Chiaramente, ogni formato ha i propri vantaggi e svantaggi comprare doxycycline senza ricetta per effettuare un acquisto, non è necessario fornire la prescrizione medica.
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
Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX
Copyright 2010 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
Subscriptions: Information about subscribing to Circulation is online at Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters
Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. 410-528-8550. E-mail: Reprints: Information about reprints can be found online at
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.
9. Hallstrom AP, Ornato JP, Weisfeldt M, Travers A, Christenson J,
1. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone
McBurnie MA, Zalenski R, Becker LB, Schron EB, Proschan M. Public-
G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K,
access defibrillation and survival after out-of-hospital cardiac arrest.
Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland
N Engl J Med
. 2004;351:637– 646.
D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D,
10. Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG.
Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P,
Outcomes of rapid defibrillation by security officers after cardiac arrest
Stafford R, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J.
in casinos. N Engl J Med
. 2000;343:1206 –1209.
Executive summary: heart disease and stroke statistics–2010 update: a
11. Agarwal DA, Hess EP, Atkinson EJ, White RD. Ventricular fibrillation
report from the American Heart Association. Circulation
in Rochester, Minnesota: experience over 18 years. Resuscitation
2. Rea TD, Helbock M, Perry S, Garcia M, Cloyd D, Becker L, Eisenberg
12. Eisenberg MS, Hallstrom AP, Copass MK, Bergner L, Short F, Pierce J.
M. Increasing use of cardiopulmonary resuscitation during out-of-
Treatment of ventricular fibrillation: emergency medical technician defi-
hospital ventricular fibrillation arrest: survival implications of guideline
brillation and paramedic services. JAMA
. 2006;114:2760 –2765.
13. Rho RW, Page RL. The automated external defibrillator. J Cardiovasc
3. Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide
. 2007;18:896 – 899.
TP, Rea T, Lowe R, Brown T, Dreyer J, Davis D, Idris A, Stiell I.
14. Becker LB, Pepe PE. Ensuring the effectiveness of community-wide
Regional variation in out-of-hospital cardiac arrest incidence and
emergency cardiac care. Ann Emerg Med
. 22(pt 2):354 –365, 1993.
15. Calle PA, Lagaert L, Vanhaute O, Buylaert WA. Do victims of an
4. Chan PS, Nichol G, Krumholz HM, Spertus JA, Nallamothu BK.
out-of-hospital cardiac arrest benefit from a training program for
Hospital variation in time to defibrillation after in-hospital cardiac arrest.
emergency medical dispatchers? Resuscitation
Arch Intern Med
16. Emergency medical dispatching: rapid identification and treatment of
5. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival
acute myocardial infarction. National Heart Attack Alert Program Coor-
from out-of-hospital cardiac arrest: a systematic review and meta-
dinating Committee Access to Care Subcommittee. Am J Emerg Med.
analysis. Circ Cardiovasc Qual Outcomes
. 2010;3:63– 81.
6. Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P, Hostler
D, Powell J, Callaway CW, Bishop D, Vaillancourt C, Davis D,
17. Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resus-
Aufderheide TP, Idris A, Stouffer JA, Stiell I, Berg R. Chest com-
citation by chest compression alone or with mouth-to-mouth ventilation.
pression fraction determines survival in patients with out-of-hospital
N Engl J Med
. 2000;342:1546 –1553.
ventricular fibrillation. Circulation
18. Culley LL, Clark JJ, Eisenberg MS, Larsen MP. Dispatcher-assisted
7. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating
telephone CPR: common delays and time standards for delivery. Ann
effectiveness of cardiac arrest interventions: a logistic regression
survival model. Circulation
. 1997;96:3308 –3313.
19. Berdowski J, Beekhuis F, Zwinderman AH, Tijssen JG, Koster RW.
8. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to
Importance of the first link: description and recognition of an out-of-
defibrillation after in-hospital cardiac arrest. N Engl J Med
hospital cardiac arrest in an emergency call. Circulation
Berg et al
Part 5: Adult Basic Life Support
20. Kuisma M, Boyd J, Vayrynen T, Repo J, Nousila-Wiik M, Holmstrom
41. Moule P. Checking the carotid pulse: diagnostic accuracy in students of
P. Emergency call processing and survival from out-of-hospital ven-
the healthcare professions. Resuscitation
tricular fibrillation. Resuscitation
. 2005;67:89 –93.
42. Nyman J, Sihvonen M. Cardiopulmonary resuscitation skills in nurses
21. Rea TD, Eisenberg MS, Culley LL, Becker L. Dispatcher-assisted car-
and nursing students. Resuscitation
. 2000;47:179 –184.
diopulmonary resuscitation and survival in cardiac arrest. Circulation
43. Owen CJ, Wyllie JP. Determination of heart rate in the baby at birth.
22. Hauff SR, Rea TD, Culley LL, Kerry F, Becker L, Eisenberg MS.
44. Sarti A, Savron F, Ronfani L, Pelizzo G, Barbi E. Comparison of three
Factors impeding dispatcher-assisted telephone cardiopulmonary resus-
sites to check the pulse and count heart rate in hypotensive infants.
citation. Ann Emerg Med
. 2006;16:394 –398.
23. Vaillancourt C, Verma A, Trickett J, Crete D, Beaudoin T, Nesbitt L,
45. Ochoa FJ, Ramalle-Gomara E, Carpintero JM, Garcia A, Saralegui I.
Wells GA, Stiell IG. Evaluating the effectiveness of dispatch-assisted
Competence of health professionals to check the carotid pulse.
cardiopulmonary resuscitation instructions. Acad Emerg Med
46. Mather C, O'Kelly S. The palpation of pulses. Anaesthesia
24. Bohm K, Rosenqvist M, Hollenberg J, Biber B, Engerstrom L, Svensson
L. Dispatcher-assisted telephone-guided cardiopulmonary resuscitation:
47. Olasveengen TM, Wik L, Steen PA. Standard basic life support vs.
an underused lifesaving system. Eur J Emerg Med
. 2007;14:256 –259.
continuous chest compressions only in out-of-hospital cardiac arrest.
25. Hallstrom AP, Cobb LA, Johnson E, Copass MK. Dispatcher assisted CPR:
Acta Anaesthesiol Scand
. 2008;52:914 –919.
implementation and potential benefit. A 12-year study. Resuscitation
48. Ong ME, Ng FS, Anushia P, Tham LP, Leong BS, Ong VY, Tiah L, Lim
SH, Anantharaman V. Comparison of chest compression only and
26. Nurmi J, Pettila V, Biber B, Kuisma M, Komulainen R, Castren M.
standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest
Effect of protocol compliance to cardiac arrest identification by
in Singapore. Resuscitation
. 2008;78:119 –126.
emergency medical dispatchers. Resuscitation
. 2006;70:463– 469.
49. Bohm K, Rosenqvist M, Herlitz J, Hollenberg J, Svensson L. Survival is
27. Clawson J, Olola C, Heward A, Patterson B. Cardiac arrest predictability
similar after standard treatment and chest compression only in out-of-
in seizure patients based on emergency medical dispatcher identification
hospital bystander cardiopulmonary resuscitation. Circulation
of previous seizure or epilepsy history. Resuscitation
. 2007;75:298 –304.
28. White L, Rogers J, Bloomingdale M, Fahrenbruch C, Culley L, Subido
50. Iwami T, Kawamura T, Hiraide A, Berg RA, Hayashi Y, Nishiuchi T,
C, Eisenberg M, Rea T. Dispatcher-assisted cardiopulmonary resusci-
Kajino K, Yonemoto N, Yukioka H, Sugimoto H, Kakuchi H, Sase K,
tation: risks for patients not in cardiac arrest. Circulation.
Yokoyama H, Nonogi H. Effectiveness of bystander-initiated
29. Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD.
cardiac-only resuscitation for patients with out-of-hospital cardiac arrest.
Hands-only (compression-only) cardiopulmonary resuscitation: a call to
. 2007;116:2900 –2907.
action for bystander response to adults who experience out-of-hospital
51. SOS-KANTO Study Group. Cardiopulmonary resuscitation by
sudden cardiac arrest: a science advisory for the public from the
bystanders with chest compression only (SOS-KANTO): an observa-
American Heart Association Emergency Cardiovascular Care Com-
tional study. Lancet.
52. Assar D, Chamberlain D, Colquhoun M, Donnelly P, Handley AJ,
30. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Nadkarni VM,
Leaves S, Kern KB. Randomised controlled trials of staged teaching for
Berg RA, Hiraide A. Conventional and chest-compression-only cardio-
basic life support, 1: skill acquisition at bronze stage. Resuscitation
pulmonary resuscitation by bystanders for children who have out-of-
hospital cardiac arrests: a prospective, nationwide, population-based
53. Heidenreich JW, Higdon TA, Kern KB, Sanders AB, Berg RA, Niebler
cohort study. Lancet.
R, Hendrickson J, Ewy GA. Single-rescuer cardiopulmonary resusci-
31. Heward A, Damiani M, Hartley-Sharpe C. Does the use of the Advanced
tation: ‘two quick breaths'–an oxymoron. Resuscitation
Medical Priority Dispatch System affect cardiac arrest detection? Emerg
54. Kobayashi M, Fujiwara A, Morita H, Nishimoto Y, Mishima T, Nitta M,
32. Roppolo LP, Westfall A, Pepe PE, Nobel LL, Cowan J, Kay JJ, Idris
Hayashi T, Hotta T, Hayashi Y, Hachisuka E, Sato K. A manikin-based
AH. Dispatcher assessments for agonal breathing improve detection of
observational study on cardiopulmonary resuscitation skills at the Osaka
cardiac arrest. Resuscitation
. 2009;80:769 –772.
Senri medical rally. Resuscitation
33. Bohm K, Stalhandske B, Rosenqvist M, Ulfvarson J, Hollenberg J,
Svensson L. Tuition of emergency medical dispatchers in the recog-
55. Baskett P, Nolan J, Parr M. Tidal volumes which are perceived to be
nition of agonal respiration increases the use of telephone assisted CPR.
adequate for resuscitation. Resuscitation
56. Ruppert M, Reith MW, Widmann JH, Lackner CK, Kerkmann R,
34. Clawson J, Olola C, Scott G, Heward A, Patterson B. Effect of a Medical
Schweiberer L, Peter K. Checking for breathing: evaluation of the
Priority Dispatch System key question addition in the seizure/
diagnostic capability of emergency medical services personnel, phy-
convulsion/fitting protocol to improve recognition of ineffective
sicians, medical students, and medical laypersons. Ann Emerg Med
(agonal) breathing. Resuscitation
35. Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people
57. Safar P, Escarraga LA, Chang F. Upper airway obstruction in the
in checking the carotid pulse. Resuscitation
unconscious patient. J Appl Physiol
. 1959;14:760 –764.
36. Brennan RT, Braslow A. Skill mastery in public CPR classes. Am J
58. Perkins GD, Stephenson B, Hulme J, Monsieurs KG. Birmingham
. 1998;16:653– 657.
assessment of breathing study (BABS). Resuscitation
37. Chamberlain D, Smith A, Woollard M, Colquhoun M, Handley AJ,
Leaves S, Kern KB. Trials of teaching methods in basic life support :
59. Handley AJ, Handley JA. Performing chest compressions in a confined
comparison of simulated CPR performance after first training and at 6
. 2004;61:55– 61.
months, with a note on the value of re-training. Resuscitation
60. Andersen LO, Isbye DL, Rasmussen LS. Increasing compression depth
during manikin CPR using a simple backboard. Acta Anaesthesiol
38. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I.
Checking the carotid pulse check: diagnostic accuracy of first
61. Perkins GD, Smith CM, Augre C, Allan M, Rogers H, Stephenson B,
responders in patients with and without a pulse. Resuscitation
Thickett DR. Effects of a backboard, bed height, and operator position
on compression depth during simulated resuscitation. Intensive Care
39. Frederick K, Bixby E, Orzel MN, Stewart-Brown S, Willett K. Will
changing the emphasis from ‘pulseless' to ‘no signs of circulation'
62. Perkins GD, Kocierz L, Smith SC, McCulloch RA, Davies RP. Com-
improve the recall scores for effective life support skills in children?
pression feedback devices over estimate chest compression depth when
performed on a bed. Resuscitation
. 2009;80:79 – 82.
40. Lapostolle F, Le Toumelin P, Agostinucci JM, Catineau J, Adnet F.
63. Noordergraaf GJ, Paulussen IW, Venema A, van Berkom PF, Woerlee
Basic cardiac life support providers checking the carotid pulse: per-
PH, Scheffer GJ, Noordergraaf A. The impact of compliant surfaces on
formance, degree of conviction, and influencing factors. Acad Emerg
in-hospital chest compressions: effects of common mattresses and a
. 2004;11:878 – 880.
. 2009;80:546 –552.
November 2, 2010
64. Delvaux AB, Trombley MT, Rivet CJ, Dykla JJ, Jensen D, Smith MR,
83. Babbs CF, Kern KB. Optimum compression to ventilation ratios in CPR
Gilbert RJ. Design and development of a cardiopulmonary resuscitation
under realistic, practical conditions: a physiological and mathematical
mattress. J Intensive Care Med
65. Perkins GD, Benny R, Giles S, Gao F, Tweed MJ. Do different mat-
84. Kern KB, Hilwig RW, Berg RA, Ewy GA. Efficacy of chest
tresses affect the quality of cardiopulmonary resuscitation? Intensive
compression-only BLS CPR in the presence of an occluded airway.
. 2003;29:2330 –2335.
. 1998;39:179 –188.
66. Kundra P, Dey S, Ravishankar M. Role of dominant hand position
85. Abella BS, Sandbo N, Vassilatos P, Alvarado JP, O'Hearn N, Wigder
during external cardiac compression. Br J Anaesth
. 2000;84:491– 493.
HN, Hoffman P, Tynus K, Vanden Hoek TL, Becker LB. Chest com-
67. Nikandish R, Shahbazi S, Golabi S, Beygi N. Role of dominant versus
pression rates during cardiopulmonary resuscitation are suboptimal: a
non-dominant hand position during uninterrupted chest compression
prospective study during in-hospital cardiac arrest. Circulation
CPR by novice rescuers: a randomized double-blind crossover study.
111:428 – 434.
. 2008;76:256 –260.
86. Wolfe JA, Maier GW, Newton JR Jr, Glower DD, Tyson GS Jr, Spratt
68. Shin J, Rhee JE, Kim K. Is the inter-nipple line the correct hand position
JA, Rankin JS, Olsen CO. Physiologic determinants of coronary blood
for effective chest compression in adult cardiopulmonary resuscitation?
flow during external cardiac massage. J Thorac Cardiovasc Surg
87. Maier GW, Tyson GS Jr, Olsen CO, Kernstein KH, Davis JW, Conn EH,
69. Kusunoki S, Tanigawa K, Kondo T, Kawamoto M, Yuge O. Safety of
Sabiston DC Jr, Rankin JS. The physiology of external cardiac massage:
the inter-nipple line hand position landmark for chest compression.
high-impulse cardiopulmonary resuscitation. Circulation
70. Babbs CF, Kemeny AE, Quan W, Freeman G. A new paradigm for
88. Feneley MP, Maier GW, Kern KB, Gaynor JW, Gall SA Jr, Sanders AB,
human resuscitation research using intelligent devices. Resuscitation
Raessler K, Muhlbaier LH, Rankin JS, Ewy GA. Influence of compression
rate on initial success of resuscitation and 24 hour survival after prolonged
71. Edelson DP, Abella BS, Kramer-Johansen J, Wik L, Myklebust H, Barry
manual cardiopulmonary resuscitation in dogs. Circulation
AM, Merchant RM, Hoek TL, Steen PA, Becker LB. Effects of com-
pression depth and pre-shock pauses predict defibrillation failure during
89. Halperin HR, Tsitlik JE, Guerci AD, Mellits ED, Levin HR, Shi AY,
cardiac arrest. Resuscitation
Chandra N, Weisfeldt ML. Determinants of blood flow to vital organs
72. Kramer-Johansen J, Myklebust H, Wik L, Fellows B, Svensson L,
during cardiopulmonary resuscitation in dogs. Circulation
Sorebo H, Steen PA. Quality of out-of-hospital cardiopulmonary resus-
citation with real time automated feedback: a prospective interventional
90. Handley AJ, Handley JA. The relationship between rate of chest com-
pression and compression:relaxation ratio. Resuscitation
73. Edelson DP, Litzinger B, Arora V, Walsh D, Kim S, Lauderdale DS,
Vanden Hoek TL, Becker LB, Abella BS. Improving in-hospital cardiac
91. Wik L, Kramer-Johansen J, Myklebust H, Sorebo H, Svensson L,
arrest process and outcomes with performance debriefing. Arch Intern
Fellows B, Steen PA. Quality of cardiopulmonary resuscitation during
out-of-hospital cardiac arrest. JAMA
. 2005;293:299 –304.
74. Talley DB, Ornato JP, Clarke AM. Computer-aided characterization and
92. Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O'Hearn
optimization of the Thumper compression waveform in closed-chest
N, Vanden Hoek TL, Becker LB. Quality of cardiopulmonary resusci-
CPR. Biomed Instrum Technol
tation during in-hospital cardiac arrest. JAMA
75. Handley AJ, Handley SA. Improving CPR performance using an audible
93. Valenzuela TD, Kern KB, Clark LL, Berg RA, Berg MD, Berg DD, Hilwig
feedback system suitable for incorporation into an automated external
RW, Otto CW, Newburn D, Ewy GA. Interruptions of chest compressions
. 2003;57:57– 62.
during emergency medical systems resuscitation. Circulation
76. Yannopoulos D, McKnite S, Aufderheide TP, Sigurdsson G, Pirrallo
RG, Benditt D, Lurie KG. Effects of incomplete chest wall decom-
94. Berg RA, Hilwig RW, Berg MD, Berg DD, Samson RA, Indik JH, Kern
pression during cardiopulmonary resuscitation on coronary and cerebral
KB. Immediate post-shock chest compressions improve outcome from
perfusion pressures in a porcine model of cardiac arrest. Resuscitation
prolonged ventricular fibrillation. Resuscitation
95. Tang W, Snyder D, Wang J, Huang L, Chang YT, Sun S, Weil MH.
77. Aufderheide TP, Pirrallo RG, Yannopoulos D, Klein JP, von Briesen C,
One-shock versus three-shock defibrillation protocol significantly improves
Sparks CW, Deja KA, Kitscha DJ, Provo TA, Lurie KG. Incomplete
outcome in a porcine model of prolonged ventricular fibrillation cardiac
chest wall decompression: A clinical evaluation of CPR performance by
trained laypersons and an assessment of alternative manual chest
96. Garza AG, Gratton MC, Salomone JA, Lindholm D, McElroy J, Archer
compression-decompression techniques. Resuscitation
R. Improved patient survival using a modified resuscitation protocol for
out-of-hospital cardiac arrest. Circulation
97. Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA,
78. Sutton RM, Niles D, Nysaether J, Abella BS, Arbogast KB, Nishisaki A,
Richman PB, Kern KB. Minimally interrupted cardiac resuscitation by
Maltese MR, Donoghue A, Bishnoi R, Helfaer MA, Myklebust H,
emergency medical services for out-of-hospital cardiac arrest. JAMA
Nadkarni V. Quantitative analysis of CPR quality during in-hospital
resuscitation of older children and adolescents. Pediatrics
98. Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M,
494 – 499.
Zuercher M, Ewy GA. Cardiocerebral resuscitation improves neurolog-
79. Sutton RM, Maltese MR, Niles D, French B, Nishisaki A, Arbogast KB,
ically intact survival of patients with out-of-hospital cardiac arrest. Ann
Donoghue A, Berg RA, Helfaer MA, Nadkarni V. Quantitative analysis
. 2008;52:244 –252.
of chest compression interruptions during in-hospital resuscitation of
99. Sayre MR, Cantrell SA, White LJ, Hiestand BC, Keseg DP, Koser S.
older children and adolescents. Resuscitation
. 2009;80:1259 –1263.
Impact of the 2005 American Heart Association cardiopulmonary resus-
80. Niles D, Nysaether J, Sutton R, Nishisaki A, Abella BS, Arbogast K,
citation and emergency cardiovascular care guidelines on out-of-hospital
Maltese MR, Berg RA, Helfaer M, Nadkarni V. Leaning is common
cardiac arrest survival. Prehosp Emerg Care
. 2009;13:469 – 477.
during in-hospital pediatric CPR, and decreased with automated cor-
100. Steinmetz J, Barnung S, Nielsen SL, Risom M, Rasmussen LS.
rective feedback. Resuscitation
Improved survival after an out-of-hospital cardiac arrest using new
81. Aufderheide TP, Pirrallo RG, Yannopoulos D, Klein JP, von Briesen C,
guidelines. Acta Anaesthesiol Scand
. 2008;52:908 –913.
Sparks CW, Deja KA, Conrad CJ, Kitscha DJ, Provo TA, Lurie KG.
101. Aufderheide TP, Yannopoulos D, Lick CJ, Myers B, Romig LA,
Incomplete chest wall decompression: a clinical evaluation of CPR
Stothert JC, Barnard J, Vartanian L, Pilgrim AJ, Benditt DG. Imple-
performance by EMS personnel and assessment of alternative manual
menting the 2005 American Heart Association Guidelines Improves
chest compression-decompression techniques. Resuscitation
Outcomes after Out-of-Hospital Cardiac Arrest. Heart Rhythm.
102. Hinchey PR, Myers JB, Lewis R, De Maio VJ, Reyer E, Licatese D,
82. Zuercher M, Hilwig RW, Ranger-Moore J, Nysaether J, Nadkarni VM,
Zalkin J, Snyder G. Improved Out-of-Hospital Cardiac Arrest Survival
Berg MD, Kern KB, Sutton R, Berg RA. Leaning during chest com-
After the Sequential Implementation of 2005 AHA Guidelines for Com-
pressions impairs cardiac output and left ventricular myocardial blood
pressions, Ventilations, and Induced Hypothermia: The Wake County
flow in piglet cardiac arrest. Crit Care Med
Experience. Ann Emerg Med.
Berg et al
Part 5: Adult Basic Life Support
103. Jost D, Degrange H, Verret C, Hersan O, Banville IL, Chapman FW,
during bystander-initiated cardiopulmonary resuscitation. A statement
Lank P, Petit JL, Fuilla C, Migliani R, Carpentier JP. DEFI 2005: a
for healthcare professionals from the Ventilation Working Group of the
randomized controlled trial of the effect of automated external defi-
Basic Life Support and Pediatric Life Support Subcommittees,
brillator cardiopulmonary resuscitation protocol on outcome from out-
American Heart Association. Resuscitation
. 1997;35:189 –201.
of-hospital cardiac arrest. Circulation
. 2010;121:1614 –1622.
124. Weil MH, Rackow EC, Trevino R, Grundler W, Falk JL, Griffel MI.
104. Sugerman NT, Edelson DP, Leary M, Weidman EK, Herzberg DL,
Difference in acid-base state between venous and arterial blood during
Vanden Hoek TL, Becker LB, Abella BS. Rescuer fatigue during actual
cardiopulmonary resuscitation. N Engl J Med
in-hospital cardiopulmonary resuscitation with audiovisual feedback: a
125. Sanders AB, Otto CW, Kern KB, Rogers JN, Perrault P, Ewy GA.
prospective multicenter study. Resuscitation
Acid-base balance in a canine model of cardiac arrest. Ann Emerg Med
105. Manders S, Geijsel FE. Alternating providers during continuous chest
compressions for cardiac arrest: every minute or every two minutes?
126. Steen-Hansen JE. Favourable outcome after 26 minutes of "Com-
pression only" resuscitation: a case report. Scand J Trauma Resusc
106. Heidenreich JW, Berg RA, Higdon TA, Ewy GA, Kern KB, Sanders
AB. Rescuer fatigue: standard versus continuous chest-compression
127. Berg RA, Hilwig RW, Kern KB, Babar I, Ewy GA. Simulated mouth-
cardiopulmonary resuscitation. Acad Emerg Med
. 2006;13:1020 –1026.
to-mouth ventilation and chest compressions (bystander cardiopul-
107. Dorph E, Wik L, Stromme TA, Eriksen M, Steen PA. Oxygen delivery
monary resuscitation) improves outcome in a swine model of prehospital
and return of spontaneous circulation with ventilation:compression ratio
pediatric asphyxial cardiac arrest. Crit Care Med
2:30 versus chest compressions only CPR in pigs. Resuscitation
128. Iglesias JM, Lopez-Herce J, Urbano J, Solana MJ, Mencia S, Del
Castillo J. Chest compressions versus ventilation plus chest com-
108. Berg RA, Sanders AB, Kern KB, Hilwig RW, Heidenreich JW, Porter
pressions in a pediatric asphyxial cardiac arrest animal model. Intensive
ME, Ewy GA. Adverse hemodynamic effects of interrupting chest
compressions for rescue breathing during cardiopulmonary resuscitation
129. Idris AH, Becker LB, Fuerst RS, Wenzel V, Rush WJ, Melker RJ, Orban
for ventricular fibrillation cardiac arrest. Circulation
DJ. Effect of ventilation on resuscitation in an animal model of cardiac
109. Berg RA, Hilwig RW, Kern KB, Ewy GA. "Bystander" chest com-
130. Guildner CW. Resuscitation: opening the airway. A comparative study
pressions and assisted ventilation independently improve outcome from
of techniques for opening an airway obstructed by the tongue. JACEP
piglet asphyxial pulseless "cardiac arrest." Circulation
131. Greene DG, Elam JO, Dobkin AB, Studley CL. Cinefluorographic study
110. Berg RA, Kern KB, Hilwig RW, Berg MD, Sanders AB, Otto CW, Ewy
of hyperextension of the neck and upper airway patency. JAMA
GA. Assisted ventilation does not improve outcome in a porcine model
of single-rescuer bystander cardiopulmonary resuscitation. Circulation
132. Ruben HM, Elam JO, al. e. Investigations of pharyngeal xrays and
perfomance by laymen. Anesthesiology.
111. Berg RA, Kern KB, Hilwig RW, Ewy GA. Assisted ventilation during
133. Elam JO, Greene DG, Schneider MA, Ruben HM, Gordon AS, Hustead
‘bystander' CPR in a swine acute myocardial infarction model does not
RF, Benson DW, Clements JA, Ruben A. Head-tilt method of oral
improve outcome. Circulation
. 1997;96:4364 – 4371.
. 1960;172:812– 815.
112. Vaillancourt C, Stiell IG, Wells GA. Understanding and improving low
134. Rhee P, Kuncir EJ, Johnson L, Brown C, Velmahos G, Martin M, Wang
bystander CPR rates: a systematic review of the literature. CJEM
D, Salim A, Doucet J, Kennedy S, Demetriades D. Cervical spine injury
is highly dependent on the mechanism of injury following blunt and
113. Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ,
penetrating assault. J Trauma
. 2006;61:1166 –1170.
Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L,
135. Lowery DW, Wald MM, Browne BJ, Tigges S, Hoffman JR, Mower
Campeau T, Dagnone E, Lyver M. Advanced cardiac life support in
WR. Epidemiology of cervical spine injury victims. Ann Emerg Med
out-of-hospital cardiac arrest. N Engl J Med
. 2004;351:647– 656.
114. Ornato JP, Hallagan LF, McMahan SB, Peeples EH, Rostafinski AG.
136. Milby AH, Halpern CH, Guo W, Stein SC. Prevalence of cervical spinal
Attitudes of BCLS instructors about mouth-to-mouth resuscitation
injury in trauma. Neurosurg Focus
during the AIDS epidemic. Ann Emerg Med
137. Mithani SK, St-Hilaire H, Brooke BS, Smith IM, Bluebond-Langner R,
115. Brenner BE, Van DC, Cheng D, Lazar EJ. Determinants of reluctance to
Rodriguez ED. Predictable patterns of intracranial and cervical spine
perform CPR among residents and applicants: the impact of experienceon helping behavior. Resuscitation
injury in craniomaxillofacial trauma: analysis of 4786 patients. Plast
116. Hew P, Brenner B, Kaufman J. Reluctance of paramedics and
emergency medical technicians to perform mouth-to-mouth resusci-
138. Hackl W, Hausberger K, Sailer R, Ulmer H, Gassner R. Prevalence of
tation. J Emerg Med
. 1997;15:279 –284.
cervical spine injuries in patients with facial trauma. Oral Surg Oral
117. Sirbaugh PE, Pepe PE, Shook JE, Kimball KT, Goldman MJ, Ward MA,
Med Oral Pathol Oral Radiol Endod
. 2001;92:370 –376.
Mann DM. A prospective, population-based study of the demographics,
139. Holly LT, Kelly DF, Counelis GJ, Blinman T, McArthur DL, Cryer HG.
epidemiology, management, and outcome of out-of-hospital pediatric
Cervical spine trauma associated with moderate and severe head injury:
cardiopulmonary arrest. Ann Emerg Med
. 1999;33:174 –184.
incidence, risk factors, and injury characteristics. J Neurosurg Spine
118. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Compton S. CPR
training and CPR performance: do CPR-trained bystanders perform
140. Demetriades D, Charalambides K, Chahwan S, Hanpeter D, Alo K,
CPR? Acad Emerg Med
. 2006;13:596 – 601.
Velmahos G, Murray J, Asensio J. Nonskeletal cervical spine injuries:
119. Tang W, Weil MH, Sun S, Kette D, Gazmuri RJ, O'Connell F, Bisera
epidemiology and diagnostic pitfalls. J Trauma
. 2000;48:724 –727.
J. Cardiopulmonary resuscitation by precordial compression but without
141. Majernick TG, Bieniek R, Houston JB, Hughes HG. Cervical spine
mechanical ventilation. Am J Respir Crit Care Med
. 1994;150(6 pt
movement during orotracheal intubation. Ann Emerg Med
120. Bobrow BJ, Zuercher M, Ewy GA, Clark L, Chikani V, Donahue D,
142. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC.
Sanders AB, Hilwig RW, Berg RA, Kern KB. Gasping during cardiac
Cervical spinal motion during intubation: efficacy of stabilization
arrest in humans is frequent and associated with improved survival.
maneuvers in the setting of complete segmental instability. J Neurosurg
. 2008;118:2550 –2554.
121. Clark JJ, Larsen MP, Culley LL, Graves JR, Eisenberg MS. Incidence of
143. Hastings RH, Wood PR. Head extension and laryngeal view during laryn-
agonal respirations in sudden cardiac arrest. Ann Emerg Med
goscopy with cervical spine stabilization maneuvers. Anesthesiology
122. Bang A, Herlitz J, Martinell S. Interaction between emergency medical
144. Gerling MC, Davis DP, Hamilton RS, Morris GF, Vilke GM, Garfin SR,
dispatcher and caller in suspected out-of-hospital cardiac arrest calls
Hayden SR. Effects of cervical spine immobilization technique and
with focus on agonal breathing. A review of 100 tape recordings of true
laryngoscope blade selection on an unstable cervical spine in a cadaver
cardiac arrest cases. Resuscitation
model of intubation. Ann Emerg Med
123. Becker LB, Berg RA, Pepe PE, Idris AH, Aufderheide TP, Barnes TA,
145. Wenzel V, Keller C, Idris AH, Dorges V, Lindner KH, Brimacombe
Stratton SJ, Chandra NC. A reappraisal of mouth-to-mouth ventilation
JR. Effects of smaller tidal volumes during basic life support venti-
November 2, 2010
lation in patients with respiratory arrest: good ventilation, less risk?
170. Kette F, Reffo I, Giordani G, Buzzi F, Borean V, Cimarosti R,
Codiglia A, Hattinger C, Mongiat A, Tararan S. The use of laryngeal
146. Dorges V, Ocker H, Hagelberg S, Wenzel V, Idris AH, Schmucker P.
tube by nurses in out-of-hospital emergencies: Preliminary expe-
Smaller tidal volumes with room-air are not sufficient to ensure
adequate oxygenation during bag-valve-mask ventilation. Resuscitation
171. Timmermann A, Russo SG, Rosenblatt WH, Eich C, Barwing J,
Roessler M, Graf BM. Intubating laryngeal mask airway for difficult
147. Dorges V, Ocker H, Hagelberg S, Wenzel V, Schmucker P. Optimi-
out-of-hospital airway management: a prospective evaluation. Br J
sation of tidal volumes given with self-inflatable bags without additional
. 2007;99:286 –291.
172. Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation
148. Finer NN, Barrington KJ, Al-Fadley F, Peters KL. Limitations of self-
improves survival of patients with out-of-hospital cardiac arrest. Am J
inflating resuscitators. Pediatrics
. 1986;77:417– 420.
149. Hirschman AM, Kravath RE. Venting vs ventilating. A danger of
173. Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB,
manual resuscitation bags. Chest
. 1982;82:369 –370.
Vadeboncoeur TF, Hilwig RW, Kern KB. Passive oxygen insufflation is
150. Berg MD, Idris AH, Berg RA. Severe ventilatory compromise due to
superior to bag-valve-mask ventilation for witnessed ventricular fibril-
gastric distention during pediatric cardiopulmonary resuscitation.
lation out-of-hospital cardiac arrest. Ann Emerg Med.
2009;54:656 – 662
151. Garnett AR, Ornato JP, Gonzalez ER, Johnson EB. End-tidal carbon
174. McNelis U, Syndercombe A, Harper I, Duggan J. The effect of cricoid
dioxide monitoring during cardiopulmonary resuscitation. JAMA
pressure on intubation facilitated by the gum elastic bougie. Anaes-
. 2007;62:456 – 459.
152. Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite
175. Harry RM, Nolan JP. The use of cricoid pressure with the intubating
S, von Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG.
laryngeal mask. Anaesthesia
. 1999;54:656 – 659.
Hyperventilation-induced hypotension during cardiopulmonary resusci-
176. Noguchi T, Koga K, Shiga Y, Shigematsu A. The gum elastic bougie
. 2004;109:1960 –1965.
eases tracheal intubation while applying cricoid pressure compared to a
153. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance
stylet. Can J Anaesth
of continuous chest compressions during cardiopulmonary resusci-
177. Asai T, Murao K, Shingu K. Cricoid pressure applied after placement of
tation: improved outcome during a simulated single lay-rescuer
laryngeal mask impedes subsequent fibreoptic tracheal intubation
. 2002;105:645– 649.
through mask. Br J Anaesth
. 2000;85:256 –261.
154. Wang HE, Simeone SJ, Weaver MD, Callaway CW. Interruptions in
178. Snider DD, Clarke D, Finucane BT. The "BURP" maneuver worsens the
cardiopulmonary resuscitation from paramedic endotracheal intubation.
glottic view when applied in combination with cricoid pressure. Can J
Ann Emerg Med.
2009;54:645– 652 e641.
. 2005;52:100 –104.
155. Wenzel V, Idris AH, Banner MJ, Fuerst RS, Tucker KJ. The compo-
179. Smith CE, Boyer D. Cricoid pressure decreases ease of tracheal intu-
sition of gas given by mouth-to-mouth ventilation during CPR. Chest
bation using fibreoptic laryngoscopy (WuScope System). Can J
. 2002;49:614 – 619.
156. Ruben H. The immediate treatment of respiratory failure. Br J Anaesth
180. Asai T, Barclay K, Power I, Vaughan RS. Cricoid pressure impedes
placement of the laryngeal mask airway and subsequent tracheal intu-
157. Bhalla RK, Corrigan A, Roland NJ. Comparison of two face masks used
bation through the mask. Br J Anaesth
to deliver early ventilation to laryngectomized patients. Ear Nose Throat
181. Domuracki KJ, Moule CJ, Owen H, Kostandoff G, Plummer JL.
Learning on a simulator does transfer to clinical practice. Resuscitation
158. Barnes TA. Emergency ventilation techniques and related equipment.
. 1992;37:673– 690, discussion 690 – 674.
182. Beavers RA, Moos DD, Cuddeford JD. Analysis of the application of
159. Johannigman JA, Branson RD, Davis K Jr, Hurst JM. Techniques of
cricoid pressure: implications for the clinician. J Perianesth Nurs
emergency ventilation: a model to evaluate tidal volume, airway
pressure, and gastric insufflation. J Trauma
183. Meek T, Gittins N, Duggan JE. Cricoid pressure: knowledge and per-
160. Elam JO. Bag-valve-mask O ventilation. In: Safar P, Elam JO, eds.
formance amongst anaesthetic assistants. Anaesthesia
. 1999;54:59 – 62.
Advances in Cardiopulmonary Resuscitation: The Wolf Creek Con-
184. Clark RK, Trethewy CE. Assessment of cricoid pressure application by
ference on Cardiopulmonary Resuscitation.
New York, NY: Springer-
emergency department staff. Emerg Med Australas
. 2005;17:376 –381.
Verlag, Inc.; 1977:73–79.
185. Kopka A, Robinson D. The 50 ml syringe training aid should be utilized
161. Dailey R, Young G, Simon B, Stewart R. The Airway: Emergency
immediately before cricoid pressure application. Eur J Emerg Med
: C.V. Mosby; 1992.
162. Elling R, Politis J. An evaluation of emergency medical technicians'
186. Flucker CJ, Hart E, Weisz M, Griffiths R, Ruth M. The 50-millilitre
ability to use manual ventilation devices. Ann Emerg Med
syringe as an inexpensive training aid in the application of cricoid
pressure. Eur J Anaesthesiol
. 2000;17:443– 447.
163. von Goedecke A, Bowden K, Wenzel V, Keller C, Gabrielli A. Effects
187. Shimabukuro A, Kawatani M, Nagao N, Inoue Y, Hayashida M, Hikawa
of decreasing inspiratory times during simulated bag-valve-mask venti-
Y. [Training in application of cricoid pressure.] Masui
164. von Goedecke A, Bowden K, Keller C, Voelckel WG, Jeske HC,
188. Schmidt A, Akeson J. Practice and knowledge of cricoid pressure in
Wenzel V. [Decreased inspiratory time during ventilation of an unpro-
southern Sweden. Acta Anaesthesiol Scand
. 2001;45:1210 –1214.
tected airway. Effect on stomach inflation and lung ventilation in a
189. Patten SP. Educating nurses about correct application of cricoid
bench model.] Anaesthesist
pressure. AORN J
. 2006;84:449 – 461.
165. von Goedecke A, Paal P, Keller C, Voelckel WG, Herff H, Lindner KH,
190. Koziol CA, Cuddeford JD, Moos DD. Assessing the force generated
Wenzel V. [Ventilation of an unprotected airway: evaluation of a new
with application of cricoid pressure. AORN J.
peak-inspiratory-flow and airway-pressure-limiting bag-valve-mask.]
. 2006;55:629 – 634.
191. Clayton TJ, Vanner RG. A novel method of measuring cricoid force.
166. Rumball CJ, MacDonald D. The PTL, Combitube, laryngeal mask, and
. 2002;57:326 –329.
oral airway: a randomized prehospital comparative study of ventilatory
192. Owen H, Follows V, Reynolds KJ, Burgess G, Plummer J. Learning to
device effectiveness and cost-effectiveness in 470 cases of cardiorespi-
apply effective cricoid pressure using a part task trainer. Anaesthesia
ratory arrest. Prehosp Emerg Care
167. Comparison of arterial blood gases of laryngeal mask airway and bag-
193. Kopka A, Crawford J. Cricoid pressure: a simple, yet effective
valve-mask ventilation in out-of-hospital cardiac arrests. Circ J
biofeedback trainer. Eur J Anaesthesiol
. 2004;21:443– 447.
73:490 – 496.
194. Quigley P, Jeffrey P. Cricoid pressure: assessment of performance and
168. Stone BJ, Chantler PJ, Baskett PJ. The incidence of regurgitation during
effect of training in emergency department staff. Emerg Med Australas
cardiopulmonary resuscitation: a comparison between the bag valve
mask and laryngeal mask airway. Resuscitation
. 1998;38:3– 6.
195. The Public Access Defibrillation Trial Investigators. Public-access defi-
169. Atherton GL, Johnson JC. Ability of paramedics to use the Combitube
brillation and survival after out-of-hospital cardiac arrest. N Engl J Med.
in prehospital cardiac arrest. Ann Emerg Med
Berg et al
Part 5: Adult Basic Life Support
196. Rea TD, Cook AJ, Stiell IG, Powell J, Bigham B, Callaway CW, Chugh
215. Body R, Carley S, Wibberley C, McDowell G, Ferguson J,
S, Aufderheide TP, Morrison L, Terndrup TE, Beaudoin T, Wittwer L,
Mackway-Jones K. The value of symptoms and signs in the emergent
Davis D, Idris A, Nichol G. Predicting survival after out-of-hospital
diagnosis of acute coronary syndromes. Resuscitation
cardiac arrest: role of the Utstein data elements. Ann Emerg Med
216. Goodacre SW, Angelini K, Arnold J, Revill S, Morris F. Clinical
197. Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of
predictors of acute coronary syndromes in patients with undifferentiated
automated external defibrillators. N Engl J Med
chest pain. QJM
. 2003;96:893– 898.
198. Fries M, Tang W, Chang YT, Wang J, Castillo C, Weil MH. Micro-
217. Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical
vascular blood flow during cardiopulmonary resuscitation is predictive
features in the diagnosis of acute, undifferentiated chest pain? Acad
of outcome. Resuscitation
. 2006;71:248 –253.
199. Stiell IG, Callaway C, Davis D, Terndrup T, Powell J, Cook A,
218. Everts B, Karlson BW, Wahrborg P, Hedner T, Herlitz J. Localization of
Kudenchuk PJ, Daya M, Kerber R, Idris A, Morrison LJ, Aufderheide T.
pain in suspected acute myocardial infarction in relation to final
Resuscitation Outcomes Consortium (ROC) PRIMED cardiac arrest trial
diagnosis, age and sex, and site and type of infarction. Heart Lung
methods part 2: rationale and methodology for "Analyze Later vs.
1996;25:430 – 437.
Analyze Early" protocol. Resuscitation
. 2008;78:186 –195.
219. McSweeney JC, Cody M, O'Sullivan P, Elberson K, Moser DK, Garvin
200. Baker PW, Conway J, Cotton C, Ashby DT, Smyth J, Woodman RJ,
BJ. Women's early warning symptoms of acute myocardial infarction.
Grantham H. Defibrillation or cardiopulmonary resuscitation first for
. 2003;108:2619 –2623.
patients with out-of-hospital cardiac arrests found by paramedics to be in
220. Panju AA, BR Hemmelgarn, GG Guyatt, DL Simel. Is this patient
ventricular fibrillation? A randomised control trial. Resuscitation
having a myocardial infarction? JAMA
. 1998;280:1256 –1263.
79:424 – 431.
221. Mant J, McManus RJ, Oakes RA, Delaney BC, Barton PM, Deeks JJ,
201. Jacobs IG, Finn JC, Oxer HF, Jelinek GA. CPR before defibrillation in
Hammersley L, Davies RC, Davies MK, Hobbs FD. Systematic review
out-of-hospital cardiac arrest: a randomized trial. Emerg Med Australas
and modelling of the investigation of acute and chronic chest pain
2005;17:39 – 45.
presenting in primary care. Health Technol Assess.
202. Wik L, Hansen TB, Fylling F, Steen T, Vaagenes P, Auestad BH, Steen
222. Berger JP, Buclin T, Haller E, Van Melle G, Yersin B. Right arm
PA. Delaying defibrillation to give basic cardiopulmonary resuscitation
involvement and pain extension can help to differentiate coronary
to patients with out-of-hospital ventricular fibrillation: a randomized
diseases from chest pain of other origin: a prospective emergency ward
. 2003;289:1389 –1395.
study of 278 consecutive patients admitted for chest pain. J Intern Med
203. Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin
M, Hallstrom AP. Influence of cardiopulmonary resuscitation prior to
223. Jonsbu J, Rollag A, Aase O, Lippestad CT, Arnesen KE, Erikssen J,
defibrillation in patients with out-of-hospital ventricular fibrillation.
Koss A. Rapid and correct diagnosis of myocardial infarction: stan-
dardized case history and clinical examination provide important infor-
204. Handley AJ. Recovery Position. Resuscitation
mation for correct referral to monitored beds. J Intern Med
205. Turner S, Turner I, Chapman D, Howard P, Champion P, Hatfield J,
James A, Marshall S, Barber S. A comparative study of the 1992 and
224. Hargarten KM, Aprahamian C, Stueven H, Olson DW, Aufderheide TP,
1997 recovery positions for use in the UK. Resuscitation
Mateer JR. Limitations of prehospital predictors of acute myocardial
infarction and unstable angina. Ann Emerg Med
206. Gunn BD, Eizenberg N, Silberstein M, McMeeken JM, Tully EA,
225. Herlitz J, Hansson E, Ringvall E, Starke M, Karlson BW, Waagstein L.
Stillman BC, Brown DJ, Gutteridge GA. How should an unconscious
Predicting a life-threatening disease and death among ambulance-
person with a suspected neck injury be positioned? Prehospital Disaster
transported patients with chest pain or other symptoms raising suspicion
. 1995;10:239 –244.
of an acute coronary syndrome. Am J Emerg Med
. 2002;20:588 –594.
207. Blake WE, Stillman BC, Eizenberg N, Briggs C, McMeeken JM. The
226. Lee TH, Pearson SD, Johnson PA, Garcia TB, Weisberg MC, Guad-
position of the spine in the recovery position–an experimental com-
agnoli E, Cook EF, Goldman L. Failure of information as an intervention
parison between the lateral recovery position and the modified HAINES
to modify clinical management. A time-series trial in patients with acute
. 2002;53:289 –297.
chest pain. Ann Intern Med
. 1995;122:434 – 437.
208. WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, Brown
227. Henrikson CA, Howell EE, Bush DE, Miles JS, Meininger GR, Fried-
TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K,
lander T, Bushnell AC, Chandra-Strobos N. Chest pain relief by nitro-
Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, HowardV, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott
glycerin does not predict active coronary artery disease. Ann Intern Med
MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL,
Rosamond W, Sacco R, Sorlie P, Stafford R, Thom T, Wasserthiel-
228. Lee TH, Rouan GW, Weisberg MC, Brand DA, Acampora D, Stasi-
Smoller S, Wong ND, Wylie-Rosett J. Committee obotAHAS, Stroke
ulewicz C, Walshon J, Terranova G, Gottlieb L, Goldstein-Wayne B, et
Statistics Subcommittee. Heart Disease and Stroke Statistics–2010
al. Clinical characteristics and natural history of patients with acute
Update: A Report From the American Heart Association. Circulation.
myocardial infarction sent home from the emergency room. Am J
2010;121:e46 – e215.
. 1987;60:219 –224.
209. Chiriboga D, Yarzebski J, Goldberg RJ, Gore JM, Alpert JS. Temporal
229. Freimark D, Matetzky S, Leor J, Boyko V, Barbash IM, Behar S, Hod
trends (1975 through 1990) in the incidence and case-fatality rates of
H. Timing of aspirin administration as a determinant of survival of
primary ventricular fibrillation complicating acute myocardial
patients with acute myocardial infarction treated with thrombolysis.
infarction: a communitywide perspective. Circulation
Am J Cardiol
230. Barbash IM, Freimark D, Gottlieb S, Hod H, Hasin Y, Battler A, Crystal
210. Anderson JL, Karagounis LA, Califf RM. Metaanalysis of five reported
E, Matetzky S, Boyko V, Mandelzweig L, Behar S, Leor J. Outcome of
studies on the relation of early coronary patency grades with mortality
myocardial infarction in patients treated with aspirin is enhanced by
and outcomes after acute myocardial infarction. Am J Cardiol
pre-hospital administration. Cardiology
231. Randomised trial of intravenous streptokinase, oral aspirin, both, or
211. Raitt MH, Maynard C, Wagner GS, Cerqueira MD, Selvester RH,
neither among 17,187 cases of suspected acute myocardial infarction:
Weaver WD. Relation between symptom duration before thrombolytic
ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collab-
therapy and final myocardial infarct size. Circulation
. 1996;93:48 –53.
orative Group. Lancet.
212. Douglas PS, Ginsburg GS. The evaluation of chest pain in women.
232. Casaccia M, Bertello F, De Bernardi A, Sicuro M, Scacciatella P.
N Engl J Med
Prehospital management of acute myocardial infarct in an experimental
213. Solomon CG, Lee TH, Cook EF, Weisberg MC, Brand DA, Rouan GW,
metropolitan system of medical emergencies [in Italian]. G Ital Cardiol
Goldman L. Comparison of clinical presentation of acute myocardial
infarction in patients older than 65 years of age to younger patients: the
233. Quan D, LoVecchio F, Clark B, Gallagher JV III. Prehospital use of
Multicenter Chest Pain Study experience. Am J Cardiol
aspirin rarely is associated with adverse events. Prehosp Disaster Med.
214. Peberdy MA, Ornato JP. Coronary artery disease in women. Heart Dis
234. Verheugt FW, van der Laarse A, Funke-Kupper AJ, Sterkman LG,
Galema TW, Roos JP. Effects of early intervention with low-dose
November 2, 2010
aspirin (100 mg) on infarct size, reinfarction and mortality in anterior
primary stroke centers. Brain Attack Coalition. JAMA
wall acute myocardial infarction. Am J Cardiol
235. Le May MR, So DY, Dionne R, Glover CA, Froeschl MP, Wells GA,
252. Barsan WG, Brott TG, Olinger CP, Adams HP Jr, Haley EC Jr, Levy
Davies RF, Sherrard HL, Maloney J, Marquis JF, O'Brien ER, Trickett
DE. Identification and entry of the patient with acute cerebral infarction.
J, Poirier P, Ryan SC, Ha A, Joseph PG, Labinaz M. A citywide protocol
Ann Emerg Med
for primary PCI in ST-segment elevation myocardial infarction. N Engl
253. Barsan WG, Brott TG, Broderick JP, Haley EC, Levy DE, Marler JR.
Time of hospital presentation in patients with acute stroke. Arch Intern
236. Stenestrand U, Lindback J, Wallentin L. Long-term outcome of primary
. 1993;153:2558 –2561.
percutaneous coronary intervention vs prehospital and in-hospital
254. Morgenstern LB, Bartholomew LK, Grotta JC, Staub L, King M, Chan
thrombolysis for patients with ST-elevation myocardial infarction.
W. Sustained benefit of a community and professional intervention to
. 2006;296:1749 –1756.
increase acute stroke therapy. Arch Intern Med
. 2003;163:2198 –2202.
237. Le May MR, Davies RF, Dionne R, Maloney J, Trickett J, So D, Ha A,
255. Scott PA. Enhancing community delivery of tissue plasminogen activator in
Sherrard H, Glover C, Marquis JF, O'Brien ER, Stiell IG, Poirier P,
stroke through community-academic collaborative clinical knowledge
Labinaz M. Comparison of early mortality of paramedic-diagnosed
translation. Emerg Med Clin North Am.
ST-segment elevation myocardial infarction with immediate transport to
256. Kleindorfer D, Khoury J, Broderick JP, Rademacher E, Woo D, Flaherty
a designated primary percutaneous coronary intervention center to that
ML, Alwell K, Moomaw CJ, Schneider A, Pancioli A, Miller R, Kissela
of similar patients transported to the nearest hospital. Am J Cardiol
BM. Temporal trends in public awareness of stroke: warning signs, risk
factors, and treatment. Stroke
238. Wijesinghe M, Perrin K, Ranchord A, Simmonds M, Weatherall M,
257. Smith WS, Isaacs M, Corry MD. Accuracy of paramedic identification
Beasley R. Routine use of oxygen in the treatment of myocardial
of stroke and transient ischemic attack in the field. Prehosp Emerg Care
infarction: systematic review. Heart
. 2009;95:198 –202.
239. Haynes BE, Pritting J. A rural emergency medical technician with
258. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying
selected advanced skills. Prehosp Emerg Care
stroke in the field. Prospective validation of the Los Angeles prehospital
240. Funk D, Groat C, Verdile VP. Education of paramedics regarding aspirin
stroke screen (LAPSS). Stroke
use. Prehosp Emerg Care
. 2000;4:62– 64.
259. Smith WS, Corry MD, Fazackerley J, Isaacs SM. Improved paramedic
241. Bussmann WD, Passek D, Seidel W, Kaltenbach M. Reduction of CK
sensitivity in identifying stroke victims in the prehospital setting.
and CK-MB indexes of infarct size by intravenous nitroglycerin.
Prehosp Emerg Care
. 1981;63:615– 622.
260. Kim SK, Lee SY, Bae HJ, Lee YS, Kim SY, Kang MJ, Cha JK.
242. Charvat J, Kuruvilla T, al Amad H. Beneficial effect of intravenous
Pre-hospital notification reduced the door-to-needle time for iv t-PA in
nitroglycerin in patients with non-Q myocardial infarction. Cardiologia
acute ischaemic stroke. Eur J Neurol
261. Quain DA, Parsons MW, Loudfoot AR, Spratt NJ, Evans MK, Russell
243. Jugdutt BI, Warnica JW. Intravenous nitroglycerin therapy to limit
ML, Royan AT, Moore AG, Miteff F, Hullick CJ, Attia J, McElduff P,
myocardial infarct size, expansion, and complications. Effect of timing,
Levi CR. Improving access to acute stroke therapies: a controlled trial of
dosage, and infarct location. Circulation
. 1988;78:906 –919.
organised pre-hospital and emergency care. Med J Aust
244. Madsen JK, Chevalier B, Darius H, Rutsch W, Wojcik J, Schneider S,
429 – 433.
Allikmets K. Ischaemic events and bleeding in patients undergoing
262. Abdullah AR, Smith EE, Biddinger PD, Kalenderian D, Schwamm LH.
percutaneous coronary intervention with concomitant bivalirudin
Advance hospital notification by EMS in acute stroke is associated with
. 2008;3:610 – 616.
shorter door-to-computed tomography time and increased likelihood of
245. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van
administration of tissue-plasminogen activator. Prehosp Emerg Care
Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK,
2008;12:426 – 431.
Fonarow GC, Ho PM, Lauer MS, Masoudi FA, Robertson RM, Roger V,
263. Gropen TI, Gagliano PJ, Blake CA, Sacco RL, Kwiatkowski T,
Schwamm LH, Sorlie P, Yancy CW, Rosamond WD. Defining and
Richmond NJ, Leifer D, Libman R, Azhar S, Daley MB. Quality
setting national goals for cardiovascular health promotion and disease
improvement in acute stroke: the New York State Stroke Center Des-
reduction: the American Heart Association's strategic Impact Goal
ignation Project. Neurology
. 2006;67:88 –93.
through 2020 and beyond. Circulation
. 2010;121:586 – 613.
264. Gladstone DJ, Rodan LH, Sahlas DJ, Lee L, Murray BJ, Ween JE, Perry
246. Grotta JC, Chiu D, Lu M, Patel S, Levine SR, Tilley BC, Brott TG,
JR, Chenkin J, Morrison LJ, Beck S, Black SE. A citywide prehospital
Haley EC Jr, Lyden PD, Kothari R, Frankel M, Lewandowski CA,
protocol increases access to stroke thrombolysis in Toronto. Stroke
Libman R, Kwiatkowski T, Broderick JP, Marler JR, Corrigan J, Huff S,
Mitsias P, Talati S, Tanne D. Agreement and variability in the interpre-
265. Langhorne P, Tong BL, Stott DJ. Association between physiological
tation of early CT changes in stroke patients qualifying for intravenous
homeostasis and early recovery after stroke. Stroke
rtPA therapy. Stroke
. 1999;30:1528 –1533.
247. Ingall TJ, O'Fallon WM, Asplund K, Goldfrank LR, Hertzberg VS,
266. National Center for Injury Prevention and Control Web-based Injury
Louis TA, Christianson TJ. Findings from the reanalysis of the NINDS
Statistics Query and Reporting System (WISQARS). Centers for
tissue plasminogen activator for acute ischemic stroke treatment trial.
Disease Control and Prevention.
Available at: http://www.cdc.gov/
. 2004;35:2418 –2424.
248. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D,
267. Youn CS, Choi SP, Yim HW, Park KN. Out-of-hospital cardiac arrest
Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer
due to drowning: An Utstein Style report of 10 years of experience from
R, Wahlgren N, Toni D. Thrombolysis with alteplase 3 to 4.5 hours after
St. Mary's Hospital. Resuscitation
. 2009;80:778 –783.
acute ischemic stroke. N Engl J Med
268. Suominen P, Baillie C, Korpela R, Rautanen S, Ranta S, Olkkola KT.
249. Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP,
Impact of age, submersion time and water temperature on outcome in
Brott T, Frankel M, Grotta JC, Haley EC Jr, Kwiatkowski T, Levine SR,
Lewandowski C, Lu M, Lyden P, Marler JR, Patel S, Tilley BC, Albers
269. Perkins GD. In-water resuscitation: a pilot evaluation. Resuscitation
G, Bluhmki E, Wilhelm M, Hamilton S. Association of outcome with
early stroke treatment: pooled analysis of ATLANTIS, ECASS, and
270. Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in
NINDS rt-PA stroke trials. Lancet
. 2004;363:768 –774.
near-drowning: Institute of Medicine report. J Emerg Med
250. Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass
LM, Koroshetz W, Marler JR, Booss J, Zorowitz RD, Croft JB, Magnis
271. Watson RS, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine
E, Mulligan D, Jagoda A, O'Connor R, Cawley CM, Connors JJ,
injuries among submersion victims. J Trauma
. 2001;51:658 – 662.
Rose-DeRenzy JA, Emr M, Warren M, Walker MD. Recommendations
272. Hwang V, Shofer FS, Durbin DR, Baren JM. Prevalence of traumatic
for comprehensive stroke centers: a consensus statement from the Brain
injuries in drowning and near drowning in children and adolescents.
Attack Coalition. Stroke
Arch Pediatr Adolesc Med
. 2003;157:50 –53.
251. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg
273. Fingerhut LA, Cox CS. Warner M International comparative analysis of
MR, Starke RD, Todd HW, Viste KM, Girgus M, Shephard T, Emr M,
injury mortality. Findings from the ICE on injury statistics. International
Shwayder P, Walker MD. Recommendations for the establishment of
Collaborative Effort on Injury Statistics. Adv Data.
Berg et al
Part 5: Adult Basic Life Support
274. Dolkas L, Stanley C, Smith AM, Vilke GM. Deaths associated with
287. Rea TD, Stickney RE, Doherty A, Lank P. Performance of chest com-
choking in San Diego county. J Forensic Sci
. 2007;52:176 –179.
pressions by laypersons during the Public Access Defibrillation Trial.
275. Soroudi A, Shipp HE, Stepanski BM, Ray LU, Murrin PA, Chan TC,
Davis DP, Vilke GM. Adult foreign body airway obstruction in the
288. Chiang WC, Chen WJ, Chen SY, Ko PC, Lin CH, Tsai MS, Chang WT,
prehospital setting. Prehosp Emerg Care
Chen SC, Tsan CY, Ma MH. Better adherence to the guidelines during
276. Redding JS. The choking controversy: critique of evidence on the
cardiopulmonary resuscitation through the provision of audio-prompts.
Heimlich maneuver. Crit Care Med
. 1979;7:475– 479.
277. Vilke GM, Smith AM, Ray LU, Steen PJ, Murrin PA, Chan TC. Airway
289. Kern KB, Sanders AB, Raife J, Milander MM, Otto CW, Ewy GA. A
obstruction in children aged less than 5 years: the prehospital expe-
study of chest compression rates during cardiopulmonary resuscitation
rience. Prehosp Emerg Care
. 2004;8:196 –199.
in humans: the importance of rate-directed chest compressions. Arch
278. Ingalls TH. Heimlich versus a slap on the back. N Engl J Med
290. Berg RA, Sanders AB, Milander M, Tellez D, Liu P, Beyda D. Efficacy
279. Heimlich HJ, Hoffmann KA, Canestri FR. Food-choking and drowning
of audio-prompted rate guidance in improving resuscitator performance
deaths prevented by external subdiaphragmatic compression. Physio-
of cardiopulmonary resuscitation on children. Acad Emerg Med
logical basis. Ann Thorac Surg
. 1975;20:188 –195.
280. Boussuges S, Maitrerobert P, Bost M. [Use of the Heimlich Maneuver
291. Abella BS, Edelson DP, Kim S, Retzer E, Myklebust H, Barry AM,
on children in the Rhone-Alpes area.] Arch Fr Pediatr
O'Hearn N, Hoek TL, Becker LB. CPR quality improvement during
in-hospital cardiac arrest using a real-time audiovisual feedback system.
281. Guildner CW, Williams D, Subitch T. Airway obstructed by foreign
. 2007;73:54 – 61.
material: the Heimlich maneuver. JACEP
. 1976;5:675– 677.
292. Fletcher D, Galloway R, Chamberlain D, Pateman J, Bryant G,
282. Langhelle A, Sunde K, Wik L, Steen PA. Airway pressure with chest
Newcombe RG. Basics in advanced life support: a role for download
compressions versus Heimlich manoeuvre in recently dead adults with
audit and metronomes. Resuscitation
complete airway obstruction. Resuscitation
293. Gruben KG, Romlein J, Halperin HR, Tsitlik JE. System for mechanical
283. Ruben H, Macnaughton FI. The treatment of food-choking. Practitioner
measurements during ardiopulmonary resuscitation in humans. IEEE
Trans Biomed Eng
. 1990;37:204 –210.
284. Brauner DJ. The Heimlich maneuver: procedure of choice? J Am Geriatr
294. Nishisaki A, Nysaether J, Sutton R, Maltese M, Niles D, Donoghue A,
285. Hartrey R, Bingham RM. Pharyngeal trauma as a result of blind finger
Bishnoi R, Helfaer M, Perkins GD, Berg R, Arbogast K, Nadkarni V.
sweeps in the choking child. J Accid Emerg Med
Effect of mattress deflection on CPR quality assessment for older
286. Kabbani M, Goodwin SR. Traumatic epiglottis following blind finger
children and adolescents. Resuscitation
. 2009;80:540 –545.
sweep to remove a pharyngeal foreign body. Clin Pediatr (Phila)
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.