Basic Life Support: Early Access

Public Access Defibrillation Programs for Adults

• Public access defibrillation programs should be an essential part of the management of out-of-hospital cardiac arrest.
• Community leaders may consider determining the locations that have a high incidence of cardiac arrest in the local area and develop methods to have public access defibrillators available at these locations at the time of arrests.

Basic Life Support: Dispatcher/Telecommunicator-Assisted CPR

 

Video-Based Dispatcher-Assisted CPR

• Video-based dispatcher instruction may be considered by dispatch centers as a supplement to standard audio instructions.

 

Basic Life Support: CPR Techniques and Sequences

CPR Prior to Call for Help

• A mobile phone with a speaker, if available, should be used to call 9-1-1, allowing activation of emergency medical services to occur parallel to the beginning of cardiopulmonary resuscitation (CPR) and to facilitate dispatcher guidance and/or support of CPR.

 

CPR Prior to Defibrillation

• Cardiopulmonary resuscitation should be performed prior to the availability of an automated external defibrillator and analysis of rhythm.

 

Optimal Surface for CPR

• It is reasonable to perform manual chest compressions on a firm surface when possible.
• It is suggested that a person in cardiac arrest in the hospital setting not be moved from their bed to the floor to improve chest compression depth.
• If a person in cardiac arrest is in a bed with cardiopulmonary resuscitation mode to increase mattress stiffness, it is reasonable to activate this mode.

 

Barrier Devices During CPR

• Although the risk of harm while performing cardiopulmonary resuscitation is considered low, precautions should be taken to minimize the risk of transmission of infectious disease. This may include, but is not limited to:
  • Using standard precautions to provide patient care in all settings including performance of hand hygiene and use of personal protective equipment (PPE), that is, gloves, gown and a face mask, based on activities being performed and the risk assessment.
  • Using additional PPE, including an N95 or higher-level respirator and eye protection (goggles or face shield) for aerosol-generating procedures or resuscitation of patients. Disposable N95 respirators should be discarded after leaving the patient’s room or care area.
  • Using an inline filter for mouth-to-mask or bag-mask ventilation.

 

CPR Start Sequence (A-B-C versus C-A-B) (Adult and Pediatric)

• Once cardiac arrest is recognized, resuscitation should begin with compressions.
• Healthcare professionals may consider rescue breaths or manual ventilations first in pediatric patients with primary respiratory etiologies of cardiac arrest.
• For the drowning process resuscitation, once cardiac arrest is recognized, resuscitation should begin with rescue breaths or manual ventilations.

 

Hand Positioning During Chest Compressions

• For adults and children, chest compressions should be performed on the lower half of the sternum.
• For infants, chest compressions should be performed just below the inter-mammary line (middle of the chest).
• For adults, the two-hand technique should be used for chest compressions.
• For children, either a two-hand or one-hand technique should be used for chest compressions.
• For infants, the two-thumb/encircling hands technique should be used for chest compressions.
• For infants, the two-finger technique (two or three fingers placed in the middle of the chest) may be considered.
• For infants, if the required depth cannot be achieved with either the two-thumb/encircling hands technique or the or two-finger technique, a one- hand technique may be considered.

 

Chest Compression Rate

• Chest compressions should be performed at a rate of 100 to 120 per minute for adults, children and infants.

 

Chest Compression Depth

• During CPR, an adult chest should be compressed to a depth of at least 2 inches.
• During cardiopulmonary resuscitation (CPR), a child’s and infant’s chest should be compressed to a depth of at least one-third the anteroposterior diameter of the chest (about 2 inches for a child and about 1 1/2 inches for an infant).

 

Chest Wall Recoil

• During compressions for adults, children and infants, the chest wall should be allowed to fully recoil, and compression and recoil times should be approximately equal.

 

Pulse Check During CPR

• When performing cardiopulmonary resuscitation (CPR), if signs of return of spontaneous circulation (ROSC) are observed:
  • Stop CPR and automated external defibrillator use.
  • Check for breathing and a carotid or femoral pulse.
  • Pauses should be minimized to less than 10 seconds.
• Routine pulse checks without signs of ROSC are not recommended.

 

Rhythm Check Timing

• Immediately after a shock is delivered, cardiopulmonary resuscitation (CPR) should be resumed for 2 minutes before pausing compressions to conduct a rhythm check.
• Based on the clinical situation, performing rhythm analysis after defibrillation may be considered by healthcare professionals.
• After every 2 minutes of CPR, the rhythm should be reassessed (while minimizing interruptions to CPR).
• If there are physiologic signs of return of spontaneous circulation, briefly pausing compressions for rhythm analysis may be considered.

 

Duration of CPR Cycles (2 minutes versus other)

• Chest compressions may be paused every 2 minutes for rhythm analysis and to allow for switching roles.

 

Tidal Volumes and Ventilation Inspiratory Time

• For adults with a pulse but insufficient respiratory effort, and during cardiopulmonary resuscitation (CPR) with an advanced airway in place, 1 rescue breath/manual ventilation should be provided every 6 seconds.
• For children and infants with a pulse but insufficient respiratory effort, and during CPR with an advanced airway in place, 1 rescue breath/manual ventilation should be provided every 2 to 3 seconds.
• Rescue breaths and manual ventilations should be delivered over 1 second in adults, children and infants and with a volume that produces visible initiation of chest rise.

 

Compression-to-Ventilation Ratio: Lay Responders

• For lay responders:
  • Cardiopulmonary resuscitation (CPR) should be performed with ventilations, using a compression-to-ventilation ratio of 30:2.
  • Compression-only CPR may be used as an alternative to CPR with compressions and ventilations when someone is unwilling or unable to provide ventilations.

 

Compression-Only CPR Versus Conventional CPR: EMS

• For healthcare professionals:
  • A compression-to-ventilation (CV) ratio of 30:2 should be used in adults with cardiac arrest without an advanced airway.
  • A CV ratio of 15:2 should be used in children and infants with cardiac arrest and with two healthcare or prehospital professionals trained in this technique.
  • With an advanced airway in place, healthcare and prehospital professionals should not pause compressions for ventilations.
  • Emergency medical services systems may consider alternative initial compression-only strategies for witnessed cardiac arrest.

 

Fatigue with Chest Compression-Only CPR

• Compression-only cardiopulmonary resuscitation (CPR) may be used as an alternative to CPR with compressions and ventilations when someone is unwilling or unable to provide ventilations.
• Compression-only CPR should be continued unless it is no longer possible due to physical exhaustion.

 

Alternative Cardiac Resuscitation Techniques

• A precordial thump and percussion pacing should not be used for cardiac arrest.
• “Cough cardiopulmonary resuscitation” should not be used for cardiac arrest.

 

Head-Up CPR

• Head-up cardiopulmonary resuscitation should not be routinely used for cardiac arrest.

 

Harm to Those Performing CPR

• Although the risk of harm while performing cardiopulmonary resuscitation (CPR) is considered low, precautions should be taken to minimize the risk of transmission of infectious disease or defibrillator-associated injury. This may include, but is not limited to:
  • Using standard precautions to provide patient care in all settings, to include performance of hand hygiene and use of personal protective equipment (PPE) (i.e., gloves, gown and a face mask) based on activities being performed and the risk assessment.
  • Using additional PPE, including an N95 or higher-level respirator, and eye protection (goggles or face shield) for aerosol-generating procedures or resuscitation of patients. Disposable N95 respirators should be discarded after leaving the patient’s room or care area.
  • Using an inline filter for mouth-to-mask or bag-mask ventilation.
  • Performing hand hygiene after removal and disposal of PPE or after providing CPR without PPE.
  • Avoiding touching a person in cardiac arrest when advised by automated external defibrillator prompts prior to the delivery of a shock.

 

Harm from CPR to Persons Not in Cardiac Arrest

• Dispatchers should provide guidance to bystanders to begin cardiopulmonary resuscitation based on their assessment and without concern for harm to persons not in cardiac arrest.

 

Basic Life Support: Defibrillation

Defibrillation Electrode Pad Size and Placement

• Use adult defibrillator electrode pads and energy levels on adult patients. Defibrillator pad size and selection should be as recommended by the defibrillator manufacturer.
• Adult electrode pads should be applied per defibrillator manufacturer instructions in either an anterolateral or an anteroposterior position.
• Defibrillator electrode pads should not incorporate any breast tissue.

 

Basic Life Support: Opioid-Associated Emergency Resuscitation

 

Suspected Opioid-Associated Emergency Resuscitation

• Cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use remain the first interventions for cardiac arrest in opioid overdose and should not be delayed or interrupted.
• For suspected cardiac arrest due to opioids, naloxone should be administered as soon as possible without disrupting or delaying CPR and AED use.

 

Advanced Life Support: CPR Techniques and Sequence

 

Rhythm Analysis During Chest Compressions

• Immediately after a shock is delivered, cardiopulmonary resuscitation (CPR) should be resumed for 2 minutes before pausing compressions to check for or analyze a rhythm.
• Based on the clinical situation, performing rhythm analysis after defibrillation may be considered by healthcare professionals.
• Compressions should be paused for rhythm analysis, even when using devices with artifact-filtering algorithms.
• After every 2 minutes of CPR, the rhythm should be reassessed (while minimizing interruptions to CPR for no more than 10 seconds).
• If there are physiologic signs of return of spontaneous circulation, briefly pausing compressions for rhythm analysis may be considered.

 

Advanced Life Support: Special Circumstances

 

Management of Cardiac Arrest in Pregnancy

• Fibrinolytic therapy, surgical embolectomy or percutaneous mechanical thrombectomy may be considered for cardiac arrest due to known or suspected pulmonary embolism.