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《心肺复苏指南》参考资料（英文版）Part 4：Adult Basic Life Support

asic life support(BLS)includes recognition of signs of means that in the first minutes after collapse the victims sudden cardiac arrest(SCA), heart attack, stroke, and chance of survival is in the hands of bystander foreign-body airway obstruction(FBAO); cardiopulmonary Shortening the EMS response interval increases survival resuscitation (CPR); and d

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Part 4: Adult Basic Life Support B asic life support(BLS)includes recognition of signs of means that in the first minutes after collapse the victims sudden cardiac arrest(SCA), heart attack, stroke, and chance of survival is in the hands of bystander foreign-body airway obstruction(FBAO); cardiopulmonary Shortening the EMS response interval increases survival resuscitation (CPR); and defibrillation with an automated from SCA, but the effect is minimal once the EMS response external defibrillator(AED). This section summarizes BLs interval (from the time of EMS call until arrival) exceeds 5 to guidelines for lay rescuers and healthcare providers 6 minutes(OE 3).2-3I EMS systems should evaluate their protocols for cardiac arrest patients and try to shorten Introduction response intervals when improvements are feasible and re- As noted in Part 3: "Overview of CPR, "SCA is a leading sources are available(Class D). Each EMS system should cause of death in the United States and Canada. l-3 At the first measure the rate of survival to hospital discharge for victims analysis of heart rhythm, about 40% of victims of out-of- of vf sca and use these measurements to document the hospital SCA demonstrate ventricular fibrillation (VP) -VF impact of changes in procedures(Class Ila).32-35 Victims of cardiac arrest need immediate CPRCPR izations that cause the heart to quiver so that it is unable to pump blood effectively. 6 It is likely that an even large provides a small but critical amount of blood flow to the heart number of SCA victims have VF or rapid ventricul and brain. CPR prolongs the time VF is present and increases tachycardia (VT)at the time of collapse, but by the time of the likelihood that a shock will terminate vf(defibrillate the first rhythm analysis the rhythm has deteriorated to asystole. 7 heart) and allow the heart to resume an effective rhythm and Many sca victims can survive if bystanders act immedi- effective systemic perfusion. CPR is especially important if a ately while VF is still present, but successful resuscitation is unlikely once the rhythm deteriorates to asystole. Treatment minutes after collapse. Defibrillation does not"restart for VF SCA is immediate bystander CPR plus delivery of heart; defibrillation "stuns"the heart, briefly stopping VF and shock with a defibrillator. The mechanism of cardiac arrest other cardiac electrical activity. If the heart is still viable, its victims of trauma, drug overdose, drowning. normal pacemakers may then resume firing and produce an children is asphyxia. CPR with both compressions and rescue effective ECG rhythm that may ultimately produce adequate breaths is critical for resuscitation of these victims blood flow The American Heart Association uses 4 links in a chain In the first few minutes after successful defibrillation (the"Chain of Survival")to illustrate the important time asystole or bradycardia may be present and the heart may sensitive actions for victims of VF SCA(Figure 1). Three and pump ineffectively. In one recent study of VF SCA, only 25% possibly all 4 of these links are also relevant for victims of to 40% of victims demonstrated an organized rhythm 60 asphyxial arrest. 9 These links are seconds after shock delivery; it is likely that even fewer had Early recognition of the emergency and activation of the needed for several minutes following defibrillation until emergency medical services (E or local emergency adequate perfusion is present. 39 response system: "phone 911. 10,11 Lay rescuers can be trained to use a computerized device Early bystander CPR: immediate CPR can double or triple called an AED to analyze the victims rhythm and deliver a the victims chance of survival from VF SCA. 8 12-14 shock if the victim has VF or rapid VT. The AED uses audio Early delivery of a shock with a defibrillator: CPR plus and visual prompts to guide the rescuer. It analyzes the defibrillation within 3 to 5 minutes of collapse can produce victims rhythm and informs the rescuer if a shock is needed. Irvival rates as high as 49% to 75%. 5- Early advanced life support followed by postresuscitation AEDs are extremely accurate and will deliver a shock onl care delivered by healthcare providers when VF (or its precursor, rapid VT) is present. 0 AED function and operation are discussed in Part 5: Electrical Bystanders can perform 3 of the 4 links in the Chain of herapies: Automated External Defibrillators, Defibril survival. When bystanders recognize the emergency and Cardioversion, and Pacing ctivate the EMS system, they ensure that basic and advanced Successful rescuer actions at the scene of an SCa are time life support providers are dispatched to the site of the critical. Several studies have shown the beneficial effects of nities the time interval from immediate CPR and the detrimental impact of delays in EMS call to EMS arrival is 7 to 8 minutes or longer. 24 This defibrillation on survival from SCA. For every minute with out CPR. survival from witnessed VF SCA decreases 7% to (Circulation. 2005: 112: IV-19.IV-34) 10%0. When bystander CPR is provided, the decrease in o 2005 American Heart Associatio survival is more gradual and averages 3% to 4% per minute This special supplement to Circulation is freely available at http://www.circulationaha.org from collapse to defibrillation 8.12 CPR has been shown to double&, 12 or triplet survival from witnessed SCA at many DOI: 10.1161/CIRCULATIONAHA 105. 166553 intervals to defibrillate IV-19

Part 4: Adult Basic Life Support Basic life support (BLS) includes recognition of signs of sudden cardiac arrest (SCA), heart attack, stroke, and foreign-body airway obstruction (FBAO); cardiopulmonary resuscitation (CPR); and defibrillation with an automated external defibrillator (AED). This section summarizes BLS guidelines for lay rescuers and healthcare providers. Introduction As noted in Part 3: “Overview of CPR,” SCA is a leading cause of death in the United States and Canada.1–3 At the first analysis of heart rhythm, about 40% of victims of out-ofhospital SCA demonstrate ventricular fibrillation (VF).3–5 VF is characterized by chaotic rapid depolarizations and repolarizations that cause the heart to quiver so that it is unable to pump blood effectively.6 It is likely that an even larger number of SCA victims have VF or rapid ventricular tachycardia (VT) at the time of collapse, but by the time of first rhythm analysis the rhythm has deteriorated to asystole.7 Many SCA victims can survive if bystanders act immediately while VF is still present, but successful resuscitation is unlikely once the rhythm deteriorates to asystole.8 Treatment for VF SCA is immediate bystander CPR plus delivery of a shock with a defibrillator. The mechanism of cardiac arrest in victims of trauma, drug overdose, drowning, and in many children is asphyxia. CPR with both compressions and rescue breaths is critical for resuscitation of these victims. The American Heart Association uses 4 links in a chain (the “Chain of Survival”) to illustrate the important timesensitive actions for victims of VF SCA (Figure 1). Three and possibly all 4 of these links are also relevant for victims of asphyxial arrest.9 These links are ● Early recognition of the emergency and activation of the emergency medical services (EMS) or local emergency response system: “phone 911.”10,11 ● Early bystander CPR: immediate CPR can double or triple the victim’s chance of survival from VF SCA.8,12–14 ● Early delivery of a shock with a defibrillator: CPR plus defibrillation within 3 to 5 minutes of collapse can produce survival rates as high as 49% to 75%.15–23 ● Early advanced life support followed by postresuscitation care delivered by healthcare providers. Bystanders can perform 3 of the 4 links in the Chain of Survival. When bystanders recognize the emergency and activate the EMS system, they ensure that basic and advanced life support providers are dispatched to the site of the emergency. In many communities the time interval from EMS call to EMS arrival is 7 to 8 minutes or longer.24 This means that in the first minutes after collapse the victim’s chance of survival is in the hands of bystanders. Shortening the EMS response interval increases survival from SCA, but the effect is minimal once the EMS response interval (from the time of EMS call until arrival) exceeds 5 to 6 minutes (LOE 3).25–31 EMS systems should evaluate their protocols for cardiac arrest patients and try to shorten response intervals when improvements are feasible and resources are available (Class I). Each EMS system should measure the rate of survival to hospital discharge for victims of VF SCA and use these measurements to document the impact of changes in procedures (Class IIa).32–35 Victims of cardiac arrest need immediate CPR. CPR provides a small but critical amount of blood flow to the heart and brain. CPR prolongs the time VF is present and increases the likelihood that a shock will terminate VF (defibrillate the heart) and allow the heart to resume an effective rhythm and effective systemic perfusion. CPR is especially important if a shock is not delivered for 4 (LOE 4),36 5 (LOE 2),37 or more minutes after collapse. Defibrillation does not “restart” the heart; defibrillation “stuns” the heart, briefly stopping VF and other cardiac electrical activity. If the heart is still viable, its normal pacemakers may then resume firing and produce an effective ECG rhythm that may ultimately produce adequate blood flow. In the first few minutes after successful defibrillation, asystole or bradycardia may be present and the heart may pump ineffectively. In one recent study of VF SCA, only 25% to 40% of victims demonstrated an organized rhythm 60 seconds after shock delivery; it is likely that even fewer had effective perfusion at that point.38 Therefore, CPR may be needed for several minutes following defibrillation until adequate perfusion is present.39 Lay rescuers can be trained to use a computerized device called an AED to analyze the victim’s rhythm and deliver a shock if the victim has VF or rapid VT. The AED uses audio and visual prompts to guide the rescuer. It analyzes the victim’s rhythm and informs the rescuer if a shock is needed. AEDs are extremely accurate and will deliver a shock only when VF (or its precursor, rapid VT) is present.40 AED function and operation are discussed in Part 5: “Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing.” Successful rescuer actions at the scene of an SCA are time critical. Several studies have shown the beneficial effects of immediate CPR and the detrimental impact of delays in defibrillation on survival from SCA. For every minute without CPR, survival from witnessed VF SCA decreases 7% to 10%.8 When bystander CPR is provided, the decrease in survival is more gradual and averages 3% to 4% per minute from collapse to defibrillation.8,12 CPR has been shown to double8,12 or triple41 survival from witnessed SCA at many intervals to defibrillation.42 (Circulation. 2005;112:IV-19-IV-34.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166553 IV-19

I-20 Circulation December 13. 2005 Public access defibrillation and first-responder AED pro- Acute Coronary Syndromes grams may increase the number of SCA victims who receive Coronary heart disease continues to be the nation bystander CPR and early defibrillation, improving survival leading cause of death, with >500 000 deaths and 1.2 from out-of-hospital SCA. 4 These programs require an patients with an acute myocardial infarction(AMD) organized and practiced response with rescuers trained and ly. 6l Approximately 52% of deaths from AMI occur out of the provide CPR, and use the AED. 43 Lay rescuer AED programs symptoms. 6263 thin the first 4 hours after onset of in airports, 9 on airplanes, 0.2I in casinos, 2 and in first- Early recognition, diagnosis, and treatment of AMI can responder programs with police officers23,44-46 have achieved improve outcome by limiting damage to the heart, 64. 65 but survival rates as high as 49% to 75%019-23 from out-of- treatment is most effective if provided within a few hours of hospital witnessed VF SCA with provision of immediate the onset of symptoms. 6.67 Patients at risk for acute coronary bystander CPR and defibrillation within 3 to 5 minutes of syndromes(ACS)and their families should be taught to collapse. These high survival rates, however, may not be recognize the signs of Acs and immediately activate the attained in programs that fail to reduce time to EMS system rather than contact the family physician or drive defibrillation. 47-49 to the hospital. The classic symptom associated with ACs is chest discomfort, but symptoms may also include discomfort Cardiopulmonary Emergencies in other areas of the upper body, shortness of breath, Emergency Medical Dispatch sweating, nausea, and lightheadedness. The symptoms of Emergency medical dispatch is an integral component of the AMI characteristically last more than 15 minutes. Atypical EMS response. 50-63 Dispatchers should receive appropriate symptoms of ACS are more common in the elderly, women, training in providing prearrival telephone CPR instructions to and diabetic patients. 68-71 callers(Class Ila).0,54-67 Observational studies (LOE 4)5 aprove ACs outcome, all dispatchers and EMS and a randomized trial (Loe 2)57 documented that dispatcher providers must be trained to recognize ACS symptoms. EMS CPR instructions increased the likelihood of bystander CPR providers should be trained to determine onset of ACS symptoms, stabilize the patient, and provide prearrival noti being performed. It is not clear if prearrival instructions fication and transport to an appropriate medical care facility increase the rate of survival from sca spatchers who provide telephone CPR instructions to EMS providers can support the airway, administer oxygen bystanders treating children and adult victims with a high (Class IIb), and administer aspirin and nitroglycerin. If the likelihood of an asphyxial cause of arrest(eg, drowning) patient has not taken aspirin and has no history of should give directions for rescue breathing followed by chest allergy, EMS providers should give the patient 160 to 325 mg compressions. In other cases(eg, likely SCA) telephone before arrival. 72-75 Paramedics should be trained and instruction in chest compressions alone may be preferable equipped to obtain a 12-lead electrocardiogram (ECG)and ( Class IIb). The EMS systems quality improvement program transmit the ECG or their interpretation of it to the receiving should include periodic review of the dispatcher CPR instruc- hospital( Class Ila). More specifics on these topics are tions provided to specific callers( Class Ila). covered in Part 8: * Stabilization of the patient with Acute When dispatchers ask bystanders to determine if breathing Coronary Syndromes is present, bystanders often misinterpret occasional gasps as indicating that the victim is breathing. This erroneous infor- Stroke mation can result in failure to initiate CPR for a victim of Stroke is the nations No. 3 killer and a leading cause of cardiac arrest (LOE 5). 0 Dispatcher CPR instruction pro- severe, long-term disability. 6l Fibrinolytic therapy adminis- grams should develop strategies to help bystanders identify tered within the first hours of the onset of symptoms limits patients with occasional gasps as likely victims of cardiac neurologic injury and improves outcome in selected patients arrest and thus increase the likelihood of provision of by- with acute ischemic stroke. 76-78 The window of opportunity is stander CPR for such victims(Class Ilb) extremely limited, however. Effective therapy requires early Figure 1. Adult Chain of Survival

Public access defibrillation and first-responder AED programs may increase the number of SCA victims who receive bystander CPR and early defibrillation, improving survival from out-of-hospital SCA.43 These programs require an organized and practiced response with rescuers trained and equipped to recognize emergencies, activate the EMS system, provide CPR, and use the AED.43 Lay rescuer AED programs in airports,19 on airplanes,20,21 in casinos,22 and in firstresponder programs with police officers23,44–46 have achieved survival rates as high as 49% to 75%19–23 from out-ofhospital witnessed VF SCA with provision of immediate bystander CPR and defibrillation within 3 to 5 minutes of collapse. These high survival rates, however, may not be attained in programs that fail to reduce time to defibrillation.47–49 Cardiopulmonary Emergencies Emergency Medical Dispatch Emergency medical dispatch is an integral component of the EMS response.50–53 Dispatchers should receive appropriate training in providing prearrival telephone CPR instructions to callers (Class IIa).10,54–57 Observational studies (LOE 4)51,58 and a randomized trial (LOE 2)57 documented that dispatcher CPR instructions increased the likelihood of bystander CPR being performed. It is not clear if prearrival instructions increase the rate of survival from SCA.58,59 Dispatchers who provide telephone CPR instructions to bystanders treating children and adult victims with a high likelihood of an asphyxial cause of arrest (eg, drowning) should give directions for rescue breathing followed by chest compressions. In other cases (eg, likely SCA) telephone instruction in chest compressions alone may be preferable (Class IIb). The EMS system’s quality improvement program should include periodic review of the dispatcher CPR instructions provided to specific callers (Class IIa). When dispatchers ask bystanders to determine if breathing is present, bystanders often misinterpret occasional gasps as indicating that the victim is breathing. This erroneous information can result in failure to initiate CPR for a victim of cardiac arrest (LOE 5).60 Dispatcher CPR instruction programs should develop strategies to help bystanders identify patients with occasional gasps as likely victims of cardiac arrest and thus increase the likelihood of provision of bystander CPR for such victims (Class IIb). Acute Coronary Syndromes Coronary heart disease continues to be the nation’s single leading cause of death, with 500 000 deaths and 1.2 million patients with an acute myocardial infarction (AMI) annually.61 Approximately 52% of deaths from AMI occur out of the hospital, most within the first 4 hours after onset of symptoms.62,63 Early recognition, diagnosis, and treatment of AMI can improve outcome by limiting damage to the heart,64,65 but treatment is most effective if provided within a few hours of the onset of symptoms.66,67 Patients at risk for acute coronary syndromes (ACS) and their families should be taught to recognize the signs of ACS and immediately activate the EMS system rather than contact the family physician or drive to the hospital. The classic symptom associated with ACS is chest discomfort, but symptoms may also include discomfort in other areas of the upper body, shortness of breath, sweating, nausea, and lightheadedness. The symptoms of AMI characteristically last more than 15 minutes. Atypical symptoms of ACS are more common in the elderly, women, and diabetic patients.68–71 To improve ACS outcome, all dispatchers and EMS providers must be trained to recognize ACS symptoms. EMS providers should be trained to determine onset of ACS symptoms, stabilize the patient, and provide prearrival notification and transport to an appropriate medical care facility. EMS providers can support the airway, administer oxygen (Class IIb), and administer aspirin and nitroglycerin. If the patient has not taken aspirin and has no history of aspirin allergy, EMS providers should give the patient 160 to 325 mg of aspirin to chew (Class I) and notify the receiving hospital before arrival.72–75 Paramedics should be trained and equipped to obtain a 12-lead electrocardiogram (ECG) and transmit the ECG or their interpretation of it to the receiving hospital (Class IIa). More specifics on these topics are covered in Part 8: “Stabilization of the Patient With Acute Coronary Syndromes.” Stroke Stroke is the nation’s No. 3 killer and a leading cause of severe, long-term disability.61 Fibrinolytic therapy administered within the first hours of the onset of symptoms limits neurologic injury and improves outcome in selected patients with acute ischemic stroke.76–78 The window of opportunity is extremely limited, however. Effective therapy requires early Figure 1. Adult Chain of Survival. IV-20 Circulation December 13, 2005

Part 4: Adult Basic Life Support 1V-21 system,prompt dispatch of EMS personnel, rapid delivery to leave the victim to phone 911. Then return as quag.ce detection of the signs of stroke, prompt activation of the EMs victim responds but is injured or needs medical assistar a hospital capable of providing acute stroke care, prearrival possible and recheck the victim's condition frequently notification, immediate and organized hospital care, appro- priate evaluation and testing, and rapid delivery of fibrino- Activate the EMS System(Box 2) lytic agents to eligible patients. If a lone rescuer finds an unresponsive adult (ie, no move- Patients at high risk for a stroke and their family members ment or response to stimulation), the rescuer should activate must learn to recognize the signs and symptoms of stroke and the EMS system(phone 911), get an AED (if available), and to call EMS as soon as they detect any of them. The signs and return to the victim to provide CPR and defibrillation if symptoms of stroke are sudden numbness or weakness of the needed. When 2 or more rescuers are present, one rescuer face,arm,or leg, especially on one side of the body; sudden should begin the steps of CPr while a second rescuer confusion, trouble speaking or understanding; sudden troul activates the EMS system and gets the AED. If the emergency seeing in one or both eyes; sudden trouble walking, dizziness, occurs in a facility with an established medical respe loss of balance or coordination; and sudden severe headache system, notify that system instead of the EMS system. with no known cause. 81, 82 Healthcare providers may tailor the sequence of rescue EMS dispatchers should be trained to suspect stroke and ctions to the most likely cause of arrest. 92 If a lone healthcare rapidly dispatch responders 83 who should be able to perform provider sees an adult or child suddenly collapse, the collapse an out-of-hospital stroke assessment(Loe 3 to 5: Class is likely to be cardiac in origin, and the provider should phor Ila), 4-87 establish the time the patient was last known to be 911, get an AED, and return to the victim to provide CPr and "normal, "support the ABCs, notify the receiving hospital use the AED. If a lone healthcare provider aids a drowning that a patient with possible stroke is being transported there, victim or other victim of likely asphyxial(primary respira and consider triaging the patient to a facility with a stroke unit tory) arrest of any age, the healthcare provider should give 5 (OE 5 to 8: Class IIb).88-91 It may be helpful for a family cycles(about 2 minutes)of CPR before leaving the victim to member to accompany the patient during transport to verify activate the EMs system. the time of symptom onset. If authorized by medical control When phoning 911 for help, the rescuer should be prepare EMS providers should check the patient's glucose level to answer the dispatcher's questions about location, what during transport to rule out hypoglycemia as the of happened, number and condition of victims, and type of aid altered neurologic function and to give glucose if blood sugar provided. The caller should hang up only when instructed to is low do so by the dispatcher and should then return to the victim When the stroke victim arrives at the emergency depart- to provide CPR and defibrillation if needed. ment(ED), the goal of care is to streamline evaluation so that initial assessment is performed with Open the Airway and Check Breathing(Box 3) puted tomography(CT) scan is performed and interpreted To prepare for CPR, place the victim on a hard surface in within 25 minutes, and fibrinolytics are administered to face up(supine)position. If an unresponsive victim is face selected patients within 60 minutes of arrival at the ED and down(prone), roll the victim to a supine(face up)position.If vithin 3 hours of the onset of symptoms. Additional infor- a hospitalized patient with an advanced airway (eg, endotra- mation about the assessment of stroke using stroke scales and cheal tube, laryngeal mask airway [LMAl, or esophageal the management of stroke is included in Part 9: " Adult tracheal combitube [Combitube]) cannot be placed in the Stroke upine position (eg, during spinal surgery), the healthcare CPR with the patient in a prone Adult BLs Sequence position( Class IIb). See below The steps of BLS consist of a series of sequential assessments and actions. which are illustrated in the bls algorithm Open the Airway: Lay Rescuer The lay rescuer should open the airway using a head tilt-chin (Figure 2). The intent of the algorithm is to present the steps lift maneuver for both injured and noninjured victims(Class in a logical and concise manner that will be easy to learn, Ila). The jaw thrust is no longer recommended for lay remember, and perform. The box numbers in the following section refer to the corresponding boxes in the Adult BLS escuers because it is difficult for lay rescuers to learn and perform, is often not an effective way to open the airway, and Healthcare Provider Algorithm may cause spinal movement( Class IIb) Safety during CPR training and performance, including the use of barrier devices, is discussed in Part 3. Before approach Open the Airway: Healthcare Provider ing the victim the rescuer must ensure that the scene is safe. a healthcare provider should use the head tilt-chin lift Lay rescuers should move trauma victims only if absolutely maneuver to open the airway of a victim without evidence of necessary(eg, the victim is in a dangerous location, such as head or neck trauma. Although the head tilt-chin lift tech- nique was developed using unconscious, paralyzed adult olunteers and has not been studied in victims with cardiac Check for Response(Box 1) arrest, clinical93 and radiographic (LOE 3)evidence94, 95 and a Once the rescuer has ensured that the scene is safe, the case series (loe 5)96 have shown it to be effective rescuer should check for response. To check for response, tap Approximately 2% of victims with blunt trauma have a the victim on the shoulder and ask, "Are you all right? " If the spinal injury, and this risk is tripled if the victim has a

detection of the signs of stroke, prompt activation of the EMS system, prompt dispatch of EMS personnel, rapid delivery to a hospital capable of providing acute stroke care, prearrival notification, immediate and organized hospital care, appropriate evaluation and testing, and rapid delivery of fibrinolytic agents to eligible patients.79,80 Patients at high risk for a stroke and their family members must learn to recognize the signs and symptoms of stroke and to call EMS as soon as they detect any of them. The signs and symptoms of stroke are sudden numbness or weakness of the face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; and sudden severe headache with no known cause.81,82 EMS dispatchers should be trained to suspect stroke and rapidly dispatch responders83 who should be able to perform an out-of-hospital stroke assessment (LOE 3 to 5; Class IIa),84–87 establish the time the patient was last known to be “normal,” support the ABCs, notify the receiving hospital that a patient with possible stroke is being transported there, and consider triaging the patient to a facility with a stroke unit (LOE 5 to 8; Class IIb).88–91 It may be helpful for a family member to accompany the patient during transport to verify the time of symptom onset. If authorized by medical control, EMS providers should check the patient’s glucose level during transport to rule out hypoglycemia as the cause of altered neurologic function and to give glucose if blood sugar is low. When the stroke victim arrives at the emergency department (ED), the goal of care is to streamline evaluation so that initial assessment is performed within 10 minutes, a computed tomography (CT) scan is performed and interpreted within 25 minutes, and fibrinolytics are administered to selected patients within 60 minutes of arrival at the ED and within 3 hours of the onset of symptoms. Additional information about the assessment of stroke using stroke scales and the management of stroke is included in Part 9: “Adult Stroke.” Adult BLS Sequence The steps of BLS consist of a series of sequential assessments and actions, which are illustrated in the BLS algorithm (Figure 2). The intent of the algorithm is to present the steps in a logical and concise manner that will be easy to learn, remember, and perform. The box numbers in the following section refer to the corresponding boxes in the Adult BLS Healthcare Provider Algorithm. Safety during CPR training and performance, including the use of barrier devices, is discussed in Part 3. Before approaching the victim, the rescuer must ensure that the scene is safe. Lay rescuers should move trauma victims only if absolutely necessary (eg, the victim is in a dangerous location, such as a burning building). Check for Response (Box 1) Once the rescuer has ensured that the scene is safe, the rescuer should check for response. To check for response, tap the victim on the shoulder and ask, “Are you all right?” If the victim responds but is injured or needs medical assistance, leave the victim to phone 911. Then return as quickly as possible and recheck the victim’s condition frequently. Activate the EMS System (Box 2) If a lone rescuer finds an unresponsive adult (ie, no movement or response to stimulation), the rescuer should activate the EMS system (phone 911), get an AED (if available), and return to the victim to provide CPR and defibrillation if needed. When 2 or more rescuers are present, one rescuer should begin the steps of CPR while a second rescuer activates the EMS system and gets the AED. If the emergency occurs in a facility with an established medical response system, notify that system instead of the EMS system. Healthcare providers may tailor the sequence of rescue actions to the most likely cause of arrest.92 If a lone healthcare provider sees an adult or child suddenly collapse, the collapse is likely to be cardiac in origin, and the provider should phone 911, get an AED, and return to the victim to provide CPR and use the AED. If a lone healthcare provider aids a drowning victim or other victim of likely asphyxial (primary respiratory) arrest of any age, the healthcare provider should give 5 cycles (about 2 minutes) of CPR before leaving the victim to activate the EMS system. When phoning 911 for help, the rescuer should be prepared to answer the dispatcher’s questions about location, what happened, number and condition of victims, and type of aid provided. The caller should hang up only when instructed to do so by the dispatcher and should then return to the victim to provide CPR and defibrillation if needed. Open the Airway and Check Breathing (Box 3) To prepare for CPR, place the victim on a hard surface in a face up (supine) position. If an unresponsive victim is face down (prone), roll the victim to a supine (face up) position. If a hospitalized patient with an advanced airway (eg, endotracheal tube, laryngeal mask airway [LMA], or esophagealtracheal combitube [Combitube]) cannot be placed in the supine position (eg, during spinal surgery), the healthcare provider may attempt CPR with the patient in a prone position (Class IIb). See below. Open the Airway: Lay Rescuer The lay rescuer should open the airway using a head tilt–chin lift maneuver for both injured and noninjured victims (Class IIa). The jaw thrust is no longer recommended for lay rescuers because it is difficult for lay rescuers to learn and perform, is often not an effective way to open the airway, and may cause spinal movement (Class IIb). Open the Airway: Healthcare Provider A healthcare provider should use the head tilt–chin lift maneuver to open the airway of a victim without evidence of head or neck trauma. Although the head tilt–chin lift technique was developed using unconscious, paralyzed adult volunteers and has not been studied in victims with cardiac arrest, clinical93 and radiographic (LOE 3) evidence94,95 and a case series (LOE 5)96 have shown it to be effective. Approximately 2% of victims with blunt trauma have a spinal injury, and this risk is tripled if the victim has a Part 4: Adult Basic Life Support IV-21

I-22 Circulation December 13. 2005 No movement or response PHONE 911 or emergency number or send second rescuer(if available) to do this Open AIRWAY, check BREATHING If not breathing, give 2 BREATHS that make chest ns Do you DEFINITELY feel pulse within 10 seconds? Recheck pulse every Figure 2. Adult BLS Healthcar No Pulse Algorithm Boxes bordered wit nes indicate actions or steps Give cycles of 30 COMPRESSIONS and 2 BREATHS by the healthcare provider but not the until AED/defibrillator arrives, ALS providers take over, or victim starts to move Push hard and fast (100/min) and release completely Minimize interruptions in compressions AED/defibrillator ARRIVES Shockable rhythm? Give 1 shock Resume CPR immediately resume CPR immediately for 5 cycles providers take over or victim starts to move craniofacial injury, 7 a Glasgow Coma Scale score of <8, 98 or Check breathing both97.99 If a healthcare provider suspects a cervical spine While maintaining an open airway, look, listen, and feel for injury, open the airway using a jaw thrust without head breathing. If you are a lay rescuer and do not confidently extension( Class IIb).96 Because maintaining a patent airway detect normal breathing or if you are a healthcare provider and providing adequate ventilation is a priority in CPR(Class and do not detect adequate breathing within 10 seconds, give D), use a head tilt-chin lift maneuver if the jaw thrust does no 2 breaths(see below ). If you are a lay rescuer and you ar open the airway unwilling or unable to give rescue breaths, begin chest Use manual spinal motion restriction rather than immobi- compressions( Class lla) lization devices for victims with suspected spinal injury Professional as well as lay rescuers may be unable to ( Class IIb). 100, 101 Manual spinal motion restriction is safer, accurately determine the presence or absence of adequate or and immobilization devices may interfere with a patent normal breathing in unresponsive victims (LOE 7)1o9-lll irway(loe 3 to 4). 102-104 Cervical collars may complicate because the airway is not open 12 or the victim has occasional airway management during CPR(LOE 4), 102 and they can gasps, which can occur in the first minutes after SCA and cause increased intracranial pressure in a victim with a head may be confused with adequate breathing. Occasional gasps injury (loe 4 to 5: Class IIb). 105-10s Spine immobilization are not effective breaths. Treat the victim who has occasional devices, however, are necessary during transport gasps as if he or she is not breathing( Class D)and give rescue

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