This Algorithm pertains to adults and pediatrics (infants [< 1 yr] and children [1 yr – 12 to14 yrs; puberty]. All notes pertain to adults, unless otherwise indicated.
- (1) Assess for Safety and Response – First ensure scene is safe. Suspected head or neck injury: do not shake; move only if necessary.
- (2) Assess Breathing and Pulse – While assessing for response, quickly distinguish adequate from inadequate (weak or agonal [reflex gasping]) breathing.
New 2015 Guidelines: Check for pulse at the same time to reduce the time to first chest compression (see Step 5)
Total time to check both breathing and pulse: < 10 sec
Integrated teams of highly trained rescuers may use a choreographed approach that accomplishes multiple steps and assessments simultaneously rather than the sequential manner used by individual rescuers (eg, one rescuer activates the emergency response system while another begins chest compressions, a third either provides ventilation or retrieves the bag-mask device for rescue breaths, and a fourth retrieves and sets up a defibrillator).
- (3) Activate Code (or EMS) and get AED
1 Rescuer – Activate code, get AED (If readily available; use as appropriate (See AED section), then begin CPR
2 Rescuers – One rescuer begins CPR, while the other activates the code (or EMS) and retrieves an AED (if available).
- Shockable rhythm (child and adult only)
- Give 1 shock, immediately resume CPR (beginning with compressions), do not check pulse.
- After 5 cycles, analyze rhythm, deliver another shock if indicated.
Infants (< 1 yr) – For infants (<1 year of age), a manual defibrillator is preferred. If a manual defibrillator is not available, an AED with pediatric dose attenuation is desirable. If neither is available, an AED without a dose attenuator may be used
Children – 2 – 4 J/kg first attempt; at least 4 J/kg subsequent attempts not to exceed 10 J/kg or the adult maximum dose.
Ages 1- 8 yrs – use pediatric dose-attenuator system, if available (See AED section)
- (4) Current guidelines recommend differentiating between Cardiac Arrest (Sudden Collapse) and Suspected Asphyxia (such as drowning). For Suspected/Presumed asphyxia, the priority is CPR: therefore provide chest compressions with rescue breathing for 5 cycles (2 minutes) before calling EMS.
- (5) Check Pulse – Take no less than 5, but no more than 10 sec (This step should ideally be incorporated with Step 2 – check pulse while checking for breathing).
Adult/child: use carotid or femoral
Infant < 1 yr: use brachial
If no pulse (or not confident) or child/infant < 60/min and poor perfusion: provide chest
If definite pulse: ventilate as needed ventilation rates are rescue breaths only, NOT CPR RATES
Adult: 10-12/min (q 5-6 sec)
Child/Infant: 12-20/min (q 3-5 sec)
(6) Chest Compressions – Equal compression/relaxation ratio. Allow chest to return to normal position without lifting hands from chest.
(i.e., avoid leaning on the chest between compressions)
Reason: allows for refilling of heart chambers with blood.
Rate: 100 to 120 per minute
Depth: 2 – 2.4 inches (5 – 6 cm)
Minimize the frequency and duration of interruptions in compressions to maximize the number of compressions delivered per minute.
Unsecured airway – Pause compressions for ventilations. Begin compressions at peak inspiration of 2nd breath.
Secured airway – Do not pause or synchronize for ventilations.
Note: Do not monitor and/or gauge chest compression force as adequate by palpable carotid or femoral pulse (may be venous).
Two rescuers should change compressor/ventilator roles approximately every 2 minutes (5 cycles)to prevent tiring (increases risk of ineffective compressions)
- (7) Position –
Victim: supine, arms alongside on firm, flat surface. Move head, shoulders, and torso as one unit without twisting.
Rescuer: kneeling beside victim’s thorax (Fig 13).
(8) Open Airway –
- Head tilt – chin lift: preferred when no evidence of head or neck trauma (Fig 1).
- Jaw thrust: use when suspect cervical spine injury. Do not tilt head back or sideways (Fig 2). Use spinal motion restriction rather than immobilization devices. Note: if jaw thrust does not open the airway: use head tilt – chin lift.
- Open mouth and remove any visible foreign material, vomitus, or loose dentures (Fig 20). A blind finger sweep is no longer recommended because of the risk of pushing a foreign body further into the airway.
• (9) Provide Breathing – Avoid large, rapid or forceful breaths. Do not deliver more volume or force than is needed to produce visible chest rise. Use mouth to mouth/nose for infants (See ACLS Section)
For patients with ongoing CPR and an advanced airway in place, a simplified ventilation rate of 1 breath every 6 seconds (10 breaths per minute) is recommended.
• (10) Recovery Position –
Unresponsive victims with normal breathing and effective circulation. Place victim as near as possible to a true and stable lateral position (lower arm in front of body) with head dependent, no pressure on chest, and good observation/access to airway (Fig 3).
Suspected spinal injury: move to recovery position only if open airway cannot be maintained (eg., lone rescuer must leave victim to get help). May opt for lower arm above head, with head on arm and knees bent.