating professional emergency responders, the dis-
police, emergency medical services (EMS) professionals, and
patcher should ask straightforward questions about whether
hospital professionals.9–12 One of these strategies is the use of
the patient is conscious and breathing normally in order to
an AED. The AED correctly assesses heart rhythm, enabling
identify patients with possible cardiac arrest. 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.
Because it is easier for rescuers receiving telephone CPR
Immediate recognition and activation
, early CPR
instructions to perform Hands-Only (compression-only) CPR
(when appropriate) are the first three
than conventional CPR (compressions plus rescue breathing),
BLS links in the adult Chain of Survival. 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, LOE B).29
may be involved in a resuscitation attempt only once in their
While Hands-Only CPR instructions have broad applicability,
lives. Thus, creating an effective strategy to translate BLS
instances remain when rescue breaths are critically important.
skills to real-world circumstances presents a challenge. 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-
pediatric victims with a high likelihood of an asphyxial cause
ing the challenges of real-world application. Everyone, re-
of arrest (eg, drowning).30
gardless of training or experience, can potentially be a
The EMS system quality improvement process, including
review of the quality of dispatcher CPR instructions provided
The rest of this chapter is organized in sections that address
to specific callers, is considered an important component of a
the emergency response system, adult BLS sequence, adult
high-quality lifesaving program (Class IIa, LOE B).31–33
BLS skills, use of an AED, special resuscitation situations,and the quality of BLS. 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. The "Adult BLS Skills" section provides greater
and actions, which are illustrated in the new simplified BLS
detail regarding individual CPR skills and more information
algorithm (Figure 1). The intent of the algorithm is to present
about Hands-Only (compression-only) CPR. 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, remember and perform.
syndromes, stroke, hypothermia, and foreign body airway
These actions have traditionally been presented as a sequence
obstruction. Because of increasing interest in monitoring and
of distinct steps to help a single rescuer prioritize actions.
ensuring the quality of CPR, the last section focuses on the
However, many workplaces and most EMS and in-hospital
quality of BLS.
resuscitations involve teams of providers who should performseveral actions simultaneously (eg, 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, and a third either provides ventilations or retrieves
EMS response.14 Bystanders (lay responders) should immedi-
the bag-mask for rescue breathing, and a fourth retrieves and
ately call their local emergency number to initiate a response
sets up a defibrillator).
anytime they find an unresponsive victim. Because dispatcherCPR instructions substantially increase the likelihood of by-
Immediate Recognition and Activation of the
stander CPR performance and improve survival from cardiac
Emergency Response System
arrest, all dispatchers should be appropriately trained to provide
If a lone rescuer finds an unresponsive adult (ie, no move-
telephone CPR instructions (Class I, LOE B).15–21
ment or response to stimulation) or witnesses an adult who
When dispatchers ask bystanders to determine if breathing
suddenly collapses, after ensuring that the scene is safe, the
is present, bystanders often misinterpret agonal gasps or
rescuer should check for a response by tapping the victim on
abnormal breathing as normal breathing. This erroneous
the shoulder and shouting at the victim. The trained or
Berg et al
Part 5: Adult Basic Life Support
Simplified adult BLS algorithm.
untrained bystander should—at a minimum—activate the
community emergency response system (eg, call 911, or if in
Studies have shown that both lay rescuers and healthcare
an institution with an emergency response system, call that
providers have difficulty detecting a pulse.35–44 Healthcare
facility's emergency response number). If the victim also has
providers also may take too long to check for a pulse.38,41
absent or abnormal breathing (ie, only gasping), the rescuershould assume the victim is in cardiac arrest (Class I,
The lay rescuer should not check for a pulse and should
LOE C).19,24,34 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
rescuer through the check for breathing and the steps of CPR,
The healthcare provider should take no more than 10
if needed. The healthcare provider can check for response and
seconds to check for a pulse and, if the rescuer does not
look for no breathing or no normal breathing (ie, only
definitely feel a pulse within that time period, the rescuer
gasping) almost simultaneously before activating the emer-
should start chest compressions (Class IIa, LOE C).45,46
gency response system. After activation of the emergencyresponse system, all rescuers should immediately begin CPR
(see steps below) for adult victims who are unresponsive withno breathing or no normal breathing (only gasping).
When phoning 911 for help, 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. These
incident, the events of the incident, the number and condition
compressions create blood flow by increasing intrathoracic
of the victim(s), and the type of aid provided. If rescuers
pressure and directly compressing the heart. This generates
never learned or have forgotten how to do CPR, they should
blood flow and oxygen delivery to the myocardium and brain.
also be prepared to follow the dispatcher's instructions.
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.
blood flow during CPR. For this reason all patients in
November 2, 2010
cardiac arrest should receive chest compressions (Class I,
Rescuer Specific CPR Strategies: Putting It
To provide effective chest compressions, push hard and
This section summarizes the sequence of CPR interventions
push fast. 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. The specific steps
100 compressions per minute (Class IIa, LOE B) with a
that rescuers should take (Hands-Only CPR, conventional
compression depth of at least 2 inches/5 cm (Class IIa,
CPR with rescue breathing, CPR and AED use) are deter-
LOE B). Rescuers should allow complete recoil of the
mined by the rescuer's level of training.
chest after each compression, to allow the heart to fill
Untrained Lay Rescuer
completely before the next compression (Class IIa, LOE B).
If a bystander is not trained in CPR, then the bystander should
Rescuers should attempt to minimize the frequency and
provide Hands-Only (chest compression only) CPR, with an
duration of interruptions in compressions to maximize the
emphasis on "push hard and fast," or follow the directions of
number of compressions delivered per minute (Class IIa, LOE
the emergency medical dispatcher. The rescuer should con-
B). A compression-ventilation ratio of 30:2 is recommended
tinue Hands-Only CPR until an AED arrives and is ready for
(Class IIa, LOE B).
use or healthcare providers take over care of the victim (ClassIIa, LOE B).
A change in the 2010 AHA Guidelines for CPR and ECC
Trained Lay Rescuer
to recommend the initiation of compressions before ventila-
All lay rescuers should, at a minimum, provide chest com-
tions. While no published human or animal evidence demon-
pressions for victims of cardiac arrest. In addition, if the
strates that starting CPR with 30 compressions rather than 2
trained lay rescuer is able to perform rescue breaths, he or she
ventilations leads to improved outcomes, it is clear that blood
should add rescue breaths in a ratio of 30 compressions to 2breaths. The rescuer should continue CPR until an AED
flow depends on chest compressions. Therefore, delays in,
arrives and is ready for use or EMS providers take over care
and interruptions of, chest compressions should be minimized
of the victim (Class I, LOE B).
throughout the entire resuscitation. Moreover, chest compres-sions can be started almost immediately, while positioning
the head, achieving a seal for mouth-to-mouth rescue breath-
Optimally all healthcare providers should be trained in BLS.
ing, and getting a bag-mask apparatus for rescue breathing all
In this trained population it is reasonable for both EMS and
take time. 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,
(Class IIb, LOE C).52–54
LOE B). This should be performed in cycles of 30 compres-
Once chest compressions have been started, a trained
sions to 2 ventilations until an advanced airway is placed;
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, as follows:
of 1 breath every 6 to 8 seconds (8 to 10 ventilations perminute) should be performed. Care should be taken to
Deliver each rescue breath over 1 second (Class IIa, LOE C).
minimize interruptions in chest compressions when placing,
Give a sufficient tidal volume to produce visible chest rise
or ventilating with, an advanced airway. In addition, exces-
(Class IIa, LOE C).55
sive ventilation should be avoided.
Use a compression to ventilation ratio of 30 chest com-
It is reasonable for healthcare providers to tailor the sequence
pressions to 2 ventilations.
of rescue actions to the most likely cause of arrest. For example,if a lone healthcare provider sees an adolescent suddenly
Early Defibrillation With an AED
collapse, 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), get an AED (if nearby), 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. The rescuer should then provide high-quality CPR.
CPR. If a lone healthcare provider aids an adult drowning victimor a victim of foreign body airway obstruction who becomes
When 2 or more rescuers are present, one rescuer should
unconscious, 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, LOE C).
defibrillator in most hospitals) (Class IIa, LOE C). The AEDshould be used as rapidly as possible and both rescuers should
Adult BLS Skills
provide CPR with chest compressions and ventilations.
The sequence of BLS skills for the healthcare provider is
depicted in the BLS Healthcare Provider Algorithm (seeFigure 2).
Turn the AED on.
Follow the AED prompts.
Recognition of Arrest (Box 1)
Resume chest compressions immediately after the shock
The necessary first step in the treatment of cardiac arrest is
immediate recognition. Bystanders may witness the sudden
Berg et al
Part 5: Adult Basic Life Support
BLS healthcare provider
collapse of a victim or find someone who appears lifeless. At
center, should emphasize how to recognize occasional gasps
that time several steps should be initiated. Before approach-
and should instruct rescuers to provide CPR even when the
ing a victim, the rescuer must ensure that the scene is safe and
unresponsive victim demonstrates occasional gasps (Class I,
then check for response. To do this, tap the victim on the
shoulder and shout, "Are you all right?" If the victim is
These 2010 AHA Guidelines for CPR and ECC
responsive he or she will answer, move, or moan. If the
deemphasize the pulse check as a mechanism to identify
victim remains unresponsive, the lay rescuer
cardiac arrest. Studies have shown that both laypersons and
the emergency response system. The health care provider
healthcare providers have difficulty detecting a pulse.35–44
should also check for no breathing or no normal breathing (ie,
For this reason pulse check was deleted from training for lay
only gasping) while checking for responsiveness; if the health-
rescuers several years ago, and is deemphasized in training for
care provider finds the victim is unresponsive with no breathing
healthcare providers. The lay rescuer should assume that cardiac
or no normal breathing (ie, only gasping), 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 notbreathing normally (ie, only gasping).
the emergency response system (Class I, LOE C19,24,34).
Healthcare providers may take too long to check for a
These 2010 AHA Guidelines for CPR and ECC
pulse38,41 and have difficulty determining if a pulse is present
size checking for breathing. Professional as well as lay
or absent.38,41,45 There is no evidence, however, that checking
rescuers may be unable to accurately determine the presence
for breathing, coughing, or movement is superior for detec-
or absence of adequate or normal breathing in unresponsive
tion of circulation.58 Because delays in chest compressions
victims35,56 because the airway is not open57 or because the
should be minimized, the healthcare provider should take no
victim has occasional gasps, which can occur in the first
more than 10 seconds to check for a pulse; 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. Occasional gasps do not necessarily result in
rescuer should start chest compressions (Class IIa, LOE C45,46).
adequate ventilation. The rescuer should treat the victim whohas occasional gasps as if he or she is not breathing (Class I,
Technique: Chest Compressions (Box 4)
LOE C). CPR training, both formal classroom training and
To maximize the effectiveness of chest compressions, place
"just in time" training such as that given through a dispatch
the victim on a firm surface when possible, in a supine
November 2, 2010
position with the rescuer kneeling beside the victim's chest
blood flow is determined partly by the duty cycle (reduced
(eg, out-of-hospital) or standing beside the bed (eg, in-
coronary perfusion is associated with a duty cycle of ⬎50%)
hospital).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.86 Although duty cycles ranging between 20%
mattress displacement rather than chest compression, we have
and 50% can result in adequate coronary and cerebral
traditionally recommended the use of a backboard despite
perfusion,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, LOE C75).
during CPR.60–63 If a backboard is used, care should be taken
In 2005 3 human observational studies91–93 showed that
to avoid delays in initiation of CPR, to minimize interruptions
interruptions of chest compressions were common, averaging
in CPR, and to avoid line/tube displacement.61 Air-filled
24% to 57%85,91–93 of the total arrest time.
mattresses should be deflated when performing CPR.64,65
The preponderance of efficacy
data94,95 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. Data are now accumulating regard-
the hands are overlapped and parallel (Class IIa, LOE B66–69).
ing the effectiveness
of these interventions in "the real
Correct performance of chest compressions requires sev-
world."2,96–102 Therefore, despite some data to the contrary,103
eral essential skills. The adult sternum should be depressed at
it is reasonable for rescuers to minimize interruption of chest
least 2 inches (5 cm) (Class IIa, LOE B70–73), with chest
compressions for checking the pulse, analyzing rhythm, or
compression and chest recoil/relaxation times approximately
performing other activities throughout the entire resuscita-
equal (Class IIb, LOE C74,75). Allow the chest to completely
tion, particularly in the period immediately before and after a
recoil after each compression (Class IIa, LOE B76–80). In
shock is delivered (Class IIa, LOE B94–98).
human studies of CPR in out-of-hospital81 and in-hospital
Additional evidence of the importance of minimizing
settings,78–80 incomplete chest wall recoil was common,
interruptions in chest compressions comes from nonrandom-
particularly when rescuers were fatigued.78,81 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, includ-
delivery of continuous chest compressions without initial
ing decreased coronary perfusion, cardiac index, myocardial
assisted ventilations,97,98 or by EMS providers using a higher
blood flow, and cerebral perfusion.76,82 Importantly, the
compression-to-ventilation ratio (50:2).96 Notably, in each of
incidence of incomplete chest wall recoil can be reduced
these studies, the airway was opened, oxygen insufflations
during CPR by using electronic recording devices that pro-
were provided, and assisted ventilation was recommended at
vide real-time feedback.80 Manikin studies suggest that lifting
some point during the EMS resuscitation. Other EMS systems
the heel of the hand slightly, but completely, off the chest can
have noted significant improvement in survival from out-of-
improve chest recoil.77,81
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
minimization of hands-off time.2,99 At this time there is
proportion of time that chest compressions are delivered
insufficient evidence to support the removal of ventilations
without interruption. The compression rate refers to the speedof compressions, not the actual number of compressions
from CPR provided by EMS professionals.
delivered per minute. The actual number of chest compres-
Rescuer fatigue may lead to inadequate compression rates
sions delivered per minute is determined by the rate of chest
or depth.104–106 Significant fatigue and shallow compressions
compressions and the number and duration of interruptions to
are common after 1 minute of CPR, although rescuers may
open the airway, deliver rescue breaths, and allow AED
not recognize that fatigue is present for ⱖ5 minutes.105 When
analysis.83,84 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.6,85
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, LOE B). Consider switching compressors during
ROSC. Extrapolation of data from an out-of-hospital obser-
any intervention associated with appropriate interruptions in
vational study6 showed improved survival to hospital dis-
chest compressions (eg, when an AED is delivering a shock).
charge when at least 68 to 89 chest compressions per minute
Every effort should be made to accomplish this switch in ⬍5
were delivered; the study also demonstrated that improved
seconds. If the 2 rescuers are positioned on either side of the
survival occurred with chest compression rates as high as
patient, 1 rescuer will be ready and waiting to relieve the
120/min. It is therefore reasonable for lay rescuers and
"working compressor" every 2 minutes.
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,
taneous pulse or to otherwise check for return of spontaneous
circulation (ROSC) can compromise vital organ perfu-
The term "duty cycle" refers to the time spent compressing
sion.2,94–99 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. Coronary
(Class IIa, LOE C). In addition lay rescuers should continue
Berg et al
Part 5: Adult Basic Life Support
CPR until an AED arrives, the victim wakes up, or EMS
also provide some air exchange.19,110,111,119–122 However, at
personnel take over CPR (Class IIa, LOE B).
some time during prolonged CPR, supplementary oxygen
Healthcare providers should interrupt chest compressions
with assisted ventilation is necessary. 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, except for specific interventions such
not known at this time.110,111,119,123–126
as insertion of an advanced airway or use of a defibrillator
Laypersons should be encouraged to provide chest com-
(Class IIa, LOE C). Because of difficulties with pulse
pressions (either Hands-Only or conventional CPR, including
assessments, interruptions in chest compressions for a pulse
rescue breaths) for anyone with a presumed cardiac arrest
check should be minimized during the resuscitation, even to
(Class I, LOE B). No prospective study of adult cardiac arrest
determine if ROSC has occurred.
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 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, LOE C). This may not be possible if the
tional CPR (including rescue breaths) as opposed to Hands-
environment is dangerous.
Only CPR was provided for children in cardiac arrest due tononcardiac causes.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, witnessed collapse of adolescents), from
adults, but further validation of this guideline is needed (Class
asphyxial cardiac arrests in both adults and children (eg,
IIb, LOE B83,107–111). This 30:2 ratio in adults is based on a
drowning, drug overdose) and from prolonged cardiac arrests,
consensus among experts and on published case series.2,99–102
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, LOE C109,123,127–129).
and to define the best compression-ventilation ratio in termsof survival and neurologic outcome in patients with or
Managing the Airway
without an advanced airway in place.
As previously stated, a significant change in these Guidelines
Once an advanced airway is in place, 2 rescuers no longer
is to recommend the initiation of chest compressions before
need to pause chest compressions for ventilations. Instead,
ventilations (CAB rather than ABC). 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, LOE B). 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. This mindset can
yields 8 to 10 breaths per minute).
occur even when more than 1 rescuer is present because
"airway and breathing before ventilations" is so ingrained in
Only about 20% to 30% of adults with out-of-hospital cardiac
many rescuers. This new emphasis on CAB helps clarify that
arrests receive any bystander CPR.29,48–51,112,113 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-
mized and chest compressions should take priority in the
pared with no bystander CPR.29,48–51 Observational studies of
resuscitation of an adult.
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.29,48–51 Of
perform both compressions and ventilations should open the
note, some healthcare providers114–116 and laypersons116,117
airway using a head tilt– chin lift maneuver (Class IIa, LOE B).
indicate that reluctance to perform mouth-to-mouth ventila-
For the rescuer providing Hands-Only CPR, 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. When actual bystanders
airway (such as hyperextending the neck to allow passive
were interviewed, however, such reluctance was not ex-
pressed; panic was cited as the major obstacle to laypersonsperformance of bystander CPR.118 The simpler Hands-Only
Open the Airway: Healthcare Provider
technique may help overcome panic and hesitation to act.
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, rescue breaths are
head or neck trauma. Although the head tilt– chin lift tech-
not as important as chest compressions because the oxygen
nique was developed using unconscious, 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. In addition, many cardiac arrest
arrest, clinical130 and radiographic evidence131,132 and a case
victims exhibit gasping or agonal gasps, and gas exchange
series133 have shown it to be effective (Class IIa, LOE B).
allows for some oxygenation and carbon dioxide (CO )
Between 0.12 and 3.7% of victims with blunt trauma have
elimination.110,111,119 If the airway is open, passive chest
a spinal injury,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,137,138 a Glasgow Coma
November 2, 2010
Scale score of ⬍8,139,140 or both.138,139 For victims with
During CPR the primary purpose of assisted ventilation is
suspected spinal injury, rescuers should initially use manual
to maintain adequate oxygenation; the secondary purpose is
spinal motion restriction (eg, placing 1 hand on either side of
to eliminate CO . However, the optimal inspired oxygen
the patient's head to hold it still) rather than immobilization
concentration, tidal volume and respiratory rate to achieve
devices (Class IIb, LOE C141,142). Spinal immobilization
those purposes are not known. As noted above, during the
devices may interfere with maintaining a patent airway,143,144
first minutes of sudden VF cardiac arrest, rescue breaths are
but ultimately the use of such a device may be necessary to
not as important as chest compressions29,108,153 because the
maintain spinal alignment during transport.
oxygen content in the noncirculating arterial blood remains
If healthcare providers suspect a cervical spine injury, they
unchanged until CPR is started; the blood oxygen content
should open the airway using a jaw thrust without head exten-
then continues to be adequate during the first several minutes
sion (Class IIb, LOE C133). Because maintaining a patent airway
of CPR. In addition, attempts to open the airway and give
and providing adequate ventilation are priorities in CPR (Class I,
rescue breaths (or to access and set up airway equipment)
LOE C), use the head tilt– chin lift maneuver if the jaw thrust
may delay the initiation of chest compressions.154 These
does not adequately open the airway.
issues support the CAB approach of the 2010 AHA Guide-
lines for CPR and ECC
(ie, starting with C
Rescue Breathing (Box 3A, 4)
prior to A
irway and B
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
the blood is consumed and oxygen in the lungs is depleted
Deliver each rescue breath over 1 second (Class IIa, LOE C).
(although the precise time course is unknown). Ventilations
Give a sufficient tidal volume to produce visible chest rise
and compressions are also important for victims of asphyxial
(Class IIa, LOE C).55
arrest, such as children and drowning victims, because they
Use a compression to ventilation ratio of 30 chest com-
are hypoxemic at the time of cardiac arrest.30,109
pressions to 2 ventilations.
When an advanced airway (ie, endotracheal tube, Combi-
Mouth-to-mouth rescue breathing provides oxygen and ven-
tube, or laryngeal mask airway [LMA]) is in place during
tilation to the victim.155 To provide mouth-to-mouth rescue
2-person CPR, give 1 breath every 6 to 8 seconds without
breaths, open the victim's airway, pinch the victim's nose,
attempting to synchronize breaths between compressions
and create an airtight mouth-to-mouth seal. Give 1 breath
(this will result in delivery of 8 to 10 breaths/minute).
over 1 second, take a "regular" (not a deep) breath, and give
There should be no pause in chest compressions for
a second rescue breath over 1 second (Class IIb, LOE C).
delivery of ventilations (Class IIb, LOE C).
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. The most common cause
normal oxygenation and elimination of CO . During CPR,
of ventilation difficulty is an improperly opened airway,57 so
cardiac output is ⬇25% to 33% of normal, so oxygen uptake
if the victim's chest does not rise with the first rescue breath,
from the lungs and CO
delivery to the lungs are also
reposition the head by performing the head tilt– chin lift again
reduced. As a result, a low minute ventilation (lower than
and then give the second rescue breath.
normal tidal volume and respiratory rate) can maintain
If an adult victim with spontaneous circulation (ie, strong
effective oxygenation and ventilation.55,110,111,119 For that
and easily palpable pulses) requires support of ventilation, 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, LOE
about 1 breath every 5 to 6 seconds, or about 10 to 12 breaths
B).145–147 This is consistent with a tidal volume that produces
per minute (Class IIb, LOE C). Each breath should be given
visible chest rise.
over 1 second regardless of whether an advanced airway is in
Patients with airway obstruction or poor lung compliance
place. Each breath should cause visible chest rise.
may require high pressures to be properly ventilated (to make
the chest visibly rise). 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.148 Ensure that the bag-mask device
to use a barrier device. The risk of disease transmission through
allows you to bypass the pressure-relief valve and use high
mouth to mouth ventilation is very low, and it is reasonable to
pressures, if necessary, to achieve visible chest expansion.149
initiate rescue breathing with or without a barrier device. When
Excessive ventilation is unnecessary and can cause gastric
using a barrier device the rescuer should not delay chest
inflation and its resultant complications, such as regurgitation
compressions while setting up the device.
and aspiration (Class III, LOE B150–152). More important,excessive ventilation can be harmful because it increases
Mouth-to-Nose and Mouth-to-Stoma Ventilation
intrathoracic pressure, decreases venous return to the heart,
Mouth-to-nose ventilation is recommended if ventilation
and diminishes cardiac output and survival.152 In summary,
through the victim's mouth is impossible (eg, the mouth is
rescuers should avoid excessive ventilation (too many breaths
seriously injured), the mouth cannot be opened, the victim is
or too large a volume) during CPR (Class III, LOE B).
in water, or a mouth-to-mouth seal is difficult to achieve
Berg et al
Part 5: Adult Basic Life Support
(Class IIa, LOE C). 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, safe, and effective.156
regions (with specific authorization from medical control).
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. 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, pediatric face mask (Class IIb, LOE C). There is no
devices for airway management during cardiac arrest (Class IIa,
published evidence on the safety, effectiveness, or feasibility
LOE B166–171). It is not clear that these devices are any more or
of mouth-to-stoma ventilation. One study of patients with
less complicated to use than a bag and mask; 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.157
of the advanced airways. These devices are discussed in greater
Ventilation With Bag and Mask
detail in Part 8.1 of these Guidelines.
Rescuers can provide bag-mask ventilation with room air or
Ventilation With an Advanced Airway
oxygen. A bag-mask device provides positive-pressure ven-
When the victim has an advanced airway in place during
tilation without an advanced airway; therefore a bag-mask
CPR, rescuers no longer deliver cycles of 30 compressions
device may produce gastric inflation and its complications.
and 2 breaths (ie, they no longer interrupt compressions to
The Bag-Mask Device
deliver 2 breaths). Instead, 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; either no pressure relief valve or a pressure relief
for ventilation, and ventilations are delivered at the rate of 1
valve that can be bypassed; standard 15-mm/22-mm fittings;
breath about every 6 to 8 seconds (which will deliver
an oxygen reservoir to allow delivery of high oxygen con-
approximately 8 to 10 breaths per minute).
centrations; a nonrebreathing outlet valve that cannot beobstructed by foreign material and will not jam with an
Passive Oxygen Versus Positive-Pressure Oxygen
oxygen flow of 30 L/min; and the capability to function
Although many studies describe outcomes after compression-
satisfactorily under common environmental conditions and
only CPR, these studies infrequently address additional tech-
extremes of temperature.
Masks should be made of transparent material to allow
niques to improve ventilation or oxygenation. Two compar-
detection of regurgitation. They should be capable of creating
ative studies97,172 and 2 post hoc analysis studies98,173 of
a tight seal on the face, covering both mouth and nose. Masks
passive ventilation airway techniques during cardiac arrest
should be fitted with an oxygen (insufflation) inlet and have
used the same protocol. The protocol included insertion of an
a standard 15-mm/22-mm connector.159 They should be
oral airway and administration of oxygen with a nonre-
available in one adult and several pediatric sizes.
breather mask, with interposed ventilations versus passiveinsufflation of oxygen during minimally interrupted chest
compressions. These studies did not demonstrate a significant
Bag-mask ventilation is a challenging skill that requires
overall improvement in outcome measures. However, sub-
considerable practice for competency.160,161 Bag-mask venti-
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.
lone rescuer during CPR. It is most effective when provided
For layperson Hands-Only CPR, evidence is insufficient to
by 2 trained and experienced rescuers. 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.
the bag. Both rescuers watch for visible chest rise.160,162
The rescuer should use an adult (1 to 2 L) bag to deliver
approximately 600 mL tidal volume163–165 for adult victims.
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. Cri-
(Class IIa, LOE C145–147). If the airway is open and a good,
coid pressure can prevent gastric inflation and reduce the risk
tight seal is established between face and mask, this volume
of regurgitation and aspiration during bag-mask ventilation,
can be delivered by squeezing a 1-L adult bag about two
but it may also impede ventilation. Seven randomized,
thirds of its volume or a 2-L adult bag about one third of its
controlled studies demonstrated that cricoid pressure can
volume. As long as the patient does not have an advanced
delay or prevent the placement of an advanced airway and
airway in place, the rescuers should deliver cycles of 30
that aspiration can occur despite application of pressure.174–180
compressions and 2 breaths during CPR. 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.
breath over 1 second (Class IIa, LOE C). The healthcare
Neither expert nor nonexpert rescuers demonstrated mastery
provider should use supplementary oxygen (O concentration
of the technique, and the applied pressure was frequently
⬎40%, at a minimum flow rate of 10 to 12 L/min) when
inconsistent and outside of effective limits. Cricoid pressure
might be used in a few special circumstances (eg, to aid in
Ventilation With a Supraglottic Airway
viewing the vocal cords during tracheal intubation). How-
Supraglottic airway devices such as the LMA, the
ever, the routine use of cricoid pressure in adult cardiac arrest
esophageal-tracheal combitube and the King airway device,
is not recommended (Class III, LOE B).
November 2, 2010
AED Defibrillation (Box 5, 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.195 For victims with VF, sur-
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 2006.208 The American Heart Association estimates
provided and defibrillation occurs within 3 to 5 minutes
that in 2010, 785 000 Americans will have a new coronary
of collapse.4,5,10,11,196,197 Rapid defibrillation is the treatment
attack and 470 000 will have a recurrent attack.208 Approxi-
of choice for VF of short duration, 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, most within the first 4
patients whose heart rhythm is monitored (Class I, LOE A).
hours after the onset of symptoms.208,209
In swine, microvascular blood flow is markedly reduced
Early recognition, diagnosis, and treatment of AMI can
within 30 seconds of the onset of VF; chest compressions
improve outcome by limiting damage to the heart,210 but
restore some of the diminished microvascular blood flow
treatment is most effective if provided within a few hours of
within 1 minute.198 Performing chest compressions while
the onset of symptoms.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, some animal models suggest that a period of
the EMS system when symptoms appear, rather than delaying
chest compressions before defibrillation may be beneficial.199
care by contacting family, calling a physician, or driving
In 2 randomized controlled trials in adults with out-of-
themselves to the hospital.
hospital VF/pulseless ventricular tachycardia (VT), a period
The classic symptoms associated with ACS are chest
discomfort, discomfort in other areas of the upper body,
2 to 3 minutes of CPR by EMS before defibrillation did
not improve ROSC or survival rates regardless of EMS
shortness of breath, sweating, nausea, and lightheadedness.
response interval.200,201 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. Atypical symptoms of ACS may be more common
no overall differences in outcomes. However, in two of these
in the elderly, women, and diabetic patients, but any patient
studies subgroups of patients with the EMS response interval
may present with atypical signs and symptoms.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
35% to 92% and specificity ranges from 28% of 91%.
Numerous studies do not support the use of any clinical signs
There is insufficient evidence to recommend for or against
and symptoms independent of electrocardiograph (ECG)
delaying defibrillation to provide a period of CPR for patients
tracings, cardiac biomarkers, or other diagnostic tests to rule
in VF/pulseless VT out-of-hospital cardiac arrest. In settings
in or rule out ACS in prehospital or emergency department
with lay rescuer AED programs (AED onsite and available)
and for in-hospital environments, or if the EMS rescuer
To improve ACS outcome, all dispatchers and EMS
witnesses the collapse, the rescuer should use the defibrillator
providers must be trained to recognize ACS symptoms, even
as soon as it is available (Class IIa, LOE C). When more than
if atypical. It is reasonable for dispatchers to advise patients
one rescuer is available, one rescuer should provide chest
with potential cardiac symptoms to chew an aspirin (160 to
compressions while another activates the emergency response
325 mg), providing the patient has no history of aspirin
system and retrieves the defibrillator. Defibrillation is dis-
allergy and no signs of active or recent gastrointestinal
cussed in further detail in Part 6: "Electrical Therapies."
bleeding (Class IIa, LOE C).229–233
EMS providers should obtain a 12-lead ECG, determine
onset of ACS symptoms, and provide prearrival notification
The recovery position is used for unresponsive adult victims
to the destination hospital.229,234 Clinical trials have shown
who clearly have normal breathing and effective circulation.
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. The
percutaneous coronary intervention (PCI)– capable hospi-
victim is placed on his or her side with the lower arm in front
tal.235–237 If the patient has a STEMI on ECG and if PCI is the
of the body.
chosen method of reperfusion, it is reasonable to transport the
There are several variations of the recovery position, each
patient directly to a PCI facility, bypassing closer emergency
with its own advantages. No single position is perfect for all
departments as necessary, in systems where time intervals
victims.204,205 The position should be stable, near a true lateral
between first medical contact and balloon times are less than
position, with the head dependent and with no pressure on the
90 minutes, and transport times are relatively short (ie, less
chest to impair breathing (Class IIa, LOE C). Studies in
than 30 minutes), or based on regional EMS protocols (Class
normal volunteers206 show that extending the lower arm
IIa, LOE B).
above the head and rolling the head onto the arm, while
Common practice has been for basic EMT's to administer
bending both legs, may be feasible for victims with known or
oxygen during the initial assessment of patients with sus-
suspected spinal injury.207
pected ACS. However, there is insufficient evidence to
Berg et al
Part 5: Adult Basic Life Support
‘support or refute oxygen use in uncomplicated ACS. If the
of stroke and to call EMS as soon as any signs of stroke are
patient is dyspneic, hypoxemic, has obvious signs of heart
present (Class I, LOE C). The signs and symptoms of stroke are
failure, or an oxyhemoglobin saturation ⬍94%, providers
sudden numbness or weakness of the face, arm, or leg, especially
should administer oxygen and titrate therapy to provide the
on one side of the body; sudden confusion, trouble speaking or
lowest administered oxygen concentration that will maintain
understanding; sudden trouble seeing in one or both eyes;
the oxyhemoglobin saturation ⱖ94% (Class I, LOE C).238 If
sudden trouble walking, dizziness, loss of balance or coordina-
the patient has not taken aspirin and has no history of aspirin
tion; and sudden severe headache with no known cause.252,253
allergy and no evidence of recent gastrointestinal bleeding,
Community and professional education is essential to improve
EMS providers should give the patient nonenteric aspirin
stroke recognition and early EMS activation.254–256
(160 to 325 mg) to chew (Class I, LOE C).229,234,239,240
EMS dispatchers should be trained to suspect stroke and
EMS providers can administer nitroglycerin for patients
rapidly dispatch emergency responders. EMS personnel
with chest discomfort and suspected ACS. Although it is
should be able to perform an out-of-hospital stroke assess-
reasonable to consider the early administration of nitroglyc-
ment (Class I, LOE B257–259), establish the time of symptom
erin in select hemodynamically stable patients, insufficient
onset when possible, provide cardiopulmonary support, 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.260–262 EMS systems should have
with a suspected ACS (Class IIb, LOE B).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, LOE B261,263,264). 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).
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, and a right-sided ECG should be performed to
Patients with acute stroke are at risk for respiratory
evaluate right ventricular infarction. Administer nitrates with
compromise, and the combination of poor perfusion and
extreme caution, if at all, 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.265 Both out-of-hospital and in-
adequate RV preload. Nitrates are contraindicated when
hospital medical personnel should administer supplementary
patients have taken a phosphodiesterase-5 (PDE-5) inhibitor
oxygen to hypoxemic (ie, oxygen saturation ⬍94%) stroke
within 24 hours (48 hours for tadalafil).
patients (Class 1, LOE C) or those with unknown oxygen
For patients diagnosed with STEMI in the prehospital
saturation. There are no data to support initiation of hyper-
setting, EMS providers should administer appropriate anal-
tension intervention in the prehospital environment. Unless
gesics, such as intravenous morphine, for persistent chest
the patient is hypotensive (systolic blood pressure
pain (Class IIa, LOE C). EMS providers may consider
⬍90 mm Hg), prehospital intervention for blood pressure is
administering intravenous morphine for undifferentiated
not recommended (Class III, LOE C). Additional information
chest pain unresponsive to nitroglycerin (Class IIb, LOE C).
about the assessment of stroke using stroke scales and the
However, morphine should be used with caution in unstable
management of stroke is included in Part 11: "Adult Stroke."
angina (UA)/NSTEMI due to an association with increasedmortality in a large registry.
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.266 Over the last 25 years, the incidence
"Acute Coronary Syndromes."
of fatal drowning has declined significantly from 3.8 deathsper 100 000 population in 1970 to 1.2 in 2006.266 The
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, and stroke is a leading cause of severe, long-term
come.267,268 Rescuers should provide CPR, particularly rescue
disability and death.245 Fibrinolytic therapy administered within
breathing, 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). When rescuing a
injury and improves outcome in selected patients with acute
drowning victim of any age, it is reasonable for the lone
ischemic stroke.246–249 The window of opportunity is extremely
healthcare provider to give 5 cycles (about 2 minutes) of CPR
limited, however. Effective therapy requires early detection of
before leaving the victim to activate the EMS system.
the signs of stroke, prompt activation of the EMS system and
Mouth-to-mouth ventilation in the water may be helpful
dispatch of EMS personnel; appropriate triage to a stroke center;
when administered by a trained rescuer (Class IIb, LOE C269).
prearrival notification; rapid triage, evaluation, and management
Chest compressions are difficult to perform in water; they
in the ED; and rapid delivery of fibrinolytic therapy to eligible
may not be effective and they could potentially cause harm to
patients. For additional information about these steps, see the
both the rescuer and the victim. There is no evidence that
AHA/American Stroke Association (ASA) Guidelines for the
water acts as an obstructive foreign body. Maneuvers to
management of acute ischemic stroke and Part 11: "Adult
relieve foreign-body airway obstruction (FBAO) are not
recommended for drowning victims because such maneuvers
Patients at high risk for stroke, their family members, and
are not necessary and they can cause injury, vomiting,
BLS providers should learn to recognize the signs and symptoms
aspiration, and delay of CPR.270
November 2, 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,
quickly as possible. Spinal cord injury is rare among fatal
rescuers must act quickly to relieve the obstruction. If mild
drowning victims.271 Victims with obvious clinical signs of
obstruction is present and the victim is coughing forcefully, do
injury, alcohol intoxication, 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, and health care
ing efforts. Attempt to relieve the obstruction only if signs of
providers may consider stabilization and possible immobiliza-
severe obstruction develop: the cough becomes silent, respira-
tion of the cervical and thoracic spine for these victims.272
tory difficulty increases and is accompanied by stridor, or thevictim becomes unresponsive. Activate the EMS system quickly
if the patient is having difficulty breathing. If more than one
In an unresponsive victim with hypothermia, assessments of
rescuer is present, one rescuer should phone 911 while the other
breathing and pulse are particularly difficult because heart rate
rescuer attends to the choking victim.
and breathing may be very slow, depending on the degree of
The clinical data about effectiveness of maneuvers to
relieve FBAO are largely retrospective and anecdotal. For
If the victim is unresponsive with no normal breathing, 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"). If the adult victim is
back blows or "slaps,"276–278 abdominal thrusts,275–277,279,280
unresponsive with no breathing or no normal breathing (ie, only
and chest thrusts.276,281 In 1 case series of 513 choking
gasping), healthcare providers can check for a pulse, but should
episodes for which EMS was summoned,275 approximately
start CPR if a pulse is not definitely felt within 10 seconds. 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. EMS intervention with abdominal thrusts
the victim is rewarmed to start CPR. To prevent further heat loss,
successfully relieved the obstruction in more than 85% of the
remove wet clothes from the victim; insulate or shield the victim
remaining cases. The few patients with persistent obstruction
from wind, heat, or cold; and if possible, ventilate the victim
usually responded to suction or the use of Magill forceps.
with warm, humidified oxygen.
Less than 4% died.275
Avoid rough movement, and transport the victim to a
Although chest thrusts, back slaps, and abdominal thrusts are
hospital as soon as possible. If VF is detected, 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, 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").
rapid sequence until the obstruction is relieved (Class IIb, LOE
For the hypothermic patient in cardiac arrest, continue
B). If abdominal thrusts are not effective, the rescuer may
resuscitative efforts until the patient is evaluated by advanced
consider chest thrusts (Class IIb, LOE B). It is important to note
care providers. In the out-of-hospital setting, passive warm-
that abdominal thrusts are not recommended for infants ⬍1 year
ing can be used until active warming is available.
of age because thrusts may cause injuries.
Chest thrusts should be used for obese patients if the
Foreign-Body Airway Obstruction (Choking)
rescuer is unable to encircle the victim's abdomen. If the
FBAO is an uncommon, but preventable, cause of death.273
choking victim is in the late stages of pregnancy, the rescuer
Most reported cases of FBAO occur in adults while they are
should use chest thrusts instead of abdominal thrusts.
eating.274 Most reported episodes of choking in infants and
If the adult victim with FBAO becomes unresponsive, the
children occur during eating or play when parents or child-
rescuer should carefully support the patient to the ground,
care providers are present. The choking event is therefore
immediately activate (or send someone to activate) EMS, and
commonly witnessed, and the rescuer usually intervenes
then begin CPR. The healthcare provider should carefully
while the victim is still responsive. Treatment is usually
lower the victim to the ground, send someone to activate the
successful, and survival rates can exceed 95%.275
emergency response system and begin CPR (without a pulsecheck). After 2 minutes, if someone has not already done so,
Recognition of Foreign-Body Airway Obstruction
the healthcare provider should activate the emeregency re-
Because recognition of FBAO is the key to successful outcome,
sponse system. A randomized trial of maneuvers to open the
it is important to distinguish this emergency from fainting, heart
airway in cadavers282 and 2 prospective studies in anesthe-
attack, seizure, or other conditions that may cause sudden
tized volunteers281,283 showed that higher sustained airway
respiratory distress, cyanosis, or loss of consciousness.
pressures can be generated using the chest thrust rather than
Foreign bodies may cause either mild or severe airway
the abdominal thrust. Each time the airway is opened during
obstruction. The rescuer should intervene if the choking victim
CPR, the rescuer should look for an object in the victim's
shows signs of severe airway obstruction. These include signs of
mouth and if found, remove it. Simply looking into the mouth
poor air exchange and increased breathing difficulty, such as a
should not significantly increase the time needed to attempt
silent cough, cyanosis, or inability to speak or breathe. The
the ventilations and proceed to the 30 chest compressions.
victim may clutch the neck, demonstrating the universal choking
No studies have evaluated the routine use of the finger
sign. Quickly ask, "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, this will verify that
obstruction. The recommendation to use the finger sweep in
the victim has severe airway obstruction.
past guidelines was based on anecdotal reports that suggested
Berg et al
Part 5: Adult Basic Life Support
that it was helpful for relieving an airway obstruc-
tion.276,277,284 However, case reports have also documented
The critical lifesaving steps of BLS are
harm to the victim236,285,286 or rescuer.
of the emergency
The Quality of BLS
The quality of unprompted CPR in both in-hospital and out-of–
hospital cardiac arrest events is often poor, and methods should
be developed to improve the quality of CPR delivered to victimsof cardiac arrest.73,91–93,287 Several studies have demonstrated
When an adult suddenly collapses, whoever is nearby
improvement in chest compression rate, depth, chest recoil,
should activate the emergency system and begin chest com-
ventilation rate, and indicators of blood flow such as end-tidal
pressions (regardless of training). Trained lay rescuers who
) when real-time feedback or prompt devices are
are able and healthcare providers should provide compres-
used to guide CPR performance.72,73,80,288–293 However, there are
sions and ventilations. Contrary to the belief of too many in
no studies to date that demonstrate a significant improvement in
this situation, CPR is not harmful. Inaction is harmful and
patient survival related to the use of CPR feedback devices
CPR can be lifesaving
. However, the quality of CPR is
during actual cardiac arrest events. Other CPR feedback devices
critical. Chest compressions should be delivered by pushing
with accelerometers may overestimate compression depth when
hard and fast in the center of the chest (ie, chest compressions
compressions are performed on a soft surface such as a mattress
should be of adequate rate and depth). 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. They should also avoid
compression of the chest.62,294 Nevertheless, real-time CPR
excessive ventilation. If and when available, an AED should
prompting and feedback technology such as visual and auditory
be applied and used without delaying chest compressions. With
prompting devices can improve the quality of CPR (Class IIa,
prompt and effective provision of these actions, lives are saved
Guidelines Part 5: Adult Basic Life Support: Writing Group Disclosures
Other Research Support
Anesthesiology and Critical
Care Medicine, Division
Chief, Pediatric Critical
Emory University, Dept. of
*Paid writer for AHA
†Philips Healthcare-research grant for
*Laerdal Medical Corp-inkind support
*legal review of two
study of CPR during inhospital cardiac
of equipment for CPR research
topics of CPR and
arrest AHA Clinical Research Program
grant-research grant for study of CPR
training in the community Doris Duke
Foundation-research grant for study of
post resuscitation injury after cardiac
Medical College of
†NIH-ROC Consortium-PI of
*Zoll Medical Corp.-Supplied AEDs
Milwaukee site NETT-PI of Milwaukee
and software capturing CPR
performance data for ROC
*ResQTrial (Advanced Circulatory
Consortium Advanced Circulatory
Systems, Inc.)-PI of Oshkosh study
Systems, Inc.-Supplied impedance
site, In Kind NHLBI Trial-PI for
threshold devices for ROC
Milwaukee site, In Kind
JoLife-Consultant Take Heart
Legacy Health System,
system consists of 5
hospitals in the Portland,
Oregon metro area.
Emanuel Hospital is a
Center.– RN, MSN;
Portland Com. College,
Institute for Health
Vanderbilt University School of
Nursing—Professor; AHA ECC
from the AHA to write and
edit the AHA Guidelines and
resuscitation statements and
November 2, 2010
Guidelines Part 5: Adult Basic Life Support: Writing Group Disclosures, Continued
Other Research Support
Medical College of
†Title: Circulation Improving Resuscitation
*Stockholder in Medtronic,
Care Trial Source: Zoll Medical
Pfizer, and General
Corporation Role: Consultant Principal
Investigator: Lars Wik, M.D. Dates:
12/2006–8/2010 Total Funding to MCW:
$345,000 (funding is received by my
employer to support my time on this
trial. My institution receives support for
20% of my time and the remaining
funds are used for other members of our
staff and supplies. My role is to advise
them on human subject protection issuesand to assist with data management and
report generation for the trial)
University of Washington:
In the past, I have received unrestricted
We conducted an AED training
I serve on a DSMB
(modest) grant support from Philips Inc
study that recently completed where
for a trial sponsored
Professor of Medicine;
and PhysioControl. The topics were
Philips and PhysioControl contributed
related to improving resuscitation
equipment for the research. I did not
Services Division of Public
generally (changing resuscitation
receive any of this equipment
Health-Seattle & King
protocols) and not specific to
algorhithm to guide
proprietary information or equipment. I
care. I receive no
am currently an investigator in the ROC.
As part of this, I am directly involved in
effort in order to
the Feedback Trial to evaluate dynamic
fdbk available on the Philips MRX. The
ROC is also evaluating the impedance
threshold device. These studies are
supported by the NIH primarily and I
receive no support from Philips or the
company that makes the impedance
threshold device. I am participating in atrial of chest compression only vs chest
compression plus ventilation for
dispatch-assisted CPR-supported in part
by Laerdal Foundation. I receive less
than 5% salary support
The Ohio State University-
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, which all members of the writing group are required to complete and submit. A relationship is considered to be "significant" if (a) the personreceives $10 000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or shareof the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under thepreceding definition.
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KEY WORDS: cardiacarrest 䡲 defibrillation 䡲 emergency
St. Catherine University Metformin versus Lifestyle Modification in Diabetes Prevention: New Considerations in the Age of Healthcare ReformBrian H. ImdiekeSt. Catherine University Follow this and additional works at: Recommended CitationImdieke, Brian H., "Metformin versus Lifestyle Modification in Diabetes Prevention: New Considerations in the Age of HealthcareReform" (2013). Master of Arts in Nursing Theses. Paper 64.
fängt am Sonntag an Du sollst deinen Nächsten lieben wie dich selbst; ich bin der Herr. (3. Mose 19,18) s ist der 1. September 2001. In Israel beginnt das neue Schul-jahr. Die zwei heißesten Sommermonate, Juli und August, sind vorbei und damit die Sommerferien. Im südafrikanischen Durbanhetzen Araber gegen Israel, bezeichnen den jüdischen Staat als ras-sistisch und vergleichen seinen Umgang mit den Palästinensern mitdem Holocaust. Ich sitze im Schulhof einer israelischen Grund-schule und schaue der Begrüßungszeremonie für die Erstklässler zu.