Basic life support (BLS) in adults
- Charles N Pozner, MD
Charles N Pozner, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Ron M Walls, MD, FRCPC, FAAEM
Ron M Walls, MD, FRCPC, FAAEM
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Adult Resuscitation
- Neskey Family Professor of Emergency Medicine
- Harvard Medical School
- Brigham and Women's Hospital
- Richard L Page, MD
Richard L Page, MD
- Section Editor — Cardiac Arrhythmias
- Chair, Department of Medicine
- University of Wisconsin, School of Medicine and Public Health
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Cardiopulmonary resuscitation (CPR) as we recognize it today was developed in the late 1950s and 1960s. Elam and Safar described the technique and benefits of mouth-to-mouth ventilation in 1958 . Kouwenhoven, Knickerbocker, and Jude subsequently described the benefits of external chest compressions , which in combination with mouth-to-mouth ventilation form the basis of modern CPR. External defibrillation, first described in 1957 by Kouwenhoven , has since been incorporated into resuscitation guidelines.
Basic life support consists of cardiopulmonary resuscitation and, when available, defibrillation using automated external defibrillators (AED). The keys to survival from sudden cardiac arrest (SCA) are early recognition and treatment, specifically, immediate initiation of excellent CPR and early defibrillation.
This topic review will discuss the critical facets of basic life support in adults for clinicians as presented in the American Heart Association's 2010 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, and the update of these guidelines published in 2015 [4-6]. Advanced cardiac life support (ACLS) and other related topics, such as airway management and basic life support for infants and children, are presented separately. (See "Advanced cardiac life support (ACLS) in adults" and "Basic airway management in adults" and "Pediatric basic life support for health care providers".)
EPIDEMIOLOGY AND SURVIVAL
The exact incidence of sudden cardiac arrest (SCA) in the United States is unknown, but estimates vary from 180,000 to over 450,000 [7,8]. In North America and Europe, the estimated incidence falls between 50 to 100 per 100,000 in the general population . The most common etiology of SCA is ischemic cardiovascular disease resulting in the development of lethal arrhythmias. Resuscitation is attempted in up to two-thirds of people who sustain SCA.
Despite the development of cardiopulmonary resuscitation (CPR), electrical defibrillation, and other advanced resuscitative techniques over the past 50 years, survival rates for SCA remain low. The epidemiology and etiology of SCA are discussed in greater detail separately. (See "Overview of sudden cardiac arrest and sudden cardiac death" and "Pathophysiology and etiology of sudden cardiac arrest".)
- SAFAR P, ESCARRAGA LA, ELAM JO. A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. N Engl J Med 1958; 258:671.
- KOUWENHOVEN WB, JUDE JR, KNICKERBOCKER GG. Closed-chest cardiac massage. JAMA 1960; 173:1064.
- KOUWENHOVEN WB, MILNOR WR, KNICKERBOCKER GG, CHESNUT WR. Closed chest defibrillation of the heart. Surgery 1957; 42:550.
- Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S640.
- https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/ (Accessed on October 28, 2015).
- Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S414.
- Kong MH, Fonarow GC, Peterson ED, et al. Systematic review of the incidence of sudden cardiac death in the United States. J Am Coll Cardiol 2011; 57:794.
- WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, et al. Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation 2010; 121:e46.
- Deo R, Albert CM. Epidemiology and genetics of sudden cardiac death. Circulation 2012; 125:620.
- Engdahl J, Holmberg M, Karlson BW, et al. The epidemiology of out-of-hospital 'sudden' cardiac arrest. Resuscitation 2002; 52:235.
- Herlitz J, Bahr J, Fischer M, et al. Resuscitation in Europe: a tale of five European regions. Resuscitation 1999; 41:121.
- Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003; 58:297.
- Wik L, Hansen TB, Fylling F, et al. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial. JAMA 2003; 289:1389.
- Cobb LA, Fahrenbruch CE, Walsh TR, et al. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA 1999; 281:1182.
- Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010; 3:63.
- Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015; 372:2307.
- McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance --- Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005--December 31, 2010. MMWR Surveill Summ 2011; 60:1.
- Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005; 293:305.
- Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA 2005; 293:299.
- Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model. JAMA 2002; 288:3035.
- Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S685.
- Baker PW, Conway J, Cotton C, et al. 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.
- 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.
- Simpson PM, Goodger MS, Bendall JC. Delayed versus immediate defibrillation for out-of-hospital cardiac arrest due to ventricular fibrillation: A systematic review and meta-analysis of randomised controlled trials. Resuscitation 2010; 81:925.
- Winship C, Williams B, Boyle MJ. Cardiopulmonary resuscitation before defibrillation in the out-of-hospital setting: a literature review. Emerg Med J 2012; 29:826.
- Van Hoeyweghen RJ, Bossaert LL, Mullie A, et al. Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study Group. Resuscitation 1993; 26:47.
- Gallagher EJ, Lombardi G, Gennis P. Effectiveness of bystander cardiopulmonary resuscitation and survival following out-of-hospital cardiac arrest. JAMA 1995; 274:1922.
- Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation 2001; 104:2465.
- Kellum MJ, Kennedy KW, Barney R, et al. Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest. Ann Emerg Med 2008; 52:244.
- Abella BS, Sandbo N, Vassilatos P, et al. Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest. Circulation 2005; 111:428.
- Guidelines 2000 for cardiopulmonary care: international consensus on science. Circulation 2000; 102(suppl):384.
- Idris AH, Guffey D, Aufderheide TP, et al. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation 2012; 125:3004.
- Andersen LØ, Isbye DL, Rasmussen LS. Increasing compression depth during manikin CPR using a simple backboard. Acta Anaesthesiol Scand 2007; 51:747.
- Perkins GD, Smith CM, Augre C, et al. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care Med 2006; 32:1632.
- Perkins GD, Kocierz L, Smith SC, et al. Compression feedback devices over estimate chest compression depth when performed on a bed. Resuscitation 2009; 80:79.
- Stiell IG, Brown SP, Christenson J, et al. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation?. Crit Care Med 2012; 40:1192.
- Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation 2009; 120:1241.
- Feneley MP, Maier GW, Kern KB, et al. Influence of compression rate on initial success of resuscitation and 24 hour survival after prolonged manual cardiopulmonary resuscitation in dogs. Circulation 1988; 77:240.
- Yeung J, Meeks R, Edelson D, et al. The use of CPR feedback/prompt devices during training and CPR performance: A systematic review. Resuscitation 2009; 80:743.
- Ristagno G, Tang W, Chang YT, et al. The quality of chest compressions during cardiopulmonary resuscitation overrides importance of timing of defibrillation. Chest 2007; 132:70.
- Vadeboncoeur T, Stolz U, Panchal A, et al. Chest compression depth and survival in out-of-hospital cardiac arrest. Resuscitation 2014; 85:182.
- Stiell IG, Brown SP, Nichol G, et al. What is the optimal chest compression depth during out-of-hospital cardiac arrest resuscitation of adult patients? Circulation 2014; 130:1962.
- Yannopoulos D, McKnite S, Aufderheide TP, et al. Effects of incomplete chest wall decompression during cardiopulmonary resuscitation on coronary and cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation 2005; 64:363.
- SOS-KANTO study group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet 2007; 369:920.
- Kern KB, Hilwig RW, Berg RA, et al. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation 2002; 105:645.
- Eftestøl T, Sunde K, Steen PA. Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest. Circulation 2002; 105:2270.
- Garza AG, Gratton MC, Salomone JA, et al. Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest. Circulation 2009; 119:2597.
- Sayre MR, Cantrell SA, White LJ, et al. 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.
- Cheskes S, Schmicker RH, Christenson J, et al. Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation 2011; 124:58.
- Brouwer TF, Walker RG, Chapman FW, Koster RW. Association Between Chest Compression Interruptions and Clinical Outcomes of Ventricular Fibrillation Out-of-Hospital Cardiac Arrest. Circulation 2015; 132:1030.
- Andreka P, Frenneaux MP. Haemodynamics of cardiac arrest and resuscitation. Curr Opin Crit Care 2006; 12:198.
- Ewy GA. Cardiocerebral resuscitation: the new cardiopulmonary resuscitation. Circulation 2005; 111:2134.
- Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA 2008; 299:1158.
- Hinchey PR, Myers JB, Lewis R, et al. 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; 56:348.
- Nichol G, Leroux B, Wang H, et al. Trial of Continuous or Interrupted Chest Compressions during CPR. N Engl J Med 2015; 373:2203.
- Koster RW. Continuous or Interrupted Chest Compressions for Cardiac Arrest. N Engl J Med 2015; 373:2278.
- Hüpfl M, Selig HF, Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. Lancet 2010; 376:1552.
- Zhan L, Yang LJ, Huang Y, et al. Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest. Cochrane Database Syst Rev 2017; 3:CD010134.
- Sanders AB, Kern KB, Berg RA, et al. Survival and neurologic outcome after cardiopulmonary resuscitation with four different chest compression-ventilation ratios. Ann Emerg Med 2002; 40:553.
- 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.
- Kern KB. Cardiopulmonary resuscitation without ventilation. Crit Care Med 2000; 28:N186.
- Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation 2004; 109:1960.
- Kern KB, Valenzuela TD, Clark LL, et al. An alternative approach to advancing resuscitation science. Resuscitation 2005; 64:261.
- Steen S, Liao Q, Pierre L, et al. The critical importance of minimal delay between chest compressions and subsequent defibrillation: a haemodynamic explanation. Resuscitation 2003; 58:249.
- Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med 2004; 32:S345.
- American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 2005. Part 1: Introduction. Circulation 2005; 112:IV.
- Morrison LJ, Dorian P, Long J, et al. Out-of-hospital cardiac arrest rectilinear biphasic to monophasic damped sine defibrillation waveforms with advanced life support intervention trial (ORBIT). Resuscitation 2005; 66:149.
- Martens PR, Russell JK, Wolcke B, et al. Optimal Response to Cardiac Arrest study: defibrillation waveform effects. Resuscitation 2001; 49:233.
- Carpenter J, Rea TD, Murray JA, et al. Defibrillation waveform and post-shock rhythm in out-of-hospital ventricular fibrillation cardiac arrest. Resuscitation 2003; 59:189.
- Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S729.
- Stiell IG, Walker RG, Nesbitt LP, et al. BIPHASIC Trial: a randomized comparison of fixed lower versus escalating higher energy levels for defibrillation in out-of-hospital cardiac arrest. Circulation 2007; 115:1511.
- Bahr J, Klingler H, Panzer W, et al. Skills of lay people in checking the carotid pulse. Resuscitation 1997; 35:23.
- White RD, Russell JK. Refibrillation, resuscitation and survival in out-of-hospital sudden cardiac arrest victims treated with biphasic automated external defibrillators. Resuscitation 2002; 55:17.
- Berg MD, Clark LL, Valenzuela TD, et al. Post-shock chest compression delays with automated external defibrillator use. Resuscitation 2005; 64:287.
- Rea TD, Shah S, Kudenchuk PJ, et al. Automated external defibrillators: to what extent does the algorithm delay CPR? Ann Emerg Med 2005; 46:132.
- EPIDEMIOLOGY AND SURVIVAL
- RESUSCITATION GUIDELINES
- Phases of resuscitation
- - Electrical phase
- - Hemodynamic phase
- - Metabolic phase
- Recognition of cardiac arrest
- Chest compressions
- - Performance of excellent chest compressions
- - Minimizing interruptions
- - Compression-only CPR (CO-CPR)
- Pulse checks and rhythm analysis
- SUMMARY AND RECOMMENDATIONS