Basic Life Support

Untrained Lay Rescuer If a bystander is not trained in CPR, then the bystander should provide Hands-Only (chest compression only) CPR, with an emphasis on push hard and fast, or follow the directions of the emergency medical dispatcher. The rescuer should continue Hands-Only CPR until an AED arrives and is ready for use or healthcare providers take over care of the victim (Class IIa, LOE B). Lay rescuers should assume cardiac arrest based on assessing unresponsiveness and absence of normal breathing (ie, the victim is not breathing or only gasping). Look, Listen, and Feel was removed from the BLS algorithm Lay rescuers should not interrupt chest compressions to palpate pulses or check for ROSC (Class IIa, LOE C). Trained Lay Rescuer All lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest. In addition, if the trained lay rescuer is able to perform rescue breaths, he or she should add rescue breaths in a ratio of 30 compressions to 2 breaths. The rescuer should continue CPR until an AED arrives and is ready for use or EMS providers take over care of the victim (Class I, LOE B). Sequence change to chest compressions before rescue breaths (CAB rather than ABC) Healthcare Providers Optimally all healthcare providers should be trained in BLS. In this trained population it is reasonable for both EMS and in-hospital professional rescuers to provide chest compressions and rescue breaths for cardiac arrest victims (Class IIa, LOE B). This should be performed in cycles of 30 compressions to 2 ventilations until an advanced airway is placed; then compressing rescuer should give continuous chest compressions at a rate of at least 100 per minute without pauses for ventilation (Class IIa, LOE B). The rescuer delivering ventilation can provide a breath every 6 to 8 seconds (which yields 8 to 10 breaths per minute). A compression-ventilation ratio of 30:2 is reasonable in adults, but further validation of this guideline is needed (Class IIb, LOE B). Increased focus on methods to ensure that high-quality CPR (compressions of adequate rate and depth, allowing full chest recoil between compressions, minimizing interruptions in chest compressions and avoiding excessive ventilation) is performed Recommendation of a simultaneous, choreographed approach for chest compressions, airway management, rescue breathing, rhythm detection, and shocks (if appropriate) by an integrated team of highlytrained rescuers in appropriate settings The healthcare provider should take no more than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that time period, the rescuer should start chest compressions (Class IIa, LOE C). Rescue Breaths Deliver each rescue breath over 1 second (Class IIa, LOE C). Give a sufficient tidal volume to produce visible chest rise (Class IIa, LOE C).55 Studies in anesthetized adults (with normal perfusion) suggest that a tidal volume of 8 to 10 mL/kg maintains normal oxygenation and elimination of CO2. During CPR, cardiac output is 25% to 33% of normal, so oxygen uptake from the lungs and CO2 delivery to the lungs are also reduced. As a result, a low minute ventilation (lower than normal tidal volume and respiratory rate) can maintain effective oxygenation and ventilation. For that reason during adult CPR tidal volumes of approximately 500 to 600 mL (6 to 7 mL/kg) should suffice (Class IIa, LOE B). This is consistent with a tidal volume that produces visible chest rise. In summary, rescuers should avoid excessive ventilation (too many breaths or too large a volume) during CPR (Class III, LOE B).

If an adult victim with spontaneous circulation (ie, strong and easily palpable pulses) requires support of ventilation, the healthcare provider should give rescue breaths at a rate of about 1 breath every 5 to 6 seconds, or about 10 to 12 breaths per minute (Class IIb, LOE C). Each breath should be given over 1 second regardless of whether an advanced airway is in place. Each breath should cause visible chest rise. Cricoid Pressure The routine use of cricoid pressure in adult cardiac arrest is not recommended (Class III, LOE B). Compressions Correct performance of chest compressions requires several essential skills. The adult sternum should be depressed at least 2 inches (5 cm) (Class IIa, LOE B), with chest compression and chest recoil/relaxation times approximately equal (Class IIb, LOE C). Allow the chest to completely recoil after each compression (Class IIa, LOE B). Although rescuers may not recognize that fatigue is present for 5 minutes. When 2 or more rescuers are available it is reasonable to switch chest compressors approximately every 2 minutes (or after about 5 cycles of compressions and ventilations at a ratio of 30:2) to prevent decreases in the quality of compressions (Class IIa, LOE B). Healthcare providers should interrupt chest compressions as infrequently as possible and try to limit interruptions to no longer than 10 seconds, except for specific interventions such as insertion of an advanced airway or use of a defibrillator (Class IIa, LOE C). Because of difficulties with pulse assessments, interruptions in chest compressions for a pulse check should be minimized during the resuscitation, even to determine if ROSC has occurred. Because of the difficulty in providing effective chest compressions while moving the patient during CPR, the resuscitation should generally be conducted where the patient is found (Class IIa, LOE C). This may not be possible if the environment is dangerous. Electrical Therapies After shock delivery, the rescuer should not delay resumption of chest compressions to recheck the rhythm or pulse. After about 5 cycles of CPR (about 2 minutes, although this time is not firm), ideally ending with compressions, the AED should then analyze the cardiac rhythm and deliver another shock if indicated (Class I, LOE B). If a nonshockable rhythm is detected, the AED should instruct the rescuer to resume CPR immediately, beginning with chest compressions (Class I, LOE B). Shortening the interval between the last compression and the shock by even a few seconds can improve shock success (defibrillation and ROSC) Thus, it is reasonable for healthcare providers to practice efficient coordination between CPR and defibrillation to minimize the hands-off interval between stopping compression and administering shock (Class IIa, LOE C). For example, when 2 rescuers are present, the rescuer operating the AED should be prepared to deliver a shock as soon as the compressor removes his or her hands from the victims chest and all rescuers are clear of contact with the victim. Biphasic waveforms are safe and have equivalent or higher efficacy for termination of VF when compared with monophasic waveforms. In the absence of biphasic defibrillators, monophasic defibrillators are acceptable (Class IIb, LOE B). Different biphasic waveforms have not been compared in humans with regard to efficacy. Therefore, for biphasic defibrillators, providers should use the manufacturers recommended energy dose (120 to 200 J) (Class I, LOE B). If the manufacturers recommended dose is not known, defibrillation at the maximal dose may be considered (Class IIb, LOE C). Fixed and Escalating Energy It is not possible to make a definitive recommendation for the selected energy for subsequent biphasic defibrillation attempts. However, based on available evidence, we recommend that second and subsequent energy levels should be at least equivalent and higher energy levels may be considered, if available (Class IIb, LOE B).

Electrode Placement Data demonstrate that 4 pad positions (anterolateral, anteroposterior, anteriorleft infrascapular, and anterior-right-infrascapular)are equally effective to treat atrial or ventricular arrhythmias. There are no studies directly pertaining to placement of pads/paddles for defibrillation success with the end point of ROSC. All 4 positions are equally effective in shock success. Any of the 4 pad positions is reasonable for defibrillation (Class IIa, LOE B). For ease of placement and education, anterolateral is a reasonable default electrode placement (Class IIa, LOE C). Ten studies indicated that larger pad/paddle size (8 to 12 cm diameter) lowers transthoracic impedance. Precordial Thump The precordial thump may be considered for termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb, LOE B), but should not delay CPR and shock delivery. There is insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole, and there is insufficient evidence to recommend percussion pacing during typical attempted resuscitation from cardiac arrest. Supraventricular Tachycardias (Reentry Rhythms) Biphasic: biphasic energy dose for cardioversion of adult atrial fibrillation is 120 to 200 J (Class IIa, LOE A). If the initial shock fails, providers should increase the dose in a stepwise fashion. Cardioversion of adult atrial flutter and other supraventricular tachycardias generally requires less energy; an initial energy of 50 J to 100 J is often sufficient. If the initial shock fails, providers should increase the dose in a stepwise fashion.Monophasic Adult cardioversion of atrial fibrillation with monophasic waveforms should begin at 200 J and increase in a stepwise fashion if not successful (Class IIa, LOE B). Ventricular Tachycardia with Pulse Biphasic & Monophasic. Adult monomorphic VT (regular form and rate) with a pulse responds well to monophasic or biphasic waveform cardioversion (synchronized) shocks at initial energies of 100 J. If there is no response to the first shock, it may be reasonable to increase the dose in a stepwise fashion. No studies were identified that addressed this issue. Thus, this recommendation represents expert opinion (Class IIb, LOE C). Asystole There was a worse outcome of ROSC and survival for those who received shocks. Thus, it is not useful to shock asystole (Class III, LOE B). Pacing is not effective for asystolic cardiac arrest and may delay or interrupt the delivery of chest compressions. Pacing for patients in asystole is not recommended (Class III, LOE B). Ventricular Fibrillation / Pulseless V-Tach Biphasic If a biphasic defibrillator is available, providers should use the manufacturers recommended energy dose (120 to 200 J) for terminating VF (Class I, LOE B). If the provider is unaware of the effective dose range, the provider may use the maximal dose (Class IIb, LOE C). Second and subsequent energy levels should be at least equivalent, and higher energy levels may be considered if available (Class IIb, LOE B). Monophasic If a monophasic defibrillator is used, providers should deliver an initial shock of 360 J and use that dose for all subsequent shocks. If VF is terminated by a shock but then recurs later in the arrest, deliver subsequent shocks at the previously successful energy level.

Advanced Cardiac Life Support