CPR of Unresponsive Adult (Age > 8 Y): Witnessed Collapse

If a patient becomes unresponsive (no response to verbal or tactile stimuli, ie, "shake and shout"), call for help (CODE, 911). Do not move the patient unless in immediate danger.

1. Get a defibrillator or AED to the bedside stat.

2. Stand or kneel at the patient's shoulder. Position patient on back as a unit, protecting the neck.

3. Airway. Open the patient's airway. If there are signs of airway compromise (apnea, stridor, coughing, use of accessory muscles), immediately open and clear the airway using the head tilt-chin lift method (nonprofessional rescuer) or a jaw thrust (health care provider) if cervical spinal injury is suspected.

4. If a foreign body is visualized in the airway, and can easily be removed, remove it. If airway care is needed, proceed according to clinical need (see Emergency Airway and Ventilatory Support).

5. Breathing. Determine whether the patient is breathing by looking, listening, and feeling. Look at the patient's chest to determine whether there are signs of movement. Listen at the patient's mouth and nose to determine whether air is being moved through (escaping) from the upper airway. Feel for warm, moist air coming out of the mouth and nose by placing your ear close to the patient's mouth and nose.

6. If the patient is breathing, place him or her in the recovery position: a stable, side-lying position in which the tongue does not block the airway and fluid can drain from the mouth. Keep the spine straight, and position the arms so that the chest is not compressed. Continue to monitor the patient for breathing. Call for assistance!

7. If the patient is not breathing, ventilate by administering two positive-pressure breaths. Allowing 1 s per breath using either a bag valve mask or a barrier device such as a pocket mask.

8. Circulation. To determine whether there are signs of circulation, check the neck for a carotid pulse for 10 s (health care provider). However, if there is any doubt regarding the presence or absence of a pulse, start chest compressions.

9. If there is a definite pulse, give 1 breath every 5–6 s, approximately 10–12 breaths/min, rechecking for a pulse every 2 min. If an advanced airway is placed, ventilate with 8–10 breaths/min (approximately 1 breath every 6–8 s asynchronously).

10. If there are no obvious signs of circulation, begin chest compressions: Place both hands the patient's sternum, the heel of one hand on top of the heel of the other. Push fast and push hard, to a depth of 1.5–2.0 in (4–5 cm), allowing full recoil of the chest. Continue compressions until a defibrillator or an AED is brought to the patient's side. If a defibrillator is not immediately available, continue chest compressions and ventilations at a ratio of 30/2 at a rate of approximately 100 compressions/min.

11. When the defibrillator or AED arrives, attach the two pads to the patient's bare chest. Right-sided sternal pad: right superoanterior infraclavicular position; left-sided apical pad: inferolateral left side of chest lateral to the left breast. Minimize interruption of chest compressions and compress until the pads are on the chest, if possible.

12. Stop compressions. Analyze the rhythm, and if indicated (presence of VF or pulseless VT), deliver a single shock.

13. Immediately resume CPR for another 5 cycles of 30 compressions/2 breaths (2 min). Do not check for a pulse until another 5 cycles of CPR have been performed. The defibrillated, stunned myocardium may not yet be pumping efficiently.

14. If there is no pulse, resume CPR, recharge the defibrillator and administer another single shock followed by immediate CPR.

15. If unsuccessful, proceed to the advanced cardiac life support (ACLS) algorithms and guidelines.