Official reprint from UpToDate

www.uptodate.com 2016 UpToDate

Basic life support (BLS) in adults

Author Section Editors Deputy Editor

Charles N Pozner, MD Ron M Walls, MD, FRCPC, Jonathan Grayzel, MD, FAAEM
FAAEM
Richard L Page, MD

Contributor disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2016. | This topic last updated: Apr 19, 2016.

INTRODUCTION Cardiopulmonary resuscitation (CPR) as we recognize it today was developed in the

late 1950s and 1960s. Elam and Safar described the technique and benefits of mouth-to-mouth ventilation
in 1958 [1]. Kouwenhoven, Knickerbocker, and Jude subsequently described the benefits of external chest
compressions [2], which in combination with mouth-to-mouth ventilation form the basis of modern CPR.
External defibrillation, first described in 1957 by Kouwenhoven [3], has since been incorporated into
resuscitation guidelines.

Basic life support consists of cardiopulmonary resuscitation and, when available, defibrillation using
automated external defibrillators (AED). The keys to survival from sudden cardiac arrest (SCA) are early
recognition and treatment, specifically, immediate initiation of excellent CPR and early defibrillation.

This topic review will discuss the critical facets of basic life support in adults for clinicians as presented in the
American Heart Association's 2010 Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care, and the update of these guidelines published in 2015 [4-6]. Advanced cardiac life
support (ACLS) and other related topics, such as airway management and basic life support for infants and
children, are presented separately. (See "Advanced cardiac life support (ACLS) in adults" and "Basic airway
management in adults" and "Pediatric basic life support for healthcare providers".)

EPIDEMIOLOGY AND SURVIVAL The exact incidence of sudden cardiac arrest (SCA) in the United
States is unknown, but estimates vary from 180,000 to over 450,000 [7,8]. In North America and Europe, the
estimated incidence falls between 50 to 100 per 100,000 in the general population [9]. The most common
etiology of SCA is ischemic cardiovascular disease resulting in the development of lethal arrhythmias.
Resuscitation is attempted in up to two-thirds of people who sustain SCA.

Despite the development of cardiopulmonary resuscitation (CPR), electrical defibrillation, and other
advanced resuscitative techniques over the past 50 years, survival rates for SCA remain low. The
epidemiology and etiology of SCA are discussed in greater detail separately. (See "Overview of sudden
cardiac arrest and sudden cardiac death" and "Pathophysiology and etiology of sudden cardiac arrest".)

Assessments of survival from SCA have reached widely disparate conclusions. In the out-of-hospital setting,
studies have reported survival rates of 1 to 6 percent [10-12]. Three systematic reviews of survival-to-
hospital discharge from out-of-hospital SCA reported 5 to 10 percent survival among those treated by
emergency medical services (EMS) and 15 percent survival when the underlying rhythm disturbance was
ventricular fibrillation (VF) [12-14]. An analysis of a national registry of in-hospital SCA reported a 17 percent
survival to discharge [12].

While early, properly performed CPR improves outcomes, not performing CPR or low quality performance
are important factors contributing to poor outcomes [15-17]. Multiple studies assessing both in-hospital and
prehospital performance of CPR have shown that trained healthcare providers consistently fail to meet basic
life support guidelines [18,19].

RESUSCITATION GUIDELINES The American Heart Association (AHA) 2010 Guidelines for
Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (AHA Guidelines) are based
upon an extensive review of the clinical and laboratory evidence performed by the International Liaison
Committee on Resuscitation (ILCOR) [4]. The Guidelines and algorithms are designed to be simple,
practical, and effective (algorithm 1). An update to the guidelines was published in 2015; the most recent
version of the AHA basic life support (BLS) algorithm can be accessed here (AHA BLS algorithm) [5,6].

Important concepts and practices for the AHA Guidelines for BLS include:

Immediate recognition of sudden cardiac arrest (SCA) by noting unresponsiveness or absent/gasping

breathing

Immediate initiation of excellent CPR "push hard, push fast" (but not too hard nor too fast) with
continuous attention to the quality of chest compressions, and to the frequency of ventilations

Minimizing interruptions in CPR

For health care professional rescuers, taking no more than 10 seconds to check for a pulse

For single untrained rescuers, encouraging performance of excellent chest compression-only CPR

Using automated external defibrillators as soon as available

Activating emergency medical services as soon as possible

Patient survival depends primarily upon immediate initiation of excellent CPR and early defibrillation [20,21].

Phases of resuscitation Many researchers in resuscitation consider there to be three distinct phases of
cardiac arrest: the electrical phase, the hemodynamic phase, and the metabolic phase [20]. The emphasis
of treatment varies according to the phase.

Electrical phase The electrical phase is defined as the first four to five minutes of arrest due to
ventricular fibrillation (VF). Immediate DC cardioversion is needed to optimize survival of these patients.
Performing excellent chest compressions while the defibrillator is readied also improves survival [21].

Hemodynamic phase The hemodynamic or circulatory phase, which follows the electrical phase,
consists of the period from 4 to 10 minutes after SCA, during which the patient may remain in VF. Early
defibrillation remains critical for survival in patients found in VF. Excellent chest compressions should be
started immediately upon recognizing SCA and continued until just before cardioversion is performed (ie,
charge the defibrillator during active compressions, stopping only briefly to confirm the rhythm and deliver
the shock). Resume CPR immediately after the shock is delivered.

It remains unclear whether it is beneficial during the hemodynamic phase to delay cardioversion in order to
perform two to three minutes of CPR. Randomized trials have reached inconsistent conclusions:

In one trial, investigators randomly assigned 200 patients with out-of-hospital VF arrest to receive
immediate defibrillation or three minutes of CPR prior to defibrillation [13]. Among cases with
ambulance response times over five minutes, patients treated with CPR prior to defibrillation had
higher rates of survival to hospital discharge than those immediately defibrillated (22 versus 4 percent,
odds ratio [OR] 7.4, 95% CI 1.6-34.3). In contrast, among cases with a rapid ambulance response,
patient outcomes did not differ.
 A similar trial of 202 patients found a nonsignificant increase in survival to hospital discharge with three
minutes of CPR prior to defibrillation, regardless of ambulance response time (17 versus 10 percent, p
= 0.16) [22].

A third trial treated 256 patients with out-of-hospital cardiac arrest using immediate defibrillation or 90
seconds (rather than three minutes) of CPR followed immediately by defibrillation [23]. There was no
significant difference in survival to hospital discharge (4.2 versus 5.1 percent, odds ratio [OR] 0.81,
95% CI 0.25-2.6). Although subgroup analysis was not planned for this study, no differences in survival
were noted in the two treatment groups based upon ambulance response time.

The AHA Guidelines state that there is insufficient evidence to determine whether a period of CPR prior to
defibrillation is beneficial in all cases of SCA. A meta-analysis of the randomized trials described above
concluded that either approach is reasonable [24], while another meta-analysis with more liberal inclusion
criteria emphasized the conflicting nature of the evidence [25].

While it is essential to provide excellent CPR until the defibrillator is attached to the patient and charged and
to resume doing so immediately after the shock is delivered, we believe there is insufficient evidence of
benefit to justify delaying defibrillation in order to perform chest compressions for any predetermined period.
For EMS systems that do advocate this approach, clinicians should consider both patient downtime and
their own response time when deciding whether to postpone defibrillation to provide CPR. As an example, it
would be reasonable to perform two minutes of excellent CPR prior to defibrillation for patients with an
unwitnessed cardiac arrest and fine ventricular fibrillation whose down time is thought to exceed three to five
minutes.

Metabolic phase Treatment of the metabolic phase, defined as greater than 10 minutes of
pulselessness, is primarily based upon postresuscitative measures, including hypothermia therapy. If not
quickly converted into a perfusing rhythm, patients in this phase generally do not survive.

Recognition of cardiac arrest Rapid recognition of cardiac arrest is the essential first step of successful
resuscitation. According to the AHA Guidelines, the rescuer who witnesses a person collapse or comes
across an apparently unresponsive person should check to be sure the area is safe before approaching the
victim and then confirm unresponsiveness by tapping the person on the shoulder and shouting: "are you all
right?" [21]. If the person does not respond, the rescuer calls for help, activates the emergency response
system, and initiates excellent chest compressions.

The AHA Guidelines emphasize that even well-trained professionals can have difficulty determining if pulses
are present or breathing is adequate in unresponsive patients. Lay rescuers should not attempt to assess
the victim's pulse and, unless the patient has what appear to be normal respirations, should assume the
patient is apneic. A knowledgeable clinician may check for a carotid pulse; however, no more than 10
seconds should be spent assessing pulselessness. The same criteria for establishing apnea is used by both
lay rescuers and healthcare providers, and should be performed in parallel with the pulse check. If the
unresponsive patient is not breathing normally, consider the patient apneic. The key principle is not to delay
the initiation of CPR in patients who require it. The most recent version of the AHA basic life support (BLS)
algorithm can be accessed here (AHA BLS algorithm) [5,6].

After assessing responsiveness, health care providers should quickly check the patient's pulse. While doing
so, it is reasonable for the healthcare provider to visually assess the patient's respirations. It is appropriate
to assume the patient is in cardiac arrest if there is no breathing or abnormal breathing (eg, gasping) or if a
pulse cannot be readily palpated within 10 seconds.

Chest compressions
 Performance of excellent chest compressions Chest compressions are the most important
element of cardiopulmonary resuscitation (CPR) [26-29]. Coronary perfusion pressure and return of
spontaneous circulation (ROSC) are maximized when excellent chest compressions are performed [30,31].
The mantra of the AHA BLS Guidelines was: "push hard and push fast on the center of the chest" (algorithm
1) [21]. Although this is easy to learn and remember, the revised guidelines have added upper limits to what
is considered hard and fast when performing chest compressions. The most recent version of the AHA
basic life support (BLS) algorithm can be accessed here (AHA BLS algorithm) [5,6].

The following goals are essential for performing excellent chest compressions:

Maintain the rate of chest compression at 100 to 120 compressions per minute [32]

Compress the chest at least 5 cm (2 inches) but no more than 6 cm (2.5 inches) with each down-stroke

Allow the chest to recoil completely after each down-stroke (it should be easy to pull a piece of paper
from between the rescuer's hand and the patient's chest just before the next down-stroke)

Minimize the frequency and duration of any interruptions

To perform excellent chest compressions, the rescuer and patient must be in optimal position. This may
require movement of the patient or bed, adjustment of the bed's height, or the use of a step-stool so the
rescuer performing chest compressions is appropriately positioned. The patient must lie on a firm surface.
This may require a backboard if chest compressions are performed on a bed [33-35]. If a backboard cannot
be used, the patient should be placed on the floor. All efforts to deliver excellent CPR must take precedence
over any advanced procedures, such as tracheal intubation.

The rescuer places the heel of one hand in the center of the chest over the lower (caudad) portion of the
sternum and the heel of their other hand atop the first. The rescuer's own chest should be directly above
their hands. This enables the rescuer to use their body weight to compress the patient's chest, rather than
just the muscles of their arms, which may fatigue quickly.

It is imperative that each facet of performing excellent chest compressions be continually reassessed and
corrections made throughout the resuscitation. Resuscitation teams often believe that compressions are
being performed appropriately when in fact they are inadequate and cerebral perfusion is compromised,
thereby reducing the chance for neurologically intact survival [36].

An inadequate rate of chest compression reduces the likelihood of ROSC and neurologically intact survival
following sudden cardiac arrest (SCA) [30,32,37,38]. Rates as high as 125 compressions per minute have
been beneficial [32]. The AHA Guidelines recommend a rate of at least 100 compressions per minute.
Audiovisual tools that provide immediate feedback may help rescuers maintain adequate rates [39].

Animal and observational clinical studies suggest that chest compressions of proper depth (at least 5 cm)
play an important role in successful resuscitation [40-42]. In addition, full chest recoil between down-strokes
promotes reduced intrathoracic pressures, resulting in enhanced cardiac preload and higher coronary
perfusion pressures [43]. According to the AHA Guidelines, rescuers are better at allowing full recoil when
they receive immediate automated feedback on CPR performance and if they remove their hands slightly
but completely from the chest wall at the end of each compression [39].

Inadequate compression and incomplete recoil are more common when rescuers fatigue, which can begin
as soon as one minute after beginning CPR [21]. The AHA Guidelines suggest that the rescuer performing
chest compressions be changed every two minutes whenever more than one rescuer is present.
Interruptions in chest compressions are reduced by changing the rescuer performing compressions at the
two-minute interval when the rhythm is assessed, and the patient is defibrillated if needed. However, if the
rescuer is unable to perform adequate compressions, immediately switching to a capable rescuer is
required.

Minimizing interruptions Interruptions in chest compressions during CPR, no matter how brief,
result in unacceptable declines in coronary and cerebral perfusion pressure and worse patient outcomes
[28,37,44-50]. Once compressions stop, up to one minute of continuous, excellent compressions may be
required to achieve sufficient perfusion pressures [51]. Two minutes of continuous CPR should be
performed following any interruption [52]. The coordination of chest compressions and ventilation during
CPR is discussed below. (See 'Ventilations' below.)

Rescuers must ensure that excellent chest compressions are provided with minimal interruption; pulse
checks and rhythm analysis without compressions should only be performed at preplanned intervals (every
two minutes). Such interruptions should not exceed 10 seconds, except for specific interventions, such as
defibrillation. (See 'Pulse checks and rhythm analysis' below.)

When preparing for defibrillation, rescuers should continue performing excellent chest compressions while
charging the defibrillator until just before the single shock is delivered, and resume immediately after shock
delivery without taking time to assess pulse or breathing. No more than three to five seconds should elapse
between stopping chest compressions and shock delivery. If a single lay rescuer is providing CPR, excellent
chest compressions should be performed continuously without ventilations. (See 'Compression-only CPR
(CO-CPR)' below.)

Multiple studies of trained rescuers support the importance of uninterrupted chest compressions:

One prospective study reported improved survival among out-of-hospital cardiac arrest patients treated
with minimally interrupted cardiac resuscitation [53]. This study was performed as urban and rural EMS
and Fire personnel in Arizona were being trained in the approach advocated by the AHA 2005 BLS
Guidelines, which were the first to emphasize continuous chest compressions with minimal
interruption. Survival among patients rescued by personnel trained according to the 2005 Guidelines
was 5.4 percent (36 out of 668) compared to 1.8 percent (4 out of 218) among those treated according
to earlier BLS guidelines (odds ratio [OR] 3.0; 95% CI 1.1-8.9).

A retrospective observational study compared survival rates and neurologic outcomes in two groups of
rural patients who sustained out-of-hospital cardiac arrest [29]. The first group was treated between
2001 and 2003 according to the 2000 AHA Guidelines (standard compressions and ventilations), while
the second group was treated between 2004 and 2007 according to the 2005 AHA Guidelines
(compression-only CPR without ventilations). Among 92 patients in the first group, 18 survived of
whom 14 (15 percent) were neurologically intact. Of the 89 patients in the second group, 42 survived of
whom 35 (39 percent) were neurologically intact. Similar subsequent studies have replicated these
results [47,54].

For patients receiving high-quality CPR from trained emergency medical personnel, the use of continuous
chest compressions (ie, ventilations are performed without interrupting CPR) may not improve outcomes. In
a cluster-randomized trial involving 114 emergency medical service (EMS) agencies, 1129 of 12,613
patients (9.0 percent) treated with continuous chest compressions survived to hospital discharge, compared
to 1072 of 11,035 patients (9.7 percent) treated with standard CPR, consisting of cycles of 30 chest
compressions interrupted briefly to provide 2 ventilations (difference 0.7 percent; 95% CI -1.5 to 0.1) [55].
Neurologic outcome among survivors also did not differ significantly between groups. As noted in the
accompanying editorial, the mean chest compression fraction (percentage of each minute during
resuscitation when compressions were being performed) was quite high in both groups, and thus essentially
neither group experienced major interruptions in CPR [56].
 Compression-only CPR (CO-CPR) When multiple trained personnel are present, the simultaneous
performance of continuous excellent chest compressions, airway protection, and proper ventilation is
recommended by the AHA for the management of sudden cardiac arrest (SCA). The importance of
ventilation increases with the duration of the arrest. (See 'Ventilations' below and 'Phases of resuscitation'
above.)

However, if a sole lay rescuer is present or multiple lay rescuers are reluctant to perform mouth-to-mouth
ventilation, the AHA Guidelines encourage the performance of CPR using excellent chest compressions
alone. The Guidelines further state that lay rescuers should not interrupt excellent chest compressions to
palpate for pulses or check for the return of spontaneous circulation, and should continue CPR until an AED
is ready to defibrillate, EMS personnel assume care, or the patient wakes up. Note that CO-CPR is not
recommended for children or arrest of noncardiac origin (eg, near drowning). (See "Pediatric basic life
support for healthcare providers".)

For many would-be rescuers, the requirement to perform mouth-to-mouth ventilation is a significant barrier
to the performance of CPR [19]. This reluctance may stem from anxiety about performing CPR correctly or
fear of contracting a communicable disease, despite scant reports of infection contracted from the
performance of mouth-to-mouth ventilation, none of which involve HIV [19]. CO-CPR circumvents these
problems, potentially increasing the willingness of bystanders to perform CPR.

A meta-analysis of studies comparing treatment with CO-CPR and standard CPR, including ventilation
(S-CPR) for patients with out-of-hospital cardiac arrest, concluded that the former is preferred for untrained
rescuers [57]. The primary meta-analysis evaluated three high-quality randomized trials and found that CO-
CPR improved survival to hospital discharge compared to S-CPR (14 percent (211 out of 1500) versus 12
percent (178 out of 1531); relative risk [RR] 1.22; 95% CI 1.01-1.46). The secondary meta-analysis of seven
observational studies found no significant difference between the two approaches.

Ventilations During the initial phase of SCA, when the pulmonary vessels and heart likely contain
sufficient oxygenated blood to meet markedly reduced demands, the importance of compressions
supersedes ventilations [58-60]. Consequently, the initiation of excellent chest compressions is the first step
to improving oxygen delivery to the tissues (algorithm 1). This is the rationale behind the compressions-
airway-breathing (C-A-B) approach to SCA advocated in the AHA Guidelines [21]. The most recent version
of the AHA basic life support (BLS) algorithm can be accessed here (AHA BLS algorithm) [5].

In some circumstances, continuing excellent compression-only CPR may be preferable to adding

ventilations, especially when lay rescuers are performing the resuscitation. However, in patients whose
cardiac arrest is associated with hypoxia, it is likely that oxygen reserves have already been depleted,
necessitating the performance of excellent standard CPR with ventilations. (See 'Chest compressions'
above and 'Compression-only CPR (CO-CPR)' above.)

Properly performed ventilations become increasingly important as pulselessness persists. In this, the
metabolic phase of resuscitation, clinicians must continue to ensure that ventilations do not interfere with the
cadence and continuity of chest compressions. The techniques used in basic airway management are
discussed separately. (See 'Phases of resuscitation' above and "Basic airway management in adults".)

Proper ventilation for adults includes the following:

Give two ventilations after every 30 compressions for patients without an advanced airway

Give each ventilation over no more than one second

Provide only enough tidal volume to see the chest rise (approximately 500 to 600 mL, or 6 to 7 mL/kg)
 Avoid excessive ventilation

Give one asynchronous ventilation every 8 to 10 seconds (6 to 8 per minute) to patients with an
advanced airway (eg, supraglottic device, endotracheal tube) in place

Although the Guidelines recommend 10 breaths per minute, we believe 6 to 8 breaths are adequate in the
low-flow state during cardiac resuscitation of adults. However, the key point is to avoid excessive ventilation.

Asynchronous implies ventilations need not be coordinated with chest compressions. Ventilations should be
delivered in as short a period as possible, not exceeding one second per breath, while avoiding excessive
ventilatory force. Only enough tidal volume to confirm initial chest rise should be given. This approach
promotes both prompt resumption of compressions and improved cerebral and coronary perfusion.

Excessive ventilation, whether by high-ventilatory rates or increased volumes, must be avoided. Positive
pressure ventilation raises intrathoracic pressure which causes a decrease in venous return, pulmonary
perfusion, cardiac output, and cerebral and coronary perfusion pressures [61]. Studies in animal models
have found that over-ventilation reduces defibrillation success rates and decreases overall survival
[28,52,62-64].

Despite the risk of compromised perfusion, rescuers routinely over-ventilate patients. One study of
prehospital resuscitation reported that average ventilation rates during CPR were 30 per minute, while a
study of in-hospital CPR revealed ventilation rates of more than 20 per minute [18,61]. It is imperative that
the rate and volume of ventilations be continually reassessed and corrections made throughout the
resuscitation. Resuscitation teams often believe that ventilations are being performed appropriately when in
fact they are not (usually due to poor bag-mask-ventilation technique), resulting in inadequate cerebral
perfusion and reducing the patient's chance for a neurologically intact survival.

Defibrillation The effectiveness of early defibrillation in patients with ventricular fibrillation (VF) and short
"downtimes" is well supported by the resuscitation literature and early defibrillation is a fundamental
recommendation of the AHA BLS Guidelines [20,65]. As soon as a defibrillator is available, providers should
assess the cardiac rhythm and, when indicated, perform defibrillation as quickly as possible. With the
exception of excellent CPR, no intervention (eg, intubation, placement of intravenous catheter,
administration of medication) is performed before rhythm assessment and defibrillation. For BLS, a single
shock from an automated external defibrillator (AED) is followed immediately by the resumption of excellent
chest compressions. For advanced cardiac life support, a single shock is recommended regardless of
whether a biphasic or monophasic defibrillator is used.

Biphasic defibrillators are preferred because of the lower energy levels needed for effective cardioversion.
Biphasic defibrillators measure the impedance between the electrodes placed on the patient (figure 1) and
adjust the energy delivered accordingly. Rates of first shock success are reported to be approximately 85
percent [66-68]. (See "Basic principles and technique of cardioversion and defibrillation".)

The AHA Guidelines recommend using the energy levels suggested by the manufacturer of the device [69].
We recommend that all defibrillations for patients in cardiac arrest be delivered at the highest available
energy in adults (generally 360 J for a monophasic defibrillator and 200 J for a biphasic defibrillator). This
approach reduces interruptions in CPR and is implicitly supported by a study in which out-of-hospital cardiac
arrest patients randomly assigned to treatment with escalating energy using a biphasic device showed
higher conversion and termination rates for ventricular fibrillation than those assigned to treatment with fixed
lower energy [70]. (See "Advanced cardiac life support (ACLS) in adults", section on 'Sudden cardiac
arrest'.)
Controversy exists about the possible benefit of delaying defibrillation in order to perform excellent chest
compressions for a predetermined period (eg, 60 to 120 seconds). This issue is discussed elsewhere. (See
'Hemodynamic phase' above.)

Pulse checks and rhythm analysis It is essential to minimize delays and interruptions in the
performance of excellent chest compressions. Therefore, cardiac rhythm analysis should only be performed
during a planned interruption at the two minute interval following a complete cycle of cardiopulmonary
resuscitation (CPR). Even short delays in the initiation or brief interruptions in the performance of CPR can
compromise cerebral and coronary perfusion pressure and decrease survival. Following any interruption,
sustained chest compressions are needed to regain pre-interruption rates of blood flow. (See 'Chest
compressions' above.)

Wide variation exists in the ability of both lay rescuers and healthcare providers to determine pulselessness
accurately and efficiently [71]. Therefore, the AHA BLS Guidelines recommend that untrained rescuers
begin CPR immediately, without a pulse check, as soon as they determine a patient is unresponsive with
abnormal respirations. Healthcare providers must not spend more than 10 seconds checking for a pulse,
and should start CPR immediately if no pulse is felt. The author advocates that clinicians use end-tidal
carbon dioxide monitoring to determine the return of spontaneous circulation, which reduces interruptions in
CPR by obviating the need for pulse checks. (See 'Recognition of cardiac arrest' above and "Carbon dioxide
monitoring (capnography)", section on 'Return of spontaneous circulation'.)

The AHA Guidelines recommend that CPR be resumed for two minutes, without a pulse check, after any
attempt at defibrillation, regardless of the resulting rhythm. Data suggest that the heart does not immediately
generate effective cardiac output after defibrillation, and CPR may enhance post-defibrillation perfusion
[13,14,68,72,73].

One observational study of 481 cases of cardiac arrest found that rhythm reanalysis, repeated shocks, and
postshock pulse checks resulted on average in a 29-second delay in restarting chest compressions [74].
Postshock pulse checks were of benefit in only 1 of 50 patients.

SUMMARY AND RECOMMENDATIONS The American Heart Association (AHA) in collaboration with
the International Liaison Committee on Resuscitation published guidelines for basic life support (BLS) and
advanced cardiac life support (ACLS) in 2010 (AHA Guidelines), and updated these guidelines in 2015
(algorithm 1). The most recent version of the AHA basic life support (BLS) algorithm can be accessed here
(AHA BLS algorithm). We recommend following the practices described in the AHA BLS Guidelines, the
important elements of which are summarized below:

Chest compressions Chest compressions are the most important element of cardiopulmonary
resuscitation (CPR). Interruptions in chest compressions during CPR, no matter how brief, result in
unacceptable declines in coronary and cerebral perfusion pressure. The CPR mantra is: "push hard
and push fast (but not too hard nor too fast) on the center of the chest." The critical performance
standards for CPR include:

Maintain the rate of chest compression at 100 to 120 compressions per minute

Compress the chest at least 5 cm (2 inches) but no more than 6 cm (2.5 inches) with each down-
stroke

Allow the chest to recoil completely between each down-stroke

Minimize the frequency and duration of any interruptions

 Compression-only CPR If a sole lay rescuer is present or multiple lay rescuers are reluctant to
perform mouth-to-mouth ventilation, the AHA Guidelines encourage the performance of CPR using
chest compressions alone. Lay rescuers should not interrupt chest compressions to palpate for pulses
and should continue CPR until an AED is ready to defibrillate, EMS personnel assume care, or the
patient wakes up. Note that CO-CPR is not recommended for children or arrest of noncardiac origin
(eg, near drowning). (See 'Chest compressions' above and 'Compression-only CPR (CO-CPR)'
above.)

Ventilations As pulselessness persists in patients with SCA, the importance of performing

ventilations increases. The AHA Guidelines suggest that each ventilation be delivered over no more
than one second. Ventilations must not be delivered with excessive force; only enough tidal volume to
confirm chest rise should be given. Avoid excessive ventilation (which can compromise cardiac
output) through high rates or increased volumes. (See 'Ventilations' above.)

Compression-ventilation ratio In adults, the AHA Guidelines recommend that CPR be performed
at a ratio of 30 excellent compressions to two ventilations until an advanced airway has been
placed. Following placement of an advanced airway, excellent compressions are continuous, and
asynchronous ventilations are delivered approximately 6 to 8 times per minute. (See 'Ventilations'
above.)

Defibrillation Early defibrillation is critical to the survival of patients with ventricular fibrillation. The
AHA Guidelines recommend a single defibrillation in all shocking sequences. In adults, we suggest
defibrillation using the highest available energy (generally 200 J with a biphasic defibrillator and 360 J
with a monophasic defibrillator) (Grade 2C). Compressions should not be stopped until the defibrillator
has been fully charged. (See 'Defibrillation' above.)

Phases of resuscitation There are three phases of sudden cardiac arrest. The electrical phase
comprises the first four to five minutes and requires immediate defibrillation. The hemodynamic phase
spans approximately minutes 4 to 10 following sudden cardiac arrest (SCA). Patients in the
hemodynamic phase benefit from excellent chest compressions to generate adequate cerebral and
coronary perfusion and immediate defibrillation. The metabolic phase occurs following approximately
10 minutes of pulselessness; few patients who reach this phase survive. (See 'Phases of resuscitation'
above.)

Instruction All healthcare providers should receive standardized training in CPR and be familiar with
the operation of automated external defibrillators (AED).

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