BLS Role in Stroke and ACS Management

1. Rescuers should “phone first” for unresponsive adults. Exceptions: “phone fast”
(provide CPR first) for adult victims of submersion, trauma, and drug intoxication
(Class Indeterminate).
2. Prehospital BLS providers should identify possible stroke victims (through use of
stroke scales or screens) and provide rapid transport and prearrival notification to
the receiving hospital to increase the likelihood of their eligibility for intravenous
fibrinolytic therapy (Class I).
3. Patients with suspected stroke merit the same priorities for dispatch as patients
with acute myocardial infarction (AMI) or major trauma (Class IIb).
4. Victims of suspected ischemic stroke (with prearrival notification) should be
transported to a facility capable of initiating fibrinolytic therapy within 1 hour of
arrival unless that facility is >30 minutes away by ground ambulance (Class IIb).

BLS Sequence

Rescue Breathing and Bag-Mask Ventilation

1. Change ventilation volumes and inspiratory times for mouth-to-mask or bag-

mask ventilation as follows: a. Without oxygen supplement: tidal volume
approximately 10 mL/kg (700 to 1000 mL) over 2 seconds (Class IIa). b. With
oxygen supplement (≥40%): a smaller tidal volume of 6 to 7 mL/kg
(approximately 400 to 600 mL) may be delivered over 1 to 2 seconds (Class IIb).
2. Alternative airway devices (ie, laryngeal mask airway and the esophageal-
tracheal Combitube) may be acceptable when rescuers are trained in their use
(Class IIb).

Pulse Check

1. Lay rescuers will no longer be taught or expected to perform a pulse check. The
signal for lay rescuers to begin chest compressions (and attach an AED) is the
absence of signs of circulation (normal breathing, coughing, or
movement). Healthcare providers should continue to perform a pulse check with
assessment of signs of circulation (breathing, coughing, or movement).

Chest Compressions

1. The compression rate for adult CPR is approximately 100 per minute (Class IIb).
2. The compression-ventilation ratio for 1- and 2-rescuer CPR is 15 compressions
to 2 ventilations when the victim’s airway is unprotected (not intubated) (Class
IIb).
3. Chest compression–only CPR is recommended for use in dispatch-assisted CPR
or when the rescuer is unwilling or unable to perform mouth-to-mouth rescue
breathing (Class IIa).
 4. Audio prompts that guide action sequences and the timing of chest compressions
and ventilations increase learning and retention of CPR skills and improve CPR
performance (Class IIb).

Relief of Foreign-Body Airway Obstruction

1. Lay rescuers will no longer be taught the sequence for management of foreign-
body airway obstruction (FBAO) for unresponsive adults (Class IIb). If FBAO is
suspected in the victim who has become unresponsive or who is found
unresponsive, lay rescuers should perform the sequence of CPR. When rescue
breathing is performed, the lay rescuer should look for a foreign body in the
mouth and if one is seen, remove it. Healthcare providers should still perform the
sequence for relief of FBAO in the unresponsive victim.

Introduction

The actions taken during the first few minutes of an emergency are critical to victim
survival. BLS defines this sequence of actions and saves lives. BLS includes

 Prompt recognition and action for myocardial infarction and stroke to prevent
respiratory and cardiac arrest
 Rescue breathing for victims of respiratory arrest
 Chest compressions and rescue breathing for victims of cardiopulmonary arrest
 Attempted defibrillation of patients with ventricular fibrillation (VF) or ventricular
tachycardia (VT) with an automated external defibrillator (AED)
 Recognition and relief of FBAO

With the inclusion of AED use in BLS skills, BLS is now defined by the first 3 links in the
Chain of Survival: early access, early CPR, and early defibrillation (Figure 1).1 Each link
must be strong throughout the community; this approach is consistent with the concept
that the community is the “ultimate coronary care unit.”2

Early access requires prompt recognition of emergencies that require time-critical BLS
interventions, such as heart attack, stroke, FBAO, and respiratory and cardiac arrest.
Early access of the EMS system quickly alerts EMS providers, who can respond with a
defibrillator.345 Emergency Medical Dispatchers (EMDs) can lead callers through the
steps of CPR until EMS personnel arrive.67891011

Early CPR is the best treatment for cardiac arrest until the arrival of an AED and
advanced cardiovascular life support (ACLS) care.1213 Early CPR prevents VF from
deteriorating to asystole, may increase the chance of defibrillation, contributes to
preservation of heart and brain function, and significantly improves survival.131415 Early
defibrillation is the single greatest determinant of survival for adult victims of cardiac
arrest.1121617181920212223 Public access defibrillation (PAD) is a healthcare initiative to make
AEDs available throughout the community for use by trained laypersons. PAD holds
promise to be the single greatest advance in the treatment of VF arrest since the
development of CPR.1121617181920212223 PAD programs, including trained flight attendants and
police officers, have achieved resuscitation success rates as high as 49%.212425262728 This
nearly doubles the resuscitation rates previously achieved by the most successful EMS
programs.2930

Three BLS actions—early access, early CPR, and early defibrillation—serve as the
foundation for emergency cardiovascular care throughout the community.2 Each
community should identify weaknesses in its Chain of Survival and strengthen the Chain
through CPR training programs, effective PAD initiatives, and an optimized
EMS.31323334353637

BLS Response to Cardiopulmonary Emergencies

Epidemiology of Adult Cardiopulmonary Arrest: “Phone First” (Adult)/“Phone

Fast” (Infants and Children)

When the initial ECG is obtained, most adults with sudden (witnessed), nontraumatic
cardiac arrest are found to be in VF.38 For these victims, the time from collapse to
defibrillation is the single greatest determinant of survival.1327383940414243444546 The window of
opportunity is small. Survival from cardiac arrest caused by VF declines by
approximately 7% to 10% for each minute without defibrillation.47 More than 12 minutes
after collapse, the cardiac arrest survival rate is only 2% to
5%.13272838394041424344454647 Structured EMS systems that can be quickly accessed by
telephoning an emergency telephone number (such as 911 in the United States, 112 in
Europe, or 119 in Japan) have been shown to improve survival from sudden cardiac
death by providing early defibrillation (see “Part 12: From Science to Survival:
Strengthening the Chain of Survival in Every Community,” for international emergency
EMS contact numbers).1328394347 Because of this compelling data in adult victims, both
trained and untrained bystanders should be instructed to activate the EMS system as
soon as they have determined that an adult victim requires emergency care.

In sharp contrast to cardiac arrest in adults, most causes of cardiopulmonary arrest in

infants (aged <1 year) or children (aged 1 to 8 years) are related to airway or ventilation
problems rather than sudden cardiac arrest.48 In these victims, rescue support
(especially rescue breathing) is essential and should be attempted first—before
activation of the EMS system—if the rescuer is trained.49 This respiratory etiology of
cardiopulmonary arrest in children provides the rationale for the “phone fast” approach
to resuscitation in children: the rescuer provides approximately 1 minute of CPR and
then activates the EMS system.

There are exceptions to the “phone first/phone fast” recommendation for unresponsive
adults and children. Some studies suggest that VT/VF may be more common in
pediatric and adolescent victims of cardiac arrest (up to 15% of cases) than previously
believed, and in some pediatric studies, VF represents the most treatable terminal
arrhythmia.505152 Conversely, noncardiac causes of cardiac arrest can occur in adults and
can have favorable outcomes.53 Ideally the lay rescuer should learn a rescue sequence
that is tailored to the cause of the victim’s arrest. However, a rescuer may become
confused attempting to learn and remember a variety of rescue sequences, and this
confusion could create barriers to action during a real emergency. Consequently, these
guidelines continue to recommend a “phone first” approach for adult victims and
children ≥8 years old and a “phone fast” approach for unresponsive victims <8 years
old. However, training materials for BLS laypersons will identify exceptions to the
“phone first/phone fast” recommendation (Class Indeterminate). Healthcare providers
should be familiar with these exceptions. Exceptions to the “phone first/phone fast” rule
include

1. Submersion/near-drowning (“phone fast,” all ages)

2. Arrest associated with trauma (“phone fast,” all ages)
3. Drug overdoses (“phone fast,” all ages)
4. Cardiac arrest in children known to be at high risk for arrhythmias (“phone first,”
all ages)

If an FBAO is present in a responsive adult victim, the trained rescuer should attempt to
clear the airway (the Heimlich maneuver is recommended by most resuscitation
councils) before activating the EMS system.49 The untrained rescuer should activate the
EMS system immediately in an emergency; trained dispatchers can then instruct the
rescuer to perform CPR or provide other assistance until EMS personnel arrive.

If a second rescuer is available when a victim of cardiac or respiratory arrest of any

age is discovered, the first rescuer should begin CPR (open airway, rescue breathing,
chest compressions as needed) while the second rescuer activates the EMS system
and retrieves the AED if appropriate.

Throughout “Part 3: Adult Basic Life Support,” an “adult” is defined as anyone ≥8 years
of age.

Out-of-Hospital EMS Care, Including Emergency Medical Dispatch

Emergency medical dispatch has evolved over the past 25 years to become a
sophisticated and integral component of a comprehensive EMS response.67895455 EMDs
provide the first link between the victim and bystanders and EMS person-
nel.67895455 Trained medical dispatchers may provide prearrival instructions to bystanders
using standard, medically approved telephone instructions.56 Dispatchers should receive
formal training in emergency medical dispatch,1057 and they should use medical dispatch
protocols, including prearrival telephone instructions for airway control, CPR, relief of
FBAO, and use of an AED.678911545558

Dispatchers play an important role in early triage and dispatch for patients with
AMI.59 Dispatchers are able to accurately identify victims of cardiac arrest.55 However,
they may need specialized training to improve their ability to correctly identify and
prioritize victims of stroke.5460 In one recent study, only 41% of ambulances responding
to calls for victims of stroke were dispatched with a high priority.60 If emergency facilities
are available for administration of fibrinolytic therapy, EMS policies should set the same
high dispatch, treatment, and transport priorities for patients with signs and symptoms of
an acute ischemic stroke as those for patients with signs and symptoms of an AMI or
major trauma. Patients with suspected stroke with airway compromise or altered level of
consciousness should be given the same high priority for dispatch, treatment, and
transport as similar patients without stroke symptoms (Class IIb).

Using a script based on written protocols for cardiac arrest, dispatchers can question
callers, rapidly assess the condition of the victim, and activate the necessary
emergency serv-ice.89101155 To dispatch appropriate rescue personnel to the scene of a
cardiac arrest, the dispatcher needs to know whether the victim is unresponsive,
whether CPR is in progress, or whether an AED is in use. If a bystander does not know
how to perform CPR or does not remember what steps to take, an EMD can instruct the
rescuer in appropriate emergency interventions.89101155

Dispatch protocols are evolving as new resuscitation science emerges.61 For example,
when providing dispatcher-assisted CPR, some centers have simplified the technique
for untrained bystanders to reduce time to bystander intervention.6263 Dispatchers instruct
rescuers to locate the lower half of the victim’s sternum by placing their hands in the
center of the chest at the nipple line.6263 In a single study of dispatcher-assisted CPR,
chest compression–only bystander CPR was associated with survival equivalent to
chest compressions plus ventilations for victims of witnessed arrest.63 Several studies
have demonstrated that chest compression–only CPR is better than no CPR for adult
cardiac arrest.6465666768 For these reasons of simplicity and elimination of barriers to action,
we recommend chest compression–only CPR for use in dispatcher-assisted CPR
instructions to untrained bystanders (Class IIa). Continued evaluation of simplified
protocols and methods to encourage bystander CPR is needed.

Dispatcher-assisted CPR is practical and effective and can increase the percentage of
cardiac arrests in which bystander CPR is performed.10115558 Because dispatch
instructions can be lifesaving, EMD assistance has rapidly become the standard of care
in EMS systems.678910115455575859606269

Some evidence suggests that priority dispatch triage systems that tier the EMS
response to send BLS ambulance responders to less urgent calls and reserve
paramedics (ACLS responders) for more critical incidents may significantly improve use
of paramedic skills.1170 Although studies of patient outcome are only inferential, traditional
systems with high survival rates have used such an approach.6117071 Research into this
concept should continue.

No scientific studies have documented improved survival with use of computerized

systems that automatically provide the EMD with the caller’s location and telephone
number (called “enhanced 911” in the United States). Such systems, however, expedite
the EMD process, and their use should be strongly encouraged.6

Recognition and Actions for Acute Coronary Syndromes

Each year millions of patients around the world are evaluated for chest pain in
Emergency Departments (EDs).72 Of these, approximately half will be diagnosed as
having an acute coronary syndrome (ACS), including unstable angina, non–Q-wave
myocardial infarction (MI), and ST-elevation MI.7273 Of all patients with ACS,
approximately half will die before reaching the hospital. Of patients who reach the
hospital, an additional 25% will die within the first year.74 In 17% of patients, ischemic
pain is the first, last, and only symptom.75

Current management of ACS contrasts dramatically with the approach used 2 decades
ago. Fibrinolytic agents and percutaneous coronary interventions (including
angioplasty/stent) may reopen the blocked coronary vessels that cause myocardial
ischemia. These treatments save lives and improve quality of life.7677787980818283 Early
diagnosis and treatment of AMI significantly reduces mortality,76 decreases infarct
size,77 improves regional78 and global798081 left ventricular function, and decreases the
incidence of resultant heart failure.8283 To be most effective, these interventions must be
administered within the first few hours of symptom onset.7677787980818283

The time-limited treatments now available for ACS have highlighted the important role of
lay rescuers, first responders, and EMS personnel. Early recognition, early intervention,
and early transport of victims with suspected ACS from the scene to the hospital can
substantially reduce morbidity and mortality.

Presentation of ACS

Early access to the EMS system is often delayed because both victim and bystanders
fail to recognize the signs and symptoms of ACS.8485868788 Public education is needed to
increase recognition of the signs and symptoms of ACS and encourage the public to
access the EMS system quickly.

The classic symptom associated with ACS is a dull, substernal discomfort variably
described as a pressure or tightness, often radiating to the left arm, neck, or jaw. It may
be associated with shortness of breath, palpitations, nausea, vomiting, or sweating.
Symptoms of angina pectoris typically last <15 minutes. In contrast, the symptoms of
AMI are characteristically more intense and last >15 minutes.

Some victims of ACS have atypical or vague chest discomfort. The victim may feel light-
headed, short of breath, nauseous, or faint, or have a cold sweat. The discomfort may
be more diffuse than classic chest pain and may radiate to the back or may be
concentrated between the shoulder blades. The elderly,89 women,909192 and persons with
diabetes and ACS are more likely to present with vague complaints rather than classic
descriptions of chest pain.

The patient with new onset of chest discomfort should rest quietly. Both angina pectoris
and AMI are caused by a lack of adequate blood supply to the heart, so activity should
be kept to a minimum. If chest discomfort lasts more than a few minutes, initiate
emergency action. The action steps for lay rescuers include (1) recognize the signs and
symptoms of ACS, (2) have the victim sit or lie down, and (3) if discomfort persists for
≥5 minutes, activate the EMS system.

After activating the EMS system, give the victim supportive care, including rest,
reassurance, and use of a recovery position. If the victim becomes unresponsive, be
prepared to provide rescue breathing, chest compressions, and (when possible and
appropriate) attempted defibrillation with an AED.

Denial is a common reaction to emergencies such as AMI. The victim’s first tendency
may be to deny the possibility of a heart attack. This response is not limited to the
victim; the lay rescuer may also deny such a possibility. In an emergency, those
involved, whether victims or bystanders, are inclined to deny or downplay the
seriousness of the problem. This response, while natural, must be overcome to give
victims the greatest chance of survival. Denial of the serious nature of symptoms delays
treatment and increases risk of death.9394

The elderly, women, and persons with diabetes, hypertension, or known coronary artery
disease are most likely to delay calling the EMS system.82 Because the victim may deny
the possibility of a heart attack, lay rescuers must be prepared to activate the EMS
system themselves and provide additional BLS as needed. Public education campaigns
have been effective in increasing public awareness of this important issue.9596

Out-of-Hospital Care for ACS

There are many benefits to early access of the EMS system as soon as you recognize
the signs and symptoms of ACS. EMDs can send the appropriate emergency team and
provide instructions for patient care before EMS personnel arrive.8 BLS ambulance
providers can provide CPR; use an AED; support airway, oxygenation, and ventilation;
and administer nitroglycerin and aspirin out of the hospital.9798 The EMS provider should
also obtain a significant medical history and inquire about risk factors for ACS.

Nitroglycerin is effective for relief of symptoms, and it dilates coronary arteries and
reduces ventricular preload and oxygen requirements.99 If the patient with chest pain has
nitroglycerin and his systolic blood pressure is >90 mm Hg, the BLS ambulance provider
can help the patient take the nitroglycerin. The patient can take up to 3 nitroglycerin
tablets at intervals of 3 to 5 minutes. After administration of each nitroglycerin tablet,
monitor blood pressure closely for signs of hypotension.

If local protocol permits, the BLS ambulance provider should administer aspirin (160 to
325 mg) en route. Aspirin inhibits coronary reocclusion and recurrent events after
fibrinolytic therapy and reduces mortality in ACS.100 Routine out-of-hospital
administration of nitroglycerin and aspirin by BLS ambulance providers is expected to
reduce morbidity and mortality from AMI.101

Some ACLS ambulance providers are authorized to administer morphine to reduce pain
and decrease myocardial oxygen requirements and left ventricular preload and
afterload. ACLS providers also monitor the heart rhythm and can immediately detect
potentially lethal cardiac arrhythmias. ACLS ambulance providers may administer
medications to manage arrhythmias, shock, and pulmonary congestion; they may
initiate transcutaneous pacing as well. The mnemonic “MONA” (morphine, oxygen,
nitroglycerin, and aspirin) is a reminder of the core out-of-hospital therapies for ACS.

In many systems, ACLS ambulance providers can attach a 12-lead ECG to the victim
and transmit the findings to the receiving facility. This allows diagnosis of a heart attack
in progress and significantly reduces time to treatment, which may include fibrinolytic
therapy, in the hospital.102103104105106107108109110 This prearrival ECG and notification has been
shown to improve outcome.111 In the event of a complication (either at the scene or en
route to the hospital), ACLS ambulance providers can administer lifesaving therapies,
including CPR, rapid defibrillation, airway management, and intravenous medications.

The BLS algorithm for EMS out-of-hospital management of patients with ACS is shown
in Figure 2. (For further information about the management of ACS, see “Part 7, Section
1: Acute Coronary Syndromes.”)

Recognition of Stroke and Actions for Patients With Suspected Stroke

Stroke is a leading cause of death and brain injury in adults. Each year millions of adults
suffer a new or recurrent stroke, and nearly a quarter of them die.112 Until recently, care
of the stroke patient was largely supportive, with therapy focused on treatment of
complications.113 Because no treatment was directed toward altering the course of the
stroke itself, little emphasis was placed on rapid identification, transport, or
intervention.113

Now fibrinolytic therapy offers the opportunity to limit neurological insult and improve
outcome in ischemic stroke patients.114115116117118119120121 Fibrinolytic therapy reduces disability
and death from stroke in eligible patients.114115116117118119120121 Furthermore, patients treated
with fibrinolytics are more likely to be discharged home and less likely to be discharged
to a rehabilitative or chronic care facility. Fibrinolytic therapy is cost-effective and results
in sustained improvement in quality of life.118122 For these reasons, intravenous fibrinolytic
therapy should be considered for all patients presenting to the hospital within 3 hours of
the onset of signs and symptoms consistent with acute ischemic stroke (Class
I).114117118121 Use of intra-arterial fibrinolytic agents within 3 to 6 hours of symptom onset
may also be beneficial for patients with stroke caused by middle cerebral artery
occlusion (Class IIb).115119120

The window of opportunity to provide this beneficial therapy is small. For most stroke
victims, definitive hospital-based intervention must occur within 3 hours of symptom
onset. The time-limited treatments now available for stroke have emphasized the
important role of lay rescuers, first responders, and emergency rescue service
personnel. Early recognition, early intervention, and early transport of victims with
suspected stroke from the scene to the hospital can substantially reduce morbidity and
mortality from stroke.

Presentation of Stroke
A transient ischemic attack (TIA) is a reversible episode of focal neurological
dysfunction that typically lasts a few minutes to a few hours. It is impossible to
distinguish between a TIA and a stroke at the time of onset. If the neurological
symptoms completely resolve within 24 hours, the event is classified as a TIA. Most
TIAs, however, last <15 minutes.123124 TIAs are a significant indicator of stroke risk.
Approximately one fourth of patients presenting with stroke have had a previous
TIA.125 In addition, approximately 5% of patients with a TIA will develop a stroke within 1
month if untreated.113126

A stroke is a neurological impairment caused by disruption of blood supply to the brain.

Approximately 75% of strokes are ischemic, the result of complete occlusion of a
cerebral artery caused by cerebral thrombosis or embolism. Hemorrhagic strokes are
caused by cerebral artery rupture with bleeding into the surface of the brain
(subarachnoid hemorrhage) or bleeding into the tissue of the brain (intracerebral
hemorrhage). The most common cause of a subarachnoid hemorrhage is an
aneurysm.127128 Hypertension is the most common cause of intracerebral hemorrhage.129130

Although both ischemic and hemorrhagic stroke can be life-threatening, ischemic stroke
rarely leads to death within the first hour. In comparison, hemorrhagic stroke can be
fatal at onset. Patients with ischemic strokes can often be treated with fibrinolytic
therapy if they are able to receive the drug within 3 hours of symptom onset. Fibrinolytic
therapy cannot be given to patients with hemorrhagic stroke because it would worsen
intracerebral bleeding. Some patients with hemorrhagic stroke can benefit from surgical
intervention.131132

In both stroke and heart attack, blood supply is inadequate, often the result of an
obstructing blood clot. Rapid intervention with fibrinolytic therapy can improve outcome
after an ischemic stroke just as it can after an AMI.114

Recognition of the signs and symptoms of stroke is critical to early intervention and
treatment. The presentation of stroke may be subtle. Signs and symptoms of stroke
may include only mild facial paralysis or difficulty speaking that may go unnoticed or be
denied by the patient or family members.133 Other signs and symptoms of stroke include
alteration in consciousness (confusion, stupor, or coma); sudden weakness or
numbness of the face, arm, or leg on one side of the body; slurred or incoherent
speech; unexplained dizziness; unsteadiness; sudden falls; and dimness or loss of
vision, particularly in one eye. The lay rescuer should immediately activate the EMS
system as soon as signs or symptoms of stroke are suspected.

Stroke victims may either be unable to understand that they are having a stroke or, like
AMI victims, deny their symptoms by rationalization.134 Most stroke victims delay access
to care for hours after symptom onset.123133134135136137138139140141142 Tragically, this delay often
eliminates the possibility of fibrinolytic therapy. Because the victim may deny having
symptoms of a stroke or be unable to understand, lay rescuers must take the initiative
and rapidly activate the EMS system, providing additional BLS as necessary.

The 7 “D’s” of Stroke Management

Management of the stroke patient can be remembered by use of the mnemonic of the 7
“D’s”: Detection, Dispatch, Delivery, Door, Data, Decision, and Drug.143 Delay may occur
at any of these points of management, so response to and management of the stroke
victim must be skilled and efficient at each point. The first 3 D’s (detection, dispatch,
and delivery) are the responsibility of BLS providers in the community, including the lay
public and EMS responders. A patient, family member, or bystander recognizes
(detects) the signs and symptoms of a stroke or TIA and activates the EMS system.
EMDs then prioritize the call for a patient with suspected stroke just as they would for a
victim of AMI or serious trauma, and they dispatch the appropriate EMS team with high
transport priority. EMS providers must respond rapidly, confirm signs and symptoms of
a suspected stroke, and provide transport (delivery) of the patient to a stroke center (a
hospital that can provide fibrinolytic therapy within 1 hour after arrival at the ED door).
The remaining 4 D’s are initiated in the hospital, including rapid triage at the door (in the
ED), neurological examination, and performance and interpretation of a CT scan to
diagnose type of stroke (data), identifying candidates eligible for fibrinolytic therapy
(decision), and treating with fibrinolytic therapy (drug).

Layperson BLS Care for Stroke

Rapid access of the EMS system is essential as soon as signs and symptoms of a
stroke appear. When the EMS is used for transport, stroke patients arrive at the hospital
faster than those who do not use the EMS (a major advantage for time-critical
treatment).133135144145146147148149 Furthermore, EMDs can send the appropriate emergency team
with a priority dispatch response and provide instructions for patient care before EMS
personnel arrive.150151152 The EMS system can then rapidly transport the victim to a stroke
center and notify the facility before arrival to ensure rapid hospital-based evaluation and
treatment. Delays in transport and initial hospital evaluation occur if the victim or family
contacts the family physician or transports the stroke victim by private car to the
hospital. Such delays may make the victim ineligible for fibrinolytic treatment.133146148

Currently, in the United States only half of stroke victims use the EMS system for
transport to the hospital.133136 If a stroke occurs while the victim is alone or sleeping, this
further delays prompt recognition of symptoms and initiation of therapy.153 Eighty-five
percent of strokes occur at home.136 As a result, public education programs have
focused on persons at risk for stroke and their friends and family members.136 Public
education has been successful in reducing time to arrival at the ED.136137

After accessing the EMS system, provide supportive care, including reassurance. Place
the victim in a recovery position. If the victim becomes unresponsive, provide rescue
breathing and other steps of CPR if needed.

Out-of-Hospital Care for Stroke

BLS ambulance providers now play a critical role in recognition, stabilization, and rapid
transport of the stroke victim as well as selection of a receiving hospital capable of
administering fibrinolytic therapy. In the past, these providers received minimal training
in stroke assessment and care.7150151152154 Programs are now needed to train EMS
personnel to accurately recognize and prioritize stroke victims.5460155156157158159160161162163164

If emergency facilities are available for administration of fibrinolytic therapy, emergency

ambulance service policies should require the same high dispatch, treatment, and
transport priorities for patients with signs and symptoms of an acute ischemic stroke as
those for patients with signs and symptoms of an AMI or major trauma. Patients with
suspected stroke with airway compromise or altered level of consciousness should be
given the same high dispatch, treatment, and transport priorities as other nonstroke
patients with similar problems (Class IIb). Airway compromise after stroke is relatively
common. Cardiac arrest is relatively uncommon, although many stroke victims
demonstrate arrhythmias, including ventricular tachyarrhythmias and atrial fibrillation, in
the first hours and days after a stroke.165166167

The goals of out-of-hospital management by BLS ambulance providers of patients with

suspected stroke include (1) priority dispatch and response; (2) initial assessment and
management, including support of airway, oxygenation, ventilation, and circulation; (3)
rapid identification of stroke (by use of a standardized stroke scale); (4) rapid transport
of the victim to a stroke center capable of delivering fibrinolytics within 1 hour of arrival;
and (5) prearrival notification of the hospital.

The clinical presentations of ischemic and hemorrhagic stroke often overlap, making a
diagnosis on the basis of symptoms alone impossible. In general, headaches (often
described by the victim as the sudden onset of “the worst headache of my life”),
disturbances in consciousness, nausea, and vomiting are more severe in association
with intracranial hemorrhages. Loss of consciousness may be transient, with resolution
by the time the patient receives medical attention. Patients with subarachnoid
hemorrhage may have an intense headache without focal neurological signs.

The patient with an ischemic stroke may be eligible for in-hospital treatment with
fibrinolytic therapy. The diagnosis of ischemic stroke and determination of eligibility,
however, require several time-consuming steps once the victim arrives at the hospital: a
treatment team is mobilized, the patient is assessed and eligibility determined, a CT
scan is obtained and interpreted to rule out intracranial hemorrhage, and therapy is
administered. All of these steps must be completed to allow drug delivery within 3 hours
after onset of patient symptoms. BLS ambulance providers can maximize the likelihood
of patient eligibility for fibrinolytic therapy by rapidly identifying a possible stroke victim,
rapidly transporting the victim to a stroke center, and providing prearrival notification to
the receiving hospital. Emphasis on the time-critical nature of this management should
be included in out-of-hospital assessment and management protocols.

BLS ambulance providers should establish the time of onset of signs and symptoms of
stroke: this timing has important implications for potential therapy. The onset of
symptoms is viewed as the beginning (onset) of the stroke, and eligibility for fibrinolytic
therapy ends 3 hours from that time. If the victim is unable to estimate the time of onset
of signs and symptoms, question family members or friends at the scene. It may be
possible to determine when the victim was last observed, what the victim was doing
when symptoms developed (eg, preparing lunch), and any other information that will
give the receiving hospital an estimate of the time of symptom onset.

Brief Neurological Evaluation: Stroke Scale and Stroke Screen

It is impractical to perform an extensive neurological examination out of hospital

because it delays the patient’s transport to the ED. The abbreviated out-of-hospital
neurological examination should include a validated tool such as the Cincinnati
Prehospital Stroke Scale158 (Table 1) or the Los Angeles Prehospital Stroke Screen
(LAPSS) (Table 2).149159 Providers using the Cincinnati Prehospital Stroke Scale attempt
to elicit any of 3 major physical findings suggestive of stroke: facial droop (Figure 3),
arm drift (Figure 4), and abnormal speech.158 The LAPSS includes several items
designed to rule out other causes of altered level of consciousness (history of seizures,
severe hyperglycemia or hypoglycemia). The provider using the LAPSS attempts to
identify asymmetry in facial weakness/grimace, hand grip, or arm strength; asymmetry
(right versus left) in any category indicates that the victim has had a possible stroke
(Table 2).149159 These scales are both sensitive and specific in identifying stroke
patients149158159 and can be quickly applied.

Assess the patient’s level of consciousness. The Glasgow Coma Scale (GCS) can be
used to score the patient’s responsiveness when the level of consciousness is
depressed. This scale evaluates eye opening, best motor response, and best verbal
response to simple stimuli, such as voice and pain. The highest possible score is 15; a
score of 13 to 14 indicates mild neurological impairment; 11 to 13, moderate
impairment; and <11, severe impairment. The GCS is well known, reproducible, and
reliable when applied to patients with stroke.160

EMS personnel can identify stroke patients with reasonable sensitivity and
specificity.150156158159161162163164Once the diagnosis of stroke is suspected, time in the field
should be minimized and the patient prepared for immediate transport to a stroke
center. (For further information, please see “Part 7, Section 2: Acute Stroke.”

EMS physicians should work with neurologists and local hospitals to establish clear
destination protocols for patients suspected of having an acute stroke.144145146154155156 EMS
ambulance services should transport a patient with stroke symptoms to an emergency
receiving facility with proven capability to initiate fibrinolytic therapy for eligible stroke
patients within 1 hour of arrival unless the emergency facility is >30 minutes away by
ground ambulance (Class IIb). A Canadian study revealed that the vast majority of
residents live within a 30-minute drive of a hospital with 24-hour CT scanning
capability.164

Prearrival notification to the receiving facility shortens the time to definitive hospital-
based evaluation and intervention for patients with stroke.* In addition to standard
information, EMS systems should communicate the results of the stroke scale or stroke
screen, the GCS, and the estimated time of symptom onset to the receiving hospital
before arrival. The receiving facility should have a written plan to initiate therapy as
quickly as possible (see Figure 5). Figure 5 summarizes BLS ambulance provider out-
of-hospital assessment and management of patients with possible stroke.

Indications for BLS

Respiratory Arrest

Respiratory arrest can result from a number of causes, including submersion/near-

drowning, stroke, FBAO, smoke inhalation, epiglottitis, drug overdose, electrocution,
suffocation, injuries, myocardial infarction, lightning strike, and coma from any cause.
When primary respiratory arrest occurs, the heart and lungs can continue to oxygenate
the blood for several minutes, and oxygen will continue to circulate to the brain and
other vital organs.168 Such patients initially demonstrate signs of circulation. When
respiratory arrest occurs or spontaneous respirations are inadequate, establishment of
a patent airway and rescue breathing can be lifesaving because it can maintain
oxygenation and may prevent cardiac arrest.

Cardiac Arrest

In cardiac arrest, circulation ceases and vital organs are deprived of oxygen. Ineffective
“gasping” breathing efforts (“agonal” respirations) may occur early in cardiac arrest and
should not be confused with effective respirations.66169170 Because lay rescuers rely on
evaluation of breathing to determine cardiac arrest, they should be carefully trained to
differentiate between adequate versus inadequate ventilation. Cardiac arrest can be
accompanied by the following cardiac rhythms: VF, VT, asystole, or pulseless electrical
activity.

AED Use

The cardiac arrest rhythms of VT and VF are treated most effectively with early
defibrillation. AED use is now considered an important and lifesaving addition to BLS
and provides the trained lay rescuer or healthcare provider with the opportunity to
implement the first 3 links in the Chain of Survival (early access, early CPR, and early
defibrillation).3334 The sequence of action for a rescuer with training and access to an
AED is identical to that of CPR except for the added step of attaching and using the
AED. AEDs are effective and easy to use.171 (See “Part 4: The Automated External
Defibrillator” later in the guidelines.)

The Sequence of BLS: Assessment, EMS Activation, the ABCs of CPR,

and the “D” of Defibrillation

The BLS sequence described in this section applies to victims ≥8 years old. This
sequence will be applied to older children, adolescents, and adults. For simplicity, the
victim is consistently referred to as an “adult” to differentiate the victim from a “pediatric”
victim who is <8 years old.
Resuscitation Sequence

BLS consists of a series of skills performed sequentially. These skills include

assessment skills and support/intervention skills. The assessment phases of BLS are
crucial. No victim should undergo the more intrusive procedures of CPR (positioning,
opening the airway, rescue breathing, or chest compressions) until need has been
established by the appropriate assessment. Assessment also involves a more subtle,
constant process of observing the victim and the victim’s response to rescue support.
The importance of the assessment phases should be stressed in teaching CPR.

Each of the ABCs of CPR—airway, breathing, and circulation—begins with an

assessment phase: assess responsiveness, breathing, and signs of circulation. In the
United States, the EMS system should be activated if any adult is found to be suddenly
unresponsive. Outside the United States, EMS activation may be recommended if the
victim is found to be unresponsive and not breathing, or activation may be delayed until
after delivery of rescue breaths and determination that the victim has no signs of
circulation. In all countries the EMS system should be activated as soon as it has been
established that emergency care is needed. Whenever ≥2 rescuers are present, 1
rescuer remains with the victim to provide CPR while the second rescuer activates the
EMS.

Hospitals and medical facilities and some businesses or building complexes will have
an established emergency medical response system that provides a first response or
early response on site. Such a response system notifies rescuers of the location of an
emergency and the type of response needed. If the cardiopulmonary emergency occurs
in a facility with an established medical response system, that system should be notified
of the emergency, because it will provide more rapid response than EMS personnel
arriving from outside the facility. For rescuers in these facilities, the emergency medical
response system should replace the EMS system in the sequences below.

Assess Responsiveness

After determining that the scene is safe, the rescuer arriving at the side of the collapsed
victim must quickly assess any injury and determine whether the person is responsive.
Tap or gently shake the victim and shout, “Are you all right?” (Figure 6). If the victim has
sustained trauma to the head and neck or if neck trauma is suspected, move the victim
only if absolutely necessary. Improper movement may cause paralysis in the victim with
injury to the spine or spinal cord.

Activate the EMS System

Activate the EMS system by calling the appropriate local emergency response system
telephone number. This number should be widely publicized in each community. The
person who calls the EMS system should be prepared to give the following information
as calmly as possible172 :
 1. Location of the emergency (with names of office or room number or cross streets
or roads, if possible)
2. Telephone number from which the call is being made
3. What happened: heart attack, auto crash, etc
4. Number of persons who need help
5. Condition of the victim(s)
6. What aid is being given to the victim(s) (eg, “CPR is being performed” or “we’re
using an AED”)
7. Any other information requested. To ensure that EMS personnel have no more
questions, the caller should hang up only when instructed to do so by the EMD.

The stage in the rescue process at which EMS activation is appropriate is determined
by each country’s resuscitation council and is based on the facilities available, the
remoteness from those facilities of the scene of collapse, and national and local
practice. In the United States, for example, the EMS should be activated as soon as the
adult victim is found to be unresponsive. In many countries in Europe, the EMS system
is activated after the airway is opened, breathing is assessed, and the unresponsive
victim is found to be not breathing. In Australia, the EMS system is activated after the
rescuer delivers rescue breaths.

Airway

If the victim is unresponsive, the rescuer will need to determine whether the victim is
breathing adequately. To assess breathing, the victim should be supine (lying on his or
her back) with an open airway.

Position the Victim

For resuscitative efforts and evaluation to be effective, the victim must be supine and on
a firm, flat surface. If the victim is lying face down, roll the victim as a unit so that the
head, shoulders, and torso move simultaneously without twisting. The head and neck
should remain in the same plane as the torso, and the body should be moved as a unit.
The nonbreathing victim should be supine with the arms alongside the body. The victim
is now appropriately positioned for CPR.

Rescuer Position

The trained rescuer should be at the victim’s side, positioned to perform both rescue
breathing and chest compression. The rescuer should anticipate the arrival of an AED, if
appropriate, and should be prepared to operate it when it arrives.

Open the Airway

When the victim is unresponsive/unconscious, muscle tone is decreased and the

tongue and epiglottis may obstruct the pharynx (Figure 7).172173174175 The tongue is the most
common cause of airway obstruction in the unresponsive victim. Because the tongue is
attached to the lower jaw, when you move the lower jaw forward you will lift the tongue
away from the back of the throat and open the airway. The tongue or the epiglottis, 175 or
both, may also create an obstruction when negative pressure is created in the airway by
spontaneous inspiratory effort; this creates a valve-type mechanism that can occlude
the entrance to the trachea.

If there is no evidence of head or neck trauma, use the head tilt–chin lift maneuver
described below (Figure 8) to open the airway. Remove any visible foreign material or
vomitus from the mouth. Wipe liquids or semiliquids out of the mouth with fingers
covered with a glove or piece of cloth. Extract solid material with a hooked index finger
while keeping the tongue and jaw supported with the other hand.

Head Tilt–Chin Lift Maneuver

To accomplish the head tilt maneuver, place one hand on the victim’s forehead and
apply firm, backward pressure with your palm, tilting the head back. To complete the
head tilt–chin lift maneuver, place the fingers of your other hand under the bony part of
the lower jaw near the chin. Lift the jaw upward to bring the chin forward and the teeth
almost to occlusion (Figure 8). This maneuver supports the jaw and helps tilt the head
back. Do not press deeply into the soft tissue under the chin, because this might
obstruct the airway. Do not use your thumb to lift the chin. Open the victim’s mouth to
facilitate spontaneous breathing and to prepare for mouth-to-mouth breathing.

If the victim’s dentures are loose, head tilt–chin lift facilitates creation of a solid mouth-
to-mouth seal.176 Remove the dentures if they cannot be kept in place.

Jaw-Thrust Maneuver

The jaw-thrust without head tilt maneuver for airway opening should be taught to both
lay rescuers and healthcare providers. Place one hand on each side of the victim’s
head, resting your elbows on the surface on which the victim is lying. Grasp the angles
of the victim’s lower jaw and lift with both hands (Figure 9). If the lips close, you can
retract the lower lip with your thumb. If mouth-to-mouth breathing is necessary while you
maintain the jaw thrust, close the victim’s nostrils by placing your cheek tightly against
them. This technique is very effective for opening the airway177 but fatiguing and
technically difficult for the rescuer.176

The jaw-thrust technique without head tilt is the safest initial approach to opening the
airway of the victim with suspected neck injury because it usually can be done without
extending the neck. Carefully support the head without tilting it backward or turning it
from side to side.

Recommendations for Opening the Airway

The recommended technique for opening the airway must be simple, safe, easily
learned, and effective. Because head tilt–chin lift meets these criteria, it should be the
method of choice for lay rescuers performing BLS, and lay rescuers should use this
technique unless trauma is suspected. Although all rescuers are taught both head tilt–
chin lift and jaw thrust methods of opening the airway, the professional rescuers (BLS
ambulance providers and other healthcare providers) should be proficient in both head
tilt–chin lift and jaw thrust.

Breathing

Assessment: Check for Breathing

To assess breathing, place your ear near the victim’s mouth and nose while maintaining
an open airway. Then, while observing the victim’s chest, (1) look for the chest to rise
and fall, (2) listen for air escaping during exhalation, and (3) feel for the flow of air. If the
chest does not rise and fall and no air is exhaled, the victim is not breathing. This
evaluation procedure should take no more than 10 seconds.

Most victims with respiratory or cardiac arrest have no signs of breathing. Occasionally,
however, the victim will demonstrate abnormal and inadequate breathing. Some victims
demonstrate apparent respiratory efforts with signs of upper airway obstruction. These
victims may resume effective breathing when you open the airway. Some victims may
have a patent airway but may make only weak, inadequate attempts to breathe. Reflex
gasping respiratory efforts (agonal respirations) are another form of inadequate
breathing that may be observed early in the course of primary cardiac arrest. Absent or
inadequate respirations require rapid intervention with rescue breathing. If you are
not confident that respirations are adequate, proceed immediately with rescue
breathing. Lay rescuers are taught to provide rescue breathing if “normal” breathing is
absent.

If a victim resumes breathing and regains signs of circulation (pulse, normal breathing,
coughing, or movement) during or after resuscitation, continue to help the victim
maintain an open airway. Place the victim in a recovery position if the victim maintains
breathing and signs of circulation.

Recovery Position

The recovery position is used in the management of victims who are unresponsive but
are breathing and have signs of circulation (Class Indeterminate). When an
unresponsive victim is lying supine and breathing spontaneously, the airway may
become obstructed by the tongue or mucus and vomit. These problems may be
prevented when the victim is placed on his or her side, because fluid can drain easily
from the mouth.

Some compromise is needed between ideal position for maximum airway patency and
optimal position to allow monitoring and support with good body alignment. A modified
lateral position is used because a true lateral posture tends to be unstable, involves
excessive lateral flexion of the cervical spine, and results in less free drainage from the
mouth. A near-prone position, on the other hand, can hinder adequate ventilation
because it splints the diaphragm and reduces pulmonary and thoracic
compliance.178 Several versions of the recovery position exist, each with its own
advantages. No single position is perfect for all victims. When deciding which position to
use, consider 6 principles179 :

1. The victim should be in as near a true lateral position as possible, with the head
dependent to allow free drainage of fluid.
2. The position should be stable.
3. Avoid any pressure on the chest that impairs breathing.
4. It should be possible to turn the victim on his or her side and to return to the back
easily and safely, with concern for a possible cervical spine injury.
5. Good observation of and access to the airway should be possible.
6. The position itself should not cause an injury to the victim.

It is particularly important to avoid injury to the victim when turning the victim. 180181 If
trauma is present or suspected, the victim should be moved only if an open airway
cannot otherwise be maintained. This might be the case if, for example, a lone rescuer
needs to leave the victim to get help. Monitor the victim, particularly for impairment of
blood flow in the lowermost arm.182183 If the victim remains in the recovery position for >30
minutes, turn the victim to the opposite side. Although no single specific recovery
position can be recommended, the one illustrated (Figure 10) is suitable for training
purposes.

Provide Rescue Breathing

When providing rescue breathing, you must inflate the victim’s lungs adequately with
each breath.

Mouth-to-Mouth Breathing

Mouth-to-mouth rescue breathing is a quick, effective way to provide oxygen and

ventilation to the victim.184 Your exhaled breath contains enough oxygen to supply the
victim’s needs.184 To provide rescue breaths, hold the victim’s airway open, pinch the
nose, and make a seal with your mouth over the victim’s mouth. Rest the palm of one
hand on the victim’s forehead and pinch the victim’s nose closed with your thumb and
index finger. Pinching the nose will prevent air from escaping through the victim’s nose.
Take a deep breath and seal your lips around the victim’s mouth, creating an airtight
seal. Give slow breaths, delivering each breath over 2 seconds, making sure the
victim’s chest rises with each breath. Be prepared to deliver approximately 10 to 12
breaths per minute (1 breath every 4 to 5 seconds) if rescue breathing alone is required
(see Figure 11).

The number of breaths delivered to initiate rescue breathing/ventilation varies

throughout the world, and there is no data to suggest superiority of one number over the
other. In the United States, 2 breaths are provided. In Europe, Australia, and New
Zealand, 5 breaths are provided to initiate resuscitation. Each approach has its
advantages. Delivery of fewer breaths will shorten the time to assessment of
circulation/pulse and attachment of an AED (and possible defibrillation), but delivery of a
greater number of breaths may help to correct hypoxia and hypercarbia. In the absence
of data to support one number of breaths over another, it is appropriate to deliver 2 to 5
initial breaths, according to local custom.

Gastric inflation frequently develops during mouth-to-mouth ventilation.185186 Gastric

inflation can produce serious complications, such as regurgitation,187188189 aspiration,190 or
pneumonia.191 It also increases intragastric pressure,185186190191192193194195 elevates the
diaphragm, restricts lung movements, and decreases respiratory system
compliance.185196197 Gastric inflation occurs when the pressure in the esophagus exceeds
the lower esophageal sphincter opening pressure, causing the sphincter to open so that
air delivered during rescue breaths enters the stomach instead of the
lungs.185196197198199200201 During cardiac arrest, the likelihood of gastric inflation increases
because the lower esophageal sphincter relaxes.198 Factors that contribute to creation of
a high esophageal pressure and gastric inflation during rescue breathing include a short
inspiratory time, a large tidal volume, and a high peak airway pressure.

Previous guidelines recommended that rescue breaths provide a tidal volume of 800 to
1200 mL delivered over 1 to 2 seconds.49 With respect to gastric inflation, a substantially
smaller tidal volume would be safer but is ineffective in maintaining adequate arterial
oxygen saturation unless supplemental oxygen can be delivered via a face mask or
bag-valve mask.202203

To reduce the risk of gastric inflation during mouth-to-mouth ventilation, deliver slow
breaths at the lowest tidal volume that will still make the chest visibly rise with each
ventilation. For mouth-to-mouth ventilation in most adults, this volume will be
approximately 10 mL/kg (approximately 700 to 1000 mL) and should be delivered over 2
seconds (Class IIa). This recommendation represents a slightly decreased range of tidal
volume compared with previous guidelines, and it uses the upper limit of inspiratory time
recommended in the previous guidelines. This new recommendation is intended to
reduce the risk of gastric inflation (and its serious consequences) while maintaining
adequate arterial oxygen saturation during respiratory and cardiac arrest.

If you take a deep breath before each ventilation, you will optimize your exhaled gas
composition, ensuring that you will provide as much oxygen as possible to the
victim.204 You are providing adequate ventilation if you see the chest rise and fall with
each breath and you hear and feel the air escape during exhalation. When possible (eg,
during 2-rescuer CPR), maintain airway patency to allow unimpeded exhalation
between rescue breaths.

If initial (or subsequent) attempts to ventilate the victim are unsuccessful, reposition the
victim’s head and reattempt rescue breathing. Improper chin and head positioning is the
most common cause of difficulty with ventilation. If the victim cannot be ventilated after
repositioning of the head, the healthcare provider (but not the lay rescuer) should
proceed with maneuvers to relieve FBAO (see “Foreign-Body Airway Obstruction
Management” below).

Mouth-to-Nose Breathing
The mouth-to-nose method of ventilation is recommended when it is impossible to
ventilate through the victim’s mouth, the mouth cannot be opened (trismus), the mouth
is seriously injured, or a tight mouth-to-mouth seal is difficult to achieve.205 Mouth-to-
nose breathing may be the best method of providing ventilation while rescuing a
submersion victim from the water. The rescuer’s hands often will be used to support the
victim’s head and shoulders during rescue. The mouth-to-nose technique may enable
the rescuer to begin rescue breathing as soon as the victim’s head is out of the water.

To provide mouth-to-nose breathing, tilt the victim’s head back with one hand on the
forehead and use the other hand to lift the victim’s mandible (as in head tilt–chin lift) and
close the victim’s mouth.175 Take a deep breath, seal your lips around the victim’s nose,
and exhale into the victim’s nose. Then remove your lips from the victim’s nose,
allowing passive exhalation (Figure 12). It may be necessary to open the victim’s mouth
intermittently and separate the lips with the thumb to allow free exhalation; this is
particularly important if partial nasal obstruction is present.206

Mouth-to-Stoma Breathing

A tracheal stoma is a permanent opening at the front of the neck that extends from the
surface of the skin into the trachea (Figure 13A).207 When a person with a tracheostomy
requires rescue breathing, direct mouth-to-stoma ventilation should be performed. Place
your mouth over the stoma, making an airtight seal around the stoma. Blow into the
stoma until the chest rises (Figure 13B). Then remove your mouth from the patient,
allowing passive exhalation.

A tracheostomy tube may be present in the tracheal stoma. This tube must be patent for
either spontaneous ventilation or rescue breathing to occur. If the tube is not patent and
you are unable to clear an obstruction or any secretions, remove and replace the tube.
If a second tube is unavailable and the original tube is obstructed, remove the tube and
provide rescue breathing through the stoma. If a significant volume of air escapes
through the victim’s nose and mouth during ventilation through the tracheostomy, seal
the victim’s mouth and nose with your hand or a tightly fitting face mask. Air escape is
alleviated if you can provide ventilation through a tracheostomy tube with an inflated
cuff.

Mouth-to–Barrier Device Breathing

Some rescuers prefer to use a barrier device during mouth-to-mouth ventilation. The
use of barrier devices should be encouraged for rescuers who may perform CPR in
areas outside the home, such as the workplace. Two broad categories of barrier
devices are available: mouth-to-mask devices and face shields. Mouth-to-mask devices
typically have a 1-way valve so that the victim’s exhaled air does not enter the rescuer’s
mouth. Face shields usually have no exhalation valve, and the victim’s expired air
escapes between the shield and the victim’s face. Barrier devices should have a low
resistance to gas flow so that they do not impede ventilation.

Mouth-to–Face Shield Rescue Breathing

Unlike mouth-to-mask devices, face shields have only a clear plastic or silicone sheet
that separates the rescuer from the victim. The opening of the face shield is placed over
the victim’s mouth. In some models a short (1- to 2-inch) tube is part of the shield. If a
tube is present, insert the tube in the victim’s mouth, over the tongue. Pinch the victim’s
nose closed and seal your mouth around the center opening of the face shield while
maintaining head tilt–chin lift or jaw thrust. Provide slow breaths (2 seconds each)
through the 1-way valve or filter in the center of the face shield, allowing the victim’s
exhaled air to escape between the shield and the victim’s face when you lift your mouth
off the shield between breaths (Figure 14).

The face shield should remain on the victim’s face during chest compressions and
ventilations. If the victim begins to vomit during rescue efforts, immediately turn the
victim onto his side, remove the face shield, and clear the airway. Proximity to the
victim’s face and the possibility of contamination if the victim vomits are major
disadvantages of face shields.208209 In addition, the efficacy of face shields has not been
documented conclusively. For these reasons, healthcare professionals and rescuers
with a duty to respond should use face shields only as a substitute for mouth-to-mouth
breathing and should use mouth-to-mask or bag-mask devices at the first
opportunity.210211

Tidal volumes and inspiratory times for rescuer breathing through barrier devices should
be the same as those for mouth-to-mouth breathing (in an adult, a tidal volume of
approximately 10 mL/kg or 700 to 1000 mL delivered over 2 seconds and sufficient to
make the chest rise clearly).

Mouth-to-Mask Rescue Breathing

A transparent mask with or without a 1-way valve is used in mouth-to-mask breathing.

The 1-way valve directs the rescuer’s breath into the victim while diverting the victim’s
exhaled air away from the rescuer. Some devices include an oxygen inlet that permits
administration of supplemental oxygen.

Mouth-to-mask ventilation is particularly effective because it allows the rescuer to use 2

hands to create a mask seal. There are 2 possible techniques for using the mouth-to-
mask device. The first technique positions the rescuer above the victim’s head (cephalic
technique). This technique can be used by a single rescuer when the patient is in
respiratory arrest (but not cardiac arrest) or during performance of 2-rescuer CPR. A
jaw thrust is used in the cephalic technique, which has the advantage of positioning the
rescuer so that the rescuer is facing the victim’s chest while performing rescue
breathing (see Figure 15A and 15B).

In the second technique (lateral technique), the rescuer is positioned at the victim’s side
and uses head tilt–chin lift. The lateral technique is ideal for performing 1-rescuer CPR,
because the rescuer can maintain the same position for both rescue breathing and
chest compressions (see Figure 16).
Cephalic technique. Position yourself directly above the victim’s head and perform the
following steps:

 Apply the mask to the victim’s face, using the bridge of the nose as a guide for
correct position.
 Place your thumbs and thenar eminence (portion of the palm at the base of the
thumb) along the lateral edges of the mask.
 Place the index fingers of both hands under the victim’s mandible and lift the jaw
into the mask as you tilt the head back. Place your remaining fingers under the
angle of the jaw (Figure 15A).
 While lifting the jaw, squeeze the mask with your thumbs and thenar eminence to
achieve an airtight seal (see jaw thrust).
 Provide slow rescue breaths (2 seconds) while observing for chest rise.

An alternative method for the cephalic technique is to use the thumb and first finger of
each hand to make a complete seal around the edges of the mask. Use the remaining
fingers to lift the angle of the jaw and extend the neck (Figure 15B). With either variation
of the cephalic technique, the rescuer uses both hands to hold the mask and open the
airway. In victims with suspected head or neck (potential cervical spine) injury, lift the
mandible at the angles of the jaw but do not tilt the head.

Lateral technique. Position yourself beside the victim’s head to provide rescue breathing
and chest compressions:

 Apply the mask to the victim’s face, using the bridge of the nose as a guide for
correct position.
 Seal the mask by placing your index finger and thumb of the hand closer to the
top of the victim’s head along the border of the mask and placing the thumb of
your other hand along the lower margin of the mask.
 Place your remaining fingers on the hand closer to the victim’s feet along the
bony margin of the jaw and lift the jaw while performing a head tilt–chin lift
(Figure 16).
 Compress firmly and completely around the outside margin of the mask to
provide a tight seal.
 Provide slow rescue breaths while observing for chest rise.

Effective use of the mask requires instruction and supervised practice. During 2-rescuer
CPR, the mask can be used in a variety of ways. The most appropriate method will
depend on the experience of personnel and equipment available. Oral airways and
cricoid pressure may be used with mouth-to-mask and any other form of rescue
breathing.

If oxygen is not available, tidal volumes and inspiratory times for mouth-to-mask
ventilation should be the same as for mouth-to-mouth breathing (in an adult, a tidal
volume of approximately 10 mL/kg or 700 to 1000 mL delivered over 2 seconds and
sufficient to make the chest rise clearly). If supplemental oxygen is used with the face
mask, a minimum flow rate of 10 L/min provides an inspired concentration of oxygen
≥40%.212 When oxygen is provided, lower tidal volumes are recommended (tidal volume
of approximately 6 to 7 mL/kg or 400 to 600 mL given over 1 to 2 seconds until the
chest rises) (Class IIb).3 The smaller tidal volumes are effective for maintaining
adequate arterial oxygen saturation, provided that supplemental oxygen is delivered to
the device, but these smaller volumes will not maintain normocarbia.202 These volumes
will reduce the risk of gastric inflation185186 and its serious consequences.185187188189190191196197

Bag-Mask Device

Bag-mask devices used in the prehospital setting consist of a self-inflating bag and a
nonrebreathing valve attached to a face mask. These devices provide the most
common method of delivering positive-pressure ventilation in both the EMS and hospital
settings. Most commercially available adult bag-mask units have a volume of
approximately 1600 mL, which is usually adequate to produce lung inflation. In several
studies, however, many rescuers were unable to deliver adequate tidal volumes to
unintubated manikins.213214215216217 Adult bag-mask units may provide a smaller tidal volume
than mouth-to-mouth or mouth-to-mask ventilation because the lone rescuer may have
difficulty obtaining a leak-proof seal to the face while squeezing the bag and maintaining
an open airway. For this reason, self-inflating bag-mask units are most effective when 2
trained and experienced rescuers work together, one sealing the mask to the face and
the other squeezing the bag slowly over 2 seconds (Figure 17). In fact, in some
countries (eg, Australia), bag-mask ventilation during BLS CPR is performed by 2
rescuers.

There are significant advantages to the use of small tidal volumes during resuscitation.
Small tidal volume will reduce the risk of gastric inflation and its consequences, but it
does risk the development of hypoxia and hypercarbia and their complications.217A The
use of small tidal volumes with oxygen supplementation during resuscitation has been
evaluated in laboratory186193194195218219 and clinical194218219220 settings. With smaller tidal volumes,
airway pressure does not exceed the victim’s lower esophageal sphincter
pressure,185196197198 so lower tidal volumes will reduce gastric inflation and its potential
consequences of regurgitation,187188189 aspiration,190 and pneumonia.191 Supplementary
oxygen will ensure maintenance of oxygen saturation at these smaller tidal volumes.202

If supplementary oxygen (minimum flow rate of 8 to 12 L/min with oxygen concentration

≥40%) is available, the rescuer skilled in bag-mask ventilation should attempt to deliver
a smaller tidal volume (6 to 7 mL/kg or approximately 400 to 600 mL) over 1 to 2
seconds (Class IIb). Of course, in the clinical setting, the actual tidal volume delivered is
impossible to determine. Tidal volume can be titrated to provide sufficient ventilation to
maintain oxygen saturation and produce visible chest expansion. The tidal volume
should be sufficient to make the chest rise. It is important to note that this smaller tidal
volume may be associated with the development of hypercarbia.217A

If oxygen is not available, the rescuer should attempt to deliver the same tidal volume
recommended for mouth-to-mouth ventilation (10 mL/kg, 700 to 1000 mL) over 2
seconds. This tidal volume should result in very obvious chest rise.
An adult bag-mask device should have the following features:

 A nonjam inlet valve system allowing a maximum oxygen inlet flow of 30 L/min
 Either no pressure relief valve or, if a pressure relief valve is present, the
pressure relief valve must be capable of being closed
 Standard 15-mm/22-mm fittings
 An oxygen reservoir to allow delivery of high concentrations of oxygen221
 A nonrebreathing outlet valve that cannot be obstructed by foreign material
 Ability to function satisfactorily under common environmental conditions and
extremes of temperature

Technique. Bag-mask ventilation technique requires instruction and practice. The

rescuer should be able to use the equipment effectively in a variety of situations.

If you are the only rescuer providing respiratory support, position yourself at the top of
the victim’s head. If there is no concern about neck injury, tilt the victim’s head back and
place it on a towel or pillow to achieve the sniffing position. Apply the mask to the
victim’s face with one hand, using the bridge of the nose as a guide for correct position.
Place the third, fourth, and fifth fingers of that hand along the bony portion of the
mandible, and place the thumb and index fingers of the same hand on the mask.
Maintain head tilt and jaw thrust to keep the airway patent and snug against the mask
(Figure 18).

Compress the bag with your other hand and watch the chest to be sure it rises,
indicating that ventilation is adequate. Deliver each breath over 2 seconds (using 1 to 2
seconds when you deliver smaller tidal volumes with oxygen supplementation). You
may want to compress the bag against your body to achieve the selected tidal volume.
It is critical to maintain an airtight seal during delivery of each breath.

Effective ventilation is more likely to be provided when 2 rescuers use the bag-mask
system: 1 rescuer holds the mask and 1 rescuer squeezes the bag (Figure 17). The
techniques for holding the mask are the same as for mouth-to-mask devices described
above. If a third rescuer is available, cricoid pressure may be applied.

Bag-mask ventilation is a complex technique that requires considerable skill and

practice. Such skill is difficult to maintain when used infrequently. Accordingly,
alternative airway devices such as the laryngeal mask airway and the esophageal-
tracheal Combitube are being introduced within the scope of BLS practice for healthcare
providers. These devices are generally easier to insert than tracheal tubes, but they
allow similar support of ventilation. These devices may provide acceptable alternatives
to bag-mask ventilation for healthcare providers who are well trained and have sufficient
opportunities to use these devices (Class IIb). A detailed explanation of these devices is
found in Part 6 of this document (see “Adjuncts for Oxygenation, Ventilation, and Airway
Control”).

Cricoid Pressure
The cricoid pressure technique applies pressure to the victim’s cricoid cartilage. This
pushes the trachea posteriorly, compressing the esophagus against the cervical
vertebrae during rescue breathing. Cricoid pressure is effective in preventing gastric
inflation, reducing the risk of regurgitation and aspiration.222223224225 It should be used only if
the victim is unconscious. Proper use of the cricoid pressure technique requires an
additional rescuer to provide cricoid pressure alone, without diversion to other
resuscitation activities. As a result, this technique should be used only by healthcare
professionals when an extra rescuer is present. This means that during “2”-rescuer
CPR, 3 rescuers would actually be required: 1 rescuer to perform rescue breathing, 1 to
perform chest compressions, and 1 to apply cricoid pressure.

The technique for applying cricoid pressure is as follows:

1. Locate the thyroid cartilage (Adam’s apple) with your index finger.
2. Slide your index finger to the base of the thyroid cartilage and palpate the
prominent horizontal ring below (cricoid cartilage).
3. Using the tips of your thumb and index finger, apply firm backward pressure to
the cricoid cartilage (Figure 19).

Apply moderate rather than excessive pressure on the cricoid. Use of moderate
pressure is particularly important if the victim is small.

Rescue Breathing Without Chest Compressions

Deliver 2 initial breaths slowly over 2 seconds each, allowing complete exhalation
between breaths to diminish the likelihood of exceeding the esophageal opening
pressure. This technique should result in less gastric inflation, regurgitation, and
aspiration. For respiratory arrest, when chest compressions are not being performed,
provide approximately 10 to 12 breaths per minute (1 breath every 4 to 5 seconds).
Check every few minutes to ensure that the victim continues to show signs of circulation
(see next section).

Circulation

Assessment: No Pulse Check for Lay Rescuers

Since the first resuscitation guidelines were published in 1968, the pulse check has
been the “gold standard” method of determining whether the heart was beating. In the
sequence of CPR, the absence of a pulse indicates cardiac arrest and the need to
provide chest compressions. In the current era of early defibrillation, absence of a pulse
is an indication for the attachment of the AED. Since 1992 several published studies
have called into question the validity of the pulse check as a test for cardiac arrest,
particularly when used by laypersons.226227228229230231232233234235 This research has used manikin
simulation,231 unconscious patients undergoing cardiopulmonary bypass,235 unconscious
mechanically ventilated patients,232 and conscious “test persons.”227232 These studies
conclude that as a diagnostic test for cardiac arrest, the pulse check has serious
limitations in accuracy, sensitivity, and specificity.
When lay persons use the pulse check, they require a long time to decide whether a
pulse is present. They then fail in 1 of 10 times to recognize the absence of a pulse or
cardiac arrest (poor sensitivity). When lay rescuers assess unresponsive victims who do
have a pulse, the rescuers miss the pulse in 4 of 10 times (poor specificity). Details of
the published studies include the following conclusions:

1. Rescuers require far too much time to perform the pulse check: The majority of
all rescue groups, including laypersons, medical students, paramedics, and
physicians, take much longer than the recommended 5 to 10 seconds to check
for the carotid pulse. In one study, half of the rescuers required more than 24
seconds to decide whether a pulse was present. With survival from VF falling by
7% to 10% for every minute defibrillation is delayed, time allotted to assessment
of circulation must be brief. Only 15% of the participants correctly confirmed the
presence of a pulse within 10 seconds, the maximum time currently allotted for a
pulse check.235
2. When considered as a diagnostic test, the pulse check is extremely inaccurate.
This accuracy can be expressed in a classic 2×2 matrix, based on results from a
representative study235 (Table 3) and summarized as follows: a. Specificity (ability
to correctly identify victims who have NO pulse and ARE in cardiac arrest) is only
90%: When subjects were pulseless, rescuers thought a pulse was present
approximately 10% of the time. By mistakenly thinking a pulse IS present when it
is not, rescuers will fail to provide chest compressions and will not attach an AED
for 10 of every 100 people in cardiac arrest. The consequences of such errors
would be death without possibility of resuscitation for 10 of every 100 victims of
cardiac arrest. b. Sensitivity (ability to correctly recognize victims who HAVE a
pulse and ARE NOT in cardiac arrest) was only 55%. When the pulse
was present, the rescuers assessed the pulse as being absent approximately
45% of the time. By erroneously thinking a pulse was absent, rescuers would
provide chest compressions for approximately 4 of 10 potential victims who do
not need them and would attach an AED, if available.
3. The overall accuracy was only 65%, leaving an error rate of 35%.

On review of this and other data, the experts and delegates at the 1999 Evidence
Evaluation Conference and the International Guidelines 2000 Conference concluded
that the pulse check could not be recommended as a tool for lay rescuers to identify
victims of cardiac arrest in the CPR sequence. If rescuers use the pulse check to
identify victims of cardiac arrest, they will “miss” true cardiac arrest at least 10 times out
of 100. In addition, rescuers will provide unnecessary chest compressions (and may
attach an AED) for many victims who are not in cardiac arrest and do not require such
intervention. This error is less serious but still undesirable. The more serious error in
this situation is clearly the potential failure to intervene for victims of cardiac arrest who
require immediate intervention to survive.

Therefore, the lay rescuer should not rely on the pulse check to determine the need for
chest compressions or use of an AED. Lay rescuers should not perform the pulse check
and will not be taught the pulse check in CPR courses (Class IIa). Instead, lay rescuers
will be taught to assess for “signs of circulation,” including normal breathing, coughing,
or movement, in response to the rescue breaths. This guideline recommendation
applies to victims of any age. Healthcare providers should continue to use the pulse
check as one of several signs of circulation. Other signs of circulation include breathing,
coughing, or movement.

It is expected that this guideline change will result in more rapid and more accurate
identification of cardiac arrest. It should eliminate delays in provision of chest
compressions and use of the AED. Most important, it should reduce the missed
opportunities to provide CPR and early defibrillation for victims in cardiac arrest.

Assessment: Check for Signs of Circulation

These guidelines often refer to assessment of “signs of circulation.” For the lay
rescuer, this means the following: deliver initial rescue breaths and evaluate the victim
for normal breathing, coughing, or movement in response to the rescue breaths. The lay
rescuer will look, listen, and feel for breathing while scanning the victim for signs of
other movement. Lay rescuers should look for “normal breathing” to minimize confusion
with agonal respirations.

When healthcare professionals assess signs of circulation, they add a pulse check while
simultaneously evaluating the victim for breathing, coughing, or movement. Professional
rescuers are instructed to look for “breathing” because they are trained to distinguish
between agonal breathing and other forms of ventilation not associated with cardiac
arrest.

In practice, the assessment for signs of circulation for the lay rescuer is performed as
follows:

1. Provide initial rescue breaths to the unresponsive, nonbreathing victim.

2. Look for signs of circulation. a. With your ear near the victim’s mouth, look, listen,
and feel for normal breathing or coughing.
3. b. Quickly scan the victim for any signs of movement.
4. If the victim is not breathing normally, coughing, or moving, immediately begin
chest compressions.

This assessment should take no more than 10 seconds. Healthcare providers should
perform a pulse check in conjunction with assessment for signs of circulation. If you are
not confident that circulation is present, begin chest compressions immediately.

When a pulse check is performed for the victim >1 year of age, the carotid artery is the
preferred artery to palpate, although the femoral artery may be used as an alternative.
Pulses will persist in these arteries even when hypotension and poor perfusion cause
peripheral pulses to disappear. To locate the carotid artery, maintain a head tilt with one
hand on the victim’s forehead and locate the trachea with 2 or 3 fingers of the other
hand (Figure 20A). Slide these 2 or 3 fingers into the groove between the trachea and
the muscles at the side of the neck, where the carotid pulse can be felt (Figure 20B).
Use only gentle pressure so that you do not compress the artery. The artery on the side
of the neck toward you is typically most readily palpated.

Provide Chest Compressions

Chest compressions for CPR are serial, rhythmic applications of pressure over the
lower half of the sternum.236 These compressions create blood flow by increasing
intrathoracic pressure or directly compressing the heart.237238 Blood circulated to the lungs
by chest compressions, accompanied by properly performed rescue breathing, will most
likely deliver adequate oxygen to the brain and other vital organs until defibrillation can
be performed.

Theoretical,239240 animal,237241242243244 and human245246 data supports a rate of chest

compression >80 per minute to achieve optimal forward blood flow during CPR. For this
reason, a compression rate of 100 per minute is recommended (Class IIb). The
compression rate refers to the speed of compressions, not to the actual number of
compressions delivered in 1 minute. A compression rate of approximately 100 per
minute will result in delivery of fewer than 100 compressions per minute by the single
rescuer who must interrupt chest compressions to deliver rescue breaths. The actual
number of chest compressions delivered per minute depends on the accuracy and
consistency of the rate of chest compressions and the time the rescuer requires to open
the airway and deliver rescue breaths.

Previous versions of the adult BLS guidelines recommended a ratio of 15 compressions

to 2 ventilations for 1-rescuer CPR and a ratio of 5 compressions to 1 ventilation for 2-
rescuer CPR.49179 A ratio of 15:2 provides more chest compressions per minute
(approximately 64 versus 50) than a ratio of 5:1.247 There is evidence to suggest that
adult cardiac arrest victims are more likely to be saved if a higher number of chest
compressions are delivered during CPR, even if the victims receive fewer
ventilations.68248 The quality of rescue breathing and chest compressions is not affected
by compression-ventilation ratio.247

During cardiac arrest, the coronary perfusion pressure gradually rises with the
performance of sequential compressions.248 This pressure is higher after 15
uninterrupted chest compressions than it is after 5 chest compressions.248 Therefore,
after each pause for ventilation, several compressions must be performed before
previous levels of brain and coronary perfusion are reestablished.248 For these reasons,
a ratio of 15 compressions to 2 ventilations is recommended for 1 or 2 rescuers (Class
IIb) until the airway is secured. This applies to adult BLS provided by both laypersons
and healthcare providers. Research is ongoing to determine the benefits of further
increasing the number of compressions between ventilations during CPR. Once the
airway is secured (protected) with a cuffed tracheal tube (as discussed in the ACLS
guidelines), compressions may be continuous and ventilations may be asynchronous,
with a ratio of 5 compressions to 1 ventilation.

During actual CPR, rescuers often compress at a slower rate than 100 per
minute.248249 For teaching and during performance of CPR, therefore, some form of audio
timing prompt may help to achieve the recommended compression rate of
approximately 100 per minute (Class IIb).250251

The victim must be in the horizontal, supine position on a firm surface during chest
compressions to optimize the effect of the compressions and blood flow to the brain.
When the head is elevated above the heart, blood flow to the brain is reduced or
eliminated. If the victim cannot be removed from a bed, place a rigid board, preferably
the full width of the bed, under the victim’s back to avoid diminished effectiveness of
chest compression.

Chest Compression Technique

Proper hand placement is established by identifying the lower half of the sternum. The
guidelines below may be used, or you may choose alternative techniques to identify the
lower sternum.

1. Place your fingers on the lower margin of the victim’s rib cage on the side nearer
you (Figure 21A).
2. Slide your fingers up the rib cage to the notch where the ribs meet the lower
sternum in the center of the lower part of the chest.
3. Place the heel of one hand on the lower half of the sternum (Figure 21B) and the
other hand on top of the first, so that the hands are parallel (Figure 21C). Be sure
the long axis of the heel of your hand is placed on the long axis of the sternum.
This will keep the main force of compression on the sternum and decrease the
chance of rib fracture. Do not compress over the lowest portion of the base of the
sternum (the xiphoid process).
4. Your fingers may be either extended or interlaced but should be kept off the
chest.

If you have difficulty creating sufficient force during compressions, an acceptable

alternative hand position is to grasp the wrist of the hand on the chest with your other
hand and push downward with both. This technique is helpful for rescuers with arthritic
hands and wrists.

A simplified method of achieving correct hand position has also been used in various
settings for teaching laypersons the chest compression technique.* To find a position on
the lower half of the sternum, the rescuer is instructed to place the heel of one hand in
the center of the chest between the nipples. This method has been used with success
for >10 years in dispatcher-assisted CPR and other settings.*

Effective compression is accomplished by attention to the following guidelines:

1. Lock the elbows in position, with the arms straightened. Position your shoulders
directly over your hands so that the thrust for each chest compression is straight
down on the sternum (Figure 22). If the thrust is not in a straight downward
direction, the victim’s torso has a tendency to roll; if this occurs, a part of the
 force of compressions will be lost, and the chest compressions may be less
effective.
2. Depress the sternum approximately 11/2 to 2 inches (4 to 5 cm) for the normal-
sized adult. Rarely, in very small victims, lesser degrees of compression may be
sufficient to generate a palpable carotid or femoral pulse. Alternatively, in large
victims, sternal compression depth of 11/2 to 2 inches (4 to 5 cm) may be
inadequate, and a slightly greater depth of chest compression may be needed to
generate a carotid or femoral pulse. Optimal sternal compression is generally
gauged by identifying the compression force that generates a palpable carotid or
femoral pulse.168 However, this validation of pulses requires at least 2 healthcare
providers (one provides compressions while the other attempts to palpate the
pulse), and it may yield misleading results. Detection of a pulse during CPR does
not necessarily mean that there is optimal or even adequate blood flow, because
a compression wave may be palpated in the absence of effective blood flow. The
best method of providing adequate compression force is to depress the sternum
11/2 to 2 inches (4 to 5 cm) with each compression.
3. Release the pressure on the chest to allow blood to flow into the chest and heart.
You must release the pressure completely and allow the chest to return to its
normal position after each compression. Keep your hands in contact with the
victim’s sternum to maintain proper hand position. Chest compressions should be
performed at a rate of approximately 100 per minute.
4. Effective cerebral and coronary perfusion has been shown to occur when 50% of
the duty cycle is devoted to the chest compression phase and 50% to the chest
relaxation phase.239249255256 Rescuers find this ratio reasonably easy to achieve with
practice.249
5. To maintain correct hand position throughout the 15-compression cycle, do not
lift your hands from the chest or change their position in any way. However, do
allow the chest to recoil to its normal position after each compression.

Rescue breathing and chest compression must be combined for effective resuscitation
of the victim of cardiopulmonary arrest. Research over the past 40 years has helped
identify the mechanisms for blood flow during chest compression. In both animal models
and humans, it appears that blood flow during CPR probably results from manipulation
of intrathoracic pressure (thoracic pump mechanism) or direct cardiac
compression.236237238 The duration of CPR affects the mechanism of CPR.257258259260261 In CPR
of short duration, blood flow is generated more by the cardiac pump mechanism. When
the duration of cardiac arrest or resuscitation with chest compressions is prolonged, the
heart becomes less compliant. Only in this setting does the thoracic pump mechanism
dominate. When the thoracic pump mechanism dominates, however, the cardiac output
generated by chest compression decreases significantly.256257258259260261

Over the past 20 years, there has been important research regarding techniques and
devices to improve blood flow during CPR, including pneumatic vest CPR,262 interposed
abdominal compression CPR (IAC-CPR),263264265 and active compression-decompression
CPR (ACD-CPR).266267268269270271272 Recent evaluation of these devices in
humans254262263264265266267268269270271272 has resulted in more specific recommendations for their
use. The interested reader will find a more expanded discussion of this topic in Part 6 of
this publication.

During cardiac arrest, properly performed chest compressions can produce systolic
arterial blood pressure peaks of 60 to 80 mm Hg, but diastolic blood pressure is
low.261 Mean blood pressure in the carotid artery seldom exceeds 40 mm Hg.261 Cardiac
output resulting from chest compressions is probably only one fourth to one third of
normal and decreases during the course of prolonged conventional CPR.261 You can
optimize blood flow during chest compression if you use the recommended chest
compression force and chest compression duration and maintain a chest compression
rate of approximately 100 per minute.255

Airway-breathing-circulation (“ABC”) is the specific sequence used to initiate CPR in the

United States and in the ILCOR Guidelines. In The Netherlands, however, “CAB”
(compression-airway-breathing) is the common sequence of CPR, with resuscitation
outcomes similar to those reported for the ABC protocol in the United States. 273 No
human studies have directly compared the ABC technique of resuscitation with CAB.
Hence, a statement of relative efficacy cannot be made and a change in present
teaching is not warranted. Both techniques are effective.

Compression-Only CPR

Mouth-to-mouth rescue breathing is a safe and effective technique that has saved many
lives. Despite decades of experience indicating its safety for victims and rescuers alike,
some published surveys have documented reluctance on the part of professional and
lay rescuers to perform mouth-to-mouth ventilation for unknown victims of cardiac
arrest. This reluctance is related to fear of infectious disease transmission. 274275276277278 If a
person is unwilling or unable to perform mouth-to-mouth ventilation for an adult victim,
chest compression–only CPR should be provided rather than no attempt at CPR being
made (Class IIa).

Current evidence indicates that the outcome of chest compression without mouth-to-
mouth ventilation is significantly better than no CPR at all in the setting of adult cardiac
arrest.6465666768 Some evidence in animal models and limited adult clinical trials suggests
that positive-pressure ventilation is not essential during the initial 6 to 12 minutes of
adult CPR.64656667 The Cerebral Resuscitation Group of Belgium also showed no
difference in outcome of CPR between victims who received mouth-to-mouth ventilation
with chest compression and those who received compressions only.68

Several mechanisms may account for the effectiveness of chest compression alone.
Studies have demonstrated that spontaneous gasping can maintain near-normal minute
ventilation, PaCO2, and PaO2 during CPR without positive-pressure
ventilation.66279 Because the cardiac output generated during chest compression is only
25% of normal, there is also a reduced requirement for ventilation to maintain optimal
ventilation/perfusion relationships.280281

Chest compression–only CPR is recommended only in the following circumstances:

 1. When a rescuer is unwilling or unable to perform mouth-to-mouth rescue
breathing (Class IIa), or
2. For use in dispatcher-assisted CPR instructions where the simplicity of this
modified technique allows untrained bystanders to rapidly intervene (Class IIa).

Cough CPR

Self-initiated CPR is possible. Its use, however, is limited to clinical situations in which
the patient has a monitored cardiac arrest, the arrest was recognized before loss of
consciousness, and the patient can cough forcefully.257258259260 These conditions are
typically present during only the first 10 to 15 seconds of the cardiac arrest. The
increase in intrathoracic pressure that occurs with coughing will generate blood flow to
the brain and maintain consciousness.

Defibrillation

Most adults with sudden, witnessed, nontraumatic cardiac arrest are found to be in
VF.38 For these victims the time from collapse to defibrillation is the single greatest
determinant of survival.13273846 Survival from VF cardiac arrest declines by approximately
7% to 10% for each minute without defibrillation.47 Healthcare providers should be
trained and equipped to provide defibrillation at the earliest possible moment for victims
of sudden cardiac arrest.

Early defibrillation in the community is defined as a shock delivered within 5 minutes of

EMS call receipt. This 5-minute call-to-defibrillation interval in the community is a Class I
recommendation.

Early defibrillation also must be provided in hospitals and medical facilities. First
responders in medical facilities should be able to provide early defibrillation to collapsed
patients in VF in all areas of the hospital and ambulatory care facilities (Class I
recommendation). In these areas healthcare providers should be able to deliver a shock
within 3±1 minutes of arrest for a high percentage of patients. To achieve these goals,
BLS providers must be trained and equipped to use defibrillators and must rehearse use
of the defibrillator present in their clinical area.

For further information, refer to “Part 4: The Automated External Defibrillator” and “Part
6, Section 2: Defibrillation.”

CPR Performed by 1 and 2 Rescuers

CPR Performed by 1 Rescuer

Laypersons with no specific duty or expectation to respond to emergencies in the

workplace should be taught 1-rescuer CPR only, because the 2-rescuer technique is
infrequently used by laypersons in rescue situations. If 2 rescuers are present, they can
alternate performing 1-rescuer CPR. Whether 1- or 2-rescuer CPR is performed,
rescuers should ensure scene safety. One-rescuer CPR should be performed as
follows:

1. Assessment: Determine unresponsiveness (tap or gently shake the victim and

shout). If unresponsive,
2. Activate the EMS system: This should be performed according to local practice.
In many countries and regions, activation of the EMS system is delayed until it
has been determined that the victim is not breathing.
3. Airway: Position the victim and open the airway by the head tilt–chin lift or jaw-
thrust maneuver.
4. Breathing: Assess breathing to identify absent or inadequate breathing.

 If the victim is unresponsive with normal breathing, and spinal injury is not
suspected, place the victim in a recovery position, maintaining an open airway.
 If the adult victim is unresponsive and not breathing, begin rescue breathing. In
the United States and many other countries, 2 initial breaths are provided, but up
to 5 breaths are recommended in areas such as Europe, Australia, and New
Zealand. If you are unable to give the initial breaths, reposition the head and
reattempt ventilation. If you are still unsuccessful in making the chest rise with
each ventilation after an attempt and reattempt: —Lay rescuers should provide
chest compressions and begin the cycle of 15 compressions and 2 ventilations.
Each time you open the airway to attempt ventilation, look for an object in the
throat. If you see an object (such as a foreign body), remove it. —Healthcare
providers follow the unresponsive FBAO sequence.

 Be sure the victim’s chest rises with each rescue breath you provide.
 Once you deliver the effective breaths, assess for signs of circulation.

1. Circulation. Check for signs of circulation: after the initial breaths, look for
normal breathing, coughing, or movement by the victim in response to the initial
breaths. Healthcare providers should also feel for a carotid pulse—take no more
than 10 seconds to do this. If there are no signs of circulation, begin chest
compressions:

 Locate proper hand position.

 Perform 15 chest compressions at a rate of approximately 100 per minute.
Depress the chest 11/2 to 2 inches (4 to 5 cm) with each compression. Make
sure you allow the chest to rebound to its normal position after each compression
by removing all pressure from the chest (while still maintaining contact with the
sternum and proper hand position). Count “1 and, 2 and, 3 and, 4 and, 5 and, 6
and, 7 and, 8 and, 9 and, 10 and, 11, 12, 13, 14, 15.” (Any mnemonic that
accomplishes the same compression rate is acceptable. For ease of recollection,
use the “and” only up to the number 10.)
 Open the airway and deliver 2 slow rescue breaths (2 seconds each).
 Find the proper hand position and begin 15 more compressions at a rate of 100
per minute.
  Perform 4 complete cycles of 15 compressions and 2 ventilations.

1. Reassessment: Reevaluate the victim according to local protocol. In the United

States, this will be after 4 cycles of compressions and ventilations (15:2 ratio);
elsewhere, reevaluation may be recommended only if the victim shows some
sign of recovery. Check for signs of circulation (10 seconds). If there are no signs
of circulation, resume CPR, beginning with chest compressions. If signs of
circulation are present, check for breathing.

 If breathing is present, place the victim in a recovery position and monitor

breathing and circulation.
 If breathing is absent but signs of circulation are present, provide rescue
breathing at 10 to 12 times per minute (1 breath every 4 to 5 seconds) and
monitor for signs of circulation every few minutes.
 If there are no signs of circulation, continue compressions and ventilations in a
15:2 ratio.
 Stop and check for signs of circulation and spontaneous breathing every few
minutes (according to local protocol).
 Do not interrupt CPR except in special circumstances.
 If adequate spontaneous breathing is restored and signs of circulation are
present, maintain an open airway and place the patient in a recovery position.

Entrance of a Second Rescuer to Replace the First Rescuer

When another rescuer is available at the scene, that rescuer should activate the EMS
system (if not done previously) and perform 1-rescuer CPR when the first rescuer
becomes fatigued. This should be done with as little interruption of CPR as possible.
When the second rescuer arrives, you should assess the victim’s responsiveness,
breathing, and signs of circulation before CPR is resumed.

CPR Performed by 2 Rescuers

All professional rescuers (BLS ambulance providers, healthcare professionals, and

appropriate laypersons who have a duty or obligation to respond, such as lifeguards or
police) should learn both the 1-rescuer and the 2-rescuer techniques. When possible,
airway adjunct methods such as mouth-to-mask devices should be used.

In 2-rescuer CPR, one person is positioned at the victim’s side and performs chest
compressions. The other professional rescuer remains at the victim’s head, maintains
an open airway, monitors the carotid pulse to assess effectiveness of chest
compressions, and provides rescue breathing. The compression rate for 2-rescuer CPR
is 100 per minute. The compression-ventilation ratio is 15:2, with a pause for ventilation
of 2 seconds each until the airway is secured by a cuffed tracheal tube. Exhalation
occurs between the 2 breaths and during the first chest compression of the next cycle.
When the person performing chest compressions becomes fatigued, the rescuers
should change positions with minimal interruption of chest compressions.
Reassessment During 2-Rescuer CPR

The rescuers must monitor the victim’s condition to assess the effectiveness of the
rescue effort. The person ventilating the victim assumes the responsibility for monitoring
signs of circulation and breathing.

To assess the effectiveness of the partner’s chest compressions, the professional

rescuer should check the pulse during compressions. To determine whether the victim
has resumed spontaneous breathing and circulation, chest compressions must be
stopped for 10 seconds at approximately the end of the first minute of CPR (or per local
protocol) and every few minutes thereafter. (See No. 6, Reassessment, above.)

Epidemiology, Recognition, and Management of FBAO

Complete airway obstruction is an emergency that will result in death within minutes if
not treated. The most common cause of upper-airway obstruction is obstruction by the
tongue during loss of consciousness and cardiopulmonary arrest. An unresponsive
victim can develop airway obstruction from intrinsic (tongue and epiglottis) and extrinsic
(foreign body) causes. The tongue may fall backward into the pharynx, obstructing the
upper airway. The epiglottis can block the entrance of the airway in unconscious
victims. Blood from head and facial injuries or regurgitated stomach contents may also
obstruct the upper airway, particularly if the victim is unconscious. Extrinsic causes may
also produce airway obstruction, although the frequency is difficult to determine.

FBAO is a relatively uncommon but preventable cause of cardiac arrest. This form of
death is much less common than death caused by other emergencies (1.2 deaths from
choking per 100 000 population versus 1.7 per 100 000 for drowning, 16.5 per 100 000
for motor vehicle crashes, and 198 per 100 000 for coronary heart disease).282283284285

FBAO is not a common problem among submersion/near-drowning victims. Water does

not act as a (solid) foreign body and does not obstruct the airway.286 Many submersion
victims do not aspirate water at all, and any aspirated water will be absorbed in the
upper airway and trachea. Near-drowning victims require immediate provision of CPR,
particularly rescue breathing, to correct hypoxia. Therefore, efforts to relieve FBAO are
not recommended for treatment of the victim of near-drowning. Such efforts may
produce complications and will delay CPR, the most important treatment for the
submersion victim.286 (For further information, see “Part 8, Section 3: Special Challenges
in ECC: Submersion or Near-Drowning.”)

Causes and Precautions

FBAO should be considered as a cause of deterioration in any victim, especially a

younger victim, who suddenly stops breathing, becomes cyanotic, and falls unconscious
for no apparent reason.
FBAO in adults usually occurs during eating,287288 and meat is the most common cause of
obstruction. A variety of other foods and foreign bodies, however, have caused choking
in children and some adults.289290291292293294 Common factors associated with choking on food
include attempts to swallow large, poorly chewed pieces of food, elevated blood alcohol
levels, and dentures.289290291292293294295 Elderly patients with dysphagia are also at risk for
FBAO and should take care while drinking and eating. In restaurants, choking
emergencies have been mistaken for a heart attack, giving rise to the term “café
coronary.”287288

The following precautions may help modify the risks and prevent FBAO:

1. Cut food into small pieces and chew slowly and thoroughly, especially if wearing
dentures.
2. Avoid laughing and talking during chewing and swallowing.
3. Avoid excessive intake of alcohol.
4. Prevent children from walking, running, or playing when they have food in their
mouths.
5. Keep foreign objects (eg, marbles, beads, thumbtacks) away from infants and
children.
6. Do not give foods that must be thoroughly chewed (eg, peanuts, peanut butter,
popcorn, hot dogs, etc) to young children.

Recognition of FBAO

Because recognition of airway obstruction is the key to successful outcome, it is

important to distinguish this emergency from fainting, stroke, heart attack, seizure, drug
overdose, or other conditions that may cause sudden respiratory failure but require
different treatment.

Foreign bodies may cause either partial or complete airway obstruction. With partial
airway obstruction, the victim may be capable of either “good air exchange” or “poor air
exchange.” With good air exchange, the victim is responsive and can cough forcefully,
although frequently there is wheezing between coughs. As long as good air exchange
continues, encourage the victim to continue spontaneous coughing and breathing
efforts. At this point the rescuer should not interfere with the victim’s own attempts to
expel the foreign body but should stay with the victim and monitor these attempts. If
partial airway obstruction persists, activate the EMS system.

The victim with FBAO may immediately demonstrate poor air exchange or may
demonstrate initially good air exchange that progresses to poor air exchange. Signs
of poor air exchange include a weak, ineffective cough, high-pitched noise while
inhaling, increased respiratory difficulty, and possibly cyanosis. Treat a victim with
partial obstruction and poor air exchange as if he had a complete airway obstruction—
you must act immediately.
With complete airway obstruction the victim is unable to speak, breathe, or cough and
may clutch the neck with the thumb and fingers. Movement of air is absent. The public
should be encouraged to use the universal distress signal for choking emergencies
(Figure 23). Ask the victim whether he or she is choking. If the victim nods, ask the
victim if he or she can speak—if the victim is unable to speak, this indicates that a
complete airway obstruction is present and you must act immediately.

If complete airway obstruction is not relieved, the victim’s blood oxygen saturation will
fall rapidly because the obstructed airway prevents entry of air into the lungs. If you do
not succeed in removing the obstruction, the victim will become unresponsive, and
death will follow rapidly.

Relief of FBAO

Several techniques are used throughout the world to relieve FBAO, and it is difficult to
compare the effectiveness of any one method with another.296 Most resuscitation
councils recommend one or more of the following: the Heimlich abdominal thrusts, back
blows, or chest thrusts. The level of evidence regarding any of these methods is weak,
largely contained in case reports,288297 cadaver studies,298 small studies involving
animals,288299 or mechanical models.300 Unfortunately, implementation of a randomized,
prospective study to compare techniques for relief of FBAO in humans would be
extremely difficult. Mechanical models of choking have been unsatisfactory.300 Cadaver
studies can provide excellent models of unresponsive/unconscious victims,298 but they
cannot replicate awake, responsive choking victims. Therefore, current
recommendations are based on a low level of evidence (LOE 5 to 8), with an emphasis
on the need to simplify information taught to the lay rescuer.

The Heimlich maneuver (also known as subdiaphragmatic abdominal thrusts or

abdominal thrusts) is recommended for lay rescuer relief of FBAO in responsive adult
(≥8 years of age) and child (1 to 8 years of age) victims in the United States, Canada,
and many other countries.288289290291292293294295 It is not recommended for relief of FBAO in
infants. The Heimlich maneuver is also recommended by the AHA and several other
resuscitation councils for use by healthcare providers for unresponsive adult and child
(but not infant) victims.

Some resuscitation councils (eg, the European Resuscitation Council) recommend that
the rescuer provide up to 5 back blows/slaps as the initial maneuver, with the back
slaps delivered between the shoulder blades with the heel of the rescuer’s hand. If back
slaps fail, up to 5 abdominal thrusts are then attempted, and groups of back slaps and
abdominal thrusts are repeated. In countries such as Australia, back slaps and lateral
chest thrusts are recommended for relief of FBAO in adults.

The Heimlich abdominal thrusts elevate the diaphragm and increase airway pressure,
forcing air from the lungs. This may be sufficient to create an artificial cough and expel a
foreign body from the airway.288297 Successful relief of FBAO in responsive victims has
been reported in the lay press and in medical case studies. Abdominal thrusts, however,
may cause complications. For this reason, the Heimlich maneuver should never be
performed unless it is necessary. Reported complications of the Heimlich maneuver
include damage to internal organs, such as rupture or laceration of abdominal or
thoracic viscera.301302303304305 In fact, victims who receive the Heimlich maneuver should be
medically evaluated to rule out any life-threatening complications.303 To minimize the
possibility of complications, do not place your hands on the xiphoid process of the
sternum or on the lower margins of the rib cage. Your hands should be below this area
but above the navel and in the midline. Some complications may develop even if the
Heimlich maneuver is performed correctly. Regurgitation may occur as a result of
abdominal thrusts and may be associated with aspiration.306

Heimlich Maneuver With Responsive Victim Standing or Sitting

Stand behind the victim, wrap your arms around the victim’s waist, and proceed as
follows (Figure 24). Make a fist with one hand. Place the thumb side of your fist against
the victim’s abdomen, in the midline slightly above the navel and well below the tip of
the xiphoid process. Grasp the fist with your other hand and press the fist into the
victim’s abdomen with a quick inward and upward thrust. Repeat the thrusts until the
object is expelled from the airway or the victim becomes unresponsive. Each new thrust
should be a separate and distinct movement administered with the intent of relieving the
obstruction.288

The Heimlich maneuver is repeated until the object is expelled or the victim becomes
unresponsive (loses consciousness). When the victim becomes unresponsive, the EMS
system should be activated, and the lay rescuer will attempt CPR. The healthcare
provider will proceed with the sequence of actions to relieve FBAO in the unconscious
victim (see below).

The Self-Administered Heimlich Maneuver

To treat his or her own complete FBAO, the victim makes a fist with one hand, places
the thumb side on the abdomen above the navel and below the xiphoid process, grasps
the fist with the other hand, and then presses inward and upward toward the diaphragm
with a quick motion. If this is unsuccessful, the victim should press the upper abdomen
quickly over any firm surface, such as the back of a chair, side of a table, or porch
railing. Several thrusts may be needed to clear the airway.

Chest Thrusts for Responsive Pregnant or Obese Victim

Chest thrusts may be used as an alternative to the Heimlich maneuver when the victim
is in the late stages of pregnancy or is markedly obese. Stand behind the victim, with
your arms directly under the victim’s armpits, and encircle the victim’s chest. Place the
thumb side of one fist on the middle of the victim’s breastbone, taking care to avoid the
xiphoid process and the margins of the rib cage. Grab the fist with your other hand and
perform backward thrusts until the foreign body is expelled or the victim becomes
unresponsive.
If you cannot reach around the pregnant or extremely obese person, you can perform
chest thrusts with the victim supine. Place the victim on his or her back and kneel close
to the victim’s side. The hand position and technique for the application of chest thrusts
are the same as for chest compressions during CPR. In the adult, for example, the heel
of the hand is on the lower half of the sternum. Deliver each thrust with the intent of
relieving the obstruction.

Lay Rescuer Actions for Relief of FBAO in the Unresponsive Victim

Previous Guidelines recommendations for treatment of FBAO in the unresponsive victim

were long, they took considerable time to teach, and they were often confusing for the
student.49 When training programs attempt to teach large amounts of material, they fail
to achieve core educational objectives (eg, the psychomotor skills of CPR), and the
result is poor skills retention and performance.307308309310311312 Focused training on small
amounts of information results in superior levels of student performance compared with
traditional CPR courses.313314315316 This compelling data indicates a need to simplify CPR
training for laypersons.

Epidemiological data282283284285 does not distinguish between FBAO fatalities in which the
victim is responsive when first encountered and those in which the victim
is unresponsive when first encountered by rescuers. The total number of all deaths
caused by choking is small, however, so the likelihood that a rescuer will encounter an
unconscious victim of FBAO is small. Cardiac arrest caused by VF is far more common
than cardiac arrest caused by complete FBAO.

Expert panelists at the 1999 Evidence Evaluation Conference and at the International
Guidelines 2000 Conference agreed that lay rescuer BLS courses should focus on
teaching a small number of essential skills. These essential skills were identified as
relief of FBAO in the responsive/conscious victim and the skills of CPR. Teaching the
complex skills of relief of FBAO in the unresponsive/unconscious victim to lay
rescuers is no longer recommended (Class IIb). If the adult choking victim becomes
unresponsive/unconscious during attempts to relieve FBAO, the lone lay rescuer should
activate the EMS system (or send someone to do it) and begin CPR. In fact, chest
compressions may be effective for relief of FBAO in the unresponsive victim.298317 A
recent study using cadaver subjects (an acceptable model of the
unresponsive/unconscious victim of FBAO) has shown that chest compressions may
create a peak airway pressure that is equal to or superior to that created by abdominal
thrusts.298 If the lay rescuer appears to encounter an unsuspected airway obstruction in
the unresponsive victim during the sequence of CPR after attempting and reattempting
ventilation, the rescuer should continue the sequence of CPR, with chest compressions
and cycles of compressions and ventilations.

The lay rescuer should attempt CPR with a single addition—each time the airway is
opened, look for the obstructing object in the back of the throat. If you see an object,
remove it. This recommendation is designed to simplify layperson CPR training and
ensure the acquisition of the core skills of rescue breathing and compression while still
providing treatment for the victim with FBAO.
Finger Sweep and Tongue-Jaw Lift

The finger sweep should be used by healthcare providers only in

the unresponsive/unconscious victim with complete FBAO. This sweep should not be
performed if the victim is responsive or is having seizures.

With the victim face up, open the victim’s mouth by grasping both the tongue and lower
jaw between the thumb and fingers and lifting the mandible (tongue-jaw lift). This action
draws the tongue away from the back of the throat and from a foreign body that may be
lodged there. This maneuver alone may be sufficient to relieve an obstruction. Insert the
index finger of your other hand down along the inside of the cheek and deeply into the
victim’s throat, to the base of the tongue. Then use a hooking action to dislodge the
foreign body and maneuver it into the mouth so that it can be removed (Figure 26). It is
sometimes necessary to use the index finger to push the foreign body against the
opposite side of the throat to dislodge and remove it. Be careful to avoid forcing the
object deeper into the airway.

Healthcare Provider Sequence for Relief of FBAO in the Unresponsive Victim

Victims of FBAO may initially be responsive when encountered by the rescuer and then
become unresponsive. In this circumstance the rescuer will know that FBAO is the
cause of the victim’s symptoms. Victims of FBAO may be unresponsive when initially
encountered by the rescuer. In this circumstance the rescuer will probably not know that
the victim has FBAO until repeated attempts at rescue breathing are unsuccessful.

Healthcare Provider Relief of FBAO in a Responsive Victim Who Becomes Unresponsive

If you observe the victim’s collapse and you know it is caused by FBAO, the following
sequence of actions is recommended:

1. Activate the emergency response system at the proper time in the CPR
sequence. If a second rescuer is available, send the second rescuer to activate
the EMS system while you remain with the victim. Be sure the victim is supine.
2. Perform a tongue-jaw lift, followed by a finger sweep to remove the object.
3. Open the airway and try to ventilate; if you are unable to make the victim’s chest
rise, reposition the head and try to ventilate again.
4. If you cannot deliver effective breaths (the chest does not rise) even after
attempts to reposition the airway consider FBAO. Straddle the victim’s thighs
(see Figure 26) and perform the Heimlich maneuver (up to 5 times).
5. Repeat the sequence of tongue-jaw lift, finger sweep, attempt (and reattempt) to
ventilate, and Heimlich maneuver (steps 2 through 4) until the obstruction is
cleared and the chest rises with ventilation or advanced procedures are available
(ie, Kelly clamp, Magill forceps, cricothyrotomy) to establish a patent airway.
6. If the FBAO is removed and the airway is cleared, check breathing. If the victim is
not breathing, provide slow rescue breaths. Then check for signs of circulation
(pulse check and evidence of breathing, coughing, or movement). If there are no
signs of circulation, begin chest compressions.
To deliver abdominal thrusts to the unresponsive/unconscious victim, kneel astride the
victim’s thighs and place the heel of one hand against the victim’s abdomen, in the
midline slightly above the navel and well below the tip of the xiphoid. Place your second
hand directly on top of the first. Press both hands into the abdomen with quick upward
thrusts (Figure 27). If you are in the correct position, you will be positioned over the
midabdomen, unlikely to direct the thrust to the right or left. You can use your body
weight to perform the maneuver.

Two types of conventional forceps are acceptable for removal of a foreign body, the
Kelly clamp and the Magill forceps. Forceps should be used only if the foreign body is
seen. Either a laryngoscope or tongue blade and flashlight can be used to permit direct
visualization. The use of such devices by untrained or inexperienced persons is
unacceptable. Cricothyrotomy should be performed only by healthcare providers trained
and authorized to perform this surgical procedure.

Healthcare Provider Relief of FBAO in Victims Found Unresponsive

If the victim is found to be unresponsive and the cause is unknown, the following
sequence of actions is recommended:

1. Activate the emergency response system at the appropriate time in the CPR
sequence. If a second rescuer is available, send that rescuer to activate the EMS
system while you remain with the victim.
2. Open the airway and attempt to provide rescue breaths. If you are unable to
make the chest rise, reposition the victim’s head (reopen the airway) and try to
ventilate again.
3. If the victim cannot be ventilated even after attempts to reposition the airway,
straddle the victim’s knees (see Figure 27) and perform the Heimlich maneuver
(up to 5 times).
4. After 5 abdominal thrusts, open the victim’s airway using a tongue-jaw lift and
perform a finger sweep to remove the object.
5. Repeat the sequence of attempts (and reattempts) to ventilate, Heimlich
maneuver, and tongue-jaw lift and finger sweep (steps 2 through 4) until the
obstruction is cleared or advanced procedures are available to establish a patent
airway (eg, Kelly clamps, Magill forceps, or cricothyrotomy).
6. If the FBAO is removed and the airway is cleared, check breathing. If the victim is
not breathing, provide 2 rescue breaths. Then check for signs of circulation
(pulse check and evidence of breathing, coughing, or movement). If there are no
signs of circulation, begin chest compressions.

Unique CPR Situations

Changing Locations During CPR Performance

If the location is unsafe, such as a burning building, move the victim to a safe area and
then immediately start CPR. Do not move a victim for convenience from a cramped or
busy location until effective CPR is provided and the victim shows a return of signs of
circulation or until help arrives. Whenever possible, perform CPR without interruption.

Stairways

In some instances a victim must be transported up or down a flight of stairs. It is best to

perform CPR at the head or foot of the stairs and, at a predetermined signal, to interrupt
CPR and move as quickly as possible to the next level, where CPR can be resumed.
Interruptions should be brief and must be avoided if possible.

Litters

Do not interrupt CPR while transferring a victim to an ambulance or other mobile

emergency care unit. If the victim is placed on a low-wheeled litter, the rescuer can
stand alongside, providing chest compressions with the locked-arm position. If the
victim is placed on a high litter or bed, it may be necessary for the rescuer to kneel
beside the victim on the bed or litter to gain the needed height over the victim’s sternum.

Generally, CPR should be interrupted only when tracheal intubation is being performed
by trained personnel, an AED or manual defibrillator is being applied or used, or there
are problems with transportation. If the rescuer is alone, a momentary delay of CPR is
necessary to activate the EMS system.11

Pitfalls and Complications of BLS

CPR can support life when it is performed properly. Even properly performed CPR,
however, can result in complications.318 Fear of complications should not prevent
potential rescuers from providing CPR to the best of their ability.

Potential Complications of Rescue Breathing

The most common complication of rescue breathing is gastric inflation resulting from
excess ventilation volume and rapid flow rates.185186 Rescue breathing frequently causes
gastric inflation, especially in children.186193194195196 This inflation can be minimized by
maintaining an open airway and limiting ventilation volumes to just the point at which the
chest rises adequately.208 This is best achieved by providing slow rescue breaths (allow
2 seconds per breath in adults). Gastric inflation can be further minimized by ensuring
that the airway remains open during inspiration and expiration. Unfortunately, in 1-
rescuer CPR this is difficult, but it can be performed during 2-rescuer CPR. When
possible, an additional rescuer should apply cricoid pressure to minimize gastric
inflation.

Marked inflation of the stomach may promote regurgitation187188189 and reduce lung volume
by elevating the diaphragm.187196197 If the stomach becomes distended during rescue
breathing, recheck and reopen the airway and look for the rise and fall of the chest.
Avoid factors (rapid breaths, short inspiratory times, forceful breaths) that may
contribute to the development of high airway pressure. Continue slow rescue breathing
and do not attempt to expel the stomach contents. Experience has shown that attempts
to relieve stomach inflation with application of manual pressure over the victim’s upper
abdomen is almost certain to cause regurgitation if the stomach is full. If regurgitation
does occur, turn the victim’s entire body to the side, wipe out the mouth, return the body
to the supine position, and continue CPR.

Potential Complications of Chest Compression

Proper CPR techniques lessen the possibility of complications. Assess for signs of
circulation before performing compressions, but allow only 10 seconds to do this. If in
any doubt, assume that there is no circulation and begin chest compressions.

Even properly performed chest compressions can cause rib fractures in adult
patients.319 However, rib fractures and other injuries rarely complicate CPR in infants and
children.320321 Other complications may occur despite proper CPR technique, including
fracture of the sternum, separation of the ribs from the sternum, pneumothorax,
hemothorax, lung contusions, lacerations of the liver and spleen, and fat
emboli.318 These complications may be minimized by use of proper hand position during
chest compressions, but they cannot be prevented entirely. Concern for injuries that
may complicate CPR should not impede prompt and energetic application of CPR. The
only alternative to timely initiation of effective CPR for the victim of cardiac arrest is
death.

Rescuer Safety During CPR Training and CPR Performance

Safety during CPR training and in actual rescue situations has gained increased
attention. The following recommendations should minimize possible risk of infectious
complications to instructors and students during CPR training and actual CPR
performance. The recommendations for manikin decontamination and rescuer safety
originally established in 1978 by the Centers for Disease Control322 have been updated
twice by the AHA, the American Red Cross, and the Centers for Disease Control and
Prevention.49323 Additional recommendations for manikin decontamination have been
developed by such organizations as the Australian National Health and Medical
Research Council.

Disease Transmission During CPR Training

The risk of disease transmission during CPR training is extremely low. Use of CPR
manikins has never been shown to be responsible for an outbreak of infection, and a
literature search through March 2000 revealed no reports of infection associated with
CPR training.323324 To date, an estimated 70 million people in the United States have had
direct contact with manikins during CPR training courses without reported infectious
complications.324
Under certain circumstances, manikin surfaces can present a very small risk of disease
transmission. Therefore, manikin surfaces should be cleaned and disinfected in a
consistent way after each rescuer use and after each class.325

Two important practices are needed to minimize risk of transmission of infectious

agents during CPR training. First, rescuers should avoid any contact with any saliva or
body fluids present on the manikins.

Second, internal manikin parts, such as the valve mechanisms and artificial lungs in
manikin airways, invariably become contaminated during use and must be thoroughly
cleaned between uses. A wide variety of manikins are commercially available, and it is
impossible here to detail the cleaning required for each model and type. Instructors and
training agencies should carefully follow the manufacturers’ recommendations for
manikin use and maintenance.325326327328

There is no evidence to date that HIV can be transmitted by casual personal contact,
indirect contact with inanimate surfaces, or an airborne route.324 The primary retroviral
agent that causes acquired immunodeficiency syndrome (AIDS), HIV, is comparatively
delicate and is inactivated in <10 minutes at room temperature by a number of
disinfectants, including those agents recommended for manikin cleaning.329330331332333 If
current recommendations published by the AHA49322323 and manikin manufacturers for
manikin cleaning and decontamination are carefully followed, risk of transmission of HIV
and hepatitis B virus (HBV), as well as bacterial and fungal infections, should be
minimized.

Disease Transmission During Actual Performance of CPR

The vast majority of CPR performed internationally is provided by healthcare and public
safety personnel, many of whom assist in ventilation of respiratory and cardiac arrest
victims who are unknown to the rescuer. A layperson is far less likely to perform CPR
than healthcare providers, and the layperson is most likely to perform CPR in the home,
where 70% to 80% of respiratory and cardiac arrests occur.49

The actual risk of disease transmission during mouth-to-mouth ventilation is quite small;
only 15 reports of CPR-related infection were published between 1960 and 1998,324 and
no reports have been published in scientific journals from 1998 through March
2000.324334 Researchers have found that there is little reluctance by lay rescuers to
perform CPR on family members, even in the presence of vomitus or alcohol on the
breath.335 At last report (1998),324 the cases of disease transmission during CPR
include Helicobacter pylori,210Mycobacterium tuberculosis,211 meningococcus,336 herpes
simplex,337338339Shigella,340Streptococcus,341Salmonella,342 and Neisseria gonorrhoeae.324 No
reports on transmission of HIV, HBV, hepatitis C virus, or cytomegalovirus were
found.324 Nevertheless, despite the remote chances of its occurring, fears regarding
disease transmission are common in the current era of universal precautions. Indeed,
not only laypersons but also physicians, nurses, and even BLS instructors are extremely
reluctant to perform mouth-to-mouth ventilation.274277278343344345346 The most commonly stated
reason for not performing mouth-to-mouth ventilation is fear of contracting AIDS. In one
survey, only 5% of 975 respondents reported a willingness to perform chest
compression with mouth-to-mouth ventilation on a stranger, whereas 68% would
“definitely” perform chest compression alone if it was offered as an effective alternative
CPR technique.338 The attitude of rescuers who have actually performed mouth-to-mouth
ventilation is much different regarding fear of infectious disease. Of bystanders who
performed CPR in one study, 92% stated that they had no fear of infectious
disease.347 Of 425 interviewed rescuers from the same group, 99.5% indicated that if
called on they would perform CPR again.347

The rescuer who responds to an emergency for an unknown victim should be guided by
individual moral and ethical values and knowledge of risks that may exist in various
rescue situations. The rescuer should assume that any emergency situation involving
exposure to certain body fluids has the potential for disease transmission for both the
rescuer and victim. If a rescuer is unwilling or unable to perform mouth-to-mouth
breathing, chest compressions alone should be attempted, because it may increase the
chances for survival (Class IIa). This is particularly true if the victim is exhibiting gasping
breaths or if the time to defibrillation is likely to be short.64656667348

The greatest concern over the risk of disease transmission should be directed to
persons who perform CPR frequently, particularly healthcare providers, both in hospital
and out of hospital. If appropriate precautions are taken to prevent exposure to blood or
other body fluids, the risk of disease transmission from infected persons to providers of
out-of-hospital emergency health care should be no higher than that for those providing
emergency care in the hospital.

The probability that a rescuer (lay or professional) will become infected with HBV or HIV
as a result of performing CPR is minimal.349 Although transmission of HBV and HIV
between healthcare workers and patients has been documented as a result of blood
exchange or penetration of the skin by blood-contaminated instruments,350 transmission
of HBV and HIV infection during mouth-to-mouth resuscitation has not been
documented.324351 There is evidence that some face masks are experimentally
impermeable to the HIV-1 virus.352

Direct mouth-to-mouth breathing will probably result in exchange of saliva between the
victim and rescuer. HBV-positive saliva, however, has not been shown to be infectious
even to oral mucous membranes, through contamination of shared musical instruments,
or through HBV carriers.349 In addition, saliva has not been implicated in the transmission
of HIV after bites, percutaneous inoculation, or contamination of cuts and open wounds
with saliva from HIV-infected patients.353354 The theoretical risk of infection is greater for
salivary or aerosol transmission of herpes simplex, Neisseria meningitidis, and airborne
diseases such as tuberculosis and other respiratory infections. Rare instances of herpes
transmission during CPR have been reported.339

The emergence of multidrug-resistant tuberculosis355356 and the risk of tuberculosis to

emergency workers357 is a cause for concern. Rescuers with impaired immune systems
may be particularly at risk. In most instances, transmission of tuberculosis requires
prolonged close exposure as is likely to occur in households, but transmission to
emergency workers can occur during resuscitative efforts by either the airborne
route357 or direct contact. The magnitude of the risk is unknown but probably low. After
performing mouth-to-mouth resuscitation on a person suspected of having tuberculosis,
the caregiver should be evaluated for tuberculosis by standard approaches based on
the caregiver’s baseline skin tests.358 Caregivers with negative baseline skin tests should
be retested 12 weeks later. Preventive therapy should be considered for all persons
with positive tests and should be started on all converters.358359 In areas where multidrug-
resistant tuberculosis is common or after exposure to known multidrug-resistant
tuberculosis, the optimal preventive therapeutic agent has not been established. Some
authorities suggest use of 2 or more agents.360

Performance of mouth-to-mouth resuscitation or invasive procedures can result in the

exchange of blood between the victim and rescuer. This is especially true in cases of
trauma or if either victim or rescuer has breaks in the skin on or around the lips or soft
tissues of the oral cavity mucosa. Thus, a theoretical risk of HBV and HIV transmission
during mouth-to-mouth resuscitation exists.361

Because of the concern about disease transmission between victim and rescuer,
rescuers with a duty to provide CPR should follow precautions and guidelines such as
those established by the Centers for Disease Control and Prevention349 and the
Occupational Safety and Health Administration.362 These guidelines include the use of
barriers, such as latex gloves, and manual ventilation equipment, such as a bag mask
and other resuscitation masks with valves capable of diverting the victim’s expired air
away from the rescuer. Rescuers who have an infection that may be transmitted by
blood or saliva should not perform mouth-to-mouth resuscitation if circumstances allow
other immediate or effective methods of ventilation.

Several studies confirm that there is a risk of transmission of pathogens (diseases)

during exposure to blood, saliva, and other body fluids.* OSHA supports this
observation. Several devices have been developed to minimize risk of pathogen
exposure to the rescuer. Participants in BLS courses should be taught to use a barrier
device (face shield or face masks) when a mouth-to-mask device is not available and
mouth-to-mouth ventilation would place the rescuer at risk. Face masks may be more
effective barriers to oral bacteria than face shields. In fact, all face masks with 1-way
valves prevent the transmission of bacteria to the rescuer side of the mask. Face
shields, on the other hand, contaminated the rescuer side of the shield in 6 of 8 tests. 356

Because the efficacy of face shields has not been proven, those with a duty to respond
should learn during CPR training how to use masks with 1-way valves and other manual
ventilation devices.210211 Masks without 1-way valves and inline filters (including those
with S-shaped devices) offer little, if any, protection and should not be considered for
routine use.210211 Intubation with tracheal tubes and other airway adjuncts obviates the
need for mouth-to-mouth resuscitation and enables ventilation that is equal to or more
effective than the use of masks alone.366367368369370371 Early intubation is encouraged when
equipment and trained professionals are available. Resuscitation equipment known or
suspected to be contaminated with blood or other body fluids should be discarded or
thoroughly cleaned and disinfected after each use.372

CPR: The Human Dimension

Since 1973, millions of people throughout the world have learned CPR. Although CPR
is considered by some to be the most successful public health initiative in recent times,
the cardiac arrest survival rate to hospital discharge averages 15%, with some studies
reporting a favorable neurological status among such survivors.273

Serious long-lasting physical and emotional symptoms may occur in rescuers who
participate in unsuccessful resuscitation attempts. Rescuers may experience grief
reactions, stress, and anxiety. The stress of the experience often leaves the rescuer
feeling fatigued and uncertain, which may result in chronic anxiety and depression.

A “critical incident debriefing” may allow rescuers to work through their feelings and their
grief. Debriefings are most useful after an unsuccessful CPR attempt, and efforts should
be made to include all members of the resuscitation team. In these sessions, rescuers
discuss their thoughts, feelings, and performance. Participants should analyze what was
done and why, with a discussion of things that went right and things that went wrong.
The critical incident debriefing is also a time for learning something that may be useful
next time. The human dimension of CPR is often not discussed. Because of its
importance, it should be incorporated into CPR training and practice.

For additional information, see “Part 6, Section 7A: The Resuscitation Attempt as a
‘Critical Incident’: Code Critique and Debriefing.”

BLS Research Initiatives

Continued improvement of BLS programs requires ongoing scientific research. This

resuscitation research must ultimately translate into effective programs to teach CPR to
anyone who may witness a cardiac arrest, so that if cardiac arrest occurs, the EMS
system is activated immediately, CPR is skillfully performed, and survival is maximized.
In many critical areas, insufficient data is available to guide resuscitation experts and
clinicians. Because scientific data is lacking in some areas, portions of the current
guidelines are based on information derived from limited published data, some clinical
experience, and consensus of experts.

BLS is a fundamental therapy, yet many questions remain to be answered about

circumstances of arrest that are fundamental to development of CPR skill sequences.
To develop optimal sequences for CPR action, it is important to know how often
rescuers are alone and how often second rescuers are present. Research is needed
about a variety of aspects of programs of public access to defibrillation: what is the
optimum retraining interval for anticipated rescuers? What factors should guide
placement of AEDs in communities? Should rescuers perform 1 minute of CPR before
defibrillation? Further research is needed to identify optimal chest compression–
ventilation rates and ratios and methods to differentiate victims who require chest
compression from those who do not. In addition, research is needed to increase the
number of people who learn CPR and to identify optimal ways to teach CPR to lay
rescuers and healthcare providers. CPR programs must be simplified to remove
distracting information and emphasize core elements, and then simplified programs
must be evaluated to ensure that participants can learn, remember, and demonstrate
the steps of CPR. Future changes and advances in CPR based on sound scientific
investigation will undoubtedly improve the quality, delivery, and outcome of BLS.

1References 7 , 114 , 134 , 136137138139140141142 , 144145146 , 149150151152153154155 , 164 .

2References 209 , 336 , 337 , 339 , 340 , 362363364 .

3References 353637 , 55 , 56 , 62 , 63 , 69 , 252253254 .

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Figure 1. The Chain of Survival. The Chain of Survival consists of 4 links or actions: early
access, early CPR, early defibrillation, and early advanced care.
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Figure 2. The algorithm reviews the out-of-hospital management of patients with acute coronary
syndromes for BLS ambulance providers.
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Figure 3. Right-sided facial droop. Left, patient in repose. Right, patient after the command
“Look up and smile and show your teeth.”

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Figure 4. Arm drift. The patient is instructed to extend arms with eyes closed. Note the right-
sided drift related to motor weakness.

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Figure 5. The algorithm reviews the out-of-hospital management of patients with stroke for BLS
ambulance providers.
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Figure 6. Check for unresponsiveness and EMS activation. The rescuer should tap the victim’s
shoulder and shout “Are you all right?” If the victim does not respond, the rescuer directs
someone to activate the emergency medical response system (telephone 911 or appropriate
emergency telephone number).
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Figure 7. Obstruction by the tongue and epiglottis. When a victim is unconscious, the tongue
and epiglottis can block the upper airway. The head tilt–chin lift opens the airway by lifting the
tongue and epiglottis.
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Figure 8. Head tilt–chin lift. This maneuver lifts the tongue to relieve airway obstruction.
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Figure 9. Jaw thrust without head tilt. The jaw is lifted without tilting the head. This is the
airway maneuver of choice for a victim suspected of having sustained a cervical spine injury.

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Figure 10. The recovery position.

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Figure 11. Mouth-to-mouth rescue breathing.

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Figure 12. Mouth-to-nose rescue breathing.

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Figure 13. Mouth-to-stoma rescue breathing. A, Stoma; B, mouth-to-stoma.

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Figure 14. Face shield. The shield is placed over the mouth and nose with the opening at the
center of the shield placed over the victim’s mouth. The technique of rescue breathing is the
same as for mouth-to-mouth.
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Figure 15. Mouth-to-mask, cephalic technique. A, Using thumb and thenar eminence on the top
of the mask. B, Circling the thumb and first finger around the top of the mask.

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Figure 16. Mouth-to-mask, lateral technique. The lateral technique allows the rescuer to perform
1-rescuer CPR from a fixed position at the side of the victim.
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Figure 17. Two-rescuer use of the bag mask. The rescuer at the head uses the thumb and first
finger of each hand to provide a complete seal around the edges of the mask. Use the remaining
fingers to lift the mandible and extend the neck while observing chest rise. The other rescuer
slowly squeezes the bag (over 2 seconds) until he observes chest rise.
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Figure 18. One-rescuer use of the bag mask. The rescuer circles the top edges of the mask with
her index and first finger and lifts the jaw with the remaining fingers. The bag is squeezed while
the rescuer observes chest rise. Mask seal is key to the successful use of the bag mask.
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Figure 19. Cricoid pressure (Sellick maneuver).

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Figure 20. Checking the carotid pulse. A, Locate the trachea. B, Gently feel for the carotid pulse.
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Figure 21. Positioning the rescuer’s hands on the lower half of the sternum. The rescuer should
(A) locate the margin of the rib using first and second finger of the hand closer to the victim’s
feet, (B) follow the rib margin to the base of the sternum (xiphoid process) and place his or her
hand above the fingers (on the lower half of the sternum), and (C) place the other hand directly
over the hand on the sternum.
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Figure 22. Position of the rescuer during compressions.

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Figure 23. Universal choking sign.

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Figure 24. Subdiaphragmatic abdominal thrust (Heimlich maneuver), victim standing.

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Figure 25. Finger sweep.

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Figure 26. Healthcare provider provision of subdiaphragmatic abdominal thrust (Heimlich

maneuver) in unresponsive/unconscious victim.

Table 1. Cincinnati Prehospital Stroke Scale

Facial droop (have patient show teeth or smile)
Normal—both sides of face move equally
Abnormal—one side of face does not move as well as the other side
Arm drift (patient closes eyes and holds both arms straight out for 10
seconds)
Normal—both arms move the same or both arms do not move at all
(other findings, such as pronator grip, may be helpful)
Abnormal—one arm does not move or one arm drifts down compared
with the other
Abnormal speech (have the patient say “you can’t teach an old dog new
tricks”)
Normal—patient uses correct words with no slurring
Abnormal—patient slurs words, uses the wrong words, or is unable to
speak
Interpretation: If any of these 3 signs is abnormal, the probability of a
stroke is 72%.
From Reference 158 .

Table 2. Los Angeles Prehospital Stroke Screen (LAPSS)

For evaluation of acute, noncomatose, nontraumatic neurological
complaint: If items 1 through 6 are ALL checked “yes” (or
“unknown”), notify the receiving hospital before arrival of the
potential stroke patient. If any are checked “no,” follow appropriate
treatment protocol.
Interpretation: Ninety-three percent of patients with stroke will have
positive findings (all items checked “yes” or “unknown”) on the
LAPSS (sensitivity=93%), and 97% of those with positive findings
will have a stroke (specificity=97%). The patient may still be having a
stroke if LAPSS criteria are not met.
Criteria Yes Unknown No
1. Age >45 years [] [] []
2. History of seizures or epilepsy [] [] []
absent
3. Symptom duration <24 hours [] [] []
4. At baseline, patient is not wheelchair [ ] [] []
bound or bedridden
5. Blood glucose between 60 and 400 [] [] []
6. Obvious asymmetry (right vs left) [] [] []
in any of the following 3 categories
(must be unilateral)
Equal R Weak L Weak
Facial smile/grimace [ ] [ ] Droop [ ] Droop
Grip [ ] [ ] Weak [ ] Weak
grip grip
[ ] [ ] No grip [ ] No
grip
Arm strength [ ] [ ] Drifts [ ] Drifts
down down
[ ] [ ] Falls [ ] Falls
rapidly rapidly
From References and .149 159

Table 3. Sensitivity, Specificity, and Reliability of Pulse Check: Performance

of Pulse Check as a Diagnostic Test
Pulse Is Present Pulse Is Absent Totals
Rescuer 81 (Sensitivity: 6b 87 (No. of times rescuer
thinks correct positive thought pulse
pulse is result of pulse present=a+b)
present check÷all times a
pulse was actually
present) a
Rescuer 66 c 53 (Specificity: 119 (No. of times rescuer
thinks correct negative thought pulse absent=c+d)
Table 3. Sensitivity, Specificity, and Reliability of Pulse Check: Performance
of Pulse Check as a Diagnostic Test
Pulse Is Present Pulse Is Absent Totals
pulse is result of pulse
absent check÷all times there
actually was no
pulse) d
Totals 147 (Total number of 59 (Total number of 206 (Total study
study opportunities study opportunities opportunities=a+b+c+d)
where a pulse was where a pulse was
actually actually absent=b+d)
present=a+c)
Calculations derived from above:

a. Positive predictive value: Of the total times the rescuer thinks a pulse is present
(total=87 times), a pulse is present=81/87 times=93%.

b. Negative predictive value: Of the total times the rescuer thinks a pulse is absent
(total=119 times), a pulse is absent=53/119=45%.

c. Sensitivity: Rescuer’s ability to detect a pulse when one actually is

present=81/147=55%.

d. Specificity: Rescuer’s ability to recognize that a pulse is absent when a pulse actually
is absent=53/59=90%.

e. Accuracy=“rescuer correct”/total=(81 pulse correctly found+53 pulse correctly thought

absent)/206=65%.

Modified from Cummins RO, Hazinski MF. Cardiopulmonary resuscitation techniques

and instruction: when does evidence justify revision? Ann Emerg Med. 1999;34:780–
784. Based on data from Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S,
Tzanova I. Checking the carotid pulse: diagnostic accuracy of first responders in
patients with and without a pulse. Resuscitation. 1996;33:107–116.

References
 1Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden
cardiac arrest: the “chain of survival” concept: a statement for health
professionals from the Advanced Cardiac Life Support Subcommittee and the
Emergency Cardiac Care Committee, American Heart
Association. Circulation.1991; 83:1832–1847.CrossrefMedlineGoogle Scholar
 2McIntyre KM. Cardiopulmonary resuscitation and the ultimate coronary care
unit. JAMA.1980; 244:510–511.CrossrefMedlineGoogle Scholar
 3Calle PA, Verbeke A, Vanhaute O, Van Acker P, Martens P, Buylaert W. The
effect of semi-automatic external defibrillation by emergency medical technicians
on survival after out-of-hospital cardiac arrest: an observational study in urban
and rural areas in Belgium. Acta Clin Belg.1997; 52:72–
83.CrossrefMedlineGoogle Scholar