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Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines
for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Robert A. Berg, 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 2010;122;S685-S705 DOI: 10.1161/CIRCULATIONAHA.110.970939 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 (CPR), and rapid de-
but a core set of actions provides a universal strategy for fibrillation with an automated external defibrillator (AED).
achieving successful resuscitation. These actions are termed Initial recognition and response to heart attack and stroke are the links in the "Chain of Survival." For adults they include also considered part of BLS. This section presents the 2010 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, and
instructions to perform Hands-Only (compression-only) CPR rapid defibrillation (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 lifesaving rescuer.
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
Figure 1. Simplified adult BLS algorithm.
untrained bystander should—at a minimum—activate the Pulse Check
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 Early 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
All Together
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).
Rescue Breaths
A change in the 2010 AHA Guidelines for CPR and ECC is
Trained Lay Rescuer
to recommend the initiation of compressions before ventila- 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
Figure 2. BLS healthcare provider
algorithm.
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 also 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 should activate
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 deempha- 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 Chest Compressions
Rescue Breathing (Box 3A, 4)
prior to Airway and Breathing).
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 During CPR
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) (ED) settings.215–228 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.
Immediate Recognition and Activation of the emergency
The Quality of BLS
The quality of unprompted CPR in both in-hospital and out-of– Early CPR and
hospital cardiac arrest events is often poor, and methods should Rapid Defibrillation for VF
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 Ownership Interest Anesthesiology and Critical Care Medicine, Division Chief, Pediatric Critical Emory University, Dept. of Emergency Medicine– Associate Professor *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 hypothermia after 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 Wisconsin–Professor of Milwaukee site NETT-PI of Milwaukee and software capturing CPR Emergency Medicine 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 America-Board Member Legacy Health System, Emanuel Hospital, Emergency Services: Not-for-profit health 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 training materials November 2, 2010
Guidelines Part 5: Adult Basic Life Support: Writing Group Disclosures, Continued
Other Research Support Ownership Interest Medical College of †Title: Circulation Improving Resuscitation *Stockholder in Medtronic, Wisconsin– Associate 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 Emergency Medical related to improving resuscitation equipment for the research. I did not evaluate quantitative Services Division of Public generally (changing resuscitation receive any of this equipment Health-Seattle & King protocols) and not specific to algorhithm to guide County–Program Medical 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 minimize (eliminate) 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- Associate Professor This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be "significant" if (a) the personreceives $10 000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or shareof the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under thepreceding definition.
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KEY WORDS: cardiacarrest 䡲 defibrillation 䡲 emergency

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