Recognition
Signs of Cardiac Arrest
Rescuers should start cardiopulmonary resuscitation (CPR) if the victim is unconscious (unresponsive), not moving, and not breathing. Even if the victim takes occasional gasps, rescuers should suspect that cardiac arrest has occurred and should start CPR.
Airway and Ventilation
Airway
Opening the Airway
Rescuers should open the airway using the head tilt-chin lift maneuver. Rescuers should use the finger sweep in the unconscious patient with a suspected airway obstruction only if solid material is visible in the oropharynx.
Foreign-Body Airway Obstruction (FBAO)
Chest thrusts, back blows/slaps, or abdominal thrusts are effective for relieving FBAO in conscious adults and children >1 year of age, although injuries have been reported with the abdominal thrust. There is insufficient evidence to determine which should be used first. These techniques should be applied in rapid sequence until the obstruction is relieved; more than one technique may be needed. Unconscious victims should receive CPR. The finger sweep should be used in the unconscious patient with an obstructed airway only if solid material is visible in the airway. There is insufficient evidence for a treatment recommendation for an obese or pregnant patient with FBAO.
Ventilation
Mouth-to-Nose Ventilation
Mouth-to-nose ventilation is an acceptable alternative to mouth-to-mouth ventilation.
Mouth-to-Tracheal Stoma Ventilation
It is reasonable to perform mouth-to-stoma breathing or to use a well-sealing, round pediatric facemask.
Tidal Volumes and Ventilation Rates
For mouth-to-mouth ventilation with exhaled air or bag-valve-mask ventilation with room air or oxygen, it is reasonable to give each breath within a 1-second inspiratory time to achieve chest rise. After an advanced airway (e.g., tracheal tube, Combitube, laryngeal mask airway [LMA]) is placed, ventilate the patient's lungs with supplementary oxygen to make the chest rise. During CPR for a patient with an advanced airway in place, it is reasonable to ventilate the lungs at a rate of 8 to 10 ventilations per minute without pausing during chest compressions to deliver ventilations. Use the same initial tidal volume and rate in patients regardless of the cause of the cardiac arrest.
Mechanical Ventilators and Automatic Transport Ventilators
There is insufficient data to recommend for or against the use of a manually triggered, flow-limited resuscitator or an automatic transport ventilator during bag-valve-mask ventilation and resuscitation of adults in cardiac arrest.
Chest Compressions
Chest Compression Technique
Hand Position
It is reasonable for laypeople and healthcare professionals to be taught to position the heel of their dominant hand in the center of the chest of an adult victim, with the nondominant hand on top.
Chest Compression Rate, Depth, Decompression, and Duty Cycle
It is reasonable for lay rescuers and healthcare providers to perform chest compressions for adults at a rate of at least 100 compressions per minute and to compress the sternum by at least 4 to 5 cm (1-1/2 to 2 inches). Rescuers should allow complete recoil of the chest after each compression. When feasible, rescuers should frequently alternate "compressor" duties, regardless of whether they feel fatigued, to ensure that fatigue does not interfere with delivery of adequate chest compressions. It is reasonable to use a duty cycle (i.e., ratio between compression and release) of 50%.
Firm Surface for Chest Compressions
Cardiac arrest victims should be placed supine on a firm surface (i.e., backboard or floor) during chest compressions to optimize the effectiveness of compressions.
CPR Process Versus Outcome
It is reasonable for instructors, trainees, providers, and Emergency Medical Services (EMS) agencies to monitor and improve the process of CPR to ensure adherence to recommended compression and ventilation rates and depths.
Alternative Compression Techniques
CPR in Prone Position
CPR with the patient in a prone position is a reasonable alternative for intubated hospitalized patients who cannot be placed in the supine position.
Compression-Ventilation Sequence
Any recommendation for a specific CPR compression-ventilation ratio represents a compromise between the need to generate blood flow and the need to supply oxygen to the lungs. At the same time any such ratio must be taught to would-be rescuers, so that skills acquisition and retention are also important factors.
Effect of Ventilations on Compressions
Interruption of Compressions
Rescuers should minimize interruptions of chest compressions.
Compression-Ventilation Ratio During CPR
There is insufficient evidence that any specific compression-ventilation ratio is associated with improved outcome in patients with cardiac arrest. To increase the number of compressions given, minimize interruptions of chest compressions, and simplify instruction for teaching and skills retention, a single compression-ventilation ratio of 30:2 for the lone rescuer of an infant, child, or adult victim is recommended. Initial steps of resuscitation may include (1) opening the airway while verifying the need for resuscitation, (2) giving 2 to 5 breaths when initiating resuscitation, and (3) then providing compressions and ventilations using a compression-ventilation ratio of 30:2.
Chest Compression-Only CPR
Rescuers should be encouraged to do compression-only CPR if they are unwilling to do airway and breathing maneuvers or if they are not trained in CPR or are uncertain how to do CPR. Researchers are encouraged to evaluate the efficacy of compression-only CPR.
Postresuscitation Positioning
Recovery Position
It is reasonable to position an unconscious adult with normal breathing on the side with the lower arm in front of the body.
Special Circumstances
Cervical Spine Injury
For victims of suspected spinal injury, additional time may be needed for careful assessment of breathing and circulation, and it may be necessary to move the victim if he or she is found face-down. In-line spinal stabilization is an effective method of reducing risk of further spinal damage.
Airway Opening
Maintaining an airway and adequate ventilation is the overriding priority in managing a patient with a suspected spinal injury. In a victim with a suspected spinal injury and an obstructed airway, the head tilt-chin lift or jaw thrust (with head tilt) techniques are feasible and may be effective for clearing the airway. Both techniques are associated with cervical spinal movement. Use of manual in-line stabilization (MILS) to minimize head movement is reasonable if a sufficient number of rescuers with adequate training are available.
Face-Down Victim
It is reasonable to roll a face-down, unresponsive victim carefully into the supine position to check for breathing.
Drowning
CPR for Drowning Victim in Water
In-water expired-air resuscitation may be considered by trained rescuers, preferably with a flotation device, but chest compressions should not be attempted in the water.
Removing Drowning Victim From Water
Drowning victims should be removed from the water and resuscitated by the fastest means available. Only victims with risk factors or clinical signs of injury (history of diving, water slide use, trauma, alcohol) or focal neurologic signs should be treated as a victim with a potential spinal cord injury, with stabilization of the cervical and thoracic spine.
EMS System
Dispatcher Instruction in CPR
Providing telephone instruction in CPR is reasonable.
Improving EMS Response Interval
Administrators responsible for EMS and other systems that respond to patients with cardiac arrest should evaluate their process of delivering care and make resources available to shorten response time intervals when improvements are feasible.
Risks to Victim and Rescuer
Risks to Trainees
Training manikins should be cleaned between trainee ventilation sessions. It is acceptable to clean them with commercially available antiseptic, 30% isopropyl alcohol, 70% alcohol solution, or 0.5% sodium hypochlorite, allowing at least 1 minute of drying time between trainee ventilation sessions.
Risks to Responders
Providers should take appropriate safety precautions when feasible and when resources are available to do so, especially if a victim is known to have a serious infection (e.g., human immunodeficiency virus [HIV], tuberculosis, hepatitis B virus [HBV], or severe acute respiratory syndrome [SARS]).
Risks for the Victim
Rib fractures and other injuries are common but acceptable consequences of CPR given the alternative of death from cardiac arrest. After resuscitation all patients should be reassessed and reevaluated for resuscitation-related injuries.
If available, the use of a barrier device during mouth-to-mouth ventilation is reasonable. Adequate protective equipment and administrative, environmental, and quality control measures are necessary during resuscitation attempts in the event of an outbreak of a highly transmittable microbe such as the SARS coronavirus.
