Primary and secondary survey of critical patient. Emergency triage.

Cardiorespiratory arrest and

cardiorespiratory resuscitation. Basic life support and AED

Chains of Survival 2015 (New): Separate Chains of Survival have been recommended that identify the
different pathways of care for patients who experience cardiac arrest in the hospital as distinct from
out-of-hospital settings. Why: The care for all post–cardiac arrest patients, regardless of where their
arrests occur, converges in the hospital, generally in an intensive care unit where post–cardiac arrest
care is provided. The elements of structure and process that are required before that convergence are
very different for the 2 settings. Patients who have an OHCA depend on their community for support.
Lay rescuers must recognize the arrest, call for help, and initiate CPR and provide defibrillation (ie,
public-access defibrillation [PAD]) until a team of professionally trained emergency medical service
(EMS) providers assumes responsibility and then transports the patient to an emergency department
and/or cardiac catheterization lab. The patient is ultimately transferred to a critical care unit for
continued care. In contrast, patients who have an IHCA depend on a system of appropriate surveillance
(eg, rapid response or early warning system) to prevent cardiac arrest. If cardiac arrest occurs, patients
depend on the smooth interaction of the institution’s various departments and services and on a
multidisciplinary team of professional providers, including physicians, nurses, respiratory therapists, and
others. Use of Social Media to Summon Rescuers 2015 (New): It may be reasonable for communities to
incorporate social media technologies that summon rescuers who are in close proximity to a victim of
suspected OHCA and are willing and able to perform CPR. Why: There is limited evidence to support the
use of social media by dispatchers to notify potential rescuers of a possible cardiac arrest nearby, and
activation of social media has not been shown to improve survival from OHCA. However, in a recent
study in Sweden, there was a significant increase in the rate of bystander-initiated CPR when a mobile-
phone dispatch system was used.6 Given the low harm and the potential benefit, as well as the
ubiquitous presence of digital devices, municipalities could consider incorporating these technologies
into their OHCA systems of care.

Team Resuscitation: Early Warning Sign Systems, Rapid Response Teams, and Medical Emergency Team
Systems

2015 (Updated): For adult patients, rapid response team (RRT) or medical emergency team (MET)
systems can be effective in reducing the incidence of cardiac arrest, particularly in the general care
wards. Pediatric MET/RRT systems may be considered in facilities where children with high-risk illnesses
are cared for in general in-patient units. The use of early warning sign systems may be considered for
adults and children. 2010 (Old): Although conflicting evidence exists, expert consensus recommended
the systematic identification of patients at risk of cardiac arrest, an organized response to such patients,
and an evaluation of outcomes to foster continuous quality improvement. Why: RRTs or METs were
established to provide early intervention for patients with clinical deterioration, with the goal of
preventing IHCA. Teams can be composed of varying combinations of physicians, nurses, and respiratory
therapists. These teams are usually summoned to a patient bedside when acute deterioration is
identified by hospital staff. The team typically brings emergency monitoring and resuscitation
equipment and drugs. Although the evidence is still evolving, there is face validity in the concept of
having teams trained in the complex choreography of resuscitation. Continuous Quality Improvement
for Resuscitation Programs 2015 (Reaffirmation of 2010): Resuscitation systems should establish
ongoing assessment and improvement of systems of care. Why: There is evidence of considerable
regional variation in the reported incidence and outcome of cardiac arrest in the United States. This
variation underscores the need for communities and systems to accurately identify each occurrence of
treated cardiac arrest and to record outcomes. There are likely to be opportunities to improve survival
rates in many communities. Community- and hospital-based resuscitation programs should
systematically monitor cardiac arrests, the level of resuscitation care provided, and outcome.
Continuous quality improvement includes systematic evaluation and feedback, measurement or
benchmarking, and analysis.

Continuous efforts are needed to optimize resuscitation care so that the gaps between ideal and actual
resuscitation performance can be narrowed. Regionalization of Care 2015 (Reaffirmation of 2010): A
regionalized approach to OHCA resuscitation that includes the use of cardiac resuscitation centers may
be considered. Why: A cardiac resuscitation center is a hospital that provides evidence-based care in
resuscitation and post– cardiac arrest care, including 24-hour, 7-day percutaneous coronary intervention
(PCI) capability, TTM with an adequate annual volume of cases, and commitment to ongoing
performance improvement that includes measurement, benchmarking, and both feedback and process
change. It is hoped that resuscitation systems of care will achieve the improved survival rates that
followed establishment of other systems of care, such as trauma.
 Adult Basic Life Support and CPR Quality: Lay Rescuer CPR Summary of Key Issues and Major Changes
Key issues and major changes in the 2015 Guidelines Update recommendations for adult CPR by lay
rescuers include the following: • The crucial links in the out-of-hospital adult Chain of Survival are
unchanged from 2010, with continued emphasis on the simplified universal Adult Basic Life Support
(BLS) Algorithm. • The Adult BLS Algorithm has been modified to reflect the fact that rescuers can
activate an emergency response (ie, through use of a mobile telephone) without leaving the victim’s
side. • It is recommended that communities with people at risk for cardiac arrest implement PAD
programs. • Recommendations have been strengthened to encourage immediate recognition of
unresponsiveness, activation of the emergency response system, and initiation of CPR if the lay rescuer
finds an unresponsive victim is not breathing or not breathing normally (eg, gasping). • Emphasis has
been increased about the rapid identification of potential cardiac arrest by dispatchers, with immediate
provision of CPR instructions to the caller (ie, dispatch-guided CPR). • The recommended sequence for a
single rescuer has been confirmed: the single rescuer is to initiate chest compressions before giving
rescue breaths (C-A-B rather than A-B-C) to reduce delay to first compression. The single rescuer should
begin CPR with 30 chest compressions followed by 2 breaths. • There is continued emphasis on the
characteristics of high-quality CPR: compressing the chest at an adequate rate and depth, allowing
complete chest recoil after each compression, minimizing interruptions in compressions, and avoiding
excessive ventilation. • The recommended chest compression rate is 100 to 120/min (updated from at
least 100/min). • The clarified recommendation for chest compression depth for adults is at least 2
inches (5 cm) but not greater than 2.4 inc. Bystander-administered naloxone may be considered for
suspected life-threatening opioid-associated emergencies. 6 American Heart Association These changes
are designed to simplify lay rescuer training and to emphasize the need for early chest compressions for
victims of sudden cardiac arrest. More information about these changes appears below. In the following
topics, changes or points of emphasis that are similar for lay rescuers and HCPs are noted with an
asterisk (*).

Community Lay Rescuer AED Programs 2015 (Updated): It is recommended that PAD programs for
patients with OHCA be implemented in public locations where there is a relatively high likelihood of
witnessed cardiac arrest (eg, airports, casinos, sports facilities). 2010 (Old): CPR and the use of
automated external defibrillators (AEDs) by public safety first responders were recommended to
increase survival rates for out-of-hospital sudden cardiac arrest. The 2010 Guidelines recommended the
establishment of AED programs in public locations where there is a relatively high likelihood of
witnessed cardiac arrest (eg, airports, casinos, sports facilities). Why: There is clear and consistent
evidence of improved survival from cardiac arrest when a bystander performs CPR and rapidly uses an
AED. Thus, immediate access to a defibrillator is a primary component of the system of care. The
implementation of a PAD program requires 4 essential components: (1) a planned and practiced
response, which ideally includes identification of locations and neighborhoods where there is high risk of
cardiac arrest, placement of AEDs in those areas and ensuring that bystanders are aware of the location
of the AEDs, and, typically, oversight by an HCP; (2) training of anticipated rescuers in CPR and use of the
AED; (3) an integrated link with the local EMS system; and (4) a program of ongoing quality
improvement. A system-of-care approach for OHCA might include public policy that encourages
reporting of public AED locations to public service access points (PSAPs; the term public service access
point has replaced the less-precise EMS dispatch center). Such a policy would enable PSAPs to direct
bystanders to retrieve nearby AEDs and assist in their use when OHCA occurs. Many municipalities as
well as the US federal government have enacted legislation to place AEDs in municipal buildings, large
public venues, airports, casinos, and schools. For the 20% of OHCAs that occur in public areas, these
community programs represent an important link in the Chain of Survival between recognition and
activation of the PSAPs. This information is expanded in “Part 4: Systems of Care and Continuous Quality
Improvement” in the 2015 Guidelines Update. There is insufficient evidence to recommend for or
against the deployment of AEDs in homes. Victims of OHCAs that occur in private residences are much
less likely to receive chest compressions than are patients who experience cardiac arrest in public
settings. Real-time instructions provided by emergency dispatchers may help potential in-home rescuers
to initiate action. Robust community CPR training programs for cardiac arrest, along with effective,
prearrival dispatch protocols, can improve outcomes. Dispatcher Identification of Agonal Gasps Cardiac
arrest victims sometimes present with seizure-like activity or agonal gasps that can confuse potential
rescuers. Dispatchers should be specifically trained to identify these presentations of cardiac arrest to
enable prompt recognition and immediate dispatcher-guided CPR. 2015 (Updated): To help bystanders
recognize cardiac arrest, dispatchers should inquire about a victim’s absence of responsiveness and
quality of breathing (normal versus not normal). If the victim is unresponsive with absent or abnormal
breathing, the rescuer and the dispatcher should assume that the victim is in cardiac arrest. Dispatchers
should be educated to identify unresponsiveness with abnormal and agonal gasps across a range of
clinical presentations and descriptions. 2010 (Old): To help bystanders recognize cardiac arrest,
dispatchers should ask about an adult victim’s responsiveness, if the victim is breathing, and if the
breathing is normal, in an attempt to distinguish victims with agonal gasps (ie, in those who need CPR)
from victims who are breathing normally and do not need CPR. Why: This change from the 2010
Guidelines emphasizes the role that emergency dispatchers can play in helping the lay rescuer recognize
absent or abnormal breathing. Dispatchers should be specifically educated to help bystanders recognize
that agonal gasps are a sign of cardiac arrest. Dispatchers should also be aware that brief generalized
seizures may be the first manifestation of cardiac arrest. In summary, in addition to activating
professional emergency responders, the dispatcher shouldask straightforward questions about whether
the patient is unresponsive and if breathing is normal or abnormal in order to identify patients with
possible cardiac arrest and enable dispatcher-guided CPR.

Chest Compression Rate* 2015 (Updated): In adult victims of cardiac arrest, it is reasonable for rescuers
to perform chest compressions at a rate of 100 to 120/min. 2010 (Old): It is reasonable for lay rescuers
and HCPs to perform chest compressions at a rate of at least 100/min. Why: The number of chest
compressions delivered per minute during CPR is an important determinant of return of spontaneous
circulation (ROSC) and survival with good neurologic function. The actual number of chest compressions
delivered per minute is determined by the rate of chest compressions and the number and duration of
interruptions in compressions (eg, to open the airway, deliver rescue breaths, allow AED analysis). In
most studies, more compressions are associated with higher survival rates, and fewer compressions are
associated with lower survival rates. Provision of adequate chest compressions requires an emphasis not
only on an adequate compression rate but also on minimizing interruptions to this critical component of
CPR. An inadequate compression rate or frequent interruptions (or both) will reduce the total number of
compressions delivered per minute. New to the 2015 Guidelines Update are upper limits of
recommended compression rate and compression depth, based on preliminary data suggesting that
excessive compression rate and depth adversely affect outcomes. The addition of an upper limit of
compression rate is based on 1 large registry study analysis associating extremely rapid compression
rates (greater than 140/min) with inadequate compression depth. Box 1 uses the analogy of automobile
travel to explain the effect of compression rate and interruptions on total number of compressions
delivered during resuscitation.

Chest Compression Depth* 2015 (Updated): During manual CPR, rescuers should perform chest
compressions to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest
compression depths (greater than 2.4 inches [6 cm]). 2010 (Old): The adult sternum should be
depressed at least 2 inches (5 cm). Why: Compressions create blood flow primarily by increasing
intrathoracic pressure and directly compressing the heart, which in turn results in critical blood flow and
oxygen delivery to the heart and brain. Rescuers often do not compress the chest deeply enough despite
the recommendation to “push hard.” While a compression depth of at least 2 inches (5 cm) is
recommended, the 2015 Guidelines Update incorporates new evidence about the potential for an upper
threshold of compression depth (greater than 2.4 inches [6 cm]), beyond which complications may
occur. Compression depth may be difficult to judge without use of feedback devices, and identification
of upper limits of compression depth may be challenging. It is important for rescuers to know that the
recommendation about the upper limit of compression depth is based on 1 very small study that
reported an association between excessive compression depth and injuries that were not life-
threatening. Most monitoring via CPR feedback devices suggests that compressions are more often too
shallow than they are too deep. Starting chest compressions

In adults needing CPR, there is a high probability of a primary cardiac cause. When blood flow stops after
cardiac arrest, the blood in the lungs and arterial system remains oxygenated for some minutes. To
emphasise the priority of chest compressions, it is recommended that CPR should start with chest
compressions rather than initial ventilations. Manikin studies indicate that this is associated with a
shorter time to commencement of CPR.81, 82, 83, and 84

When providing manual chest compressions:

1. Deliver compressions ‘in the centre of the chest’.

2. Compress to a depth of at least 5 cm but not more than 6 cm.

3. Compress the chest at a rate of 100–120 min−1 with as few interruptions as possible.

4. Allow the chest to recoil completely after each compression; do not lean on the chest.

Hand position

Experimental studies show better haemodynamic responses when chest compressions are performed
on the lower half of the sternum.85, 86, and 87 It is recommended that this location be taught in a
simplified way, such as, “place the heel of your hand in the centre of the chest with the other hand on
top”. This instruction should be accompanied by a demonstration of placing the hands on the lower half
of the sternum.88 and 89

Chest compressions are most easily delivered by a single CPR provider kneeling by the side of the victim,
as this facilitates movement between compressions and ventilations with minimal interruptions. Over-
the-head CPR for single CPR providers and straddle-CPR for two CPR providers may be considered when
it is not possible to perform compressions from the side, for example when the victim is in a confined
space.90 and 91
Compression depth

Fear of doing harm, fatigue and limited muscle strength frequently result in CPR providers compressing
the chest less deeply than recommended. Four observational studies, published after the 2010
Guidelines, suggest that a compression depth range of 4.5–5.5 cm in adults leads to better outcomes
than all other compression depths during manual CPR.92, 93, 94, and 95 Based on an analysis of 9136
patients, compression depths between 40 and 55 mm with a peak at 46 mm, were associated with
highest survival rates. 94 There is also evidence from onne observational study suggesting that a
compression depth of more than 6 cm is associated with an increased rate of injury in adults when
compared with compression depths of 5–6 cm during manual CPR. 96 The ERC endorses the ILCOR
recommendation that it is reasonable to aim for a chest compression of approximately 5 cm but not
more than 6 cm in the average sized adult. In making this recommendation the ERC recognises that it
can be difficult to estimate chest compression depth and that compressions that are too shallow are
more harmful than compressions that are too deep. The ERC therefore decided to retain the 2010
guidance that chest compressions should be at least 5 cm but not more than 6 cm. Training should
continue to prioritise achieving adequate compression depth.

Compression rate

Chest compression rate is defined as the actual rate of compressions being given at any one time. It
differs from the number of chest compressions in a specific time period, which takes into account any
interruptions in chest compressions.

Two studies, with a total of 13,469 patients, found higher survival among patients who received chest
compressions at a rate of 100–120 min−1, compared to >140, 120–139, <80 and 80–99 min−1. Very high
chest compression rates were associated with declining chest compression depths. 97 and 98 The ERC
recommends, therefore, that chest compressions should be performed at a rate of 100–120 min −1.

Rescue breaths

In non-paralysed, gasping pigs with unprotected, unobstructed airways, continuous-chest-compression

CPR without artificial ventilation resulted in improved outcome. 140 Gasping may be present early after
the onset of cardiac arrest in about one third of humans, thus facilitating gas exchange. 48 During CPR in
intubated humans, however, the median tidal volume per chest compression was only about 40 mL,
insufficient for adequate ventilation. 141 In witnessed cardiac arrest with ventricular fibrillation,
immediate continuous chest compressions tripled survival. 142 Accordingly, continuous chest
compressions may be most beneficial in the early, ‘electric’ and ‘circulatory’ phases of CPR, while
additional ventilation becomes more important in the later, ‘metabolic’ phase. 39

During CPR, systemic blood flow, and thus blood flow to the lungs, is substantially reduced, so lower
tidal volumes and respiratory rates than normal can maintain effective oxygenation and
ventilation.143, 144, 145, and 146When the airway is unprotected, a tidal volume of 1 L produces significantly
more gastric inflation than a tidal volume of 500 mL. 147 Inflation durations of 1 s are feasible without
causing excessive gastric insufflation. 148Inadvertent hyperventilation during CPR may occur frequently,
especially when using manual bag-valve-mask ventilation in a protected airway. While this increased
intrathoracic pressure 149 and peak airway pressure, 150 a carefully controlled animal experiment revealed
no adverse effects. 151
From the available evidence we suggest that during adult CPR tidal volumes of approximately 500–600
mL (6–7 mL kg−1) are delivered. Practically, this is the volume required to cause the chest to rise
visibly. 152 CPR providers should aim for an inflation duration of about 1 s, with enough volume to make
the victim's chest rise, but avoid rapid or forceful breaths. The maximum interruption in chest
compression to give two breaths should not exceed 10 s. 153 These recommendations apply to all forms
of ventilation during CPR when the airway is unprotected, including mouth-to-mouth and bag-mask
ventilation, with and without supplementary oxygen.

Mouth-to-nose ventilation

Mouth-to-nose ventilation is an acceptable alternative to mouth-to-mouth ventilation. 154 It may be

considered if the victim's mouth is seriously injured or cannot be opened, the CPR provider is assisting a
victim in the water, or a mouth-to-mouth seal is difficult to achieve.

Mouth-to-tracheostomy ventilation

Mouth-to-tracheostomy ventilation may be used for a victim with a tracheostomy tube or tracheal
stoma who requires rescue breathing. 155

Compression–ventilation ratio

Animal data support a ratio of compression to ventilation of greater than 15:2.156, 157, and 158 A
mathematical model suggests that a ratio of 30:2 provides the best compromise between blood flow
and oxygen delivery.159 and 160 A ratio of 30:2 was recommended in Guidelines 2005 and 2010 for the
single CPR provider attempting resuscitation of an adult. This decreased the number of interruptions in
compression and the no-flow fraction,161 and 162 and reduced the likelihood of
hyperventilation.149 and 163 Several observational studies have reported slightly improved outcomes after
implementation of the guideline changes, which included switching from a compression ventilation ratio
of 15:2–30:2.161, 162, 164, and 165 The ERC continues, therefore, to recommend a compression to ventilation
ratio of 30:2.

Use of an automated external defibrillator

AEDs are safe and effective when used by laypeople with minimal or no training. 185 AEDs make it
possible to defibrillate many minutes before professional help arrives. CPR providers should continue
CPR with minimal interruption of chest compressions while attaching an AED and during its use. CPR
providers should concentrate on following the voice prompts immediately when they are spoken, in
particular resuming CPR as soon as instructed, and minimizing interruptions in chest compression.
Indeed, pre-shock and post-shock pauses in chest compressions should be as short as possible. 99, 100, 103,
and 186
Standard AEDs are suitable for use in children older than 8 years.187, 188, and 189

For children between 1 and 8 years paediatric pads should be used, together with an attenuator or a
paediatric mode if available; if these are not available, the AED should be used as it is. There are a few
case reports of successful use of AEDS in children ages less than 1 year.190 and 191 The incidence of
shockable rhythms in infants is very low except when there is cardiac disease. 187, 188, 189, 192, 193, 194, and 195 In
these rare cases, if an AED is the only defibrillator available, its use should be considered (preferably
with a dose attenuator).

CPR before defibrillation

The importance of immediate defibrillation has always been emphasised in guidelines and during
teaching, and is considered to have a major impact on survival from ventricular fibrillation. This concept
was challenged in 2005 because evidence suggested that a period of up to 180 s of chest compression
before defibrillation might improve survival when the EMS response time exceeded 4–5
min.196 and 197 Three more recent trials have not confirmed this survival benefit.198, 199, and 200 An analysis of
one randomised trial suggested a decline in survival to hospital discharge by a prolonged period of CPR
(180 s) and delayed defibrillation in patients with a shockable initial rhythm. 200 Yet, for EMS agencies
with higher baseline survival-to-hospital discharge rates (defined as >20% for an initial shockable
rhythm), 180 s of CPR prior to defibrillation was more beneficial compared to a shorter period of CPR
(30–60 s). 201 The ERC recommends that CPR should be continued while a defibrillator or AED is being
brought on-site and applied, but defibrillation should not be delayed any longer.

Interval between rhythm checks

The 2015 ILCOR Consensus on Science reported that there are currently no studies that directly address
the question of optimal intervals between rhythm checks, and their effect on survival: ROSC; favourable
neurological or functional outcome; survival to discharge; coronary perfusion pressure or cardiac
output.