Part 3: Overview of CPR

Circulation 2005;112;IV-12-IV-18; originally published online Nov 28, 2005;

DOI: 10.1161/CIRCULATIONAHA.105.166552
Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX
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 Part 3: Overview of CPR

W e have always known that CPR is not a single skill but a

series of assessments and interventions. More recently
we have become aware that cardiac arrest is not a single problem
some blood to the coronary arteries and brain.18,19 CPR is also
important immediately after shock delivery; most victims
demonstrate asystole or pulseless electrical activity (PEA) for
and that the steps of CPR may need to vary depending on the several minutes after defibrillation. CPR can convert these
type or etiology of the cardiac arrest. At the 2005 Consensus rhythms to a perfusing rhythm.20 22
Conference researchers debated all aspects of detection and Not all adult deaths are due to SCA and VF. An unknown
treatment of cardiac arrest. Yet the last summation returned to number have an asphyxial mechanism, as in drowning or drug
the beginning question: how do we get more bystanders and overdose. Asphyxia is also the mechanism of cardiac arrest in
healthcare providers to learn CPR and perform it well? most children, although about 5% to 15% have VF.2325
Studies in animals have shown that the best results for
Epidemiology resuscitation from asphyxial arrest are obtained by a combi-
Sudden cardiac arrest (SCA) is a leading cause of death in the nation of chest compressions and ventilations, although chest
United States and Canada.13 Although estimates of the compressions alone are better than doing nothing.26,27
annual number of deaths due to out-of-hospital SCA vary
widely,1,2,4,5 data from the Centers for Disease Control and Differences in CPR Recommendations by Age
Prevention estimates that in the United States approximately of Victim and Rescuer
330 000 people die annually in the out-of-hospital and emer-
gency department settings from coronary heart disease. About Simplification
250 000 of these deaths occur in the out-of-hospital setting.1,6 The authors of the 2005 AHA Guidelines for CPR and ECC
The annual incidence of SCA in North America is 0.55 per simplified the BLS sequences, particularly for lay rescuers, to
1000 population.3,4 minimize differences in the steps and techniques of CPR used
for infant, child, and adult victims. For the first time, a
Cardiac Arrest and the Chain of Survival universal compression-ventilation ratio (30:2) is recom-
Most victims of SCA demonstrate ventricular fibrillation (VF) at mended for all single rescuers of infant, child, and adult
some point in their arrest.35 Several phases of VF have been victims (excluding newborns).
described,7 and resuscitation is most successful if defibrillation is Some skills (eg, rescue breathing without chest compres-
performed in about the first 5 minutes after collapse. Because the sions) will no longer be taught to lay rescuers. The goal of
interval between call to the emergency medical services (EMS) these changes is to make CPR easier for all rescuers to learn,
system and arrival of EMS personnel at the victims side is remember, and perform.
typically longer than 5 minutes,8 achieving high survival rates
depends on a public trained in CPR and on well-organized Differences in CPR for Lay Rescuers and
public access defibrillation programs.9,10 The best results of lay Healthcare Providers
rescuer CPR and automated external defibrillation programs Differences between lay rescuer and healthcare provider CPR
have occurred in controlled environments, with trained, moti- skills include the following:
vated personnel, a planned and practiced response, and short Lay rescuers should immediately begin cycles of chest
response times. Examples of such environments are airports,9 compressions and ventilations after delivering 2 rescue
airlines,11 casinos,12 and hospitals (see Part 4: Adult Basic Life breaths for an unresponsive victim. Lay rescuers are not
Support). Significant improvement in survival from out-of- taught to assess for pulse or signs of circulation for an
hospital VF SCA also has been reported in well-organized police unresponsive victim.
CPR and AED rescuer programs.13 Lay rescuers will not be taught to provide rescue breathing
CPR is important both before and after shock delivery. without chest compressions.
When performed immediately after collapse from VF SCA, The lone healthcare provider should alter the sequence of
CPR can double or triple the victims chance of survival.14 17
rescue response based on the most likely etiology of the
CPR should be provided until an automated external defibril-
victims problem.
lator (AED) or manual defibrillator is available. After about 5
For sudden, collapse in victims of all ages, the lone
minutes of VF with no treatment, outcome may be better if
healthcare provider should telephone the emergency
shock delivery (attempted defibrillation) is preceded by a
response number and get an AED (when readily avail-
period of CPR with effective chest compressions that deliver
able) and then return to the victim to begin CPR and use
the AED.
(Circulation. 2005;112:IV-12-IV-18.) For unresponsive victims of all ages with likely asphyx-
2005 American Heart Association.
ial arrest (eg, drowning) the lone healthcare provider
This special supplement to Circulation is freely available at should deliver about 5 cycles (about 2 minutes) of CPR
http://www.circulationaha.org
before leaving the victim to telephone the emergency
DOI: 10.1161/CIRCULATIONAHA.105.166552 response number and get the AED. The rescuer should
IV-12 by on September 21, 2010
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 Part 3: Overview of CPR IV-13

then return to the victim, begin the steps of CPR, and Child CPR guidelines for healthcare providers apply to
use the AED. victims from about 1 year of age to the onset of adolescence
After delivery of 2 rescue breaths, healthcare providers or puberty (about 12 to 14 years of age) as defined by the
should attempt to feel a pulse in the unresponsive, non- presence of secondary sex characteristics. Hospitals (partic-
breathing victim for no more than 10 seconds. If the ularly childrens hospitals) or pediatric intensive care units
provider does not definitely feel a pulse within 10 seconds, may choose to extend the use of Pediatric Advanced Life
the provider should begin cycles of chest compressions and Support (PALS) guidelines to pediatric patients of all ages
ventilations. (generally up to about 16 to 18 years of age) rather than use
Healthcare providers will be taught to deliver rescue onset of puberty for the application of ACLS versus PALS
breaths without chest compressions for the victim with guidelines.
respiratory arrest and a perfusing rhythm (ie, pulses).
Rescue breaths without chest compressions should be Use of AED and Defibrillation for the Child
delivered at a rate of about 10 to 12 breaths per minute for When treating a child found in cardiac arrest in the out-of-
the adult and a rate of about 12 to 20 breaths per minute for hospital setting, lay rescuers and healthcare providers should
the infant and child. provide about 5 cycles (about 2 minutes) of CPR before
Healthcare providers should deliver cycles of compres- attaching an AED. This recommendation is consistent with
sions and ventilations during CPR when there is no the recommendation published in 2003.29 As noted above,
advanced airway (eg, endotracheal tube, laryngeal mask most cardiac arrests in children are not caused by ventricular
airway [LMA], or esophageal-tracheal combitube [Combi- arrhythmias. Immediate attachment and operation of an AED
tube]) in place. Once an advanced airway is in place for (with hands-off time required for rhythm analysis) will delay
infant, child, or adult victims, 2 rescuers no longer deliver or interrupt provision of rescue breathing and chest compres-
cycles of compressions interrupted with pauses for ven- sions for victims who are most likely to benefit from them.
If a healthcare provider witnesses a sudden collapse of a
tilation. Instead, the compressing rescuer should deliver
child, the healthcare provider should use an AED as soon as
100 compressions per minute continuously, without pauses
it is available.
for ventilation. The rescuer delivering the ventilations
There is no recommendation for or against the use of AEDs
should give 8 to 10 breaths per minute and should be
for infants (1 year of age).
careful to avoid delivering an excessive number of venti-
Rescuers should use a pediatric dose-attenuating system,
lations. The 2 rescuers should change compressor and
when available, for children 1 to 8 years of age. These
ventilator roles approximately every 2 minutes to prevent
pediatric systems are designed to deliver a reduced shock
compressor fatigue and deterioration in quality and rate of
dose that is appropriate for victims up to about 8 years of age
chest compressions. When multiple rescuers are present,
(about 25 kg [55 pounds] in weight or about 127 cm [50
they should rotate the compressor role about every 2
inches] in length). A conventional AED (without pediatric
minutes. The switch should be accomplished as quickly as
attenuator system) should be used for children about 8 years
possible (ideally in less than 5 seconds) to minimize
of age and older (larger than about 25 kg [55 pounds] in
interruptions in chest compressions.
weight or about 127 cm [50 inches] in length) and for adults.
A pediatric attenuating system should not be used for victims
Age Delineation 8 years of age and older because the energy dose (ie, shock)
Differences in the etiology of cardiac arrest between child
delivered through the pediatric system is likely to be inade-
and adult victims necessitate some differences in the recom- quate for an older child, adolescent, or adult.
mended resuscitation sequence for infant and child victims For in-hospital resuscitation, rescuers should begin CPR
compared with the sequence used for adult victims. Because immediately and use an AED or manual defibrillator as soon
there is no single anatomic or physiologic characteristic that as it is available. If a manual defibrillator is used, a defibril-
distinguishes a child victim from an adult victim and no lation dose of 2 J/kg is recommended for the first shock and
scientific evidence that identifies a precise age to initiate a dose of 4 J/kg for the second and subsequent shocks.
adult rather than child CPR techniques, the ECC scientists
made a consensus decision for age delineation that is based Sequence
largely on practical criteria and ease of teaching. If more than one person is present at the scene of a cardiac
In these 2005 guidelines the recommendations for newborn arrest, several actions can occur simultaneously. One or more
CPR apply to newborns in the first hours after birth until the trained rescuers should remain with the victim to begin the
newborn leaves the hospital. Infant CPR guidelines apply to steps of CPR while another bystander phones the emergency
victims less than approximately 1 year of age. response system and retrieves an AED (if available). If a lone
Child CPR guidelines for the lay rescuer apply to children rescuer is present, then the sequences of actions described
about 1 to 8 years of age, and adult guidelines for the lay below are recommended. These sequences are described in
rescuer apply to victims about 8 years of age and older. To more detail in Part 4: Adult Basic Life Support, Part 5:
simplify learning for lay rescuers retraining in CPR and AED Electrical Therapies, and Part 11: Pediatric Basic Life
apropos the 2005 guidelines, the same age divisions for Support.
children are used in the 2005 guidelines as in the ECC For the unresponsive adult, the lay rescuer sequence of
Guidelines 2000.28 action is as follows:
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IV-14 Circulation December 13, 2005

The lone rescuer should telephone the emergency response Rescue Breaths
system and retrieve an AED (if available). The rescuer Each rescue breath should be delivered in 1 second and
should then return to the victim to begin CPR and use the should produce visible chest rise. Other new recommenda-
AED when appropriate. tions for rescue breaths are these:
The lay rescuer should open the airway and check for
Healthcare providers should take particular care to provide
normal breathing. If no normal breathing is detected, the
effective breaths in infants and children because asphyxial
rescuer should give 2 rescue breaths.
arrest is more common than sudden cardiac arrest in infants
Immediately after delivery of the rescue breaths, the rescuer
and children. To ensure that a rescue breath is effective, it
should begin cycles of 30 chest compressions and 2
may be necessary to reopen the airway and reattempt
ventilations and use an AED as soon as it is available. ventilation. The rescuer may need to try a couple of times
For the unresponsive infant or child, the lay rescuer to deliver 2 effective breaths for the infant and child.
When rescue breaths are provided without chest compres-
sequence for action is as follows:
sions to the victim with a pulse, the healthcare provider
The rescuer will open the airway and check for breathing; should deliver 12 to 20 breaths per minute for an infant or
if no breathing is detected, the rescuer should give 2 child and 10 to 12 breaths per minute for an adult.
breaths that make the chest rise. As noted above, once an advanced airway is in place (eg,
The rescuer should provide 5 cycles (a cycle is 30 com- endotracheal tube, Combitube, LMA) during 2-rescuer CPR,
pressions and 2 breaths) of CPR (about 2 minutes) before the compressor should provide 100 compressions per minute
leaving the pediatric victim to phone 911 and get an AED without pausing for ventilation, and the rescuer delivering
for the child if available. The reasons for immediate breaths should deliver 8 to 10 breaths per minute.
provision of CPR are that asphyxial arrest (including
primary respiratory arrest) is more common than sudden Chest Compressions
Both lay rescuers and healthcare providers should deliver
cardiac arrest in children, and the child is more likely to
chest compressions that depress the chest of the infant and
respond to, or benefit from, the initial CPR.
child by one third to one half the depth of the chest. Rescuers
In general, the rescue sequence performed by the health- should push hard, push fast (rate of 100 compressions per
care provider is similar to that recommended for the lay minute), allow complete chest recoil between compressions,
rescuer, with the following differences: and minimize interruptions in compressions for all victims.
Because children and rescuers can vary widely in size,
If the lone healthcare provider witnesses the sudden col- rescuers are no longer instructed to use a single hand for chest
lapse of a victim of any age, after verifying that the victim compression of all children. Instead the rescuer is instructed
is unresponsive the provider should first phone 911 and get to use 1 hand or 2 hands (as in the adult) as needed to
an AED if available, then begin CPR and use the AED as compress the childs chest to one third to one half its depth.
appropriate. Sudden collapse is more likely to be caused by Lay rescuers should use a 30:2 compression-ventilation
an arrhythmia that may require shock delivery. ratio for all (infant, child, and adult) victims. Healthcare pro-
If the lone healthcare provider is rescuing an unresponsive viders should use a 30:2 compression-ventilation ratio for all
victim with a likely asphyxial cause of arrest (eg, drown- 1-rescuer and all adult CPR and should use a 15:2 compression-
ing), the rescuer should provide 5 cycles (about 2 minutes) ventilation ratio for infant and child 2-rescuer CPR.
of CPR (30 compressions and 2 ventilations) before leav-
For the Infant
ing the victim to phone the emergency response number. Recommendations for lay rescuer and healthcare provider
As noted above, the healthcare provider will perform some chest compressions for infants (up to 1 year of age) include
skills and steps that are not taught to the lay rescuer. the following:
Checking Breathing and Rescue Breaths Lay rescuers and healthcare providers should compress the
Checking Breathing infant chest just below the nipple line (on lower half of
When lay rescuers check breathing in the unresponsive adult sternum).
Lay rescuers will use 2 fingers to compress the infant chest
victim, they should look for normal breathing. This should
help the lay rescuer distinguish between the victim who is with a compression-ventilation ratio of 30:2.
The lone healthcare provider should use 2 fingers to
breathing (and does not require CPR) and the victim with
agonal gasps (who is likely in cardiac arrest and needs CPR). compress the infant chest.
When 2 healthcare providers are performing CPR, the
Lay rescuers who check breathing in the infant or child
should look for the presence or absence of breathing. Infants compression-ventilation ratio should be 15:2 until an ad-
and children often demonstrate breathing patterns that are not vanced airway is in place. The healthcare provider who is
normal but are adequate. compressing the chest should, when feasible, use the
2-thumb encircling hands technique.
The healthcare provider should assess for adequate breath-
ing in the adult. Some patients will demonstrate inadequate For the Child
breathing that requires delivery of assisted ventilation. As- Recommendations for lay rescuer and healthcare provider
sessment of ventilation in the infant and child is taught in the compressions for child victims (about 1 to 8 years of age)
PALS Course. include the following:
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 Part 3: Overview of CPR IV-15

Summary of BLS ABCD Maneuvers for Infants, Children, and Adults (Newborn Information Not Included)

Adult Child Infant

Lay rescuer: 8 years Lay rescuers: 1 to 8 years Under 1 year of age
Maneuver HCP: Adolescent and older HCP: 1 year to adolescent
Airway Head tiltchin lift (HCP: suspected trauma, use jaw thrust)
Breathing Initial 2 breaths at 1 second/breath 2 effective breaths at 1 second/breath
HCP: Rescue breathing without chest 10 to 12 breaths/min 12 to 20 breaths/min (approximate)
compressions (approximate)
HCP: Rescue breaths for CPR with 8 to 10 breaths/min (approximately)
advanced airway
Foreign-body airway obstruction Abdominal thrusts Back slaps and chest thrusts
Circulation HCP: Pulse check (10 sec) Carotid Brachial or femoral
Compression landmarks Lower half of sternum, between nipples Just below nipple line (lower
half of sternum)
Compression method Heel of one hand, other hand Heel of one hand or as for adults 2 or 3 fingers
Push hard and fast on top HCP (2 rescuers):
Allow complete recoil 2 thumbencircling hands
Compression depth 112 to 2 inches Approximately one third to one half the depth of the chest
Compression rate Approximately 100/min
Compression-ventilation ratio 30:2 (one or two rescuers) 30:2 (single rescuer)
HCP: 15:2 (2 rescuers)
Defibrillation AED Use adult pads Use AED after 5 cycles of CPR (out of No recommendation for
Do not use child pads hospital). infants
Use pediatric system for child 1 to 8 years 1 year of age
if available
HCP: For sudden collapse (out of
hospital) or in-hospital arrest use AED as
soon as available.
Note: Maneuvers used by only Healthcare Providers are indicated by HCP.

Lay rescuers should use a 30:2 compression-ventilation CPR for Newborns

ratio for CPR for all victims. Recommendations for the newborn are different from recom-
Rescuers should compress over the lower half of the mendations for infants. Because most providers who care for
sternum, at the nipple line (as for adults). newborns do not provide care to infants, children, and adults,
Lay rescuers should use 1 or 2 hands, as needed, to the educational imperative for universal or more uniform
compress the childs chest to one third to one half the depth recommendations is less compelling. There are no major
of the chest. changes from the ECC Guidelines 2000 recommendations for
Lay rescuers and lone healthcare providers should use a CPR in newborns28:
compression-ventilation ratio of 30:2.
The rescue breathing rate for the newborn infant with
Healthcare providers (and all rescuers who complete the
pulses is approximately 40 to 60 breaths per minute.
healthcare provider course, such as lifeguards) performing When providing compressions for newborn infants, the
2-rescuer CPR should use a 15:2 compression-ventilation
rescuer should compress to one third the depth of the chest.
ratio until an advanced airway is in place. For resuscitation of the newborn infant (with or without an
advanced airway in place), providers should deliver 90
For the Adult compressions and 30 ventilations (about 120 events) per
Recommendations for lay rescuer and healthcare provider
minute.
chest compressions for adult victims (about 8 years of age and Rescuers should try to avoid giving simultaneous compres-
older) include the following:
sions and ventilations.
The rescuer should compress in the center of the chest at
the nipple line. Important Lessons About CPR
The rescuer should compress the chest approximately 112 What have we learned about CPR? To be successful, CPR
to 2 inches, using the heel of both hands. must be started as soon as a victim collapses, and we must
therefore rely on a trained and willing public to initiate CPR
Comparison of CPR skills used for adult, child, and infant and call for professional help and an AED. We have learned
victims are highlighted in the Table. that when these steps happen in a timely manner, CPR makes
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IV-16 Circulation December 13, 2005

a difference.30 32 Sadly we have also learned that bystander Quality Improvement

CPR is performed in about only a third of witnessed arrests or Processes for continuous quality improvement are essential
fewer31,32 and that when CPR is performed, even by profes- for the success of out-of-hospital and in-hospital resuscitation
sionals, it is often not done well. Excessive ventilation is programs. For out-of-hospital resuscitation programs the
provided during CPR for victims with advanced airways, with Utstein Registries provide templates to facilitate outcome
a resulting decrease in cardiac output33; compressions are monitoring.48 51
interrupted too frequently,34 37 with a resulting drop in In the United States the Joint Commission for the Accredita-
coronary perfusion pressure and worse outcomes38 40; and tion of Healthcare Organizations (JCAHO) revised standards for
chest compressions are often too slow and too shallow. individual in-hospital resuscitation capabilities to include evalu-
These guidelines have addressed issues of CPR quality by ation of resuscitation policies, procedures, processes, protocols,
stressing good CPRpush hard, push fast, allow full chest equipment, staff training, and outcome review.52
recoil after each compression, and minimize interruptions in In 2000 the American Heart Association established the
chest compressions, and by simplifying recommendations to National Registry of Cardiopulmonary Resuscitation
make it easer for lay rescuers and healthcare providers alike to (NRCPR) to assist participating hospitals with systematic
learn, remember, and perform these critical skills. To minimize data collection on resuscitative efforts.53 The objectives of the
interruptions, other changes have been made in recommenda- registry are to develop a well-defined database to document
tions regarding CPR and debrillation (see Part 5: Electric resuscitation performance of hospitals over time. This informa-
tion can establish the baseline performance of a hospital, target
Therapies).
its problem areas, and identify opportunities for improvement in
Why are bystanders reluctant to perform CPR? We dont
data collection and the resuscitation program in general. The
have enough data to answer this important question defini-
registry is also the largest repository of information on in-
tively, but a number of possible reasons have been suggested:
hospital cardiopulmonary arrest. For further information about
Some claim that CPR has been made too complicated with the NRCPR, visit the website: www.nrcpr.org.
too many steps that tax the memory. In these guidelines we
have tried to simplify the steps whenever the science allows Medical Emergency Teams (METs)
it. For example, the compression-ventilation ratio for lay The concept of Medical Emergency Teams (METs) has been
rescuers is now the same for infants, children, and adults, explored as a method to identify patients at risk and intervene
to prevent the development of cardiac arrest. METs studied
and the same technique can be used for chest compressions
generally consist of a physician and nurse with critical care
for children and adults.

training. The team is available at all times, with nurses and

Some feel that our training methods are inadequate, and
other hospital staff authorized to activate the team based on
skills retention has been shown to decline fairly rapidly
specific calling criteria, following implementation of an
after training.41 The American Heart Association has es-
education and awareness program.
tablished an ECC education subcommittee to find better
Three supportive before-and-after single center studies
and more efficient educational methods. We must also try (LOE 3)54 56 documented significant reductions in cardiac
to apply the lessons of self-efficacy from the field of arrest rates and improved outcome following cardiac arrest.
psychology to understand why people with the same Two neutral studies (LOE 3)57,58 documented a trend toward
knowledge apply it so differently in emergencies. reduction in the rates of adult in-hospital cardiac arrest and
Others point out that the public is afraid of transmitted improved outcome57 and a reduction in unplanned ICU
diseases and is reluctant to perform mouth-to-mouth resus- admissions.58 The most recent study, a cluster-randomized
citation.42 45 The guidelines emphasize that the data shows controlled trial in 23 hospitals, documented no difference in
that transmission of infection is very low.46 The guidelines the composite primary outcome (cardiac arrest, unexpected
encourage anyone who is still concerned about infection to death, unplanned ICU admission) between 12 hospitals in
use a barrier device to give ventilations, although simple which a MET system was introduced and 11 hospitals that
barrier devices (ie, face shields) may not reduce the risk of had no MET system in place (LOE 2).59
bacterial transmission.47 The guidelines also encourage Introduction of a MET system for adult in-hospital patients
those who would rather not give mouth-to-mouth ventila- should be considered, with special attention to details of
tions to call for help and start chest compressions only. implementation (eg, composition and availability of the team,
calling criteria, education and awareness of hospital staff, and
About 10% of newborns require some of the steps of CPR to method of team activation). There is insufficient evidence to
make a successful transition from uterine to extrauterine life. make a recommendation on the use of a MET for children.
The Neonatal Resuscitation Program (NRP), which is based on Further research is needed about the critical details of
these guidelines, has trained more than 1.75 million providers implementation and the potential effectiveness of METs in
worldwide. The NRP is used throughout the United States and preventing cardiac arrest or improving other important patient
Canada and in many other countries. The educational challenges outcomes.
for resuscitation of the newborn are quite different from those
applying to education of rescuers for response to SCA: because Summary
most births in the United States occur in hospitals, resuscitations These guidelines provide simplified information and empha-
are performed by healthcare personnel. size the importance and fundamentals of high-quality CPR.
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 Part 3: Overview of CPR IV-17

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CPR, coordination of CPR with defibrillation, the role of brillation waveform and post-shock rhythm in out-of-hospital ventricular
fibrillation cardiac arrest. Resuscitation. 2003;59:189 196.
CPR in advanced life support, and basic and advanced life 22. Berg MD, Clark LL, Valenzuela TD, Kern KB, Berg RA. Post-shock
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