AHA 2010 Part 5 Adult Basic Life Support

AHA 2010 Part 5 Adult Basic Life Support

Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Robert A. Berg, Robin Hemphill, Benjamin S. Abella, Tom P. Aufderheide, Diana M.

Cave, Mary Fran Hazinski, E. Brooke Lerner, Thomas D. Rea, Michael R. Sayre and

Robert A. Swor



DOI: 10.1161/CIRCULATIONAHA.110.970939

Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX


Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online

ISSN: 1524-4539

The online version of this article, along with updated information and services, is located on the World Wide Web at:


Subscriptions: Information about subscribing to Circulation is online at http://circ.ahajournals.org/subscriptions/

Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters

Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Fax:

410-528-8550. E-mail: [email protected]

Reprints: Information about reprints can be found online at http://www.lww.com/reprints

Downloaded from circ.ahajournals.org

by on December 4, 2010

Part 5: Adult Basic Life Support

2010 American Heart Association Guidelines for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care

Robert A. Berg, Chair; Robin Hemphill; Benjamin S. Abella; Tom P. Aufderheide; Diana M. Cave;

Mary Fran Hazinski; E. Brooke Lerner; Thomas D. Rea; Michael R. Sayre; Robert A. Swor

B asic life support (BLS) is the foundation for saving lives following cardiac arrest. Fundamental aspects of BLS include immediate recognition of sudden cardiac arrest

(SCA) and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), and rapid de-

fibrillation with an automated external defibrillator (AED).

Initial recognition and response to heart attack and stroke are also considered part of BLS. This section presents the 2010 adult BLS guidelines for lay rescuers and healthcare providers. Key changes and continued points of emphasis from the

2005 BLS Guidelines include the following:

Immediate recognition of SCA based on assessing unresponsiveness and absence of normal breathing (ie, the victim is not breathing or only gasping)

“Look, Listen, and Feel” removed from the BLS algorithm

Encouraging Hands-Only (chest compression only) CPR

(ie, continuous chest compression over the middle of the chest) for the untrained lay-rescuer

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

Health care providers continue effective chest compressions/CPR until return of spontaneous circulation (ROSC) or termination of resuscitative efforts

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

Continued de-emphasis on pulse check for health care providers

A simplified adult BLS algorithm is introduced with the revised traditional algorithm

Recommendation of a simultaneous, choreographed approach for chest compressions, airway management, rescue breathing, rhythm detection, and shocks (if appropriate) by an integrated team of highly-trained rescuers in appropriate settings

Despite important advances in prevention, SCA continues to be a leading cause of death in many parts of the world.


SCA has many etiologies (ie, cardiac or noncardiac causes), circumstances (eg, witnessed or unwitnessed), and settings

(eg, out-of-hospital or in-hospital). This heterogeneity suggests that a single approach to resuscitation is not practical, but a core set of actions provides a universal strategy for achieving successful resuscitation. These actions are termed the links in the “Chain of Survival.” For adults they include

Immediate recognition of cardiac arrest and activation of the emergency response system

Early CPR that emphasizes chest compressions

Rapid defibrillation if indicated

Effective advanced life support

Integrated post– cardiac arrest care

When these links are implemented in an effective way, survival rates can approach 50% following witnessed out-ofhospital ventricular fibrillation (VF) arrest.


Unfortunately survival rates in many out-of-hospital and in-hospital settings fall far short of this figure. For example, survival rates following cardiac arrest due to VF vary from approximately

5% to 50% in both out-of-hospital and in-hospital settings.


This variation in outcome underscores the opportunity for improvement in many settings.

Recognition of cardiac arrest is not always straightforward, especially for laypersons. Any confusion on the part of a rescuer can result in a delay or failure to activate the emergency response system or to start CPR. Precious time is lost if bystanders are too confused to act. Therefore, these adult BLS Guidelines focus on recognition of cardiac arrest with an appropriate set of rescuer actions. Once the lay bystander recognizes that the victim is unresponsive, that bystander must immediately activate (or send someone to activate) the emergency response system. Once the healthcare provider recognizes that the victim is unresponsive with no breathing or no normal breathing (ie, only gasping) the healthcare provider will activate the emergency response system. After activation, rescuers should immediately begin CPR.

Early CPR can improve the likelihood of survival, and yet

CPR is often not provided until the arrival of professional emergency responders.


Chest compressions are an especially critical component of CPR because perfusion during CPR

The American Heart Association requests that this document be cited as follows: Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM,

Hazinski MF, Lerner EB, Rea TD, Sayre MR, Swor RA. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S685–S705.

(Circulation. 2010;122[suppl 3]:S685–S705.)

© 2010 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.110.970939

Downloaded from


by on December 4, 2010

S686 Circulation

November 2, 2010

depends on these compressions. Therefore, chest compressions should be the highest priority and the initial action when starting CPR in the adult victim of sudden cardiac arrest. The phrase “push hard and push fast” emphasizes some of these critical components of chest compression. High-quality CPR is important not only at the onset but throughout the course of resuscitation. Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPR.


Rapid defibrillation is a powerful predictor of successful resuscitation following VF SCA.


Efforts to reduce the interval from collapse to defibrillation can potentially improve survival in both out-of-hospital and in-hospital settings.


Depending on the setting and circumstances, earlier defibrillation may be achieved by a variety of strategies that include rescuers who are laypersons, nontraditional first responders, police, emergency medical services (EMS) professionals, and hospital professionals.

9 –12 One of these strategies is the use of an AED. The AED correctly assesses heart rhythm, enabling a rescuer who is not trained in heart rhythm interpretation to accurately provide a potentially lifesaving shock to a victim of SCA.


Immediate recognition and activation, early CPR, and rapid defibrillation (when appropriate) are the first three

BLS links in the adult Chain of Survival. BLS care in the out-of-hospital setting is often provided by laypersons who may be involved in a resuscitation attempt only once in their lives. Thus, creating an effective strategy to translate BLS skills to real-world circumstances presents a challenge. This section updates the adult BLS guidelines with the goal of incorporating new scientific information while acknowledging the challenges of real-world application. Everyone, regardless of training or experience, can potentially be a lifesaving rescuer.

The rest of this chapter is organized in sections that address the emergency response system, adult BLS sequence, adult

BLS skills, use of an AED, special resuscitation situations, and the quality of BLS. The “Adult BLS Sequence” section provides an overview and an abridged version of the BLS sequence. The “Adult BLS Skills” section provides greater detail regarding individual CPR skills and more information about Hands-Only (compression-only) CPR. The “Special

Resuscitation Situations” section addresses acute coronary syndromes, stroke, hypothermia, and foreign body airway obstruction. Because of increasing interest in monitoring and ensuring the quality of CPR, the last section focuses on the quality of BLS.

information can result in failure by 911 dispatchers to instruct bystanders to initiate CPR for a victim of cardiac arrest.


To help bystanders recognize cardiac arrest, dispatchers should inquire about a victim’s absence of consciousness and quality of breathing (normal versus not normal). Dispatchers should be specifically educated in recognition of abnormal breathing in order to improve recognition of gasping and cardiac arrest (Class I, LOE B). Notably, dispatchers should be aware that brief generalized seizures may be the first manifestation of cardiac arrest.

26,27 Dispatchers should recommend CPR for unresponsive victims who are not breathing normally because most are in cardiac arrest and the frequency of serious injury from chest compressions in the nonarrest group is very low (Class I, LOE B).

28 In summary, in addition to activating professional emergency responders, the dispatcher should ask straightforward questions about whether the patient is conscious and breathing normally in order to identify patients with possible cardiac arrest. The dispatcher should also provide CPR instructions to help bystanders initiate CPR when cardiac arrest is suspected.

Because it is easier for rescuers receiving telephone CPR instructions to perform Hands-Only (compression-only) CPR than conventional CPR (compressions plus rescue breathing), dispatchers should instruct untrained lay rescuers to provide

Hands-Only CPR for adults with SCA (Class I, LOE B).


While Hands-Only CPR instructions have broad applicability, instances remain when rescue breaths are critically important.

Dispatchers should include rescue breathing in their telephone CPR instructions to bystanders treating adult and pediatric victims with a high likelihood of an asphyxial cause of arrest (eg, drowning).


The EMS system quality improvement process, including review of the quality of dispatcher CPR instructions provided to specific callers, is considered an important component of a high-quality lifesaving program (Class IIa, LOE B).


Adult BLS Sequence

The steps of BLS consist of a series of sequential assessments and actions, which are illustrated in the new simplified BLS algorithm (Figure 1). The intent of the algorithm is to present the steps of BLS in a logical and concise manner that is easy for all types of rescuers to learn, remember and perform.

These actions have traditionally been presented as a sequence of distinct steps to help a single rescuer prioritize actions.

However, many workplaces and most EMS and in-hospital resuscitations involve teams of providers who should perform several actions simultaneously (eg, one rescuer activates the emergency response system while another begins chest compressions, and a third either provides ventilations or retrieves the bag-mask for rescue breathing, and a fourth retrieves and sets up a defibrillator).

Activating the Emergency Response System

Emergency medical dispatch is an integral component of the

EMS response.

14 Bystanders (lay responders) should immediately call their local emergency number to initiate a response anytime they find an unresponsive victim. Because dispatcher

CPR instructions substantially increase the likelihood of bystander CPR performance and improve survival from cardiac arrest, all dispatchers should be appropriately trained to provide telephone CPR instructions (Class I, LOE B).


When dispatchers ask bystanders to determine if breathing is present, bystanders often misinterpret agonal gasps or abnormal breathing as normal breathing. This erroneous

Immediate Recognition and Activation of the

Emergency Response System

If a lone rescuer finds an unresponsive adult (ie, no movement or response to stimulation) or witnesses an adult who suddenly collapses, after ensuring that the scene is safe, the rescuer should check for a response by tapping the victim on the shoulder and shouting at the victim. The trained or

Downloaded from circ.ahajournals.org

by on December 4, 2010

Berg et al Part 5: Adult Basic Life Support


Figure 1. Simplified adult BLS algorithm.

untrained bystander should—at a minimum—activate the community emergency response system (eg, call 911, or if in an institution with an emergency response system, call that facility’s emergency response number). If the victim also has absent or abnormal breathing (ie, only gasping), the rescuer should assume the victim is in cardiac arrest (Class I,


19,24,34 The lay rescuer should phone the emergency response system once the rescuer finds that the victim is unresponsive—the dispatcher should be able to guide the lay rescuer through the check for breathing and the steps of CPR, if needed. The healthcare provider can check for response and look for no breathing or no normal breathing (ie, only gasping) almost simultaneously before activating the emergency response system. After activation of the emergency response system, all rescuers should immediately begin CPR

(see steps below) for adult victims who are unresponsive with no breathing or no normal breathing (only gasping).

When phoning 911 for help, the rescuer should be prepared to answer the dispatcher’s questions about the location of the incident, the events of the incident, the number and condition of the victim(s), and the type of aid provided. If rescuers never learned or have forgotten how to do CPR, they should also be prepared to follow the dispatcher’s instructions.

Finally the rescuer making the phone call should hang up only when instructed to do so by the dispatcher.

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse.

35– 44

Healthcare providers also may take too long to check for a pulse.


The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally.

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).


Early CPR

Chest Compressions

Chest compressions consist of forceful rhythmic applications of pressure over the lower half of the sternum. These compressions create blood flow by increasing intrathoracic pressure and directly compressing the heart. This generates blood flow and oxygen delivery to the myocardium and brain.

Effective chest compressions are essential for providing blood flow during CPR. For this reason all patients in

Downloaded from circ.ahajournals.org

by on December 4, 2010

S688 Circulation

November 2, 2010

● cardiac arrest should receive chest compressions (Class I,



To provide effective chest compressions, push hard and push fast. It is reasonable for laypersons and healthcare providers to compress the adult chest at a rate of at least

100 compressions per minute (Class IIa, LOE B) with a compression depth of at least 2 inches/5 cm (Class IIa,

LOE B). Rescuers should allow complete recoil of the chest after each compression, to allow the heart to fill completely before the next compression (Class IIa, LOE B).

Rescuers should attempt to minimize the frequency and duration of interruptions in compressions to maximize the number of compressions delivered per minute (Class IIa, LOE

B). A compression-ventilation ratio of 30:2 is recommended

(Class IIa, LOE B).

Rescue Breaths

A change in the 2010 AHA Guidelines for CPR and ECC is to recommend the initiation of compressions before ventilations. While no published human or animal evidence demonstrates that starting CPR with 30 compressions rather than 2 ventilations leads to improved outcomes, it is clear that blood flow depends on chest compressions. Therefore, delays in, and interruptions of, chest compressions should be minimized throughout the entire resuscitation. Moreover, chest compressions can be started almost immediately, while positioning the head, achieving a seal for mouth-to-mouth rescue breathing, and getting a bag-mask apparatus for rescue breathing all take time. Beginning CPR with 30 compressions rather than

2 ventilations leads to a shorter delay to first compression

(Class IIb, LOE C).


Once chest compressions have been started, a trained rescuer should deliver rescue breaths by mouth-to-mouth or bag-mask to provide oxygenation and ventilation, as follows:

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).


Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations.

Early Defibrillation With an AED

After activating the emergency response system the lone rescuer should next retrieve an AED (if nearby and easily accessible) and then return to the victim to attach and use the

AED. The rescuer should then provide high-quality CPR.

When 2 or more rescuers are present, one rescuer should begin chest compressions while a second rescuer activates the emergency response system and gets the AED (or a manual defibrillator in most hospitals) (Class IIa, LOE C). The AED should be used as rapidly as possible and both rescuers should provide CPR with chest compressions and ventilations.

Rescuer Specific CPR Strategies: Putting It

All Together

This section summarizes the sequence of CPR interventions that should be performed by 3 prototypical rescuers after they activate the emergency response system. The specific steps that rescuers should take (Hands-Only CPR, conventional

CPR with rescue breathing, CPR and AED use) are determined by the rescuer’s level of training.

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).

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).

Healthcare Provider

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 continuous chest compressions with ventilations at a rate of 1 breath every 6 to 8 seconds (8 to 10 ventilations per minute) should be performed. Care should be taken to minimize interruptions in chest compressions when placing, or ventilating with, an advanced airway. In addition, excessive ventilation should be avoided.

It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrest. For example, if a lone healthcare provider sees an adolescent suddenly collapse, the provider may assume that the victim has suffered a sudden cardiac arrest and call for help (phone 911 or the emergency response number), get an AED (if nearby), and return to the victim to attach and use the AED and then provide

CPR. If a lone healthcare provider aids an adult drowning victim or a victim of foreign body airway obstruction who becomes unconscious, the healthcare provider may give about 5 cycles

(approximately 2 minutes) of CPR before activating the emergency response system (Class IIa, LOE C).

Defibrillation Sequence

Turn the AED on.

Follow the AED prompts.

Resume chest compressions immediately after the shock

(minimize interruptions).

Adult BLS Skills

The sequence of BLS skills for the healthcare provider is depicted in the BLS Healthcare Provider Algorithm (see

Figure 2).

Recognition of Arrest (Box 1)

The necessary first step in the treatment of cardiac arrest is immediate recognition. Bystanders may witness the sudden

Downloaded from circ.ahajournals.org

by on December 4, 2010

Berg et al Part 5: Adult Basic Life Support


Figure 2. BLS healthcare provider algorithm.

collapse of a victim or find someone who appears lifeless. At that time several steps should be initiated. Before approaching a victim, the rescuer must ensure that the scene is safe and then check for response. To do this, tap the victim on the shoulder and shout, “Are you all right?” If the victim is responsive he or she will answer, move, or moan. If the victim remains unresponsive, the lay rescuer should activate the emergency response system. The health care provider should also check for no breathing or no normal breathing (ie, only gasping) while checking for responsiveness; if the healthcare provider finds the victim is unresponsive with no breathing or no normal breathing (ie, only gasping), the rescuer should assume the victim is in cardiac arrest and immediately activate the emergency response system (Class I, LOE C 19,24,34 ).

These 2010 AHA Guidelines for CPR and ECC deemphasize checking for breathing. Professional as well as lay rescuers may be unable to accurately determine the presence or absence of adequate or normal breathing in unresponsive victims 35,56 because the airway is not open 57 or because the victim has occasional gasps, which can occur in the first minutes after SCA and may be confused with adequate breathing. Occasional gasps do not necessarily result in adequate ventilation. The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class I,

LOE C). CPR training, both formal classroom training and

“just in time” training such as that given through a dispatch center, should emphasize how to recognize occasional gasps and should instruct rescuers to provide CPR even when the unresponsive victim demonstrates occasional gasps (Class I,


These 2010 AHA Guidelines for CPR and ECC also deemphasize the pulse check as a mechanism to identify cardiac arrest. Studies have shown that both laypersons and healthcare providers have difficulty detecting a pulse.

35– 44

For this reason pulse check was deleted from training for lay rescuers several years ago, and is deemphasized in training for healthcare providers. The lay rescuer should assume that cardiac arrest is present and should begin CPR if an adult suddenly collapses or an unresponsive victim is not breathing or not breathing normally (ie, only gasping).

Healthcare providers may take too long to check for a pulse 38,41 or absent.

and have difficulty determining if a pulse is present

38,41,45 There is no evidence, however, that checking for breathing, coughing, or movement is superior for detection of circulation.

58 Because delays in chest compressions should be minimized, 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

Technique: Chest Compressions (Box 4)

To maximize the effectiveness of chest compressions, place the victim on a firm surface when possible, in a supine

Downloaded from circ.ahajournals.org

by on December 4, 2010



S690 Circulation

November 2, 2010

position with the rescuer kneeling beside the victim’s chest

(eg, out-of-hospital) or standing beside the bed (eg, inhospital).

59 Because hospital beds are typically not firm and some of the force intended to compress the chest results in mattress displacement rather than chest compression, we have traditionally recommended the use of a backboard despite insufficient evidence for or against the use of backboards during CPR.

60 – 63

If a backboard is used, care should be taken to avoid delays in initiation of CPR, to minimize interruptions in CPR, and to avoid line/tube displacement.

61 Air-filled mattresses should be deflated when performing CPR.


The rescuer should place the heel of one hand on the center

(middle) of the victim’s chest (which is the lower half of the sternum) and the heel of the other hand on top of the first so that the hands are overlapped and parallel (Class IIa, LOE B 66 – 69 ).

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 70 –73 ), 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 76 – 80 ). In human studies of CPR in out-of-hospital 81 and in-hospital settings,

78 – 80 incomplete chest wall recoil was common, particularly when rescuers were fatigued.

78,81 Incomplete recoil during BLS CPR is associated with higher intrathoracic pressures and significantly decreased hemodynamics, including decreased coronary perfusion, cardiac index, myocardial blood flow, and cerebral perfusion.

76,82 Importantly, the incidence of incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback.

80 Manikin studies suggest that lifting the heel of the hand slightly, but completely, off the chest can improve chest recoil.


The total number of chest compressions delivered to the victim is a function of the chest compression rate and the proportion of time that chest compressions are delivered without interruption. The compression rate refers to the speed of compressions, not the actual number of compressions delivered per minute. The actual number of chest compressions delivered per minute is determined by the rate of chest compressions and the number and duration of interruptions to open the airway, deliver rescue breaths, and allow AED analysis.

83,84 The number of chest compressions delivered per minute is an important determinant of return of spontaneous circulation (ROSC) and neurologically intact survival.


One study of in-hospital cardiac arrest patients 85 showed that delivery of

⬎80 compressions/min was associated with

ROSC. Extrapolation of data from an out-of-hospital observational study

6 showed improved survival to hospital discharge when at least 68 to 89 chest compressions per minute were delivered; the study also demonstrated that improved survival occurred with chest compression rates as high as

120/min. It is therefore reasonable for lay rescuers and healthcare providers to perform chest compressions for adults at a rate of at least 100 compressions per minute (Class IIa,


The term “duty cycle” refers to the time spent compressing the chest as a proportion of the time between the start of 1 cycle of compression and the start of the next. Coronary

Downloaded from circ.ahajournals.org

by on December 4, 2010 blood flow is determined partly by the duty cycle (reduced coronary perfusion is associated with a duty cycle of

⬎50%) and partly by how fully the chest is relaxed at the end of each compression.

86 Although duty cycles ranging between 20% and 50% can result in adequate coronary and cerebral perfusion,

87–90 a duty cycle of 50% is recommended because it is easy to achieve with practice (Class IIb, LOE C 75 ).

In 2005 3 human observational studies 91–93 showed that interruptions of chest compressions were common, averaging

24% to 57% 85,91–93 of the total arrest time.

The preponderance of efficacy data

94,95 suggests that limiting the frequency and duration of interruptions in chest compressions may improve clinically meaningful outcomes in cardiac arrest patients. Data are now accumulating regarding the effectiveness of these interventions in “the real world.” 2,96 –102 Therefore, despite some data to the contrary, 103 it is reasonable for rescuers to minimize interruption of chest compressions for checking the pulse, analyzing rhythm, or performing other activities throughout the entire resuscitation, particularly in the period immediately before and after a shock is delivered (Class IIa, LOE B 94 –98 ).

Additional evidence of the importance of minimizing interruptions in chest compressions comes from nonrandomized studies suggesting that survival from out-of-hospital cardiac arrest may be improved by the initial EMS provider delivery of continuous chest compressions without initial assisted ventilations,

97,98 or by EMS providers using a higher compression-to-ventilation ratio (50:2).

96 Notably, in each of these studies, the airway was opened, oxygen insufflations were provided, and assisted ventilation was recommended at some point during the EMS resuscitation. Other EMS systems have noted significant improvement in survival from out-ofhospital arrest with use of compressions-plus-ventilations with emphases on improved quality of compressions and minimization of hands-off time.


At this time there is insufficient evidence to support the removal of ventilations from CPR provided by EMS professionals.

Rescuer fatigue may lead to inadequate compression rates or depth.

104 –106 Significant fatigue and shallow compressions are common after 1 minute of CPR, although rescuers may not recognize that fatigue is present for ⱖ5 minutes.



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). Consider switching compressors during any intervention associated with appropriate interruptions in chest compressions (eg, when an AED is delivering a shock).

Every effort should be made to accomplish this switch in

⬍5 seconds. If the 2 rescuers are positioned on either side of the patient, 1 rescuer will be ready and waiting to relieve the

“working compressor” every 2 minutes.

Interruptions of chest compressions to palpate for a spontaneous pulse or to otherwise check for return of spontaneous circulation (ROSC) can compromise vital organ perfusion.

2,94 –99

Accordingly lay rescuers should not interrupt chest compressions to palpate pulses or check for ROSC

(Class IIa, LOE C). In addition lay rescuers should continue

Berg et al Part 5: Adult Basic Life Support


CPR until an AED arrives, the victim wakes up, or EMS personnel take over CPR (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.

Compression-Ventilation Ratio (Box 4)

A compression-ventilation ratio of 30:2 is reasonable in adults, but further validation of this guideline is needed (Class

IIb, LOE B 83,107–111 ). This 30:2 ratio in adults is based on a consensus among experts and on published case series.

2,99 –102

Further studies are needed to define the best method for coordinating chest compressions and ventilations during CPR and to define the best compression-ventilation ratio in terms of survival and neurologic outcome in patients with or without an advanced airway in place.

Once an advanced airway is in place, 2 rescuers no longer need to pause chest compressions for ventilations. Instead, the 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).

Hands-Only CPR

Only about 20% to 30% of adults with out-of-hospital cardiac arrests receive any bystander CPR.

29,48 –51,112,113 Hands-Only

(compression-only) bystander CPR substantially improves survival following adult out-of-hospital cardiac arrests compared with no bystander CPR.

29,48 –51

Observational studies of adults with cardiac arrest treated by lay rescuers showed similar survival rates among victims receiving Hands-Only

CPR versus conventional CPR with rescue breaths.

29,48 –51 note, some healthcare providers 114 –116 and laypersons 116,117 indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR. When actual bystanders were interviewed, however, such reluctance was not expressed; panic was cited as the major obstacle to laypersons performance of bystander CPR.


The simpler Hands-Only technique may help overcome panic and hesitation to act.


How can bystander CPR be effective without rescue breathing? Initially during SCA with VF, rescue breaths are not as important as chest compressions because the oxygen level in the blood remains adequate for the first several minutes after cardiac arrest. In addition, many cardiac arrest victims exhibit gasping or agonal gasps, and gas exchange allows for some oxygenation and carbon dioxide (CO


) elimination.


If the airway is open, passive chest recoil during the relaxation phase of chest compressions can also provide some air exchange.

some time during prolonged CPR, supplementary oxygen with assisted ventilation is necessary. The precise interval for which the performance of Hands-Only CPR is acceptable is not known at this time.


Laypersons should be encouraged to provide chest compressions (either Hands-Only or conventional CPR, including rescue breaths) for anyone with a presumed cardiac arrest

(Class I, LOE B). No prospective study of adult cardiac arrest has demonstrated that layperson conventional CPR provides better outcomes than Hands-Only CPR when provided before

EMS arrival. A recent large study of out-of-hospital pediatric cardiac arrests showed that survival was better when conventional CPR (including rescue breaths) as opposed to Hands-

Only CPR was provided for children in cardiac arrest due to noncardiac causes.


Because rescue breathing is an important component for successful resuscitation from pediatric arrests

(other than sudden, witnessed collapse of adolescents), from asphyxial cardiac arrests in both adults and children (eg, drowning, drug overdose) and from prolonged cardiac arrests, conventional CPR with rescue breathing is recommended for all trained rescuers (both in hospital and out of hospital) for those specific situations (Class IIa, LOE C 109,123,127–129 ).

Managing the Airway

19,110,111,119 –122

However, at

As previously stated, a significant change in these Guidelines is to recommend the initiation of chest compressions before ventilations (CAB rather than ABC). This change reflects the growing evidence of the importance of chest compressions and the reality that setting up airway equipment takes time.

The ABC mindset may reinforce the idea that compressions should wait until ventilations have begun. This mindset can occur even when more than 1 rescuer is present because

“airway and breathing before ventilations” is so ingrained in many rescuers. This new emphasis on CAB helps clarify that airway maneuvers should be performed quickly and efficiently so that interruptions in chest compressions are minimized and chest compressions should take priority in the resuscitation of an adult.

Open the Airway: Lay Rescuer

The trained lay rescuer who feels confident that he or she can perform both compressions and ventilations should open the airway using a head tilt– chin lift maneuver (Class IIa, LOE B).

For the rescuer providing Hands-Only CPR, there is insufficient evidence to recommend the use of any specific passive airway (such as hyperextending the neck to allow passive ventilation).

Open the Airway: Healthcare Provider

A healthcare provider should use the head tilt– chin lift maneuver to open the airway of a victim with no evidence of head or neck trauma. Although the head tilt– chin lift technique was developed using unconscious, paralyzed adult volunteers and has not been studied in victims with cardiac arrest, clinical

130 and radiographic evidence

131,132 and a case series

133 have shown it to be effective (Class IIa, LOE B).

Between 0.12 and 3.7% of victims with blunt trauma have a spinal injury,

134 –136 and the risk of spinal injury is increased if the victim has a craniofacial injury,

137,138 a Glasgow Coma

Downloaded from circ.ahajournals.org

by on December 4, 2010

S692 Circulation

November 2, 2010

Scale score of


139,140 or both.


For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction (eg, placing 1 hand on either side of the patient’s head to hold it still) rather than immobilization devices (Class IIb, LOE C 141,142 ). Spinal immobilization devices may interfere with maintaining a patent airway, 143,144 but ultimately the use of such a device may be necessary to maintain spinal alignment during transport.

If healthcare providers suspect a cervical spine injury, they should open the airway using a jaw thrust without head extension (Class IIb, LOE C 133 ). Because maintaining a patent airway and providing adequate ventilation are priorities in CPR (Class I,

LOE C), use the head tilt– chin lift maneuver if the jaw thrust does not adequately open the airway.

Rescue Breathing (Box 3A, 4)

The 2010 AHA Guidelines for CPR and ECC make many of the same recommendations regarding rescue breathing as in


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).


Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations.

When an advanced airway (ie, endotracheal tube, Combitube, or laryngeal mask airway [LMA]) is in place during

2-person CPR, give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions

(this will result in delivery of 8 to 10 breaths/minute).

There should be no pause in chest compressions for delivery of ventilations (Class IIb, LOE C).

During CPR the primary purpose of assisted ventilation is to maintain adequate oxygenation; the secondary purpose is to eliminate CO


. However, the optimal inspired oxygen concentration, tidal volume and respiratory rate to achieve those purposes are not known. As noted above, during the first minutes of sudden VF cardiac arrest, rescue breaths are not as important as chest compressions 29,108,153 because the oxygen content in the noncirculating arterial blood remains unchanged until CPR is started; the blood oxygen content then continues to be adequate during the first several minutes of CPR. In addition, attempts to open the airway and give rescue breaths (or to access and set up airway equipment) may delay the initiation of chest compressions.

154 These issues support the CAB approach of the 2010 AHA Guide-

lines for CPR and ECC (ie, starting with Chest Compressions prior to Airway and Breathing).

For victims of prolonged cardiac arrest both ventilations and compressions are important because over time oxygen in the blood is consumed and oxygen in the lungs is depleted

(although the precise time course is unknown). Ventilations and compressions are also important for victims of asphyxial arrest, such as children and drowning victims, because they are hypoxemic at the time of cardiac arrest.


Studies in anesthetized adults (with normal perfusion) suggest that a tidal volume of 8 to 10 mL/kg maintains normal oxygenation and elimination of CO


. During CPR, cardiac output is

⬇25% to 33% of normal, so oxygen uptake from the lungs and CO

2 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.

55,110,111,119 For that reason during adult CPR tidal volumes of approximately 500 to 600 mL (6 to 7 mL/kg) should suffice (Class IIa, LOE


145–147 This is consistent with a tidal volume that produces visible chest rise.

Patients with airway obstruction or poor lung compliance may require high pressures to be properly ventilated (to make the chest visibly rise). A pressure-relief valve on a resuscitation bag-mask may prevent the delivery of a sufficient tidal volume in these patients.


Ensure that the bag-mask device allows you to bypass the pressure-relief valve and use high pressures, if necessary, to achieve visible chest expansion.


Excessive ventilation is unnecessary and can cause gastric inflation and its resultant complications, such as regurgitation and aspiration (Class III, LOE B 150 –152 ). More important, excessive ventilation can be harmful because it increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output and survival.

152 In summary, rescuers should avoid excessive ventilation (too many breaths or too large a volume) during CPR (Class III, LOE B).

Mouth-to-Mouth Rescue Breathing

Mouth-to-mouth rescue breathing provides oxygen and ventilation to the victim.

155 To provide mouth-to-mouth rescue breaths, open the victim’s airway, pinch the victim’s nose, and create an airtight mouth-to-mouth seal. Give 1 breath over 1 second, take a “regular” (not a deep) breath, and give a second rescue breath over 1 second (Class IIb, LOE C).

Taking a regular rather than a deep breath prevents the rescuer from getting dizzy or lightheaded and prevents overinflation of the victim’s lungs. The most common cause of ventilation difficulty is an improperly opened airway,

57 so if the victim’s chest does not rise with the first rescue breath, reposition the head by performing the head tilt– chin lift again and then give the second rescue breath.

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.

Mouth-to–Barrier Device Breathing

Some healthcare providers 114 –116 and lay rescuers state that they may hesitate to give mouth-to-mouth rescue breathing and prefer to use a barrier device. The risk of disease transmission through mouth to mouth ventilation is very low, and it is reasonable to initiate rescue breathing with or without a barrier device. When using a barrier device the rescuer should not delay chest compressions while setting up the device.

Mouth-to-Nose and Mouth-to-Stoma Ventilation

Mouth-to-nose ventilation is recommended if ventilation through the victim’s mouth is impossible (eg, the mouth is seriously injured), the mouth cannot be opened, the victim is in water, or a mouth-to-mouth seal is difficult to achieve

Downloaded from circ.ahajournals.org

by on December 4, 2010

Berg et al Part 5: Adult Basic Life Support


(Class IIa, LOE C). A case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and effective.


Give mouth-to-stoma rescue breaths to a victim with a tracheal stoma who requires rescue breathing. A reasonable alternative is to create a tight seal over the stoma with a round, pediatric face mask (Class IIb, LOE C). There is no published evidence on the safety, effectiveness, or feasibility of mouth-to-stoma ventilation. One study of patients with laryngectomies showed that a pediatric face mask created a better peristomal seal than a standard ventilation mask.


Ventilation With Bag and Mask

Rescuers can provide bag-mask ventilation with room air or oxygen. A bag-mask device provides positive-pressure ventilation without an advanced airway; therefore a bag-mask device may produce gastric inflation and its complications.

The Bag-Mask Device

A bag-mask device should have the following extremes of temperature.

a standard 15-mm/22-mm connector.

Bag-Mask Ventilation

considerable practice for competency.

approximately 600 mL tidal volume

(Class IIa, LOE C 145–147




158 available in one adult and several pediatric sizes.

: a nonjam inlet valve; either no pressure relief valve or a pressure relief valve that can be bypassed; standard 15-mm/22-mm fittings; an oxygen reservoir to allow delivery of high oxygen concentrations; a nonrebreathing outlet valve that cannot be obstructed by foreign material and will not jam with an oxygen flow of 30 L/min; and the capability to function satisfactorily under common environmental conditions and

Masks should be made of transparent material to allow detection of regurgitation. They should be capable of creating a tight seal on the face, covering both mouth and nose. Masks should be fitted with an oxygen (insufflation) inlet and have

They should be

Bag-mask ventilation is a challenging skill that requires

Bag-mask ventilation is not the recommended method of ventilation for a lone rescuer during CPR. It is most effective when provided by 2 trained and experienced rescuers. One rescuer opens the airway and seals the mask to the face while the other squeezes the bag. Both rescuers watch for visible chest rise.


The rescuer should use an adult (1 to 2 L) bag to deliver for adult victims.

This amount is usually sufficient to produce visible chest rise and maintain oxygenation and normocarbia in apneic patients

). If the airway is open and a good, tight seal is established between face and mask, this volume can be delivered by squeezing a 1-L adult bag about two thirds of its volume or a 2-L adult bag about one third of its volume. As long as the patient does not have an advanced airway in place, the rescuers should deliver cycles of 30 compressions and 2 breaths during CPR. The rescuer delivers ventilations during pauses in compressions and delivers each breath over 1 second (Class IIa, LOE C). The healthcare provider should use supplementary oxygen (O

2 concentration

⬎40%, at a minimum flow rate of 10 to 12 L/min) when available.

Ventilation With a Supraglottic Airway

Supraglottic airway devices such as the LMA, the esophageal-tracheal combitube and the King airway device, are currently within the scope of BLS practice in a number of regions (with specific authorization from medical control).

Ventilation with a bag through these devices provides an acceptable alternative to bag-mask ventilation for well-trained healthcare providers who have sufficient experience to use the devices for airway management during cardiac arrest (Class IIa,


166 –171

). It is not clear that these devices are any more or less complicated to use than a bag and mask; training is needed for safe and effective use of both the bag-mask device and each of the advanced airways. These devices are discussed in greater detail in Part 8.1 of these Guidelines.

Ventilation With an Advanced Airway

When the victim has an advanced airway in place during

CPR, rescuers no longer deliver cycles of 30 compressions and 2 breaths (ie, they no longer interrupt compressions to deliver 2 breaths). Instead, continuous chest compressions are performed at a rate of at least 100 per minute without pauses for ventilation, and ventilations are delivered at the rate of 1 breath about every 6 to 8 seconds (which will deliver approximately 8 to 10 breaths per minute).

Passive Oxygen Versus Positive-Pressure Oxygen

During CPR

Although many studies describe outcomes after compressiononly CPR, these studies infrequently address additional techniques to improve ventilation or oxygenation. Two comparative studies 97,172 and 2 post hoc analysis studies 98,173 of passive ventilation airway techniques during cardiac arrest used the same protocol. The protocol included insertion of an oral airway and administration of oxygen with a nonrebreather mask, with interposed ventilations versus passive insufflation of oxygen during minimally interrupted chest compressions. These studies did not demonstrate a significant overall improvement in outcome measures. However, subgroup analysis showed better survival with passive oxygen insufflation among patients with witnessed VF cardiac arrest.

For layperson Hands-Only CPR, evidence is insufficient to support recommending the use of any specific passive airway or ventilation technique.

Cricoid Pressure

Cricoid pressure is a technique of applying pressure to the victim’s cricoid cartilage to push the trachea posteriorly and compress the esophagus against the cervical vertebrae. Cricoid pressure can prevent gastric inflation and reduce the risk of regurgitation and aspiration during bag-mask ventilation, but it may also impede ventilation. Seven randomized, controlled studies demonstrated that cricoid pressure can delay or prevent the placement of an advanced airway and that aspiration can occur despite application of pressure.

174 –180

Additional manikin studies 181–194 found training in the maneuver to be difficult for both expert and nonexpert rescuers.

Neither expert nor nonexpert rescuers demonstrated mastery of the technique, and the applied pressure was frequently inconsistent and outside of effective limits. Cricoid pressure might be used in a few special circumstances (eg, to aid in viewing the vocal cords during tracheal intubation). However, the routine use of cricoid pressure in adult cardiac arrest is not recommended (Class III, LOE B).

Downloaded from circ.ahajournals.org

by on December 4, 2010

S694 Circulation

November 2, 2010

AED Defibrillation (Box 5, 6)

All BLS providers should be trained to provide defibrillation because VF is a common and treatable initial rhythm in adults with witnessed cardiac arrest.

195 For victims with VF, survival rates are highest when immediate bystander CPR is provided and defibrillation occurs within 3 to 5 minutes of collapse.


Rapid defibrillation is the treatment of choice for VF of short duration, such as for victims of witnessed out-of-hospital cardiac arrest or for hospitalized patients whose heart rhythm is monitored (Class I, LOE A).

In swine, microvascular blood flow is markedly reduced within 30 seconds of the onset of VF; chest compressions restore some of the diminished microvascular blood flow within 1 minute.

198 Performing chest compressions while another rescuer retrieves and charges a defibrillator improves the probability of survival.

6 After about 3 to 5 minutes of untreated VF, some animal models suggest that a period of chest compressions before defibrillation may be beneficial.


In 2 randomized controlled trials in adults with out-ofhospital VF/pulseless ventricular tachycardia (VT), a period of 1


2 to 3 minutes of CPR by EMS before defibrillation did not improve ROSC or survival rates regardless of EMS response interval.


A third randomized controlled trial

202 and a cohort clinical trial with historic controls

203 also found no overall differences in outcomes. However, in two of these studies subgroups of patients with the EMS response interval intervals longer than 4 to 5 minutes showed increased survival to hospital discharge with a period of CPR prior to defibrillation.

202, 203

There is insufficient evidence to recommend for or against delaying defibrillation to provide a period of CPR for patients in VF/pulseless VT out-of-hospital cardiac arrest. In settings with lay rescuer AED programs (AED onsite and available) and for in-hospital environments, or if the EMS rescuer witnesses the collapse, the rescuer should use the defibrillator as soon as it is available (Class IIa, LOE C). When more than one rescuer is available, one rescuer should provide chest compressions while another activates the emergency response system and retrieves the defibrillator. Defibrillation is discussed in further detail in Part 6: “Electrical Therapies.”

Recovery Position

The recovery position is used for unresponsive adult victims who clearly have normal breathing and effective circulation.

This position is designed to maintain a patent airway and reduce the risk of airway obstruction and aspiration. The victim is placed on his or her side with the lower arm in front of the body.

There are several variations of the recovery position, each with its own advantages. No single position is perfect for all victims.

204,205 The position should be stable, near a true lateral position, with the head dependent and with no pressure on the chest to impair breathing (Class IIa, LOE C). Studies in normal volunteers 206 show that extending the lower arm above the head and rolling the head onto the arm, while bending both legs, may be feasible for victims with known or suspected spinal injury.


Special Resuscitation Situations

Acute Coronary Syndromes

In the United States coronary heart disease was responsible for 1 of every 6 hospital admissions in 2005 and 1 in every 6 deaths in 2006.

208 The American Heart Association estimates that in 2010, 785 000 Americans will have a new coronary attack and 470 000 will have a recurrent attack.

208 Approximately 70% of deaths from acute myocardial infarction

(AMI) occur outside of the hospital, most within the first 4 hours after the onset of symptoms.


Early recognition, diagnosis, and treatment of AMI can improve outcome by limiting damage to the heart, 210 but treatment is most effective if provided within a few hours of the onset of symptoms.

211 Patients at risk for acute coronary syndromes (ACS) and their families should be taught to recognize the symptoms of ACS and to immediately activate the EMS system when symptoms appear, rather than delaying care by contacting family, calling a physician, or driving themselves to the hospital.

The classic symptoms associated with ACS are chest discomfort, discomfort in other areas of the upper body, shortness of breath, sweating, nausea, and lightheadedness.

The symptoms of AMI characteristically last more than 15 minutes. Atypical symptoms of ACS may be more common in the elderly, women, and diabetic patients, but any patient may present with atypical signs and symptoms.

212–214 Signs and symptoms cannot be used to confirm or exclude the diagnosis of ACS because reported sensitivity ranges from

35% to 92% and specificity ranges from 28% of 91%.

Numerous studies do not support the use of any clinical signs and symptoms independent of electrocardiograph (ECG) tracings, cardiac biomarkers, or other diagnostic tests to rule in or rule out ACS in prehospital or emergency department

(ED) settings.


To improve ACS outcome, all dispatchers and EMS providers must be trained to recognize ACS symptoms, even if atypical. It is reasonable for dispatchers to advise patients with potential cardiac symptoms to chew an aspirin (160 to

325 mg), providing the patient has no history of aspirin allergy and no signs of active or recent gastrointestinal bleeding (Class IIa, LOE C).

229 –233

EMS providers should obtain a 12-lead ECG, determine onset of ACS symptoms, and provide prearrival notification to the destination hospital.

229,234 Clinical trials have shown improved outcomes in ST-segment elevation myocardial infarction (STEMI) patients transported by EMS directly to a percutaneous coronary intervention (PCI)– capable hospital.

235–237 If the patient has a STEMI on ECG and if PCI is the chosen method of reperfusion, it is reasonable to transport the patient directly to a PCI facility, bypassing closer emergency departments as necessary, in systems where time intervals between first medical contact and balloon times are less than

90 minutes, and transport times are relatively short (ie, less than 30 minutes), or based on regional EMS protocols (Class

IIa, LOE B).

Common practice has been for basic EMT’s to administer oxygen during the initial assessment of patients with suspected ACS. However, there is insufficient evidence to

Downloaded from circ.ahajournals.org

by on December 4, 2010

Berg et al Part 5: Adult Basic Life Support


‘support or refute oxygen use in uncomplicated ACS. If the patient is dyspneic, hypoxemic, has obvious signs of heart failure, or an oxyhemoglobin saturation

⬍94%, providers should administer oxygen and titrate therapy to provide the lowest administered oxygen concentration that will maintain the oxyhemoglobin saturation ⱖ94% (Class I, LOE C).

238 If the patient has not taken aspirin and has no history of aspirin allergy and no evidence of recent gastrointestinal bleeding,

EMS providers should give the patient nonenteric aspirin

(160 to 325 mg) to chew (Class I, LOE C).


EMS providers can administer nitroglycerin for patients with chest discomfort and suspected ACS. Although it is reasonable to consider the early administration of nitroglycerin in select hemodynamically stable patients, insufficient evidence exists to support or refute the routine administration of nitroglycerin in the ED or prehospital setting in patients with a suspected ACS (Class IIb, LOE B).

241–243 Nitrates in all forms are contraindicated in patients with initial systolic blood pressure

⬍90 mm Hg or ⱖ30 mm Hg below baseline and in patients with right ventricular infarction (see Part 10).

Caution is advised in patients with known inferior wall

STEMI, and a right-sided ECG should be performed to evaluate right ventricular infarction. Administer nitrates with extreme caution, if at all, to patients with inferior STEMI and suspected RV involvement because these patients require adequate RV preload. Nitrates are contraindicated when patients have taken a phosphodiesterase-5 (PDE-5) inhibitor within 24 hours (48 hours for tadalafil).

For patients diagnosed with STEMI in the prehospital setting, EMS providers should administer appropriate analgesics, such as intravenous morphine, for persistent chest pain (Class IIa, LOE C). EMS providers may consider administering intravenous morphine for undifferentiated chest pain unresponsive to nitroglycerin (Class IIb, LOE C).

However, morphine should be used with caution in unstable angina (UA)/NSTEMI due to an association with increased mortality in a large registry.

Additional information about the assessment and treatment of the patient with ACS and STEMI is included in Part 10:

“Acute Coronary Syndromes.” of stroke and to call EMS as soon as any signs of stroke are present (Class I, LOE C). The signs and symptoms of stroke are sudden numbness or weakness of the face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; and sudden severe headache with no known cause.


Community and professional education is essential to improve stroke recognition and early EMS activation.

254 –256

EMS dispatchers should be trained to suspect stroke and rapidly dispatch emergency responders. EMS personnel should be able to perform an out-of-hospital stroke assessment (Class I, LOE B 257–259 ), establish the time of symptom onset when possible, provide cardiopulmonary support, and notify the receiving hospital that a patient with possible stroke is being transported.

260 –262 EMS systems should have protocols that address triaging the patient when possible directly to a stroke center (Class I, LOE B


). It may be important for a family member to accompany the patient during transport to verify the time of symptom onset and provide consent for interventional therapy.

Patients with acute stroke are at risk for respiratory compromise, and the combination of poor perfusion and hypoxemia will exacerbate and extend ischemic brain injury leading to worse outcomes.

265 Both out-of-hospital and inhospital medical personnel should administer supplementary oxygen to hypoxemic (ie, oxygen saturation

⬍94%) stroke patients (Class 1, LOE C) or those with unknown oxygen saturation. There are no data to support initiation of hypertension intervention in the prehospital environment. Unless the patient is hypotensive (systolic blood pressure

⬍90 mm Hg), prehospital intervention for blood pressure is not recommended (Class III, LOE C). Additional information about the assessment of stroke using stroke scales and the management of stroke is included in Part 11: “Adult Stroke.”


Almost 800 000 people suffer stroke each year in the United

States, and stroke is a leading cause of severe, long-term disability and death.

245 Fibrinolytic therapy administered within the first hours of the onset of symptoms limits neurological injury and improves outcome in selected patients with acute ischemic stroke.

246 –249 The window of opportunity is extremely limited, however. Effective therapy requires early detection of the signs of stroke, prompt activation of the EMS system and dispatch of EMS personnel; appropriate triage to a stroke center; prearrival notification; rapid triage, evaluation, and management in the ED; and rapid delivery of fibrinolytic therapy to eligible patients. For additional information about these steps, see the

AHA/American Stroke Association (ASA) Guidelines for the management of acute ischemic stroke and Part 11: “Adult

Stroke.” 250,251

Patients at high risk for stroke, their family members, and

BLS providers should learn to recognize the signs and symptoms


Drowning is a preventable cause of death for more than 3500

Americans annually.


Over the last 25 years, the incidence of fatal drowning has declined significantly from 3.8 deaths per 100 000 population in 1970 to 1.2 in 2006.


The duration and severity of hypoxia sustained as a result of drowning is the single most important determinant of outcome.


Rescuers should provide CPR, particularly rescue breathing, as soon as an unresponsive submersion victim is removed from the water (Class I, LOE C). When rescuing a drowning victim of any age, it is reasonable for the lone healthcare provider to give 5 cycles (about 2 minutes) of CPR before leaving the victim to activate the EMS system.

Mouth-to-mouth ventilation in the water may be helpful when administered by a trained rescuer (Class IIb, LOE C 269 ).

Chest compressions are difficult to perform in water; they may not be effective and they could potentially cause harm to both the rescuer and the victim. There is no evidence that water acts as an obstructive foreign body. Maneuvers to relieve foreign-body airway obstruction (FBAO) are not recommended for drowning victims because such maneuvers are not necessary and they can cause injury, vomiting, aspiration, and delay of CPR.


Downloaded from circ.ahajournals.org

by on December 4, 2010

S696 Circulation

November 2, 2010

Rescuers should remove drowning victims from the water by the fastest means available and should begin resuscitation as quickly as possible. Spinal cord injury is rare among fatal drowning victims.

271 Victims with obvious clinical signs of injury, alcohol intoxication, or a history of diving into shallow water are at a higher risk of spinal cord injury, and health care providers may consider stabilization and possible immobilization of the cervical and thoracic spine for these victims.


In an unresponsive victim with hypothermia, assessments of breathing and pulse are particularly difficult because heart rate and breathing may be very slow, depending on the degree of hypothermia.

If the victim is unresponsive with no normal breathing, lay rescuers should begin chest compressions immediately (see Part

12: “Cardiac Arrest in Special Situations”). If the adult victim is unresponsive with no breathing or no normal breathing (ie, only gasping), healthcare providers can check for a pulse, but should start CPR if a pulse is not definitely felt within 10 seconds. Do not wait to check the victim’s temperature and do not wait until the victim is rewarmed to start CPR. To prevent further heat loss, remove wet clothes from the victim; insulate or shield the victim from wind, heat, or cold; and if possible, ventilate the victim with warm, humidified oxygen.

Avoid rough movement, and transport the victim to a hospital as soon as possible. If VF is detected, emergency personnel should deliver shocks using the same protocols used for the normothermic cardiac arrest victim (see Part 12:

“Cardiac Arrest in Special Situations”).

For the hypothermic patient in cardiac arrest, continue resuscitative efforts until the patient is evaluated by advanced care providers. In the out-of-hospital setting, passive warming can be used until active warming is available.

Foreign-Body Airway Obstruction (Choking)


FBAO is an uncommon, but preventable, cause of death.


Most reported cases of FBAO occur in adults while they are eating.


Most reported episodes of choking in infants and children occur during eating or play when parents or childcare providers are present. The choking event is therefore commonly witnessed, and the rescuer usually intervenes while the victim is still responsive. Treatment is usually successful, and survival rates can exceed 95%.


Recognition of Foreign-Body Airway Obstruction

Because recognition of FBAO is the key to successful outcome, it is important to distinguish this emergency from fainting, heart attack, seizure, or other conditions that may cause sudden respiratory distress, cyanosis, or loss of consciousness.

Foreign bodies may cause either mild or severe airway obstruction. The rescuer should intervene if the choking victim shows signs of severe airway obstruction. These include signs of poor air exchange and increased breathing difficulty, such as a silent cough, cyanosis, or inability to speak or breathe. The victim may clutch the neck, demonstrating the universal choking sign. Quickly ask, “Are you choking?” If the victim indicates

“yes” by nodding his head without speaking, this will verify that the victim has severe airway obstruction.

Relief of Foreign-Body Airway Obstruction

When FBAO produces signs of severe airway obstruction, rescuers must act quickly to relieve the obstruction. If mild obstruction is present and the victim is coughing forcefully, do not interfere with the patient’s spontaneous coughing and breathing efforts. Attempt to relieve the obstruction only if signs of severe obstruction develop: the cough becomes silent, respiratory difficulty increases and is accompanied by stridor, or the victim becomes unresponsive. Activate the EMS system quickly if the patient is having difficulty breathing. If more than one rescuer is present, one rescuer should phone 911 while the other rescuer attends to the choking victim.

The clinical data about effectiveness of maneuvers to relieve FBAO are largely retrospective and anecdotal. For responsive adults and children

⬎1 year of age with severe

FBAO, case reports show the feasibility and effectiveness of back blows or “slaps,”

276 –278 abdominal thrusts,

275–277,279,280 and chest thrusts.

276,281 In 1 case series of 513 choking episodes for which EMS was summoned, 275 approximately

50% of the episodes of airway obstruction were relieved prior to arrival of EMS. EMS intervention with abdominal thrusts successfully relieved the obstruction in more than 85% of the remaining cases. The few patients with persistent obstruction usually responded to suction or the use of Magill forceps.

Less than 4% died.


Although chest thrusts, back slaps, and abdominal thrusts are feasible and effective for relieving severe FBAO in conscious

(responsive) adults and children ⱖ1 year of age, for simplicity in training it is recommended that abdominal thrusts be applied in rapid sequence until the obstruction is relieved (Class IIb, LOE

B). If abdominal thrusts are not effective, the rescuer may consider chest thrusts (Class IIb, LOE B). It is important to note that abdominal thrusts are not recommended for infants

⬍1 year of age because thrusts may cause injuries.

Chest thrusts should be used for obese patients if the rescuer is unable to encircle the victim’s abdomen. If the choking victim is in the late stages of pregnancy, the rescuer should use chest thrusts instead of abdominal thrusts.

If the adult victim with FBAO becomes unresponsive, the rescuer should carefully support the patient to the ground, immediately activate (or send someone to activate) EMS, and then begin CPR. The healthcare provider should carefully lower the victim to the ground, send someone to activate the emergency response system and begin CPR (without a pulse check). After 2 minutes, if someone has not already done so, the healthcare provider should activate the emeregency response system. A randomized trial of maneuvers to open the airway in cadavers tized volunteers


281,283 and 2 prospective studies in anestheshowed that higher sustained airway pressures can be generated using the chest thrust rather than the abdominal thrust. Each time the airway is opened during

CPR, the rescuer should look for an object in the victim’s mouth and if found, remove it. Simply looking into the mouth should not significantly increase the time needed to attempt the ventilations and proceed to the 30 chest compressions.

No studies have evaluated the routine use of the finger sweep to clear an airway in the absence of visible airway obstruction. The recommendation to use the finger sweep in past guidelines was based on anecdotal reports that suggested

Downloaded from circ.ahajournals.org

by on December 4, 2010

that it was helpful for relieving an airway obstruction.


However, case reports have also documented harm to the victim

236,285,286 or rescuer.

The Quality of BLS

The quality of unprompted CPR in both in-hospital and out-of– hospital cardiac arrest events is often poor, and methods should be developed to improve the quality of CPR delivered to victims of cardiac arrest.


Several studies have demonstrated improvement in chest compression rate, depth, chest recoil, ventilation rate, and indicators of blood flow such as end-tidal






) when real-time feedback or prompt devices are used to guide CPR performance.

72,73,80,288 –293

However, there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events. Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest.

62,294 Nevertheless, real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa,


Berg et al Part 5: Adult Basic Life Support



The critical lifesaving steps of BLS are

Immediate Recognition and Activation of the emergency response system

Early CPR and

Rapid Defibrillation for VF

When an adult suddenly collapses, whoever is nearby should activate the emergency system and begin chest compressions (regardless of training). Trained lay rescuers who are able and healthcare providers should provide compressions and ventilations. Contrary to the belief of too many in this situation, CPR is not harmful. Inaction is harmful and

CPR can be lifesaving. However, the quality of CPR is critical. Chest compressions should be delivered by pushing hard and fast in the center of the chest (ie, chest compressions should be of adequate rate and depth). Rescuers should allow complete chest recoil after each compression and minimize interruptions in chest compressions. They should also avoid excessive ventilation. If and when available, an AED should be applied and used without delaying chest compressions. With prompt and effective provision of these actions, lives are saved every day.


Guidelines Part 5: Adult Basic Life Support: Writing Group Disclosures

Writing Group


Robert A. Berg

Robin Hemphill

Benjamin S.



University of

Pennsylvania–Professor of

Anesthesiology and Critical

Care Medicine, Division

Chief, Pediatric Critical


Emory University, Dept. of

Emergency Medicine–

Associate Professor

*Paid writer for AHA guidelines

University of



Research Grant



Other Research Support



*Laerdal Medical Corp-inkind support of equipment for CPR research

Tom P.


Diana M. Cave

Medical College of

Wisconsin–Professor of

Emergency Medicine

†Philips Healthcare-research grant for study of CPR during inhospital cardiac arrest AHA Clinical Research Program grant-research grant for study of CPR training in the community Doris Duke

Foundation-research grant for study of post resuscitation injury after cardiac arrest

†NIH-ROC Consortium-PI of

Milwaukee site NETT-PI of Milwaukee site

*ResQTrial (Advanced Circulatory

Systems, Inc.)-PI of Oshkosh study site, In Kind NHLBI Trial-PI for

Milwaukee site, In Kind


JoLife-Consultant Take Heart

America-Board Member


*Zoll Medical Corp.-Supplied AEDs and software capturing CPR performance data for ROC

Consortium Advanced Circulatory

Systems, Inc.-Supplied impedance threshold devices for ROC



Mary Fran


Legacy Health System,

Emanuel Hospital,

Emergency Services:

Not-for-profit health system consists of 5 hospitals in the Portland,

Oregon metro area.

Emanuel Hospital is a

Level I Trauma

Center.– RN, MSN;

Portland Com. College,

Institute for Health



Vanderbilt University School of

Nursing—Professor; AHA ECC

Product Development–Senior

Science Editor

†Significant compensation from the AHA to write and edit the AHA Guidelines and resuscitation statements and training materials

None None





*CME lectures on topics of CPR and hypothermia after cardiac arrest

*EMS Today-

Compensated speaker, $2,000



Ownership Interest












*Take Heart










*legal review of two cardiac arrest cases, no trial appearances





Downloaded from circ.ahajournals.org

by on December 4, 2010

S698 Circulation

November 2, 2010

Guidelines Part 5: Adult Basic Life Support: Writing Group Disclosures, Continued

Writing Group


E. Brooke



Medical College of

Wisconsin– Associate


Research Grant


Other Research Support

†Title: Circulation Improving Resuscitation

Care Trial Source: Zoll Medical

Corporation Role: Consultant Principal

Investigator: Lars Wik, M.D. Dates:

12/2006–8/2010 Total Funding to MCW:

$345,000 (funding is received by my employer to support my time on this trial. My institution receives support for

20% of my time and the remaining funds are used for other members of our staff and supplies. My role is to advise them on human subject protection issues and to assist with data management and report generation for the trial)

*We conducted an AED training study that recently completed where

Philips and PhysioControl contributed equipment for the research. I did not receive any of this equipment




Ownership Interest

*Stockholder in Medtronic,

Pfizer, and General







Thomas D.


University of Washington:


Professor of Medicine;

Emergency Medical

Services Division of Public

Health-Seattle & King

County–Program Medical


*In the past, I have received unrestricted

(modest) grant support from Philips Inc and PhysioControl. The topics were related to improving resuscitation generally (changing resuscitation protocols) and not specific to proprietary information or equipment. I am currently an investigator in the ROC.

As part of this, I am directly involved in the Feedback Trial to evaluate dynamic fdbk available on the Philips MRX. The

ROC is also evaluating the impedance threshold device. These studies are supported by the NIH primarily and I receive no support from Philips or the company that makes the impedance threshold device. I am participating in a trial of chest compression only vs chest compression plus ventilation for dispatch-assisted CPR-supported in part by Laerdal Foundation. I receive less than 5% salary support


None None None *I serve on a DSMB for a trial sponsored by Philips to evaluate quantitative

VF waveform algorhithm to guide care. I receive no support for this effort in order to minimize (eliminate) any conflict

Michael R.


The Ohio State University-

Associate Professor

Robert A. Swor Beaumont Hospital–Director

EMS Programs












This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the

Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.




1. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone

G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K,

Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland

D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D,

Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P,

Stafford R, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J.

Executive summary: heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation. 2010;121:

948 –954.

2. Rea TD, Helbock M, Perry S, Garcia M, Cloyd D, Becker L, Eisenberg

M. Increasing use of cardiopulmonary resuscitation during out-ofhospital ventricular fibrillation arrest: survival implications of guideline changes. Circulation. 2006;114:2760 –2765.

3. Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide

TP, Rea T, Lowe R, Brown T, Dreyer J, Davis D, Idris A, Stiell I.

Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300:1423–1431.

4. Chan PS, Nichol G, Krumholz HM, Spertus JA, Nallamothu BK.

Hospital variation in time to defibrillation after in-hospital cardiac arrest.

Arch Intern Med. 2009;169:1265–1273.

5. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and metaanalysis. Circ Cardiovasc Qual Outcomes. 2010;3:63– 81.

6. Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P, Hostler

D, Powell J, Callaway CW, Bishop D, Vaillancourt C, Davis D,

Aufderheide TP, Idris A, Stouffer JA, Stiell I, Berg R. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009;120:1241–1247.

7. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model. Circulation. 1997;96:3308 –3313.

8. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;

358:9 –17.

9. Hallstrom AP, Ornato JP, Weisfeldt M, Travers A, Christenson J,

McBurnie MA, Zalenski R, Becker LB, Schron EB, Proschan M. Publicaccess defibrillation and survival after out-of-hospital cardiac arrest.

N Engl J Med. 2004;351:637– 646.

10. Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG.

Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000;343:1206 –1209.

11. Agarwal DA, Hess EP, Atkinson EJ, White RD. Ventricular fibrillation in Rochester, Minnesota: experience over 18 years. Resuscitation. 2009;


12. Eisenberg MS, Hallstrom AP, Copass MK, Bergner L, Short F, Pierce J.

Treatment of ventricular fibrillation: emergency medical technician defibrillation and paramedic services. JAMA. 1984;251:1723–1726.

13. Rho RW, Page RL. The automated external defibrillator. J Cardiovasc

Electrophysiol. 2007;18:896 – 899.

14. Becker LB, Pepe PE. Ensuring the effectiveness of community-wide emergency cardiac care. Ann Emerg Med. 22(pt 2):354 –365, 1993.

15. Calle PA, Lagaert L, Vanhaute O, Buylaert WA. Do victims of an out-of-hospital cardiac arrest benefit from a training program for emergency medical dispatchers? Resuscitation. 1997;35:213–218.

16. Emergency medical dispatching: rapid identification and treatment of acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee. Am J Emerg Med.


17. Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation.

N Engl J Med. 2000;342:1546 –1553.

18. Culley LL, Clark JJ, Eisenberg MS, Larsen MP. Dispatcher-assisted telephone CPR: common delays and time standards for delivery. Ann

Emerg Med. 1991;20:362–366.

19. Berdowski J, Beekhuis F, Zwinderman AH, Tijssen JG, Koster RW.

Importance of the first link: description and recognition of an out-ofhospital cardiac arrest in an emergency call. Circulation. 2009;119:

2096 –2102.

Downloaded from circ.ahajournals.org

by on December 4, 2010

Berg et al Part 5: Adult Basic Life Support


20. Kuisma M, Boyd J, Vayrynen T, Repo J, Nousila-Wiik M, Holmstrom

P. Emergency call processing and survival from out-of-hospital ventricular fibrillation. Resuscitation. 2005;67:89 –93.

21. Rea TD, Eisenberg MS, Culley LL, Becker L. Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest. Circulation.


22. Hauff SR, Rea TD, Culley LL, Kerry F, Becker L, Eisenberg MS.

Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation. Ann Emerg Med. 2003;42:731–737.

23. Vaillancourt C, Verma A, Trickett J, Crete D, Beaudoin T, Nesbitt L,

Wells GA, Stiell IG. Evaluating the effectiveness of dispatch-assisted cardiopulmonary resuscitation instructions. Acad Emerg Med. 2007;14:

877– 883.

24. Bohm K, Rosenqvist M, Hollenberg J, Biber B, Engerstrom L, Svensson

L. Dispatcher-assisted telephone-guided cardiopulmonary resuscitation: an underused lifesaving system. Eur J Emerg Med. 2007;14:256 –259.

25. Hallstrom AP, Cobb LA, Johnson E, Copass MK. Dispatcher assisted CPR: implementation and potential benefit. A 12-year study. Resuscitation. 2003;


26. Nurmi J, Pettila V, Biber B, Kuisma M, Komulainen R, Castren M.

Effect of protocol compliance to cardiac arrest identification by emergency medical dispatchers. Resuscitation. 2006;70:463– 469.

27. Clawson J, Olola C, Heward A, Patterson B. Cardiac arrest predictability in seizure patients based on emergency medical dispatcher identification of previous seizure or epilepsy history. Resuscitation. 2007;75:298 –304.

28. White L, Rogers J, Bloomingdale M, Fahrenbruch C, Culley L, Subido

C, Eisenberg M, Rea T. Dispatcher-assisted cardiopulmonary resuscitation: risks for patients not in cardiac arrest. Circulation.121:91–97.

29. Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD.

Hands-only (compression-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest: a science advisory for the public from the

American Heart Association Emergency Cardiovascular Care Committee. Circulation. 2008;117:2162–2167.

30. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Nadkarni VM,

Berg RA, Hiraide A. Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-ofhospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet. 2010.

31. Heward A, Damiani M, Hartley-Sharpe C. Does the use of the Advanced

Medical Priority Dispatch System affect cardiac arrest detection? Emerg

Med J. 2004;21:115–118.

32. Roppolo LP, Westfall A, Pepe PE, Nobel LL, Cowan J, Kay JJ, Idris

AH. Dispatcher assessments for agonal breathing improve detection of cardiac arrest. Resuscitation. 2009;80:769 –772.

33. Bohm K, Stalhandske B, Rosenqvist M, Ulfvarson J, Hollenberg J,

Svensson L. Tuition of emergency medical dispatchers in the recognition of agonal respiration increases the use of telephone assisted CPR.

Resuscitation. 2009;80:1025–1028.

34. Clawson J, Olola C, Scott G, Heward A, Patterson B. Effect of a Medical

Priority Dispatch System key question addition in the seizure/ convulsion/fitting protocol to improve recognition of ineffective

(agonal) breathing. Resuscitation. 2008;79:257–264.

35. Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people in checking the carotid pulse. Resuscitation. 1997;35:23–26.

36. Brennan RT, Braslow A. Skill mastery in public CPR classes. Am J

Emerg Med. 1998;16:653– 657.

37. Chamberlain D, Smith A, Woollard M, Colquhoun M, Handley AJ,

Leaves S, Kern KB. Trials of teaching methods in basic life support : comparison of simulated CPR performance after first training and at 6 months, with a note on the value of re-training. Resuscitation. 2002;53:

179 –187.

38. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I.

Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33:


39. Frederick K, Bixby E, Orzel MN, Stewart-Brown S, Willett K. Will changing the emphasis from ‘pulseless’ to ‘no signs of circulation’ improve the recall scores for effective life support skills in children?

Resuscitation. 2002;55:255–261.

40. Lapostolle F, Le Toumelin P, Agostinucci JM, Catineau J, Adnet F.

Basic cardiac life support providers checking the carotid pulse: performance, degree of conviction, and influencing factors. Acad Emerg

Med. 2004;11:878 – 880.

41. Moule P. Checking the carotid pulse: diagnostic accuracy in students of the healthcare professions. Resuscitation. 2000;44:195–201.

42. Nyman J, Sihvonen M. Cardiopulmonary resuscitation skills in nurses and nursing students. Resuscitation. 2000;47:179 –184.

43. Owen CJ, Wyllie JP. Determination of heart rate in the baby at birth.

Resuscitation. 2004;60:213–217.

44. Sarti A, Savron F, Ronfani L, Pelizzo G, Barbi E. Comparison of three sites to check the pulse and count heart rate in hypotensive infants.

Paediatr Anaesth. 2006;16:394 –398.

45. Ochoa FJ, Ramalle-Gomara E, Carpintero JM, Garcia A, Saralegui I.

Competence of health professionals to check the carotid pulse.

Resuscitation. 1998;37:173–175.

46. Mather C, O’Kelly S. The palpation of pulses. Anaesthesia. 1996;51:

189 –191.

47. Olasveengen TM, Wik L, Steen PA. Standard basic life support vs.

continuous chest compressions only in out-of-hospital cardiac arrest.

Acta Anaesthesiol Scand. 2008;52:914 –919.

48. Ong ME, Ng FS, Anushia P, Tham LP, Leong BS, Ong VY, Tiah L, Lim

SH, Anantharaman V. Comparison of chest compression only and standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Singapore. Resuscitation. 2008;78:119 –126.

49. Bohm K, Rosenqvist M, Herlitz J, Hollenberg J, Svensson L. Survival is similar after standard treatment and chest compression only in out-ofhospital bystander cardiopulmonary resuscitation. Circulation. 2007;

116:2908 –2912.

50. Iwami T, Kawamura T, Hiraide A, Berg RA, Hayashi Y, Nishiuchi T,

Kajino K, Yonemoto N, Yukioka H, Sugimoto H, Kakuchi H, Sase K,

Yokoyama H, Nonogi H. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest.

Circulation. 2007;116:2900 –2907.

51. SOS-KANTO Study Group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet. 2007;369:920 –926.

52. Assar D, Chamberlain D, Colquhoun M, Donnelly P, Handley AJ,

Leaves S, Kern KB. Randomised controlled trials of staged teaching for basic life support, 1: skill acquisition at bronze stage. Resuscitation.


53. Heidenreich JW, Higdon TA, Kern KB, Sanders AB, Berg RA, Niebler

R, Hendrickson J, Ewy GA. Single-rescuer cardiopulmonary resuscitation: ‘two quick breaths’–an oxymoron. Resuscitation. 2004;62:


54. Kobayashi M, Fujiwara A, Morita H, Nishimoto Y, Mishima T, Nitta M,

Hayashi T, Hotta T, Hayashi Y, Hachisuka E, Sato K. A manikin-based observational study on cardiopulmonary resuscitation skills at the Osaka

Senri medical rally. Resuscitation. 2008;78:333–339.

55. Baskett P, Nolan J, Parr M. Tidal volumes which are perceived to be adequate for resuscitation. Resuscitation. 1996;31:231–234.

56. Ruppert M, Reith MW, Widmann JH, Lackner CK, Kerkmann R,

Schweiberer L, Peter K. Checking for breathing: evaluation of the diagnostic capability of emergency medical services personnel, physicians, medical students, and medical laypersons. Ann Emerg Med.

1999;34:720 –729.

57. Safar P, Escarraga LA, Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol. 1959;14:760 –764.

58. Perkins GD, Stephenson B, Hulme J, Monsieurs KG. Birmingham assessment of breathing study (BABS). Resuscitation. 2005;64:

109 –113.

59. Handley AJ, Handley JA. Performing chest compressions in a confined space. Resuscitation. 2004;61:55– 61.

60. Andersen LO, Isbye DL, Rasmussen LS. Increasing compression depth during manikin CPR using a simple backboard. Acta Anaesthesiol

Scand. 2007;51:747–750.

61. Perkins GD, Smith CM, Augre C, Allan M, Rogers H, Stephenson B,

Thickett DR. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care

Med. 2006;32:1632–1635.

62. Perkins GD, Kocierz L, Smith SC, McCulloch RA, Davies RP. Compression feedback devices over estimate chest compression depth when performed on a bed. Resuscitation. 2009;80:79 – 82.

63. Noordergraaf GJ, Paulussen IW, Venema A, van Berkom PF, Woerlee

PH, Scheffer GJ, Noordergraaf A. The impact of compliant surfaces on in-hospital chest compressions: effects of common mattresses and a backboard. Resuscitation. 2009;80:546 –552.

Downloaded from circ.ahajournals.org

by on December 4, 2010

S700 Circulation

November 2, 2010

64. Delvaux AB, Trombley MT, Rivet CJ, Dykla JJ, Jensen D, Smith MR,

Gilbert RJ. Design and development of a cardiopulmonary resuscitation mattress. J Intensive Care Med. 2009;24:195–199.

65. Perkins GD, Benny R, Giles S, Gao F, Tweed MJ. Do different mattresses affect the quality of cardiopulmonary resuscitation? Intensive

Care Med. 2003;29:2330 –2335.

66. Kundra P, Dey S, Ravishankar M. Role of dominant hand position during external cardiac compression. Br J Anaesth. 2000;84:491– 493.

67. Nikandish R, Shahbazi S, Golabi S, Beygi N. Role of dominant versus non-dominant hand position during uninterrupted chest compression

CPR by novice rescuers: a randomized double-blind crossover study.

Resuscitation. 2008;76:256 –260.

68. Shin J, Rhee JE, Kim K. Is the inter-nipple line the correct hand position for effective chest compression in adult cardiopulmonary resuscitation?

Resuscitation. 2007;75:305–310.

69. Kusunoki S, Tanigawa K, Kondo T, Kawamoto M, Yuge O. Safety of the inter-nipple line hand position landmark for chest compression.

Resuscitation. 2009;80:1175–1180.

70. Babbs CF, Kemeny AE, Quan W, Freeman G. A new paradigm for human resuscitation research using intelligent devices. Resuscitation.

2008;77:306 –315.

71. Edelson DP, Abella BS, Kramer-Johansen J, Wik L, Myklebust H, Barry

AM, Merchant RM, Hoek TL, Steen PA, Becker LB. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 2006;71:137–145.

72. Kramer-Johansen J, Myklebust H, Wik L, Fellows B, Svensson L,

Sorebo H, Steen PA. Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study. Resuscitation. 2006;71:283–292.

73. Edelson DP, Litzinger B, Arora V, Walsh D, Kim S, Lauderdale DS,

Vanden Hoek TL, Becker LB, Abella BS. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern

Med. 2008;168:1063–1069.

74. Talley DB, Ornato JP, Clarke AM. Computer-aided characterization and optimization of the Thumper compression waveform in closed-chest

CPR. Biomed Instrum Technol. 1990;24:283–288.

75. Handley AJ, Handley SA. Improving CPR performance using an audible feedback system suitable for incorporation into an automated external defibrillator. Resuscitation. 2003;57:57– 62.

76. Yannopoulos D, McKnite S, Aufderheide TP, Sigurdsson G, Pirrallo

RG, Benditt D, Lurie KG. Effects of incomplete chest wall decompression during cardiopulmonary resuscitation on coronary and cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation.


77. Aufderheide TP, Pirrallo RG, Yannopoulos D, Klein JP, von Briesen C,

Sparks CW, Deja KA, Kitscha DJ, Provo TA, Lurie KG. Incomplete chest wall decompression: A clinical evaluation of CPR performance by trained laypersons and an assessment of alternative manual chest compression-decompression techniques. Resuscitation. 2006;71:


78. Sutton RM, Niles D, Nysaether J, Abella BS, Arbogast KB, Nishisaki A,

Maltese MR, Donoghue A, Bishnoi R, Helfaer MA, Myklebust H,

Nadkarni V. Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents. Pediatrics. 2009;124:

494 – 499.

79. Sutton RM, Maltese MR, Niles D, French B, Nishisaki A, Arbogast KB,

Donoghue A, Berg RA, Helfaer MA, Nadkarni V. Quantitative analysis of chest compression interruptions during in-hospital resuscitation of older children and adolescents. Resuscitation. 2009;80:1259 –1263.

80. Niles D, Nysaether J, Sutton R, Nishisaki A, Abella BS, Arbogast K,

Maltese MR, Berg RA, Helfaer M, Nadkarni V. Leaning is common during in-hospital pediatric CPR, and decreased with automated corrective feedback. Resuscitation. 2009;80:553–557.

81. Aufderheide TP, Pirrallo RG, Yannopoulos D, Klein JP, von Briesen C,

Sparks CW, Deja KA, Conrad CJ, Kitscha DJ, Provo TA, Lurie KG.

Incomplete chest wall decompression: a clinical evaluation of CPR performance by EMS personnel and assessment of alternative manual chest compression-decompression techniques. Resuscitation. 2005;64:


82. Zuercher M, Hilwig RW, Ranger-Moore J, Nysaether J, Nadkarni VM,

Berg MD, Kern KB, Sutton R, Berg RA. Leaning during chest compressions impairs cardiac output and left ventricular myocardial blood flow in piglet cardiac arrest. Crit Care Med. 2010;38:1141–1146.

83. Babbs CF, Kern KB. Optimum compression to ventilation ratios in CPR under realistic, practical conditions: a physiological and mathematical analysis. Resuscitation. 2002;54:147–157.

84. Kern KB, Hilwig RW, Berg RA, Ewy GA. Efficacy of chest compression-only BLS CPR in the presence of an occluded airway.

Resuscitation. 1998;39:179 –188.

85. Abella BS, Sandbo N, Vassilatos P, Alvarado JP, O’Hearn N, Wigder

HN, Hoffman P, Tynus K, Vanden Hoek TL, Becker LB. Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest. Circulation. 2005;

111:428 – 434.

86. Wolfe JA, Maier GW, Newton JR Jr, Glower DD, Tyson GS Jr, Spratt

JA, Rankin JS, Olsen CO. Physiologic determinants of coronary blood flow during external cardiac massage. J Thorac Cardiovasc Surg. 1988;


87. Maier GW, Tyson GS Jr, Olsen CO, Kernstein KH, Davis JW, Conn EH,

Sabiston DC Jr, Rankin JS. The physiology of external cardiac massage: high-impulse cardiopulmonary resuscitation. Circulation. 1984;70:

86 –101.

88. Feneley MP, Maier GW, Kern KB, Gaynor JW, Gall SA Jr, Sanders AB,

Raessler K, Muhlbaier LH, Rankin JS, Ewy GA. Influence of compression rate on initial success of resuscitation and 24 hour survival after prolonged manual cardiopulmonary resuscitation in dogs. Circulation. 1988;77:

240 –250.

89. Halperin HR, Tsitlik JE, Guerci AD, Mellits ED, Levin HR, Shi AY,

Chandra N, Weisfeldt ML. Determinants of blood flow to vital organs during cardiopulmonary resuscitation in dogs. Circulation. 1986;73:

539 –550.

90. Handley AJ, Handley JA. The relationship between rate of chest compression and compression:relaxation ratio. Resuscitation. 1995;30:


91. Wik L, Kramer-Johansen J, Myklebust H, Sorebo H, Svensson L,

Fellows B, Steen PA. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005;293:299 –304.

92. Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O’Hearn

N, Vanden Hoek TL, Becker LB. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005;293:305–310.

93. Valenzuela TD, Kern KB, Clark LL, Berg RA, Berg MD, Berg DD, Hilwig

RW, Otto CW, Newburn D, Ewy GA. Interruptions of chest compressions during emergency medical systems resuscitation. Circulation. 2005;112:

1259 –1265.

94. Berg RA, Hilwig RW, Berg MD, Berg DD, Samson RA, Indik JH, Kern

KB. Immediate post-shock chest compressions improve outcome from prolonged ventricular fibrillation. Resuscitation. 2008;78:71–76.

95. Tang W, Snyder D, Wang J, Huang L, Chang YT, Sun S, Weil MH.

One-shock versus three-shock defibrillation protocol significantly improves outcome in a porcine model of prolonged ventricular fibrillation cardiac arrest. Circulation. 2006;113:2683–2689.

96. Garza AG, Gratton MC, Salomone JA, Lindholm D, McElroy J, Archer

R. Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest. Circulation. 2009;119:2597–2605.

97. Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA,

Richman PB, Kern KB. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA.

2008;299:1158 –1165.

98. Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M,

Zuercher M, Ewy GA. Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest. Ann

Emerg Med. 2008;52:244 –252.

99. Sayre MR, Cantrell SA, White LJ, Hiestand BC, Keseg DP, Koser S.

Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival. Prehosp Emerg Care. 2009;13:469 – 477.

100. Steinmetz J, Barnung S, Nielsen SL, Risom M, Rasmussen LS.

Improved survival after an out-of-hospital cardiac arrest using new guidelines. Acta Anaesthesiol Scand. 2008;52:908 –913.

101. Aufderheide TP, Yannopoulos D, Lick CJ, Myers B, Romig LA,

Stothert JC, Barnard J, Vartanian L, Pilgrim AJ, Benditt DG. Implementing the 2005 American Heart Association Guidelines Improves

Outcomes after Out-of-Hospital Cardiac Arrest. Heart Rhythm. 2010.

102. Hinchey PR, Myers JB, Lewis R, De Maio VJ, Reyer E, Licatese D,

Zalkin J, Snyder G. Improved Out-of-Hospital Cardiac Arrest Survival

After the Sequential Implementation of 2005 AHA Guidelines for Compressions, Ventilations, and Induced Hypothermia: The Wake County

Experience. Ann Emerg Med. 2010.

Downloaded from circ.ahajournals.org

by on December 4, 2010

Berg et al Part 5: Adult Basic Life Support


103. Jost D, Degrange H, Verret C, Hersan O, Banville IL, Chapman FW,

Lank P, Petit JL, Fuilla C, Migliani R, Carpentier JP. DEFI 2005: a randomized controlled trial of the effect of automated external defibrillator cardiopulmonary resuscitation protocol on outcome from outof-hospital cardiac arrest. Circulation. 2010;121:1614 –1622.

104. Sugerman NT, Edelson DP, Leary M, Weidman EK, Herzberg DL,

Vanden Hoek TL, Becker LB, Abella BS. Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study. Resuscitation. 2009;80:981–984.

105. Manders S, Geijsel FE. Alternating providers during continuous chest compressions for cardiac arrest: every minute or every two minutes?

Resuscitation. 2009;80:1015–1018.

106. Heidenreich JW, Berg RA, Higdon TA, Ewy GA, Kern KB, Sanders

AB. Rescuer fatigue: standard versus continuous chest-compression cardiopulmonary resuscitation. Acad Emerg Med. 2006;13:1020 –1026.

107. Dorph E, Wik L, Stromme TA, Eriksen M, Steen PA. Oxygen delivery and return of spontaneous circulation with ventilation:compression ratio

2:30 versus chest compressions only CPR in pigs. Resuscitation. 2004;

60:309 –318.

108. Berg RA, Sanders AB, Kern KB, Hilwig RW, Heidenreich JW, Porter

ME, Ewy GA. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104:


109. Berg RA, Hilwig RW, Kern KB, Ewy GA. “Bystander” chest compressions and assisted ventilation independently improve outcome from piglet asphyxial pulseless “cardiac arrest.” Circulation. 2000;101:


110. Berg RA, Kern KB, Hilwig RW, Berg MD, Sanders AB, Otto CW, Ewy

GA. Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation. Circulation.


111. Berg RA, Kern KB, Hilwig RW, Ewy GA. Assisted ventilation during

‘bystander’ CPR in a swine acute myocardial infarction model does not improve outcome. Circulation. 1997;96:4364 – 4371.

112. Vaillancourt C, Stiell IG, Wells GA. Understanding and improving low bystander CPR rates: a systematic review of the literature. CJEM.

2008;10:51– 65.

113. Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ,

Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L,

Campeau T, Dagnone E, Lyver M. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med. 2004;351:647– 656.

114. Ornato JP, Hallagan LF, McMahan SB, Peeples EH, Rostafinski AG.

Attitudes of BCLS instructors about mouth-to-mouth resuscitation during the AIDS epidemic. Ann Emerg Med. 1990;19:151–156.

115. Brenner BE, Van DC, Cheng D, Lazar EJ. Determinants of reluctance to perform CPR among residents and applicants: the impact of experience on helping behavior. Resuscitation. 1997;35:203–211.

116. Hew P, Brenner B, Kaufman J. Reluctance of paramedics and emergency medical technicians to perform mouth-to-mouth resuscitation. J Emerg Med. 1997;15:279 –284.

117. Sirbaugh PE, Pepe PE, Shook JE, Kimball KT, Goldman MJ, Ward MA,

Mann DM. A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med. 1999;33:174 –184.

118. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Compton S. CPR training and CPR performance: do CPR-trained bystanders perform

CPR? Acad Emerg Med. 2006;13:596 – 601.

119. Tang W, Weil MH, Sun S, Kette D, Gazmuri RJ, O’Connell F, Bisera

J. Cardiopulmonary resuscitation by precordial compression but without mechanical ventilation. Am J Respir Crit Care Med. 1994;150(6 pt

1):1709 –1713.

120. Bobrow BJ, Zuercher M, Ewy GA, Clark L, Chikani V, Donahue D,

Sanders AB, Hilwig RW, Berg RA, Kern KB. Gasping during cardiac arrest in humans is frequent and associated with improved survival.

Circulation. 2008;118:2550 –2554.

121. Clark JJ, Larsen MP, Culley LL, Graves JR, Eisenberg MS. Incidence of agonal respirations in sudden cardiac arrest. Ann Emerg Med. 1992;21:

1464 –1467.

122. Bang A, Herlitz J, Martinell S. Interaction between emergency medical dispatcher and caller in suspected out-of-hospital cardiac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases. Resuscitation. 2003;56:25–34.

123. Becker LB, Berg RA, Pepe PE, Idris AH, Aufderheide TP, Barnes TA,

Stratton SJ, Chandra NC. A reappraisal of mouth-to-mouth ventilation

Downloaded from circ.ahajournals.org

by on December 4, 2010 during bystander-initiated cardiopulmonary resuscitation. A statement for healthcare professionals from the Ventilation Working Group of the

Basic Life Support and Pediatric Life Support Subcommittees,

American Heart Association. Resuscitation. 1997;35:189 –201.

124. Weil MH, Rackow EC, Trevino R, Grundler W, Falk JL, Griffel MI.

Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation. N Engl J Med. 1986;315:153–156.

125. Sanders AB, Otto CW, Kern KB, Rogers JN, Perrault P, Ewy GA.

Acid-base balance in a canine model of cardiac arrest. Ann Emerg Med.

1988;17:667– 671.

126. Steen-Hansen JE. Favourable outcome after 26 minutes of “Compression only” resuscitation: a case report. Scand J Trauma Resusc

Emerg Med. 2010;18:19.

127. Berg RA, Hilwig RW, Kern KB, Babar I, Ewy GA. Simulated mouthto-mouth ventilation and chest compressions (bystander cardiopulmonary resuscitation) improves outcome in a swine model of prehospital pediatric asphyxial cardiac arrest. Crit Care Med. 1999;27:1893–1899.

128. Iglesias JM, Lopez-Herce J, Urbano J, Solana MJ, Mencia S, Del

Castillo J. Chest compressions versus ventilation plus chest compressions in a pediatric asphyxial cardiac arrest animal model. Intensive

Care Med. 2010;36:712–716.

129. Idris AH, Becker LB, Fuerst RS, Wenzel V, Rush WJ, Melker RJ, Orban

DJ. Effect of ventilation on resuscitation in an animal model of cardiac arrest. Circulation. 1994;90:3063–3069.

130. Guildner CW. Resuscitation: opening the airway. A comparative study of techniques for opening an airway obstructed by the tongue. JACEP.

1976;5:588 –590.

131. Greene DG, Elam JO, Dobkin AB, Studley CL. Cinefluorographic study of hyperextension of the neck and upper airway patency. JAMA. 1961;

176:570 –573.

132. Ruben HM, Elam JO, al. e. Investigations of pharyngeal xrays and perfomance by laymen. Anesthesiology. 1961;22:271–279.

133. Elam JO, Greene DG, Schneider MA, Ruben HM, Gordon AS, Hustead

RF, Benson DW, Clements JA, Ruben A. Head-tilt method of oral resuscitation. JAMA. 1960;172:812– 815.

134. Rhee P, Kuncir EJ, Johnson L, Brown C, Velmahos G, Martin M, Wang

D, Salim A, Doucet J, Kennedy S, Demetriades D. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma. 2006;61:1166 –1170.

135. Lowery DW, Wald MM, Browne BJ, Tigges S, Hoffman JR, Mower

WR. Epidemiology of cervical spine injury victims. Ann Emerg Med.


136. Milby AH, Halpern CH, Guo W, Stein SC. Prevalence of cervical spinal injury in trauma. Neurosurg Focus. 2008;25:E10.

137. Mithani SK, St-Hilaire H, Brooke BS, Smith IM, Bluebond-Langner R,

Rodriguez ED. Predictable patterns of intracranial and cervical spine injury in craniomaxillofacial trauma: analysis of 4786 patients. Plast

Reconstr Surg. 2009;123:1293–1301.

138. Hackl W, Hausberger K, Sailer R, Ulmer H, Gassner R. Prevalence of cervical spine injuries in patients with facial trauma. Oral Surg Oral

Med Oral Pathol Oral Radiol Endod. 2001;92:370 –376.

139. Holly LT, Kelly DF, Counelis GJ, Blinman T, McArthur DL, Cryer HG.

Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. J Neurosurg Spine.


140. Demetriades D, Charalambides K, Chahwan S, Hanpeter D, Alo K,

Velmahos G, Murray J, Asensio J. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma. 2000;48:724 –727.

141. Majernick TG, Bieniek R, Houston JB, Hughes HG. Cervical spine movement during orotracheal intubation. Ann Emerg Med. 1986;15:

417– 420.

142. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC.

Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. J Neurosurg

Spine. 2001;94:265–270.

143. Hastings RH, Wood PR. Head extension and laryngeal view during laryngoscopy with cervical spine stabilization maneuvers. Anesthesiology. 1994;

80:825– 831.

144. Gerling MC, Davis DP, Hamilton RS, Morris GF, Vilke GM, Garfin SR,

Hayden SR. Effects of cervical spine immobilization technique and laryngoscope blade selection on an unstable cervical spine in a cadaver model of intubation. Ann Emerg Med. 2000;36:293–300.

145. Wenzel V, Keller C, Idris AH, Dorges V, Lindner KH, Brimacombe

JR. Effects of smaller tidal volumes during basic life support venti-

S702 Circulation

November 2, 2010

lation in patients with respiratory arrest: good ventilation, less risk?

Resuscitation. 1999;43:25–29.

146. Dorges V, Ocker H, Hagelberg S, Wenzel V, Idris AH, Schmucker P.

Smaller tidal volumes with room-air are not sufficient to ensure adequate oxygenation during bag-valve-mask ventilation. Resuscitation.

2000;44:37– 41.

147. Dorges V, Ocker H, Hagelberg S, Wenzel V, Schmucker P. Optimisation of tidal volumes given with self-inflatable bags without additional oxygen. Resuscitation. 2000;43:195–199.

148. Finer NN, Barrington KJ, Al-Fadley F, Peters KL. Limitations of selfinflating resuscitators. Pediatrics. 1986;77:417– 420.

149. Hirschman AM, Kravath RE. Venting vs ventilating. A danger of manual resuscitation bags. Chest. 1982;82:369 –370.

150. Berg MD, Idris AH, Berg RA. Severe ventilatory compromise due to gastric distention during pediatric cardiopulmonary resuscitation.

Resuscitation. 1998;36:71–73.

151. Garnett AR, Ornato JP, Gonzalez ER, Johnson EB. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. JAMA. 1987;


152. Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite

S, von Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG.

Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109:1960 –1965.

153. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation. 2002;105:645– 649.

154. Wang HE, Simeone SJ, Weaver MD, Callaway CW. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation.

Ann Emerg Med. 2009;54:645– 652 e641.

155. Wenzel V, Idris AH, Banner MJ, Fuerst RS, Tucker KJ. The composition of gas given by mouth-to-mouth ventilation during CPR. Chest.

1994;106:1806 –1810.

156. Ruben H. The immediate treatment of respiratory failure. Br J Anaesth.


157. Bhalla RK, Corrigan A, Roland NJ. Comparison of two face masks used to deliver early ventilation to laryngectomized patients. Ear Nose Throat

J. 2004;83:414, 416.

158. Barnes TA. Emergency ventilation techniques and related equipment.

Respir Care. 1992;37:673– 690, discussion 690 – 674.

159. Johannigman JA, Branson RD, Davis K Jr, Hurst JM. Techniques of emergency ventilation: a model to evaluate tidal volume, airway pressure, and gastric insufflation. J Trauma. 1991;31:93–98.

160. Elam JO. Bag-valve-mask O

2 ventilation. In: Safar P, Elam JO, eds.

Advances in Cardiopulmonary Resuscitation: The Wolf Creek Con-

ference on Cardiopulmonary Resuscitation. New York, NY: Springer-

Verlag, Inc.; 1977:73–79.

161. Dailey R, Young G, Simon B, Stewart R. The Airway: Emergency

Management: C.V. Mosby; 1992.

162. Elling R, Politis J. An evaluation of emergency medical technicians’ ability to use manual ventilation devices. Ann Emerg Med. 1983;12:


163. von Goedecke A, Bowden K, Wenzel V, Keller C, Gabrielli A. Effects of decreasing inspiratory times during simulated bag-valve-mask ventilation. Resuscitation. 2005;64:321–325.

164. von Goedecke A, Bowden K, Keller C, Voelckel WG, Jeske HC,

Wenzel V. [Decreased inspiratory time during ventilation of an unprotected airway. Effect on stomach inflation and lung ventilation in a bench model.] Anaesthesist. 2005;54:117–122.

165. von Goedecke A, Paal P, Keller C, Voelckel WG, Herff H, Lindner KH,

Wenzel V. [Ventilation of an unprotected airway: evaluation of a new peak-inspiratory-flow and airway-pressure-limiting bag-valve-mask.]

Anaesthesist. 2006;55:629 – 634.

166. Rumball CJ, MacDonald D. The PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital comparative study of ventilatory device effectiveness and cost-effectiveness in 470 cases of cardiorespiratory arrest. Prehosp Emerg Care. 1997;1:1–10.

167. Comparison of arterial blood gases of laryngeal mask airway and bagvalve-mask ventilation in out-of-hospital cardiac arrests. Circ J. 2009;

73:490 – 496.

168. Stone BJ, Chantler PJ, Baskett PJ. The incidence of regurgitation during cardiopulmonary resuscitation: a comparison between the bag valve mask and laryngeal mask airway. Resuscitation. 1998;38:3– 6.

169. Atherton GL, Johnson JC. Ability of paramedics to use the Combitube in prehospital cardiac arrest. Ann Emerg Med. 1993;22:1263–1268.

Downloaded from circ.ahajournals.org

by on December 4, 2010

170. Kette F, Reffo I, Giordani G, Buzzi F, Borean V, Cimarosti R,

Codiglia A, Hattinger C, Mongiat A, Tararan S. The use of laryngeal tube by nurses in out-of-hospital emergencies: Preliminary experience. Resuscitation. 2005;66:21–25.

171. Timmermann A, Russo SG, Rosenblatt WH, Eich C, Barwing J,

Roessler M, Graf BM. Intubating laryngeal mask airway for difficult out-of-hospital airway management: a prospective evaluation. Br J

Anaesth. 2007;99:286 –291.

172. Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J

Med. 2006;119:335–340.

173. Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB,

Vadeboncoeur TF, Hilwig RW, Kern KB. Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med. 2009;54:656 – 662 e651.

174. McNelis U, Syndercombe A, Harper I, Duggan J. The effect of cricoid pressure on intubation facilitated by the gum elastic bougie. Anaes-

thesia. 2007;62:456 – 459.

175. Harry RM, Nolan JP. The use of cricoid pressure with the intubating laryngeal mask. Anaesthesia. 1999;54:656 – 659.

176. Noguchi T, Koga K, Shiga Y, Shigematsu A. The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet. Can J Anaesth. 2003;50:712–717.

177. Asai T, Murao K, Shingu K. Cricoid pressure applied after placement of laryngeal mask impedes subsequent fibreoptic tracheal intubation through mask. Br J Anaesth. 2000;85:256 –261.

178. Snider DD, Clarke D, Finucane BT. The “BURP” maneuver worsens the glottic view when applied in combination with cricoid pressure. Can J

Anaesth. 2005;52:100 –104.

179. Smith CE, Boyer D. Cricoid pressure decreases ease of tracheal intubation using fibreoptic laryngoscopy (WuScope System). Can J

Anaesth. 2002;49:614 – 619.

180. Asai T, Barclay K, Power I, Vaughan RS. Cricoid pressure impedes placement of the laryngeal mask airway and subsequent tracheal intubation through the mask. Br J Anaesth. 1994;72:47–51.

181. Domuracki KJ, Moule CJ, Owen H, Kostandoff G, Plummer JL.

Learning on a simulator does transfer to clinical practice. Resuscitation.

2009;80:346 –349.

182. Beavers RA, Moos DD, Cuddeford JD. Analysis of the application of cricoid pressure: implications for the clinician. J Perianesth Nurs. 2009;


183. Meek T, Gittins N, Duggan JE. Cricoid pressure: knowledge and performance amongst anaesthetic assistants. Anaesthesia. 1999;54:59 – 62.

184. Clark RK, Trethewy CE. Assessment of cricoid pressure application by emergency department staff. Emerg Med Australas. 2005;17:376 –381.

185. Kopka A, Robinson D. The 50 ml syringe training aid should be utilized immediately before cricoid pressure application. Eur J Emerg Med.


186. Flucker CJ, Hart E, Weisz M, Griffiths R, Ruth M. The 50-millilitre syringe as an inexpensive training aid in the application of cricoid pressure. Eur J Anaesthesiol. 2000;17:443– 447.

187. Shimabukuro A, Kawatani M, Nagao N, Inoue Y, Hayashida M, Hikawa

Y. [Training in application of cricoid pressure.] Masui. 2006;55:


188. Schmidt A, Akeson J. Practice and knowledge of cricoid pressure in southern Sweden. Acta Anaesthesiol Scand. 2001;45:1210 –1214.

189. Patten SP. Educating nurses about correct application of cricoid pressure. AORN J. 2006;84:449 – 461.

190. Koziol CA, Cuddeford JD, Moos DD. Assessing the force generated with application of cricoid pressure. AORN J. 2000;72:1018 –1028,


191. Clayton TJ, Vanner RG. A novel method of measuring cricoid force.

Anaesthesia. 2002;57:326 –329.

192. Owen H, Follows V, Reynolds KJ, Burgess G, Plummer J. Learning to apply effective cricoid pressure using a part task trainer. Anaesthesia.

2002;57:1098 –1101.

193. Kopka A, Crawford J. Cricoid pressure: a simple, yet effective biofeedback trainer. Eur J Anaesthesiol. 2004;21:443– 447.

194. Quigley P, Jeffrey P. Cricoid pressure: assessment of performance and effect of training in emergency department staff. Emerg Med Australas.

2007;19:218 –222.

195. The Public Access Defibrillation Trial Investigators. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med.

2004;351:637– 646.

Berg et al Part 5: Adult Basic Life Support


196. Rea TD, Cook AJ, Stiell IG, Powell J, Bigham B, Callaway CW, Chugh

S, Aufderheide TP, Morrison L, Terndrup TE, Beaudoin T, Wittwer L,

Davis D, Idris A, Nichol G. Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements. Ann Emerg Med.

2010;55:249 –257.

197. Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators. N Engl J Med. 2002;347:1242–1247.

198. Fries M, Tang W, Chang YT, Wang J, Castillo C, Weil MH. Microvascular blood flow during cardiopulmonary resuscitation is predictive of outcome. Resuscitation. 2006;71:248 –253.

199. Stiell IG, Callaway C, Davis D, Terndrup T, Powell J, Cook A,

Kudenchuk PJ, Daya M, Kerber R, Idris A, Morrison LJ, Aufderheide T.

Resuscitation Outcomes Consortium (ROC) PRIMED cardiac arrest trial methods part 2: rationale and methodology for “Analyze Later vs.

Analyze Early” protocol. Resuscitation. 2008;78:186 –195.

200. Baker PW, Conway J, Cotton C, Ashby DT, Smyth J, Woodman RJ,

Grantham H. Defibrillation or cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular fibrillation? A randomised control trial. Resuscitation. 2008;

79:424 – 431.

201. Jacobs IG, Finn JC, Oxer HF, Jelinek GA. CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial. Emerg Med Australas.

2005;17:39 – 45.

202. Wik L, Hansen TB, Fylling F, Steen T, Vaagenes P, Auestad BH, Steen

PA. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial. JAMA. 2003;289:1389 –1395.

203. Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin

M, Hallstrom AP. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.

JAMA. 1999;281:1182–1188.

204. Handley AJ. Recovery Position. Resuscitation. 1993;26:93–95.

205. Turner S, Turner I, Chapman D, Howard P, Champion P, Hatfield J,

James A, Marshall S, Barber S. A comparative study of the 1992 and

1997 recovery positions for use in the UK. Resuscitation. 1998;39:


206. Gunn BD, Eizenberg N, Silberstein M, McMeeken JM, Tully EA,

Stillman BC, Brown DJ, Gutteridge GA. How should an unconscious person with a suspected neck injury be positioned? Prehospital Disaster

Med. 1995;10:239 –244.

207. Blake WE, Stillman BC, Eizenberg N, Briggs C, McMeeken JM. The position of the spine in the recovery position–an experimental comparison between the lateral recovery position and the modified HAINES position. Resuscitation. 2002;53:289 –297.

208. WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, Brown

TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K,

Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard

V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott

MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL,

Rosamond W, Sacco R, Sorlie P, Stafford R, Thom T, Wasserthiel-

Smoller S, Wong ND, Wylie-Rosett J. Committee obotAHAS, Stroke

Statistics Subcommittee. Heart Disease and Stroke Statistics–2010

Update: A Report From the American Heart Association. Circulation.

2010;121:e46 – e215.

209. Chiriboga D, Yarzebski J, Goldberg RJ, Gore JM, Alpert JS. Temporal trends (1975 through 1990) in the incidence and case-fatality rates of primary ventricular fibrillation complicating acute myocardial infarction: a communitywide perspective. Circulation. 1994;89:

998 –1003.

210. Anderson JL, Karagounis LA, Califf RM. Metaanalysis of five reported studies on the relation of early coronary patency grades with mortality and outcomes after acute myocardial infarction. Am J Cardiol. 1996;

78:1– 8.

211. Raitt MH, Maynard C, Wagner GS, Cerqueira MD, Selvester RH,

Weaver WD. Relation between symptom duration before thrombolytic therapy and final myocardial infarct size. Circulation. 1996;93:48 –53.

212. Douglas PS, Ginsburg GS. The evaluation of chest pain in women.

N Engl J Med. 1996;334:1311–1315.

213. Solomon CG, Lee TH, Cook EF, Weisberg MC, Brand DA, Rouan GW,

Goldman L. Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: the

Multicenter Chest Pain Study experience. Am J Cardiol. 1989;63:


214. Peberdy MA, Ornato JP. Coronary artery disease in women. Heart Dis

Stroke. 1992;1:315–319.

Downloaded from circ.ahajournals.org

by on December 4, 2010

215. Body R, Carley S, Wibberley C, McDowell G, Ferguson J,

Mackway-Jones K. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81:


216. Goodacre SW, Angelini K, Arnold J, Revill S, Morris F. Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain. QJM. 2003;96:893– 898.

217. Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad

Emerg Med. 2002;9:203–208.

218. Everts B, Karlson BW, Wahrborg P, Hedner T, Herlitz J. Localization of pain in suspected acute myocardial infarction in relation to final diagnosis, age and sex, and site and type of infarction. Heart Lung.

1996;25:430 – 437.

219. McSweeney JC, Cody M, O’Sullivan P, Elberson K, Moser DK, Garvin

BJ. Women’s early warning symptoms of acute myocardial infarction.

Circulation. 2003;108:2619 –2623.

220. Panju AA, BR Hemmelgarn, GG Guyatt, DL Simel. Is this patient having a myocardial infarction? JAMA. 1998;280:1256 –1263.

221. Mant J, McManus RJ, Oakes RA, Delaney BC, Barton PM, Deeks JJ,

Hammersley L, Davies RC, Davies MK, Hobbs FD. Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care. Health Technol Assess. 2004;8:iii,1–158.

222. Berger JP, Buclin T, Haller E, Van Melle G, Yersin B. Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain. J Intern Med.


223. Jonsbu J, Rollag A, Aase O, Lippestad CT, Arnesen KE, Erikssen J,

Koss A. Rapid and correct diagnosis of myocardial infarction: standardized case history and clinical examination provide important information for correct referral to monitored beds. J Intern Med. 1991;229:


224. Hargarten KM, Aprahamian C, Stueven H, Olson DW, Aufderheide TP,

Mateer JR. Limitations of prehospital predictors of acute myocardial infarction and unstable angina. Ann Emerg Med. 1987;16:1325–1329.

225. Herlitz J, Hansson E, Ringvall E, Starke M, Karlson BW, Waagstein L.

Predicting a life-threatening disease and death among ambulancetransported patients with chest pain or other symptoms raising suspicion of an acute coronary syndrome. Am J Emerg Med. 2002;20:588 –594.

226. Lee TH, Pearson SD, Johnson PA, Garcia TB, Weisberg MC, Guadagnoli E, Cook EF, Goldman L. Failure of information as an intervention to modify clinical management. A time-series trial in patients with acute chest pain. Ann Intern Med. 1995;122:434 – 437.

227. Henrikson CA, Howell EE, Bush DE, Miles JS, Meininger GR, Friedlander T, Bushnell AC, Chandra-Strobos N. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med.

2003;139:979 –986.

228. Lee TH, Rouan GW, Weisberg MC, Brand DA, Acampora D, Stasiulewicz C, Walshon J, Terranova G, Gottlieb L, Goldstein-Wayne B, et al. Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J

Cardiol. 1987;60:219 –224.

229. Freimark D, Matetzky S, Leor J, Boyko V, Barbash IM, Behar S, Hod

H. Timing of aspirin administration as a determinant of survival of patients with acute myocardial infarction treated with thrombolysis.

Am J Cardiol. 2002;89:381–385.

230. Barbash IM, Freimark D, Gottlieb S, Hod H, Hasin Y, Battler A, Crystal

E, Matetzky S, Boyko V, Mandelzweig L, Behar S, Leor J. Outcome of myocardial infarction in patients treated with aspirin is enhanced by pre-hospital administration. Cardiology. 2002;98:141–147.

231. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction:

ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet. 1988;2:349 –360.

232. Casaccia M, Bertello F, De Bernardi A, Sicuro M, Scacciatella P.

Prehospital management of acute myocardial infarct in an experimental metropolitan system of medical emergencies [in Italian]. G Ital Cardiol.

1996;26:657– 672.

233. Quan D, LoVecchio F, Clark B, Gallagher JV III. Prehospital use of aspirin rarely is associated with adverse events. Prehosp Disaster Med.


234. Verheugt FW, van der Laarse A, Funke-Kupper AJ, Sterkman LG,

Galema TW, Roos JP. Effects of early intervention with low-dose

S704 Circulation

November 2, 2010

aspirin (100 mg) on infarct size, reinfarction and mortality in anterior wall acute myocardial infarction. Am J Cardiol. 1990;66:267–270.

235. Le May MR, So DY, Dionne R, Glover CA, Froeschl MP, Wells GA,

Davies RF, Sherrard HL, Maloney J, Marquis JF, O’Brien ER, Trickett

J, Poirier P, Ryan SC, Ha A, Joseph PG, Labinaz M. A citywide protocol for primary PCI in ST-segment elevation myocardial infarction. N Engl

J Med. 2008;358:231–240.

236. Stenestrand U, Lindback J, Wallentin L. Long-term outcome of primary percutaneous coronary intervention vs prehospital and in-hospital thrombolysis for patients with ST-elevation myocardial infarction.

JAMA. 2006;296:1749 –1756.

237. Le May MR, Davies RF, Dionne R, Maloney J, Trickett J, So D, Ha A,

Sherrard H, Glover C, Marquis JF, O’Brien ER, Stiell IG, Poirier P,

Labinaz M. Comparison of early mortality of paramedic-diagnosed

ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital. Am J Cardiol.

2006;98:1329 –1333.

238. Wijesinghe M, Perrin K, Ranchord A, Simmonds M, Weatherall M,

Beasley R. Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart. 2009;95:198 –202.

239. Haynes BE, Pritting J. A rural emergency medical technician with selected advanced skills. Prehosp Emerg Care. 1999;3:343–346.

240. Funk D, Groat C, Verdile VP. Education of paramedics regarding aspirin use. Prehosp Emerg Care. 2000;4:62– 64.

241. Bussmann WD, Passek D, Seidel W, Kaltenbach M. Reduction of CK and CK-MB indexes of infarct size by intravenous nitroglycerin.

Circulation. 1981;63:615– 622.

242. Charvat J, Kuruvilla T, al Amad H. Beneficial effect of intravenous nitroglycerin in patients with non-Q myocardial infarction. Cardiologia.

1990;35:49 –54.

243. Jugdutt BI, Warnica JW. Intravenous nitroglycerin therapy to limit myocardial infarct size, expansion, and complications. Effect of timing, dosage, and infarct location. Circulation. 1988;78:906 –919.

244. Madsen JK, Chevalier B, Darius H, Rutsch W, Wojcik J, Schneider S,

Allikmets K. Ischaemic events and bleeding in patients undergoing percutaneous coronary intervention with concomitant bivalirudin treatment. EuroIntervention. 2008;3:610 – 616.

245. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van

Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK,

Fonarow GC, Ho PM, Lauer MS, Masoudi FA, Robertson RM, Roger V,

Schwamm LH, Sorlie P, Yancy CW, Rosamond WD. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. 2010;121:586 – 613.

246. Grotta JC, Chiu D, Lu M, Patel S, Levine SR, Tilley BC, Brott TG,

Haley EC Jr, Lyden PD, Kothari R, Frankel M, Lewandowski CA,

Libman R, Kwiatkowski T, Broderick JP, Marler JR, Corrigan J, Huff S,

Mitsias P, Talati S, Tanne D. Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy. Stroke. 1999;30:1528 –1533.

247. Ingall TJ, O’Fallon WM, Asplund K, Goldfrank LR, Hertzberg VS,

Louis TA, Christianson TJ. Findings from the reanalysis of the NINDS tissue plasminogen activator for acute ischemic stroke treatment trial.

Stroke. 2004;35:2418 –2424.

248. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D,

Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer

R, Wahlgren N, Toni D. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317–1329.

249. Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP,

Brott T, Frankel M, Grotta JC, Haley EC Jr, Kwiatkowski T, Levine SR,

Lewandowski C, Lu M, Lyden P, Marler JR, Patel S, Tilley BC, Albers

G, Bluhmki E, Wilhelm M, Hamilton S. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and

NINDS rt-PA stroke trials. Lancet. 2004;363:768 –774.

250. Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass

LM, Koroshetz W, Marler JR, Booss J, Zorowitz RD, Croft JB, Magnis

E, Mulligan D, Jagoda A, O’Connor R, Cawley CM, Connors JJ,

Rose-DeRenzy JA, Emr M, Warren M, Walker MD. Recommendations for comprehensive stroke centers: a consensus statement from the Brain

Attack Coalition. Stroke. 2005;36:1597–1616.

251. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg

MR, Starke RD, Todd HW, Viste KM, Girgus M, Shephard T, Emr M,

Shwayder P, Walker MD. Recommendations for the establishment of

Downloaded from circ.ahajournals.org

by on December 4, 2010 primary stroke centers. Brain Attack Coalition. JAMA. 2000;283:


252. Barsan WG, Brott TG, Olinger CP, Adams HP Jr, Haley EC Jr, Levy

DE. Identification and entry of the patient with acute cerebral infarction.

Ann Emerg Med. 1988;17:1192–1195.

253. Barsan WG, Brott TG, Broderick JP, Haley EC, Levy DE, Marler JR.

Time of hospital presentation in patients with acute stroke. Arch Intern

Med. 1993;153:2558 –2561.

254. Morgenstern LB, Bartholomew LK, Grotta JC, Staub L, King M, Chan

W. Sustained benefit of a community and professional intervention to increase acute stroke therapy. Arch Intern Med. 2003;163:2198 –2202.

255. Scott PA. Enhancing community delivery of tissue plasminogen activator in stroke through community-academic collaborative clinical knowledge translation. Emerg Med Clin North Am. 2009;27:115–136, ix.

256. Kleindorfer D, Khoury J, Broderick JP, Rademacher E, Woo D, Flaherty

ML, Alwell K, Moomaw CJ, Schneider A, Pancioli A, Miller R, Kissela

BM. Temporal trends in public awareness of stroke: warning signs, risk factors, and treatment. Stroke. 2009;40:2502–2506.

257. Smith WS, Isaacs M, Corry MD. Accuracy of paramedic identification of stroke and transient ischemic attack in the field. Prehosp Emerg Care.

1998;2:170 –175.

258. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field. Prospective validation of the Los Angeles prehospital stroke screen (LAPSS). Stroke. 2000;31:71–76.

259. Smith WS, Corry MD, Fazackerley J, Isaacs SM. Improved paramedic sensitivity in identifying stroke victims in the prehospital setting.

Prehosp Emerg Care. 1999;3:207–210.

260. Kim SK, Lee SY, Bae HJ, Lee YS, Kim SY, Kang MJ, Cha JK.

Pre-hospital notification reduced the door-to-needle time for iv t-PA in acute ischaemic stroke. Eur J Neurol. 2009;16:1331–1335.

261. Quain DA, Parsons MW, Loudfoot AR, Spratt NJ, Evans MK, Russell

ML, Royan AT, Moore AG, Miteff F, Hullick CJ, Attia J, McElduff P,

Levi CR. Improving access to acute stroke therapies: a controlled trial of organised pre-hospital and emergency care. Med J Aust. 2008;189:

429 – 433.

262. Abdullah AR, Smith EE, Biddinger PD, Kalenderian D, Schwamm LH.

Advance hospital notification by EMS in acute stroke is associated with shorter door-to-computed tomography time and increased likelihood of administration of tissue-plasminogen activator. Prehosp Emerg Care.

2008;12:426 – 431.

263. Gropen TI, Gagliano PJ, Blake CA, Sacco RL, Kwiatkowski T,

Richmond NJ, Leifer D, Libman R, Azhar S, Daley MB. Quality improvement in acute stroke: the New York State Stroke Center Designation Project. Neurology. 2006;67:88 –93.

264. Gladstone DJ, Rodan LH, Sahlas DJ, Lee L, Murray BJ, Ween JE, Perry

JR, Chenkin J, Morrison LJ, Beck S, Black SE. A citywide prehospital protocol increases access to stroke thrombolysis in Toronto. Stroke.


265. Langhorne P, Tong BL, Stott DJ. Association between physiological homeostasis and early recovery after stroke. Stroke. 2000;31:

2518 –2519.

266. National Center for Injury Prevention and Control Web-based Injury

Statistics Query and Reporting System (WISQARS). Centers for

Disease Control and Prevention. Available at: http://www.cdc.gov/ injury/wisqars/index.html.

267. Youn CS, Choi SP, Yim HW, Park KN. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from

St. Mary’s Hospital. Resuscitation. 2009;80:778 –783.

268. Suominen P, Baillie C, Korpela R, Rautanen S, Ranta S, Olkkola KT.

Impact of age, submersion time and water temperature on outcome in near-drowning. Resuscitation. 2002;52:247–254.

269. Perkins GD. In-water resuscitation: a pilot evaluation. Resuscitation.


270. Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in near-drowning: Institute of Medicine report. J Emerg Med. 1995;13:

397– 405.

271. Watson RS, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine injuries among submersion victims. J Trauma. 2001;51:658 – 662.

272. Hwang V, Shofer FS, Durbin DR, Baren JM. Prevalence of traumatic injuries in drowning and near drowning in children and adolescents.

Arch Pediatr Adolesc Med. 2003;157:50 –53.

273. Fingerhut LA, Cox CS. Warner M International comparative analysis of injury mortality. Findings from the ICE on injury statistics. International

Collaborative Effort on Injury Statistics. Adv Data. 1998(303):1–20.

Berg et al Part 5: Adult Basic Life Support


274. Dolkas L, Stanley C, Smith AM, Vilke GM. Deaths associated with choking in San Diego county. J Forensic Sci. 2007;52:176 –179.

275. Soroudi A, Shipp HE, Stepanski BM, Ray LU, Murrin PA, Chan TC,

Davis DP, Vilke GM. Adult foreign body airway obstruction in the prehospital setting. Prehosp Emerg Care. 2007;11:25–29.

276. Redding JS. The choking controversy: critique of evidence on the

Heimlich maneuver. Crit Care Med. 1979;7:475– 479.

277. Vilke GM, Smith AM, Ray LU, Steen PJ, Murrin PA, Chan TC. Airway obstruction in children aged less than 5 years: the prehospital experience. Prehosp Emerg Care. 2004;8:196 –199.

278. Ingalls TH. Heimlich versus a slap on the back. N Engl J Med. 1979;


279. Heimlich HJ, Hoffmann KA, Canestri FR. Food-choking and drowning deaths prevented by external subdiaphragmatic compression. Physiological basis. Ann Thorac Surg. 1975;20:188 –195.

280. Boussuges S, Maitrerobert P, Bost M. [Use of the Heimlich Maneuver on children in the Rhone-Alpes area.] Arch Fr Pediatr. 1985;42:


281. Guildner CW, Williams D, Subitch T. Airway obstructed by foreign material: the Heimlich maneuver. JACEP. 1976;5:675– 677.

282. Langhelle A, Sunde K, Wik L, Steen PA. Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with complete airway obstruction. Resuscitation. 2000;44:105–108.

283. Ruben H, Macnaughton FI. The treatment of food-choking. Practitioner.


284. Brauner DJ. The Heimlich maneuver: procedure of choice? J Am Geriatr

Soc. 1987;35:78.

285. Hartrey R, Bingham RM. Pharyngeal trauma as a result of blind finger sweeps in the choking child. J Accid Emerg Med. 1995;12:52–54.

286. Kabbani M, Goodwin SR. Traumatic epiglottis following blind finger sweep to remove a pharyngeal foreign body. Clin Pediatr (Phila).

1995;34:495– 497.

287. Rea TD, Stickney RE, Doherty A, Lank P. Performance of chest compressions by laypersons during the Public Access Defibrillation Trial.

Resuscitation. 2010;81:293–296.

288. Chiang WC, Chen WJ, Chen SY, Ko PC, Lin CH, Tsai MS, Chang WT,

Chen SC, Tsan CY, Ma MH. Better adherence to the guidelines during cardiopulmonary resuscitation through the provision of audio-prompts.

Resuscitation. 2005;64:297–301.

289. Kern KB, Sanders AB, Raife J, Milander MM, Otto CW, Ewy GA. A study of chest compression rates during cardiopulmonary resuscitation in humans: the importance of rate-directed chest compressions. Arch

Intern Med. 1992;152:145–149.

290. Berg RA, Sanders AB, Milander M, Tellez D, Liu P, Beyda D. Efficacy of audio-prompted rate guidance in improving resuscitator performance of cardiopulmonary resuscitation on children. Acad Emerg Med. 1994;

1:35– 40.

291. Abella BS, Edelson DP, Kim S, Retzer E, Myklebust H, Barry AM,

O’Hearn N, Hoek TL, Becker LB. CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system.

Resuscitation. 2007;73:54 – 61.

292. Fletcher D, Galloway R, Chamberlain D, Pateman J, Bryant G,

Newcombe RG. Basics in advanced life support: a role for download audit and metronomes. Resuscitation. 2008;78:127–134.

293. Gruben KG, Romlein J, Halperin HR, Tsitlik JE. System for mechanical measurements during ardiopulmonary resuscitation in humans. IEEE

Trans Biomed Eng. 1990;37:204 –210.

294. Nishisaki A, Nysaether J, Sutton R, Maltese M, Niles D, Donoghue A,

Bishnoi R, Helfaer M, Perkins GD, Berg R, Arbogast K, Nadkarni V.

Effect of mattress deflection on CPR quality assessment for older children and adolescents. Resuscitation. 2009;80:540 –545.





: cardiacarrest

䡲 defibrillation

䡲 emergency

Downloaded from circ.ahajournals.org

by on December 4, 2010

Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Download PDF