Bon, AC,. Bechtel, AK. Cardiopulmonary Resuscitation. 2017

6/26/2017 Cardiopulmonary Resuscitation (CPR): Practice Essentials, Preparation, Technique
Cardiopulmonary Resuscitation (CPR)

Updated: Feb 06, 2017
Author: Catharine A Bon, MD Chief Editor: Kirsten A Bechtel, MD more...
Practice Essentials
Cardiopulmonary resuscitation (CPR) consists of the use of chest compressions and artificial
ventilation to maintain circulatory flow and oxygenation during cardiac arrest (see the images below).
Although survival rates and neurologic outcomes are poor for patients with cardiac arrest, early
appropriate resuscitationinvolving early defibrillationand appropriate implementation of post
cardiac arrest care lead to improved survival and neurologic outcomes.
Delivery of chest compressions. Note the overlapping hands placed on the center of the sternum, with the
rescuer's arms extended. Chest compressions are to be delivered at a rate of at least 100 compressions
per minute.
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http://emedicine.medscape.com/article/1344081-overview 1/41
Delivery of mouth-to-mouth ventilations.

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Indications and contraindications
CPR should be performed immediately on any person who has become unconscious and is found to
be pulseless. Assessment of cardiac electrical activity via rapid rhythm strip recording can provide a
more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options.
Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing
arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing
arrhythmias include the following:
Ventricular fibrillation (VF)
Pulseless ventricular tachycardia (VT)
Pulseless electrical activity (PEA)
Asystole
Pulseless bradycardia
CPR should be started before the rhythm is identified and should be continued while the defibrillator is
being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory
shock until a pulsatile state is established.
Contraindications
The only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced
directive indicating a persons desire to not be resuscitated in the event of cardiac arrest. A relative
contraindication to performing CPR is if a clinician justifiably feels that the intervention would be
medically futile.
Equipment
CPR, in its most basic form, can be performed anywhere without the need for specialized equipment.
Universal precautions (ie, gloves, mask, gown) should be taken. However, CPR is delivered without
such protections in the vast majority of patients who are resuscitated in the out-of-hospital setting, and
no cases of disease transmission via CPR delivery have been confirmed. Some hospitals and EMS
systems employ devices to provide mechanical chest compressions. A cardiac defibrillator provides
an electrical shock to the heart via 2 electrodes placed on the patients torso and may restore the
heart into a normal perfusing rhythm.
Technique
In its full, standard form, CPR comprises the following 3 steps, performed in order:
Chest compressions
Airway
Breathing
For lay rescuers, compression-only CPR (COCPR) is recommended.
Positioning for CPR is as follows:
CPR is most easily and effectively performed by laying the patient supine on a relatively hard
surface, which allows effective compression of the sternum
Delivery of CPR on a mattress or other soft material is generally less effective
The person giving compressions should be positioned high enough above the patient to achieve
sufficient leverage, so that he or she can use body weight to adequately compress the chest
For an unconscious adult, CPR is initiated as follows:
Give 30 chest compressions

Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is
breathing
Before beginning ventilations, look in the patients mouth for a foreign body blocking the airway
Chest compression
The provider should do the following:
Place the heel of one hand on the patients sternum and the other hand on top of the first,
fingers interlaced
Extend the elbows and the provider leans directly over the patient (see the image below)
Press down, compressing the chest at least 2 in Release the chest and allow it to recoil
completely
The compression depth for adults should be at least 2 inches (instead of up to 2 inches, as in
the past)
The compression rate should be at least 100/min
The key phrase for chest compression is, Push hard and fast
Untrained bystanders should perform chest compressiononly CPR (COCPR)
After 30 compressions, 2 breaths are given however, an intubated patient should receive
continuous compressions while ventilations are given 8-10 times per minute
This entire process is repeated until a pulse returns or the patient is transferred to definitive care
To prevent provider fatigue or injury, new providers should intervene every 2-3 minutes (ie,
providers should swap out, giving the chest compressor a rest while another rescuer continues
CPR
Ventilation
If the patient is not breathing, 2 ventilations are given via the providers mouth or a bag-valve-mask
(BVM). If available, a barrier device (pocket mask or face shield) should be used.
To perform the BVM or invasive airway technique, the provider does the following:
Ensure a tight seal between the mask and the patients face
Squeeze the bag with one hand for approximately 1 second, forcing at least 500 mL of air into
the patients lungs
To perform the mouth-to-mouth technique, the provider does the following:
Pinch the patients nostrils closed to assist with an airtight seal

Put the mouth completely over the patients mouth
After 30 chest compression, give 2 breaths (the 30:2 cycle of CPR)
Give each breath for approximately 1 second with enough force to make the patients chest rise
Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion
After giving the 2 breaths, resume the CPR cycle
Complications
Complications of CPR include the following:
Fractures of ribs or the sternum from chest compression (widely considered uncommon)
Gastric insufflation from artificial respiration using noninvasive ventilation methods (eg, mouth-
tomouth, BVM) this can lead to vomiting, with further airway compromise or aspiration
insertion of an invasive airway (eg, endotracheal tube) prevents this problem
ACLS
In the in-hospital setting or when a paramedic or other advanced provider is present, ACLS guidelines
call for a more robust approach to treatment of cardiac arrest, including the following:
Drug interventions
ECG monitoring
Defibrillation
Invasive airway procedures
Emergency cardiac treatments no longer recommended include the following:
Routine atropine for pulseless electrical activity (PEA)/asystole

Cricoid pressure (with CPR)
Airway suctioning for all newborns (except those with obvious obstruction)
Background
For patients with cardiac arrest, survival rates and neurologic outcomes are poor, though early
appropriate resuscitation, involving cardiopulmonary resuscitation (CPR), early defibrillation, and
appropriate implementation of postcardiac arrest care, leads to improved survival and neurologic
outcomes. Targeted education and training regarding treatment of cardiac arrest directed at
emergency medical services (EMS) professionals as well as the public has significantly increased
[1]
cardiac arrest survival rates.
CPR consists of the use of chest compressions and artificial ventilation to maintain circulatory flow
and oxygenation during cardiac arrest. A variation of CPR known as handsonly or compression
only CPR (COCPR) consists solely of chest compressions. This variant therapy is receiving growing
attention as an option for lay providers (that is, nonmedical witnesses to cardiac arrest events).
The relative merits of standard CPR and COCPR continue to be widely debated. An observational
study involving more than 40,000 patients concluded that standard CPR was associated with
[2]
increased survival and more favorable neurologic outcomes than COCPR was. However, other
studies have shown opposite results, and it is currently accepted that COCPR is superior to standard
CPR in out-of-hospital cardiac arrest.
Several large randomized controlled and prospective cohort trials, as well as one meta-analysis,
demonstrated that bystander-performed COCPR leads to improved survival in adults with out-of-
[3, 4, 5]Differences between these results
hospital cardiac arrest, in comparison with standard CPR.
may be attributable to a subgroup of younger patients arresting from noncardiac causes, who clearly
[2]
demonstrate better outcomes with conventional CPR.
The 2010 revisions to the American Heart Association (AHA) CPR guidelines state that untrained
bystanders should perform COCPR in place of standard CPR or no CPR (see American Heart
[6]
Association CPR Guidelines).
Of the more than 300,000 cardiac arrests that occur annually in the United States, survival rates are
[7, 8, 9,
typically lower than 10% for out-of-hospital events and lower than 20% for in-hospital events.
10, 11]
A study by Akahane et al suggested that survival rates may be higher in men but that
neurologic outcomes may be better in women of younger age, though the reasons for such sex
[12]
differences are unclear.
Additionally, studies have shown that survival falls by 10-15% for each minute of cardiac arrest without
[13, 14]
CPR delivery. Bystander CPR initiated within minutes of the onset of arrest has been shown to
[15, 16]
improve survival rates 2- to 3-fold, as well as improve neurologic outcomes at 1 month.
It has also been demonstrated that out-of hospital cardiac arrests occurring in public areas are more
likely to be associated with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT)
[17]
and have better survival rates than arrests occurring at home.
This article focuses on CPR, which is just one aspect of resuscitation care. Other interventions, such
as the administration of pharmacologic agents, cardiac defibrillation, invasive airway procedures,
[18, 19, 20, 21, 22]
postcardiac arrest therapeutic hypothermia, the use of echocardiography in
[23] [24, 25]
resuscitation, and various diagnostic maneuvers, are beyond the scope of this article. For
more information, see the Resuscitation Resource Center for specific information on the resuscitation
of neonates, see Neonatal Resuscitation.
See the guidelines sections detailed later in the article.
Indications
CPR should be performed immediately on any person who has become unconscious and is found to
be pulseless. Assessment of cardiac electrical activity via rapid rhythm strip recording can provide a
more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options.
Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing
arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing
arrhythmias include the following:
VF
Pulseless VT
PEA
Asystole
Pulseless bradycardia
Although prompt defibrillation has been shown to improve survival for VF and pulseless VT rhythms,
[26] CPR should be started before the rhythm is identified and should be continued while the defibrillator is
being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory shock
until a pulsatile state is established. This is supported by studies showing that preshock pauses in CPR
[27]
result in lower rates of defibrillation success and patient recovery.
In a study involving out-of-hospital cardiac arrests in Seattle, 84% of patients regained a pulse when
[28]
defibrillated during VF. Defibrillation is generally most effective the faster it is deployed.
The American College of Surgeons, the American College of Emergency Physicians, the National
Association of EMS Physicians, and the American Academy of Pediatrics have issued guidelines on
the withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary
[29]
arrest. Recommendations include the following:
Withholding resuscitation should be considered in cases of penetrating or blunt trauma victims
who will obviously not survive.
Standard resuscitation should be initiated in arrested patients who have not experienced a
traumatic injury.
Victims of lighting strike or drowning with significant hypothermia should be resuscitated.
Children who showed signs of life before traumatic CPR should be taken immediately to the
emergency room CPR should be performed, the airway should be managed, and intravenous or
intraosseous lines should be placed en route.
In cases in which the trauma was not witnessed, it may be assumed that a longer period of
hypoxia might have occurred and limiting CPR to 30 minutes or less may be considered.
When the circumstances or timing of the traumatic event are in doubt, resuscitation can be
initiated and continued until arrival at the hospital.
Terminating resuscitation in children should be included in state protocols.
Contraindications
The only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced
directive indicating a persons desire to not be resuscitated in the event of cardiac arrest.
A relative contraindication to performing CPR may arise if a clinician justifiably feels that the
intervention would be medically futile, although this is clearly a complex issue that is an active area of
[30, 31]
research.
Preparation
Anesthesia
Because a person in cardiac arrest is almost invariably unconscious, anesthetic agents are not
typically required for cardiopulmonary resuscitation (CPR).
Equipment
CPR, in its most basic form, can be performed anywhere without the need for specialized equipment.
Regardless of the equipment available, proper technique (see Technique) is essential.
Universal precautions (ie, gloves, mask, gown) should be taken. However, in the vast majority of
patients who are resuscitated in the out-of-hospital setting, CPR is delivered without such protections,
and no cases of disease transmission via CPR delivery have been reported.
Some hospitals and emergency medical services (EMS) systems employ devices to provide mechanical
chest compressions, although until relatively recently, such devices had not been shown
[32]
to be more effective than high-quality manual compressions. One study has shown increased
survival with better neurologic outcome in patients receiving active compression-decompression CPR
with augmentation of negative intrathoracic pressure (achieved with an impedance threshold device),
[33]
compared with patients receiving standard CPR.
In a meta-analysis of 12 studies, mechanical chest compression devices proved superior to manual
chest compressions in the ability to achieve return of spontaneous circulation. In the meta-analysis,
Westfall and colleagues found that devices that use a distributing band to deliver chest compression
(load-distributing band CPR) was significantly superior to manual CPR (odds ratio, 1.62), while the
difference between piston-driven CPR devices and manual resuscitation did not reach significance
[34] [35]
(odds ratio, 1.25) This finding was supported by a study conducted by Pinto et al.
Additionally, other health systems have begun to implement devices to monitor CPR electronically
and provide audiovisual CPR feedback to providers, thereby helping them improve the quality of
[27, 36, 37, 38]
compressions during CPR.
An Advanced Cardiac Life Support (ACLS) provider (ie, physician, nurse, paramedic) may also elect
to insert an endotracheal tube directly into the trachea of the patient (intubation), which provides the
most efficient and effective ventilations. However, 2 retrospective cohort studies have called into
[39, 40]
question the value of prehospital endotracheal intubation, and further study in this area
is warranted.
An additional device employed in the treatment of cardiac arrest is a cardiac defibrillator. This device
provides an electrical shock to the heart via 2 electrodes placed on the patients chest and can restore
the heart into a normal perfusing rhythm.
Positioning
CPR is most easily and effectively performed by laying the patient supine on a relatively hard surface,
which allows effective compression of the sternum. Delivery of CPR on a mattress or other soft
material is generally less effective.
The health care provider giving compressions should be positioned high enough above the patient to
achieve sufficient leverage, so that he or she can use body weight to adequately compress the chest
(see the video below).
6/26/2017 Cardiopulmonary Resuscitation (CPR): Practice Essentials, Preparation, Techniqu
CPR positioning. Video courtesy of Daniel Herzberg, 2008.

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In the hospital setting, where patients are in gurneys or beds, appropriate positioning is often
achieved by lowering the bed, having the CPR provider stand on a step-stool, or both. In the out-of-
hospital setting, the patient is often positioned on the floor, with the CPR provider kneeling over him or
her.
Technique
Overview
In its full, standard form, cardiopulmonary resuscitation (CPR) comprises 3 steps: chest
compressions, airway, and breathing (CAB), to be performed in that order in accordance with the 2010
American Heart Association (AHA) guidelines.
Note that artificial respirations are no longer recommended for bystander rescuers thus, lay rescuers
should perform compression-only CPR (COCPR). Healthcare providers, however, should perform all
3 components of CPR (chest compressions, airway, and breathing).
For an unconscious adult, CPR is initiated using 30 chest compressions. Perform the head-tilt chin-lift
maneuver to open the airway and determine if the patient is breathing. Before beginning ventilations,
rule out airway obstruction by looking in the patients mouth for a foreign body blocking the patients
airway. CPR in the presence of an airway obstruction results in ineffective ventilation/oxygenation
and may lead to worsening hypoxemia.
The techniques described here refer specifically to CPR as prescribed by the Basic Cardiac Life
Support (BCLS) guidelines. In the in-hospital setting, or when a paramedic or other advanced provider
is present in the out-of-hospital setting, Advanced Cardiac Life Support (ACLS) guidelines call for a
more robust approach to treatment of cardiac arrest, including drug interventions, electrocardiographic
(ECG) monitoring, defibrillation, and invasive airway procedures.
Attempting to perform CPR is better than doing nothing at all, even if the provider is unsure if he or
she is doing it correctly. This especially applies to many peoples aversion to providing mouthto
mouth ventilations. If one does not feel comfortable giving ventilations, chest compressions alone are
still better than doing nothing.
Chest compression
The heel of one hand is placed on the patients sternum, and the other hand is placed on top of the
first, fingers interlaced. The elbows are extended and the provider leans directly over the patient (see
the image below). The provider presses down, compressing the chest at least 2 in. The chest is
released and allowed to recoil completely (see the video below).
Delivery of chest compressions. Note the overlapping hands placed on the center of the sternum, with the
rescuer's arms extended. Chest compressions are to be delivered at a rate of at least 100 compressions
per minute.
View Media Gallery
0:00 / 0:39
CPR compressions. Video courtesy of Daniel Herzberg, 2008.

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With the hands kept in place, the compressions are repeated 30 times at a rate of 100/min. The key
thing to keep in mind when doing chest compressions during CPR is to push fast and hard. Care
should be taken to not lean on the patient between compressions, as this prevents chest recoil and
worsens blood flow.
After 30 compressions, 2 breaths are given (see Ventilation). Of note, an intubated patient should
receive continuous compressions while ventilations are given 8-10 times per minute. This entire
process is repeated until a pulse returns or the patient is transferred to definitive care.
When done properly, CPR can be quite fatiguing for the provider. If possible, in order to give
consistent, high-quality CPR and prevent provider fatigue or injury, new providers should intervene
every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest while another
rescuer continues CPR).
For COCPR (ie, CPR without rescue breaths), the provider delivers only the chest compression
portion of care at a rate of 100/min to a depth of 38-51 mm (1-1.5 in.) without pause. This delivery of
compressions continues until the arrival of medical professionals or until another rescuer is available
[3]
to continue compressions.
The use of mechanical CPR devices was reviewed in three large trials. Outcomes were similar
between mechanical devices and manual compressions. The studies did not recommend routinely
replacing manual compressions with mechanical CPR devices, but they did not rule out a role for the
[41]
mechanical devices if high-quality manual chest compression is not available.
Ventilation
If the patient is not breathing, 2 ventilations are given via the providers mouth (see the image below)
or a bag-valve-mask (BVM).
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The mouth-to-mouth technique is performed as follows (see the video below):
The nostrils of the patient are pinched closed to assist with an airtight seal
The provider puts his mouth completely over the patients mouth
The provider gives a breath for approximately 1 second with enough force to make the patients
chest rise
0:00 / 0:56
CPR ventilation. Video courtesy of Daniel Herzberg, 2008.

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Effective mouth-to-mouth ventilation is determined by observation of chest rise during each

exhalation. Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion. As
noted (see above), 2 such exhalations should be given in sequence after 30 compressions (the 30:2
cycle of CPR). When breaths are completed, compressions are restarted. If available, a barrier device
(pocket mask or face shield) should be used.
More commonly, health care providers use a BVM, which forces air into the lungs when the bag
is squeezed. Several adjunct devices may be used with a BVM, including oropharyngeal and
nasopharyngeal airways.
The BVM or invasive airway technique is performed as follows:
The provider ensures a tight seal between the mask and the patients face.
The bag is squeezed with one hand for approximately 1 second, forcing at least 500 mL of air
into the patients lungs.
Next, the provider checks for a carotid or femoral pulse. If the patient has no pulse, chest
compressions are begun.
Post Procedure
Complications
Performing chest compressions may result in the fracturing of ribs or the sternum, though the
incidence of such fractures is widely considered to be low.
Artificial respiration using noninvasive ventilation methods (eg, mouth-to-mouth, bag-valve-mask
[BVM]) can often result in gastric insufflation. This can lead to vomiting, which can further lead to
airway compromise or aspiration. The problem is eliminated by inserting an invasive airway,
which prevents air from entering the esophagus.
CPR and ECC Guidelines Summary

Updated cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) guidelines
were issued in 2015 by the following organizations:
American Heart Association (AHA)
European Resuscitation Council (ERC)
The International Liaison Committee on Resuscitation (ILCOR)
American Heart Association (AHA)
With the 2015 update for CPR and ECC, the AHA guidelines will transition from a 5-year revision and
update print publication to a continuously updated online publication. The first release of the Web-
[42] [43]
based Integrated Guidelines isbased on the comprehensive 2010 guidelines plusthe
[44]
2015update.
The guidelines include recommendations in the following areas:
Ethical Issues
Adult basic life support (BLS)
Alternative techniques and ancillary devices for CPR
Adult advanced cardiac life support (ACLS)
Postcardiac arrest care
Acute coronary syndromes
Cardiac arrest in special circumstances
Pediatric BLS
Pediatric ACLS
Neonatal resuscitation
European Resuscitation Council (ERC)
The ERC guidelines provide detailed algorithms and recommendations in 10 areas, which are
updated and published every 5 years in separate papers. The 2015 guidelines cover the following
areas:
[45]
Adult BLS
[46]
Adult ACLS
[47]
Cardiac arrest in special circumstances
[48]
Postresuscitation care
[49]
Pediatric life support
[50]
[51]
[52]
First aid
[53]
Principles of education in resuscitation
[54]
The ethics of resuscitation and end-of-life decisions
The International Liaison Committee on Resuscitation (ILCOR)
Initially formed in 1993, the International Liaison Committee on Resuscitation (ILCOR) includes
representatives from the American Heart Association (AHA), the European Resuscitation Council, the
Heart and Stroke Foundation of Canada, the Australian and New Zealand Committee on
Resuscitation, the Resuscitation Council of Southern Africa, the InterAmerican Heart Foundation, and
the Resuscitation Council of Asia. The ILCOR defines emergency cardiac care as all responses
necessary to treat sudden life-threatening events affecting the cardiovascular and respiratory
[55]
systems, with a particular focus on sudden cardiac arrest.
Like the AHA and ERC guidelines, the ILCOR guidelines are updated on a 5-year cycle and include
consensus treatment recommendations in the following areas:
[56]
Adult BLS
[57]
Adult ACLS, including postcardiac arrest care
[58]
[59]
Pediatric BLS and ALS
[60]
[61]
Education, implementation, and teams (EIT)
[62]
First aid
Chain of Survival Guidelines

The 2015 update differentiates in-hospital cardiac arrests (IHCAs) from out-of-hospital cardiac arrests
(OHCAs), with separate adult chain of survival recommendations that identify the different pathways
[44]
for IHCA and OHCA, as outlined in Table 1, below.
Table 1. Adult Chain of Survival (Open Table in a new window)
Link 1 Link 2 Link 3 Link 4 Link 5
Recognition Advanced
and activation life
Immediate
Surveillance of the Rapid support
IHCA high-quality
and prevention emergency defibrillation and post-
response CPR arrest
system care
Primary Cath
Responder(s) Code Team
Provider Lab/ICU
OHCA Recognition Immediate Rapid Basic and Advanced

and activation high-quality defibrillation advanced life
of the CPR emergency support
emergency medical and post-
response services arrest
system care
Responder(s) Lay Rescuers
Emergency
ED/Cath
Medical
Lab/ICU
Services (EMS)
ILCOR and ERC do not separate in-hospital from out-of-hospital cardiac arrest in their definition of
chain of survival, and, therefore, they do not have the IHCAs link 1 of surveillance and prevention.
[45, 55]
Otherwise they have similar chains of survival.
Postresuscitation care recommendations were added to the 2015 update as a new section in
collaboration with the European Society of Intensive Care Medicine. These postresuscitation care
guidelines acknowledge the importance of high-quality postresuscitation care as a vital link in the
[48]
chain of survival.
Adult BLS and AED Guidelines

In the AHA 2015 guidelines, the adult basic life support (BLS) algorithm has been modified to reflect
the widespread use of mobile telephones that can be used for assistance without leaving the patient.
[42]
The algorithm is detailed in Table 2, below.
Table 2. Adult BLS Algorithm (Open Table in a new window)
Untrained Lay Trained Lay

Healthcare Professionals
Responders Responders
Step
Ensure scene safety
1
Step
Check for response
2
Responder should Responder should

shout for nearby help shout for nearby help
and phone or have and activate the
another bystander emergency response Responder should shout for nearby
Step phone 911 the system (9-1-1, help. The resuscitation team can
3 phone should remain emergency be activated before or after
on speaker for response). Ensure checking breathing and pulse.
receiving further that the phone
instructions from the remains on speaker,
dispatcher. if at all possible.
Step Follow dispatchers Check for no A check for no breathing or only

4 instructions. breathing or only gasping and a check of pulse ideally
gasping if there is should be done simultaneously.
none, begin CPR Activation and retrieval of the
with chest AED/emergency equipment by either
compressions. the lone healthcare provider or by a
second person must occur immediately
after the check of breathing and pulse
identifies cardiac arrest.
As instructed by Answer dispatchers

Step dispatcher to check questions and follow CPR begins immediately, and the
5 for no breathing or subsequent AED/defibrillator is used if available.
only gasping. instructions.
Dispatchers Send another With arrival of a second responder,

Step
instructions person for an AED, if two-person CPR is provided and
6
are followed. one is available. AED/defibrillator is used.
The AHA 2010 guidelines revised the initial CPR sequence of steps from ABC (airway, breathing, chest
[43] this was reaffirmed in the 2015
compressions) to CAB (chest compressions, airway, breathing)
[42]:
update, which also offered the following revised recommendations for performance of CPR
Chest compressions should be performed at a rate of 100-120/min (class I)
During manual CPR, chest compressions should be at a depth of at least 2 inches for an
average adult, while avoiding excessive chest compression depths (>2.4 inches) (class I)
Total preshock and postshock pauses in chest compressions should be as short as
possible (class I)
For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to
pause compressions for less than 10 seconds to deliver two breaths (class IIa)
In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR, in
which case, the chest compression target fraction should still be as high as possible (at least
60%) (class IIb)
[44]
Class I recommendations specifically for lay responders include the following :
Untrained responders should provide compression-only CPR, with or without dispatcher
assistance
Compression-only CPR should continue until the arrival of an AED or responders with additional
training
All responders should, at a minimum, provide chest compressions for victims of cardiac arrest in
addition, if a trained lay responder is able to perform rescue breaths, they should be added in a
ratio of 30 compressions to two breaths
[44]
Recommendations specifically for dispatchers include the following :
Emergency dispatchers should be educated to identify unresponsiveness with abnormal
breathing and agonal gasps across a range of clinical presentations and descriptions (class I)
After acquiring the requisite information to determine the location of the event, dispatchers
should determine whether a patient is unresponsive with abnormal breathing (class I) if the
caller reports that the patient is unresponsive with abnormal or no breathing, it is reasonable to
assume the patient is in cardiac arrest (class IIa)
To increase bystander performance of CPR, telephone instructions on compression-only CPR
should be provided to callers reporting an unresponsive adult who is not breathing or not
breathing normally (ie, only gasping) (class I)

Dispatchers should instruct responders to provide CPR if the victim is unresponsive with no
normal breathing, even when the victim demonstrates occasional gasps (class I)
Review of the quality of dispatcher CPR instructions provided to specific callers is an important
component of a high-quality lifesaving program (class IIb)
Although the guideline recommends that dispatchers ask only about responsiveness and breathing,
cardiac arrest is defined physiologically by the lack of a detectable pulse. For example, a person who
is post ictal may be unresponsive and have abnormal breathing, yet have a completely normal heart
and normal pulse. Therefore, one should consider simultaneous detection of pulse if possible.
The 2015 update includes recommendation for a simultaneous, choreographed approach to the
performance of chest compressions, airway management, rescue breathing, rhythm detection, and
[44]
shocks (if indicated) by an integrated team of highly trained rescuers in applicable settings.
Additional recommendations specifically for EMS and other healthcare providers include the following
[44] :
If the patient is unresponsive with no breathing or only gasping, the patient should be assumed
to be in cardiac arrest and the emergency response system should be immediately activated
(class I)
If a pulse is not definitely felt within 10 seconds, chest compressions should be initiated (class
IIa)
It is reasonable for healthcare providers to provide chest compressions and ventilation for all
adult patients in cardiac arrest, from either a cardiac or noncardiac cause (class IIa) (However,
note that chest compression must pause during rhythm analysis by an AED.)
Rapid defibrillation is the treatment of choice for ventricular fibrillation of short duration for
victims of witnessed OHCA or for IHCA in a patient whose heart rhythm is monitored (class I)
For a witnessed OHCA with a shockable rhythm, it may be reasonable for EMS systems with
priority-based, multitiered response to delay positive-pressure ventilation for up to three cycles
of 200 continuous compressions with passive oxygen insufflation and airway adjuncts (class IIb)
Routine use of passive ventilation techniques during conventional CPR for adults is not
recommended (class III) in EMS systems that use bundles of care involving continuous chest
compressions, the use of passive ventilation techniques may be considered as part of that
bundle (class IIb)
When the victim has an advanced airway in place during CPR, rescuers need no longer deliver
cycles of 30 compressions and two breaths (ie, interrupt compressions to deliver breaths)
instead, it may be reasonable for one rescuer to deliver one breath every 6 seconds (10 breaths
per minute) while another rescuer performs continuous chest compressions (class IIb)
To open the airway in victims with suspected spinal injury, lay rescuers should initially use manual
spinal motion restriction (eg, placing their hands on the sides of the patients head to hold it still) rather
than immobilization devices, because use of immobilization devices by lay rescuers may be harmful
(class III). For healthcare providers and others trained in two-person CPR, if there is evidence of
trauma that suggests spinal injury, a jaw thrust without head tilt should be used to open the airway
(class IIb)
[45, 56]
There are no significant differences in the recommendations from ERC or ILCOR.
Adult ACLS Guidelines

Although management of cardiac arrest begins with BLS and progresses sequentially through the
links of the chain of survival, there is some overlap as each stage of care progresses to the next.
Generally, in the three guidelines, ACLS comprises the level of care between BLS and postcardiac
arrest care.
The ERC 2015 updates emphasize care delivery with revised recommendations focused on improving
outcomes and do not include any major changes in core ACLS interventions since the 2010
[46]
guidelines.
The following summarizes the AHA adult cardiac arrest algorithm for ventricular fibrillation (VF) or
[42]
pulseless ventricular tachycardia (pVT)
Activate emergency response system
Initiate CPR and give oxygen when available
Verify patient is in VF as soon as possible (ie, AED or quick look with paddles)
Defibrillate once: Use a device-specific recommendation (ie, 120-200 J for biphasic waveform
and 360 J for monophasic waveform) if unknown, use the maximum available
Resume CPR immediately without pulse check and continue for five cycles. One cycle of CPR
equals 30 compressions and two breaths five cycles of CPR should take roughly 2 minutes
(compression rate 100 per minute) do not check for rhythm/pulse until five cycles of CPR are
completed.
During CPR, minimize interruptions while securing intravenous (IV) access and performing
endotracheal intubation. Once the patient is intubated, continue CPR at 100 compressions per
minute without pauses for respirations, and administer respirations at 10 breaths per minute.
Check rhythm after 2 minutes of CPR.
Repeat a single defibrillation if the patient is still in VF/pVT with rhythm check. Selection of fixed
versus escalating energy for subsequent shocks is based on the specific manufacturers
instructions. For a manual defibrillator capable of escalating energies, higher energy for the
second and subsequent shocks may be considered. Resume CPR for 2 minutes immediately
after defibrillation.
Continuously repeat the cycle of (1) rhythm check, (2) defibrillation, and (3) 2 minutes of CPR
Administer epinephrine,1 mg every 35 minutes during CPR, before or after shock, when IV or
intraosseous (IO) access is available (Note that vasopressin has not been shown to have benefit
in addition to epinephrine, so for simplicity it has been removed from the algorithm for most
cases.)
Administer amiodarone 300 mg IV/IO once, if dysrhythmic during CPR, before or after shock
then consider administering an additional 150 mg once.
Note that defibrillation is perhaps the single most effective therapeutic step for this particular type of
cardiac arrest. However, it is important to make sure the pads are correctly placed.
In addition, correct the following if necessary and/or possible:
Hypovolemia
Hypoxia
Hydrogen ion (acidosis): Consider bicarbonate therapy
Hyperkalemia/hypokalemia and metabolic disorders
Hypoglycemia: Check fingerstick or administer glucose
Hypothermia: Check core rectal temperature
Toxins
Tamponade, cardiac: Check with ultrasonography
Tension pneumothorax: Consider needle thoracostomy
Thrombosis, coronary or pulmonary: Consider thrombolytic therapy if suspected
Trauma
According to the AHA, if all the following are present, termination of resuscitation in OHCA may be
considered:
Arrest was not witnessed by EMS personnel
No return of spontaneous circulation (ROSC) prior to transport
No AED shock delivered prior to transport
In addition, in intubated patients, failure to achieve an end-tidal carbon dioxide (ETCO 2) level of
greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one
component of a multimodal approach to decide when to end resuscitative efforts. However, no studies of
nonintubated patients have been reviewed, and ETCO 2 should not be used as an indication
to end resuscitative efforts in those cases.
Defibrillation
[42]
AHA recommendations for defibrillation include the following :
Use defibrillators (using , or monophasic waveforms) to treat atrial and ventricular arrhythmias
(class I)
Defibrillators using biphasic waveforms (BTE or RLB) are preferred (class IIa)
Use a single-shock strategy (as opposed to stacked shocks) for defibrillation (class IIa)
Overall, the ERC and ILCOR guidelines concur with the AHA, but ERC guidelines include an
additional recommendation for self-adhesive defibrillation pads, which are generally preferred over
[46]
manual paddles.
Adjuncts for airway control and ventilation
[42]
The AHA guidelines provide the following recommendations for airway control and ventilation :
Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for
cardiac arrest
If advanced airway placement will interrupt chest compressions, consider deferring insertion of
the airway until the patient fails to respond to initial CPR and defibrillation attempts or
demonstrates return of spontaneous circulation
The routine use of cricoid pressure in cardiac arrest is not recommended (class III)
Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation
during CPR in both the inhospital and outofhospital setting (class IIb) t
For healthcare providers trained in their use, either a supraglottic airway (SGA) device or an
may be used as the initial advanced airway during CPR (class IIb)
Providers who perform endotracheal intubation should undergo frequent retraining (class I)
To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be
used in unconscious (unresponsive) patients with no cough or gag reflex and should be
inserted only by trained personnel (class IIa)
In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral
airway is preferred
Continuous waveform capnography in addition to clinical assessment is the most reliable
method of confirming and monitoring correct placement of an ETT (class I)
If continuous waveform capnometry is not available, a nonwaveform carbon dioxide detector,
esophageal detector device, and ultrasound used by an experienced operator are reasonable
alternatives (class IIa)
Automatic transport ventilators (ATVs) can be useful for ventilation of adult patients in
noncardiac arrest who have an advanced airway in place in both out-of-hospital and in-hospital
settings (class IIb)
[46, 57]
The recommendations from ERC or ILCOR do not differ significantly from those of the AHA.
Medication management
The 2015 AHA guidelines offer the following recommendations for the administration of drugs during
[42]
cardiac arrest :
Amiodarone may be considered for or pVT that is unresponsive to CPR, defibrillation, and a
vasopressor lidocaine may be considered as an alternative (class IIb)
Routine use of magnesium for VF/pVT is not recommended in adult patients (class III)
Inadequate evidence exists to support routine use of lidocaine however, the initiation or
continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to
VF/pVT (class IIb)
Inadequate evidence exists to support the routine use of a betablocker after cardiac arrest
however, the initiation or continuation of a beta-blocker may be considered after
hospitalization from cardiac arrest due to VF/pVT (class IIb)
Atropine during pulseless electrical activity (PEA) or asystole is unlikely to have a therapeutic
benefit (class IIb)
There is insufficient evidence for or against the routine initiation or continuation of other
antiarrhythmic medications after ROSC from cardiac arrest
Standard-dose epinephrine (1 mg every 3-5 min) may be reasonable for patients in cardiac
arrest (class IIb) highdose epinephrine is not recommended for routine use in cardiac arrest
(class III)
Vasopressin has been removed from the Adult Cardiac Arrest Algorithm and offers no
advantage in combination with epinephrine or as a substitute for standard-dose epinephrine
(class IIb)
It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac
arrest due to an initial nonshockable rhythm (class IIb)
PostCardiac Arrest Care Guidelines

According to the AHA guidelines, although the best hospital care for patients with ROSC after cardiac
arrest is not completely known, a comprehensive, structured, multidisciplinary system of care should
be implemented in a consistent manner for the treatment of post-cardiac arrest patients (class I).
[42]
Components of structured interventions include the following :
Therapeutic hypothermia
Optimization of hemodynamics and gas exchange
Immediate coronary reperfusion, when indicated for restoration of coronary blood flow, with
percutaneous coronary intervention (PCI)
Glycemic control
Neurological diagnosis, management, and prognostication
The key issues and major changes in the 2015 AHA guidelines update for postcardiac-arrest care
[42]
include the following :
Emergency coronary angiography is recommended for all patients with ST elevation and for
hemodynamically or electrically unstable patients without ST elevation in whom a cardiovascular
lesion is suspected the decision to perform revascularization should not be affected by the
patients neurological status, which can change
Targeted temperature management (TTM) with a range of acceptable temperatures from

32 36C is recommended (at least for the first 24 h).
Identification and correction of hypotension is recommended in the immediate postcardiac-
arrest period
Prognostication no sooner than 72 hours after the completion of TTM
The following summarizes the AHA algorithm for adult immediate postcardiac arrest care after ROSC
[42] :
Optimize ventilation and oxygenation
Treat hypotension
Perform a 12-lead ECG to determine whether acute ST elevation or ischemia is present
For ST-elevation myocardial infarction (STEMI), perform coronary reperfusion with PCI
TTM
In the 2015 update, the ERC collaborated with the European Society of Intensive Care Medicine to
produce a new guideline section to address postresuscitation care. In general, the recommendations
[48]
are in agreement with the AHA 2015 update.
Targeted temperature management
The 2010 AHA guidelines strongly advised induced hypothermia (3234C) for patients with outof
hospital VF/pVT cardiac arrest and post-ROSC coma (the absence of purposeful movements) and
encouraged consideration of induced hypothermia for most other comatose patients after cardiac
arrest. However, the precise duration and optimal temperature targets were unknown.
Because a range of temperatures is used, the term targeted temperature management (TTM) has
been adopted. This term encompasses both induced hypothermia and active control of temperature at
[42]
any target.
[42]
The revised 2015 recommendations for TTM include the following :
TTM for comatose adult patients with ROSC (class I)
A constant temperature of 32-36 C during TTM (class I)
TTM for at least 24 hours after achieving target temperature (class IIa)
Routine prehospital cooling of patients after ROSC with rapid infusion of cold IV fluids is not
recommended (class III)
Prevention of fever in comatose patients after TTM may be reasonable (class IIb)
Use of sedation and analgesia in critically ill patients who require mechanical ventilation or
shivering suppression during induced hypothermia after cardiac arrest is reasonable (class IIb)
Management of seizures
Unchanged from the 2010 AHA guidelines, the detection and treatment of nonconvulsive status
[42]:
epilepticus remains a priority. The 2015 guidelines offer the following new recommendations
An electroencephalogram (EEG) for the diagnosis of seizure should be promptly performed and
interpreted, and thereafter monitored in comatose patients after ROSC (class I)
Anticonvulsant regimens used to treat status epilepticus caused by other etiologies may be
considered after cardiac arrest (class IIb)
Prognostication
The 2015 AHA guidelines note that the timing for prognostication is typically 4.5-5 days after ROSC
for patients treated with TTM, in order to minimize false-positive results due to a drug-induced
depression of neurologic function. However, the guidelines acknowledge that withdrawal of life
support may occur before 72 hours because of underlying terminal disease, brain herniation, or other
[42]
clearly nonsurvivable situations.
[42]
Additional recommendations for the timing of prognostication include the following :
Clinical examination results may be used for prognostication in patients treated with TTM, where
sedation or paralysis could be a confounder, in a minimum of 72 hours after completion of TTM
(class IIb)
In patients not treated with TTM, 72 hours after cardiac arrest is the earliest time to
prognosticate a poor neurologic outcome using clinical examination (class I)
Time until prognostication can be longer than 72 hours after cardiac arrest if the residual
effect of sedation or paralysis confounds the clinical examination (class IIa)
The ERC guidelines indicate that poor outcome is very likely in patients who are unconscious for 72
[48]
hours or more after ROSC and have one or both of the following :
No pupillary and corneal reflexes
Bilaterally absent N20 somatosensory-evoked potential (SSEP) wave
If neither of those are present, the ERC recommends waiting at least 24 hours. At that point, poor
outcome is very likely in patients with two or more of the following:
Status myoclonus 48 hours or less after ROSC
High neuron-specific enolase
Status epilepticus on EEG
Diffuse anoxic injury on brain CT/MRI
Organ donation
All three guidelines recommend that all patients who are resuscitated from cardiac arrest but
[42, 48, 57]In addition,
subsequently progress to death or brain death be evaluated for organ donation.
the AHA guidelines recommend considering kidney or liver donation in patients who do not have
[42]
ROSC after resuscitation efforts and would otherwise have termination of efforts.
Acute Coronary Syndromes Guidelines

With the publication of the 2015 updates, AHA, ERC, and ILCOR limit recommendations to
prehospital and ED care for acute coronary syndromes (ACS). For in-hospital care, clinicians are
advised to consult either the AHA/American College of Cardiology or European Society of Cardiology
[42, 51, 58]
guidelines for the management of STEMI and non-STEMI ACS.
[42]
The following summarizes the AHA algorithm for emergent treatment of ACS :
All patients being transported for chest pain should be managed as if the pain were ischemic in
origin, unless clear evidence to the contrary is established
Prehospital notification by EMS personnel should alert ED staff to the possibility of a patient with
myocardial infarction (MI)
Specific prehospital care is as follows:
Monitor ABCs be prepared to provide CPR and defibrillation

12-Lead ECG
Supplemental oxygen
Immediate administration of aspirin (160-325 mg) en route
Nitroglycerin for active chest pain (avoid in hypotensive patients) and morphine, if needed
Establish IV access
If fibrinolysis is considered, complete fibrinolytic checklist
ED assessment and immediate treatment is as follows:
Vital signs and pulse oximetry if oxygen saturation is less than 90%, start oxygen at 4 L/min,
titrate
Intravenous access and aspirin, if not administered by EMS
Nitroglycerin given sublingually or by spray IV morphine if needed
Brief, targeted history and physical examination Review/complete
fibrinolytic checklist
Obtain cardiac marker, electrolyte, and coagulation
studies Portable chest radiograph in less than 30 minutes
Further therapy is based on ECG diagnosis, as follows:
STEMI: ST elevation or new left bundle-branch block (LBBB)

High-risk non-STEMI ACS: ST depression or dynamic T-wave inversion
Low/intermediate-risk ACS: Normal or nondiagnostic changes in ST segment or T wave
For STEMI and high-risk non-STEMI ACS, adjunctive therapies should begin as indicated. For STEMI
with symptom onset 12 or fewer hours ago, reperfusion should not be delayed. Selection of therapy is
defined by patient and center criteria, with the following door-to-treatment goals:
Percutaneous coronary intervention (PCI): 90 minutes
Fibrinolysis: 30 minutes
In patients with suspected STEMI for whom primary PCI reperfusion is planned, unfractionated
heparin can be administered either in the prehospital or the hospital setting (class IIb)
For STEMI with onset of symptoms more than 12 hours or high-risk non-STEMI ACS, an early
invasive strategy is indicated for patients with any of the following:
Refractory ischemic chest discomfort
Recurrent or persistent ST deviation
Ventricular tachycardia
Hemodynamic instability
Signs of heart failure
For low/intermediate-risk ACS, admit to the ED chest pain unit or appropriate bed for further
monitoring and possible intervention.
Further medical management of ACS should be conducted according to the other related guidelines.
Diagnostic interventions
The 2015 guidelines include the following class I recommendations for prehospital diagnostic
[42]
intervention :
12-Lead ECG should be acquired early for patients with possible ACS
Notification of the receiving hospital (if fibrinolysis is the likely reperfusion strategy) and/or
prehospital activation of the catheterization laboratory should occur for all patients with a
recognized STEMI on ECG
If providers are not trained to interpret the 12-lead ECG, field transmission of the ECG or a
computer report should be sent to the receiving hospital
12-Lead ECG diagnostic programs should be implemented with concurrent medically directed
quality assurance
[42]
Additional recommendations include the following :
Negative high-sensitivity cardiac troponin (hs-cTn) and cardiac-specific troponin I (cTnI) levels
during initial patient evaluation should not be used as a standalone measure to exclude an ACS
(class III)
[51, 58]
There are no significant variances in the ERC and ILCOR recommendations.
Emergent reperfusion decisions in STEMI
The AHA guidelines advocate for a systems-of-care approach involving a reperfusion team that
mobilizes hospital resources for an optimized approach. The guidelines argue that when such a
system is active either in the ED or based on prehospital data, time-sensitive therapies can be offered
[42]
more rapidly.
Specific recommendations for emergent reperfusion include the following:
For patients presenting in less than 12 hours of symptom onset, reperfusion should be initiated
as soon as possible independent of the method chosen (class I)
If fibrinolysis is chosen, fibrinolytics should be administered in the ED as early as possible
according to a predetermined process developed by the ED and cardiology staff (class I)
Fibrinolytic therapy is generally not recommended for patients presenting between 12 and 24
hours after onset of symptoms unless continuing ischemic pain is present with continuing
ST- segment elevation (class IIb)
Fibrinolytic therapy is contraindicated in patients who present more than 24 hours after the onset
of symptoms (class III)
Coronary angioplasty with or without stent placement is the treatment of choice when it can be
performed effectively with a door-to-balloon time of less than 90 minutes by a skilled provider at
a skilled PCI facility (class I)
When fibrinolysis is contraindicated, PCI should be performed despite the delay, rather
than forgoing reperfusion therapy (class I)
Fibrinolytic therapy followed by immediate PCI (as contrasted with immediate PCI alone) is not
recommended (class III)
Administration of fibrinolytics in the prehospital setting ideally requires protocols using fibrinolytic
checklists, 12-lead ECG interpretation, staff experienced in advanced life support,
communication with the receiving institution, a medical director experienced in STEMI
management, and continuous quality improvement (class I)
Where prehospital fibrinolysis and direct transport to a PCI center are both available, prehospital
triage and transport directly to a PCI center may be preferred (class IIb)
Regardless of whether time of symptom onset is known, the interval between first medical
contact and reperfusion should not exceed 2 hours (class I)
In patients presenting within 2 hours of symptom onset, immediate fibrinolysis rather than
primary PCI may be considered when the expected delay to primary PCI is more than 60
minutes (class IIb)
In adult patients presenting with STEMI in the ED of a nonPCI-capable hospital, immediate

transfer without fibrinolysis from the initial facility to a PCI center is recommended, instead of
immediate fibrinolysis at the initial hospital with transfer only for ischemia-driven PCI (class I)
ERC guidelines include one additional recommendation: When fibrinolysis is the treatment strategy, if
[51]
transport times exceed 30 minutes, fibrinolysis using trained EMS staff is preferred.
Pediatric BLS Guidelines

As with the adult BLS recommendations, the AHA 2010 guidelines revised the initial CPR sequence of
steps from ABC (airway, breathing, chest compressions) to CAB (chest compressions, airway,
[43]
breathing). This change was reaffirmed in the 2015 update, which also offered the
[42]
revised algorithms for BLS in pediatric cardiac arrest described below.
If the child is unresponsive and not breathing, the responder should shout for help. The first rescuer
remains with the child and the second activates the emergency response system and retrieves an
AED and other emergency equipment, if available. If the first responder is alone, the emergency
response system should be activated via mobile phone.
Healthcare providers trained to assess pediatric pulses should take no more than 10 seconds to feel
for a pulse before initiating chest compressions. This is a subtle distinction from lay person BLS,
which instructs the immediate initiation of chest compressions if the child is unresponsive and not
breathing.
If no pulse is palpated, then chest compressions should be initiated at a rate of 100-120 per minute
and at a depth of one third of the anteroposterior diameter of the chest. If a pulse is detected, rescue
breaths should be initiated at a rate of 12-20 per minute, or one every 3-5 seconds. If the pulse
remains below 60 bpm with evidence of poor perfusion, chest compressions should be initiated. Pulse
checks should occur every 2 minutes.
If CPR is initiated, the following recommendations for one-rescuer CPR versus two-rescuer CPR
apply:
One-rescuer CPR should cycle between 30 chest compressions and 2 breaths
Two-rescuer CPR should cycle between 15 chest compressions and 2 breaths.
After 2 minutes of CPR, the emergency response system should be activated if not already done.
CPR should then be continued until an AED is available. Once an AED arrives, it should be promptly
connected to the patient, minimizing interruptions in CPR.
If the patient's rhythm is analyzed and determined to be a "shockable" rhythm, rescuers should clear
the patient and deliver a shock. Chest compressions should be reinitiated immediately following the
shock and should be continued for 2 minutes before another pulse check and rhythm analysis.
If a shockable rhythm is detected, this cycle is repeated.
If no shock is advised, chest compressions should be continued for 2 minutes.
There should be a pulse check and rhythm analysis every 2 minutes until ALS providers arrive
or the patient begins to move.
High-quality CPR
The following are considered essential elements of high-quality CPR:
Compression rate of 100-120/min

Compression depth to at least one third of the anterior-posterior diameter of the chest
(approximately 4 cm in infants to 5 inches in children) for adolescents, the adult compression
depth of at least 5 cm, but no more than 6 cm should be used. Complete chest recoil after
each compression
Minimized interruptions in chest compressions
Avoidance of excessive ventilation
Pediatric ALS Guidelines

As with BLS, algorithms are a key component of pediatric advanced life support (PALS) and are
designed to simplify and expedite recognition and treatment of life-threatening conditions. Unlike BLS,
PALS typically involves a coordinated team of trained responders who are able to initiate several
processes simultaneously.
VF or pVT
[42]
The following summarizes the AHA PALS algorithm for VF or pVT :
Call for help and activate the emergency response
Initiate high-quality CPR and give oxygen
Attach an ECG monitor and defibrillator pads
Establish vascular access initially, attempting peripheral IV access is acceptable but only for a
short, limited time if a peripheral IV access cannot be quickly established, then an IO line
should be placed by a trained provider
Once the child is attached to the monitor or AED, the rhythm should be analyzed and determined to
be shockable or nonshockable. Shockable rhythms include pulseless ventricular tachycardia or
ventricular fibrillation. Nonshockable rhythms include pulseless electrical activity or asystole.
If the rhythm indicates ventricular tachycardia or ventricular fibrillation, then it is a shockable rhythm
and intervention proceeds as follows:
The defibrillator should be charged to 2 J/kg, and a shock should be delivered as soon as
possible once all team members are clear
Promptly restart CPR for an additional 2 minutes
Establish IV/IO access if not already done
After 2 minutes, recheck the rhythm
If the rechecked rhythm is determined to be shockable, intervention proceeds as follows:
The defibrillator should be charged to 4 J/kg and a shock should be delivered

Promptly restart CPR for an additional 2 minutes
Give epinephrine 0.01 mg/kg IV or IO this may be repeated every 35 minutes
Consider endotracheal intubation or other advanced airway placement
Consider amiodarone 5 mg/kg IV/IO for refractory VF/pVT (may repeat up to 2 times)
If the rhythm is nonshockable, intervention proceeds as follows:
Continue CPR for an additional 2 minutes

Establish IV/IO access
Give epinephrine 0.01 mg/kg IV/IO this may be repeated every 35 minutes
Consider endotracheal intubation or other advanced airway placement
Once the patient is intubated, chest compressions and ventilations should work independently,
with the compressions at a continuous rate of 100/min and the ventilations 10/min.
In addition, identify and correct the following if necessary:
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hyperkalemia/hypokalemia and metabolic disorders
Hypoglycemia
Hypothermia
Toxins
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary or pulmonary
Bradyarrhythmias
Emergency treatment of bradycardia is indicated when the rhythm results in hemodynamic

compromise. The AHA algorithm for the recognition and management of bradyarrhythmias is
[42]
summarized below.
When a pediatric patient is found to be bradycardiac, quickly check for a pulse. If no pulse is found,
proceed to the pulseless arrest algorithm. If a pulse is found, assess for signs of cardiopulmonary
compromise. These signs include the following:
Hypotension
Acutely altered mental status
Other signs of shock
If cardiopulmonary compromise is evident, the following immediate steps should be taken:
Put the patient on supplemental oxygen and assist ventilations as needed

Attach cardiac monitoring, blood pressure cuff, pulse oximetry, and pacing pads
Establish vascular access (IV, or IO if necessary)
Get a 12-lead ECG for rhythm analysis if possible
If the heart rate continues to be below 60 bpm and cardiopulmonary compromise is evident despite
oxygenation and ventilation, then chest compressions should be initiated.
While the algorithm is being applied, attempt to identify and treat any underlying causes. If
bradycardia persists after 2 minutes of chest compressions, consider the following:
Epinephrine: 0.01 mg/kg IV or IO repeat every 35 minutes
Atropine: 0.02 mg/kg, not to exceed 0.5 mg/dose (for increased vagal tone or primary heart
block) may be repeated once
Transcutaneous or transvenous pacing
Continue to identify and treat any underlying causes
If the bradycardia resolves, continue to support the ABCs, monitor the child, and consider expert
consultation.
If the bradycardia evolves into pulseless arrest, proceed to the pulseless arrest algorithm.
Tachyarrhythmia
The most common types of tachycardia in the pediatric population are sinus tachycardia,
supraventricular tachycardia, and ventricular tachycardia. As with other elements of PALS,
an algorithmic approach is used for tachyarrhythmia, as outlined below.
If a pediatric patient is found to be unresponsive and not breathing in the context of tachycardia on the
monitor, then proceed to the pulseless arrest algorithm. If a pulse is found, assess for signs of
cardiopulmonary compromise. These signs include the following:
Hypotension
Acutely altered mental status
Other signs of shock
If cardiopulmonary compromise is evident, the following immediate steps should be taken:
Put the patient on supplemental oxygen and assist ventilations as needed

Attach cardiac monitoring, blood pressure cuff, pulse oximetry, and defibrillator pads
Establish vascular access (IV, or IO if necessary)
Get a 12-lead ECG for rhythm analysis
Evaluate the ECG and determine if the QRS duration is narrow or wide
If the QRS is wide on the initial ECG, ventricular tachycardia should be assumed. Supraventricular
tachycardia with aberrant conduction is a less common possibility.
If the patient shows signs of cardiopulmonary compromise, synchronized cardioversion is delivered at
0.5-1 J/kg, with an increase to 2 J/kg if initially unsuccessful. If the patient shows no signs of
cardiopulmonary compromise, adenosine may be empirically given for the possibility of
supraventricular tachycardia with aberrancy.
Amiodarone and procainamide should not be routinely administered together, but they may be given
in conjunction with expert consultation, as follows:
Amiodarone: 5 mg/kg IV infused over 20-60 minutes
Procainamide: 15 mg/kg IV infused over 30-60 minutes
If the QRS is narrow, determine whether sinus tachycardia or supraventricular tachycardia is

more probable. Evidence supporting sinus tachycardia includes the following:
Presence of P waves
Variable R-R intervals
Heart rate less than 180 bpm
Evidence supporting supraventricular tachycardia includes the following:
Absence of P waves
No R-R variability
Heart rate 180 bpm or greater
Sinus tachycardia
Treat the underlying cause(s). Common causes of sinus tachycardia include hypovolemia, sepsis,
fever, pain, hypoxia, and anemia. The history and physical examination can provide important
information for narrowing the differential diagnosis.
Supraventricular tachycardia
While preparations are being made for chemical or electrical cardioversion, vagal maneuvers may be
attempted to break the dysrhythmia. Vagal maneuvers include the following:
Application of an ice bag to the child's face
Unilateral carotid massage in older children.
If vagal maneuvers are unsuccessful and the patient has IV or IO access, then chemical cardioversion
with adenosine is indicated. The regimen is as follows:
Push adenosine 0.1 mg/kg (not to exceed 6 mg)
If unsuccessful, second dose of 0.2 mg/kg (not to exceed 12 mg)
If chemical cardioversion is unsuccessful or not available, electrical cardioversion is indicated. The

regimen is as follows:
If possible, sedate the patient beforehand, but do not delay cardioversion
Deliver a synchronized shock at 0.5-1 J/kg
If this is not successful, increase the charge to 2 J/kg
If chemical and electrical cardioversion continue to be unsuccessful, consider expert consultation for
additional antiarrhythmics and rate-controlling recommendations.
Neonatal Resuscitation Guidelines

The 2015 update of the AHA guidelines for neonatal resuscitation are the foundation for the seventh
edition of the American Academy of Pediatrics Textbook of Neonatal Resuscitation. The textbook, in
turn, forms the basis for the training provided by the Neonatal Resuscitation Program (NPR).
The NRP should be completed by all cliniciansincluding physicians, nurses, and respiratory
therapistswho may be involved in the stabilization and resuscitation of neonates in the delivery
[23]
room. In the 2015 AHA guidelines, a revised recommendation suggests that neonatal
[42]
resuscitation training occur more frequently than the current 2-year interval.
[42]
The following is a summary of the AHA revised algorithm for neonatal resuscitation.
Resuscitation equipment and anticipation of potential problems
Prior to delivery, risk factors should be identified, neonatal problems anticipated, equipment checked,
qualified personal should be available, and a care plan formulated. A known perinatal risk factor, such
as preterm birth, requires preparation of supplies specific to thermoregulation and respiratory support,
and the delivery room should be equipped with all the tools necessary for successful resuscitation. A
standardized checklist may be helpful to ensure that all necessary supplies and equipment are
present and functioning.
First minute
Time: 0-30 seconds
The initial evaluation is the following questions:
Term gestation?
Good muscle tone?

Breathing or crying?
If initial findings are normal, the infant stays with the mother and the following routine care is provided:
Warm and maintain normal temperature

Clear airway if necessary
Dry newborn
If initial findings are abnormal, care consists of the following:
Warm and maintain normal temperature

Clear airway if necessary
Dry, stimulate, and reposition
Time: 30-60 seconds
Secondary evaluation is the following:
Breathing
Heart rate
Color
If the heart rate is greater than 100 bpm and the baby is pink with nonlabored breathing, proceed with
routine care. If the heart rate is greater than 100 bpm and the baby is cyanotic or has labored
breathing, do the following:
Clear airway and begin monitoring pulse oximetry oxygen saturation (SpO 2)
Consider supplementary oxygen
Consider continuous positive airway pressure (CPAP)
Institute postresuscitation care
If the heart rate is less than 100 bpm and the baby is gasping or has apnea, do the following:
Clear airway and begin SpO 2 monitoring

Provide positive-pressure ventilation (PPV)
Consider ECG monitor
Reassess heart rate, and, if greater 100 bpm, institute postresuscitation care
After first minute
If heart rate is less than 100 bpm, do the following:
Check chest movement

Take ventilation correction steps, if needed
ETT or laryngeal mask, if needed
Reassess heart rate
If the heart rate is less than 60 bpm, do the following:
Intubate if not already done

Start chest compressions
Coordinate with PPV
100% oxygen
ECG monitor
Consider emergency umbilical vein catheterization (UVC)
If the heart rate is greater than 60 bpm, stop compressions and continue ventilation.
If the heart rate remains less than 60 bpm, do the following:
Administer IV epinephrine
Consider hypovolemia
Consider pneumothorax
Oxygen saturation
A comparison of the preductal oxygen saturation (SpO2) targets after birth are listed in Table 3, below.
[42, 50]
Table 3. Preductal Oxygen Saturation (SpO2) Targets (Open Table in a new window)
1 Minute 2 Minutes 3 Minutes 4 Minutes 5 Minutes
AHA 60-65% 65-70% 70-75% 75-80% 85-95%
ERC 60% 70% 80% 85% 90%
Umbilical cord management
[42]
The following are the AHA recommendations for umbilical cord management :
Delaying cord clamping for longer than 30 seconds is suggested for both term and preterm
infants who do not require resuscitation at birth (class IIa)
There is insufficient evidence to recommend an approach to cord clamping for infants who
require resuscitation at birth (class IIb)
In light of the limited information regarding the safety of rapid changes in blood volume for
extremely preterm infants, routine use of cord milking for infants born at less than 29 weeks of
gestation is recommended against outside of a research setting (class IIb)
Compressions
[42]
The AHA guidelines include the following specific recommendation for delivering compressions :
Method: The 2 thumbencircling hands technique is preferred (class IIb) allow complete chest
recoil after each compression (class IIa)
Depth: At least one-third anteroposterior chest diameter (class IIb)
Compression rate: 90 compressions and 30 breaths per minute (class IIa)
Compression-to-ventilation ratio: 3:1 (class IIa)
Oxygen concentration should be increased to 100% whenever chest compressions are provided
(class IIa)
To reduce the risks of complications associated with hyperoxia, supplementary
oxygen concentration should be weaned as soon as the heart rate recovers (class I)
Meconium-stained amniotic fluid

The 2015 AHA guidelines offer the following revised recommendations for infants born with
[42]
meconium-stained amniotic fluid :
Initial steps of resuscitation should be completed under the radiant warmer and PPV should be
initiated if the infant is not breathing or the heart rate is less than 100 bpm after the initial steps
are completed (class IIb)
Routine intubation for tracheal suction is not recommended (class IIb)
Withholding or discontinuing resuscitation
The guidelines offer the following recommendations for withholding or discontinuance of resuscitation
[42] :
It is possible to identify conditions associated with high mortality and poor outcome in which
withholding resuscitative efforts may be considered reasonable, particularly when there has
been the opportunity for parental agreement (class IIb)
In infants with an Apgar score of 0 after 10 minutes of resuscitation, if the heart rate remains
undetectable, it may be reasonable to stop assisted ventilations however, the decision to
continue or discontinue resuscitative efforts must be individualized (class IIb)
Variables to be considered may include whether the resuscitation was considered optimal
availability of advanced neonatal care, such as therapeutic hypothermia specific circumstances
before delivery (eg, known timing of the insult) and wishes expressed by the family (class IIb)
When gestation, birth weight, or congenital anomalies are associated with almost certain early
death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is
not indicated (class IIb)
Under circumstances when an outcome remains unclear, the desires of the parents should be
supported (class IIb)
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Media Gallery
Delivery of chest compressions. Note the overlapping hands placed on the center of the
sternum, with the rescuer's arms extended. Chest compressions are to be delivered at a rate of
at least 100 compressions per minute.

CPR positioning. Video courtesy of Daniel Herzberg, 2008.
CPR ventilation. Video courtesy of Daniel Herzberg, 2008.
CPR compressions. Video courtesy of Daniel Herzberg, 2008.
of 5
Tables
Table 1. Adult Chain of Survival

Table 2. Adult BLS Algorithm
Table 3. Preductal Oxygen Saturation (SpO2)
Targets Table 1. Adult Chain of Survival
Link 1 Link 2 Link 3 Link 4 Link 5
Recognition Advanced
and activation life
Immediate
Surveillance of the Rapid support
IHCA high-quality
and prevention emergency defibrillation and post-
response CPR arrest
system care
Primary Cath
Responder(s) Code Team
Provider Lab/ICU
OHCA Recognition Immediate Rapid Basic and Advanced

and activation high-quality defibrillation advanced life
of the CPR emergency support
emergency medical and post-
response services arrest
system care
Responder(s) Lay Rescuers

Emergency ED/Cath
Medical Lab/ICU
Services (EMS)
Table 2. Adult BLS Algorithm
Untrained Lay Trained Lay

Healthcare Professionals
Responders Responders
Step
Ensure scene safety
1
Step
Check for response
2
Responder should Responder should

shout for nearby help shout for nearby help
and phone or have and activate the
another bystander emergency response Responder should shout for nearby
Step phone 911 the system (9-1-1, help. The resuscitation team can
3 phone should remain emergency be activated before or after
on speaker for response). Ensure checking breathing and pulse.
receiving further that the phone
instructions from the remains on speaker,
dispatcher. if at all possible.
A check for no breathing or only gasping

and a check of pulse ideally should be
Check for no
done simultaneously. Activation and
breathing or only
Step Follow dispatchers gasping if there is retrieval of the AED/emergency
4 instructions. none, begin CPR equipment by either the lone healthcare
with chest provider or by a second person must
occur immediately after the check of
compressions.
breathing and pulse identifies cardiac
arrest.
As instructed by Answer dispatchers

Step dispatcher to check questions and follow CPR begins immediately, and the
5 for no breathing or subsequent AED/defibrillator is used if available.
only gasping. instructions.
Dispatchers Send another person With arrival of a second responder,

Step
instructions are for an AED, if one is two-person CPR is provided and
6
followed. available. AED/defibrillator is used.
Table 3. Preductal Oxygen Saturation (SpO 2) Targets
1 Minute 2 Minutes 3 Minutes 4 Minutes 5 Minutes
AHA 60-65% 65-70% 70-75% 75-80% 85-95%
ERC 60% 70% 80% 85% 90%
Back to List
Contributor Information and Disclosures
Author
Catharine A Bon, MD Assistant Clinical Instructor, Resident Physician, Department of Emergency

Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center
Disclosure: Nothing to disclose.
Coauthor(s)
Baruch Berzon, MD Resident Physician, Departments of Emergency Medicine and Internal Medicine,
State University of New York Downstate Medical Center, Kings County Hospital Center
Joshua Schechter, MD Clinical Assistant Professor, Director of Emergency Ultrasound Resident

Education, Kings County Hospital Center, State University of New York Downstate Medical Center
Joshua Schechter, MD is a member of the following medical societies: American College

ofEmergency Physicians, Society for Academic Emergency Medicine
Ali A Sovari, MD, FACP, FACC Attending Physician, Cardiac Electrophysiologist, Cedars Sinai
Medical Center and St John's Regional Medical Center
Ali A Sovari, MD, FACP, FACC is a member of the following medical societies: American College
ofCardiology, American College of Physicians, American Physician Scientists Association,
AmericanPhysiological Society, Biophysical Society, Heart Rhythm Society, Society for
CardiovascularMagnetic Resonance
Specialty Editor Board
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College
of Pharmacy EditorinChief, Medscape Drug Reference
Chief Editor
Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine,

Yale University School of Medicine CoDirector, Injury Free Coalition for Kids, Yale-New Haven
Children's Hospital
Kirsten A Bechtel, MD is a member of the following medical societies: American Academy

ofPediatrics
Additional Contributors
Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein

College of Medicine, Montefiore Medical Center
Andrew K Chang, MD is a member of the following medical societies: American Academy

ofEmergency Medicine, American Academy of Neurology, American College of Emergency
Physicians,Society for Academic Emergency Medicine
Acknowledgements
Benjamin S Abella, MD, MPH Assistant Professor, Department of Emergency Medicine, Clinical
Research Director, Center for Resuscitation Science, Co-Chair, Hospital Code Committee,
University of Pennsylvania School of Medicine
Benjamin S Abella, MD, MPH is a member of the following medical societies: Alpha Omega Alpha,
American Heart Association, Phi Beta Kappa, Sigma Xi, and Society for Academic Emergency
Medicine
Disclosure: Philips Healthcare, Grant/research funds, Other Philips Healthcare, Honoraria, Speaking
and teaching Medivance Corporation, Honoraria, Speaking and teaching Doris Duke Foundation,
Grant/research funds, Other American Heart Association, Grant/research funds, Other Laerdal,
Grant/research funds, Other
Alena Lira, MD Resident Physician, Departments of Emergency Medicine and Internal Medicine,
Kings County Hospital Center, State University of New York Downstate Medical Center
Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of

Medicine, Research Director, State University of New York College of Medicine Consulting Staff,
Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians
and Society for Academic Emergency Medicine
Noah T Sugerman, EMT Clinical Research Assistant, Center for Resuscitation Science, Department
of Emergency Medicine, Hospital of the University of Pennsylvania Emergency Medical Technician,
Narberth Ambulance
Acknowledgments
Special thanks to Matthew Jones for appearing in the video demonstrations.

Bon, AC,. Bechtel, AK. Cardiopulmonary Resuscitation. 2017

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6/26/2017 Cardiopulmonary Resuscitation (CPR): Practice Essentials, Preparation, Technique

Cardiopulmonary Resuscitation (CPR)

Delivery of mouth-to-mouth ventilations.

Indications and contraindications

For lay rescuers, compression-only CPR (COCPR) is recommended.

Positioning for CPR is as follows:

Give 30 chest compressions

The provider should do the following:

Pinch the patients nostrils closed to assist with an airtight seal

Complications of CPR include the following:

Routine atropine for pulseless electrical activity (PEA)/asystole

CPR positioning. Video courtesy of Daniel Herzberg, 2008.

CPR compressions. Video courtesy of Daniel Herzberg, 2008.

View Media Gallery

Delivery of mouth-to-mouth ventilations.

View Media Gallery

The mouth-to-mouth technique is performed as follows (see the video below):

CPR ventilation. Video courtesy of Daniel Herzberg, 2008.

Effective mouth-to-mouth ventilation is determined by observation of chest rise during each

CPR and ECC Guidelines Summary

American Heart Association (AHA)

European Resuscitation Council (ERC)

Chain of Survival Guidelines

Link 1 Link 2 Link 3 Link 4 Link 5

OHCA Recognition Immediate Rapid Basic and Advanced

Responder(s) Lay Rescuers

Adult BLS and AED Guidelines

Untrained Lay Trained Lay

Responder should Responder should

Step Follow dispatchers Check for no A check for no breathing or only

As instructed by Answer dispatchers

Dispatchers Send another With arrival of a second responder,

breathing normally (ie, only gasping) (class I)

Adult ACLS Guidelines

settings (class IIb)

PostCardiac Arrest Care Guidelines

Targeted temperature management (TTM) with a range of acceptable temperatures from

Acute Coronary Syndromes Guidelines

Monitor ABCs be prepared to provide CPR and defibrillation

STEMI: ST elevation or new left bundle-branch block (LBBB)

Emergent reperfusion decisions in STEMI

In adult patients presenting with STEMI in the ED of a nonPCI-capable hospital, immediate

Pediatric BLS Guidelines

The following are considered essential elements of high-quality CPR:

Compression rate of 100-120/min

Pediatric ALS Guidelines

If the rechecked rhythm is determined to be shockable, intervention proceeds as follows:

The defibrillator should be charged to 4 J/kg and a shock should be delivered

If the rhythm is nonshockable, intervention proceeds as follows:

Continue CPR for an additional 2 minutes

Emergency treatment of bradycardia is indicated when the rhythm results in hemodynamic

If cardiopulmonary compromise is evident, the following immediate steps should be taken:

Put the patient on supplemental oxygen and assist ventilations as needed

If cardiopulmonary compromise is evident, the following immediate steps should be taken:

Put the patient on supplemental oxygen and assist ventilations as needed

If the QRS is narrow, determine whether sinus tachycardia or supraventricular tachycardia is

If chemical cardioversion is unsuccessful or not available, electrical cardioversion is indicated. The

Neonatal Resuscitation Guidelines

Resuscitation equipment and anticipation of potential problems

Time: 0-30 seconds

The initial evaluation is the following questions:

Good muscle tone?

Warm and maintain normal temperature