Basic Life Support Provider Manual ‘© 2020 American Heart Association ISBN 978-1-61669-768-6 Printed in the United States of America First American Heart Association Printing October 2020 eBook edition © 2020 American Heart Association. ISBN 978-1-61669-799-0, 20-3102 Acknowledgments ‘The American Heart Association thanks the following people for their contributions to the development ofthis manual: Jose G. Cabafias, MD, MPH; Jeanette Previdi, MPH, RN: Matthew Douma, RN; Bryan Fischberg, NRP; Sonni Logan, MSN, RN, CEN, CVN, CPEN: Mary Elizabeth Mancini, RN, PaD, NE- BC; Randy Wax, MD, MEd; Sharon T. Wilson, PhD, RN, FCN: Brenda D. Schooifield; and the AHA BLS. Project Team. To find out about any updates or corrections to this text, visit www.heart.orgicourseupdatesContents Part 1: General Course Concepts Course Description Completion Requirements Your Approach tea Resi ot Personal Protective Es ‘The BLS Provider Manual Part 2: The Chain of Survival Leaming Objectives Overview Chain of Survival Elements Comparison of the In-Hospital and Qut-of-Hospital Chains of Survival ‘Key Differences in Adult and Pediatric Chains of Survival Review Questions Part 3: BLS for Adults Leaming Objectives Basic Framework for CPR High-Performance Rescue Teams Main Components of CPR Adult BLS Algorithm for Healthcare Providers ‘Quality CPR Skills: Adults ‘Ghest Compressions Chest Compression Technique Give Breaths Barrier Devices for Giving Breaths Pocket Masks Bag-Mask Devices Adult 2-Reseuer BLS What Is a CPR Coach? Review Questions Part 4: Automated External Defibrillator for Adults and Children 8 Years of Age and Older Leaming Objectives Defibrillation Using the AED Operating an AED: Universal Steps Minimize Time Between Last Compression and Shock Delivery Do Not Delay High-Quality CPR After AED Use Child AED Pads‘Special Circumstances Review Questions Part 5: Team Dynamics ‘Leaming Objectives Elements of Effective Team Dynamics Roles and Responsibilities ‘Communication ‘Coaching and Debriefing Review Questions Part 6: BLS for Infants and Children Leaming Objectives Pediatric BLS Algorithm for Healthcare Providers—Single Rescuer High-Quality CPR Skills: infants and Children Assess for Breathing and a Pulse Perform High-Quality Chest Compressions Give Breaths Pediatric BLS Algorithm for Healthcare Providers Infant and Child 2-Rescuer BLS Review Questions or More Rescuers tor for Infants and Children Younger Than 8 Years of Age Part 7: Automated External Defibr Learning Objectives Know Your AED Pediatric-Capable AEDs for Reduced Shock Doses ‘Choosing and Placing the AED Pads AED Use for Victims 8 Years of Age and Older AED Use for Victims Younger Than 8 Years of Age AED Use for infants, Review Questions Part 8: Alternate Ventilation Techniques. Leaming Objectives ‘CR and Breaths With an Advanced Rescue Breathing Review Questions Part 9: Opioid Associated Life-Threatening Emergencies Learning Objectives ‘What Are Opioids? Problematic Opioid Use Adentifying an Opioid EmergencyAntidote to Opioid Qverdose: Naloxone d Life-Threatening Emergency Response Sequence Review Questions Part 40: Other Life-Threatening Emergencies Leaming Objectives Heart Attack ‘Stroke Drowning Anaphylaxis Review Questions Part 11: Choking Relief for Adults, Children, and Infants Leaming Objectives. ‘Signs of Choking Choking Relief in a Responsive Adult or Child Choking Relief in Pregnant and Obese Victims Choking Relief in an Unresponsive Adult oF Child Giving Effective Breaths When There Is an Ainvay Obstruction Actions After Choking Relief Choking Relief in Infants Review Questions pendix Adult 4 Adult 2-Rescuer BLS Sequence Cardiac Arrest in Pregnancy: Out-of-Hospital BLS Considerations Qploid-Associated Emergency for Healthcare Providers Algorithm and Sequence. Infant and Child 4-Rescuer BLS Sequence Infant and Child 2-Rescuer BLS Sequence escuer BLS Sequence Adult CPR and AED Skills Testing Checklist Adult CPR and AED Skills Testing Critical Skills Descriptors Infant CPR Skills Testing Checklist infant CPR Skills Testing Critical Skills Descriptors Glossary Answers to Review Questions Recommended ReadingAbbreviations eed Definition automated external defibrillator Basic Life Support ‘cardiopulmonary resusctatfon ‘emergency department lateral uterine displacement eT [Rose | retemof spontaneous crulonPart 1: General Course Concepts Welcome to the American Heart Assaciation Basic Life Support (BLS) Provider Course. BLS is the foundation for saving lives after cardiac arrest. In this course, you will learn the skills of high-quality cardiopulmonary resuscitation (CPR) for victims of all ages. You will practice delivering these skills both as a single rescuer and as a member of a multirescuer team. The skills you learn in this course will enable you to + Recognize cardiac arrest + Activate the emergency response system early + Respond quickly and confidently Despite important advances in prevention, sudden cardiac arrest remains a leading cause of death in many countries. About half of cardiac arrests are unwitnessed. Qutcome from out-of hospital cardiac arrest remains poor. Only about 10% of adult patients with nontraumatic cardiac arrest who are treated by emergency medical services (EMS) survive to hospital discharge. This course will help you give victims the best chance of survival BLS Course Objectives ‘The BLS Course focuses on what you need to know to perform high-quality CPR in a wide variety of settings. You will also learn how te respond to choking and other types of life-threatening emergencies. After successfully completing the BLS Course, you should be able to + Describe the importance of high-quality CPR ang its impact on survival ‘Describe all the steps in the Chains of Survival Apply the BLS concepts of the Chains of Survival Recognize the signs of someone needing CPR Perform high-quality CPR for an adult, a child, and an infant Describe the importance of early use of an automated external defibrillator (AED) ‘Demonstrate the appropriate use of an AED Provide effective ventilation by using a barrier device Describe the importance of teams in multirescuer resuscitation Perform as an effective team member during muttirescuer CPR Describe the technique for relief of foreign-body airway obstruction for an adult, a child, and an infant Course Description This course prepares you to perform high-quality CPR skills. CPR is a lifesaving procedure for a victim whe has signs of cardiac arrest (ie, unresponsive, no normal breathing, and no pulse}. The 2 key components of CPR are chest compressions and breaths. High-qualtty CPR improves a victim's chances of survival. Study and practice the characteristics of high-quality CPR so that you can perform each skill effectively.Gritical Goncepts: High-Quality GPR «Start compressions within 10 seconds after recognizing cardiac arrest, + Push hard, push fast Compress at a rate of 100 to 120/min with a depth of — Atleast 2 inches (5 em) for adults but no more than 2.4 inches (6 cm) — Atleast one third the depth of the chest, approximately 2 inches (5 cm), for children — Atleast one third the depth of the chest, approximately 1% inches (4 cm), for infants + Allow complete chest recoil after each compression. Avoid leaning on the chest between compressions. + Minimize interruptions in compressions (try to limit interruptions to less than 10 seconds). ve effective breaths. Deliver each breath over 4 second, enough to make the victim's chest rise Avoid excessive ventilation Completion Req Dies To successfully complete this course and receive your BLS course completion card, you must do the following + Participate in hands-on interactive demonstrations of high-quality CPR skills, + Pass the Adult CPR and AED Skills Test + Pass the Infant CPR Skills Test + Score at least 24% on the exam in the instructorted course (or successfully complete the online portion of the HeartCode® BLS course) Skills Tests. ‘You must pass 2 skills tests to receive your BLS course completion card, During the course, you will have an opportunity to learn and practice chest compressions, bag-mask ventilation, and using an AED. After practice, your instructor will test your skills by reading a brief scenario. You will be asked to Tespond as you would in a real-life situation. The instructor will not coach or help you during the skills: tests. Exam ‘The exam is open resource. This means that you may refer to print or digital resources while you are taking the exam. You may not, however, discuss the exam questions with other students or your instructor. Examples of resources that you may use include notes you take in class, this Provider Manual, and the American Heart Association’s Handbook of Emergency Cardiovascular Care for Healthcare Providers. ‘Your Approach to a Resuscitation Attempt The BLS techniques and sequences you will learn offer 1 approach to @ resuscitation attempt. But every situation is unique. Your response will be determined by + Available emergency equipment + Availabilty of trained rescuers + Level of training expertise + Local protocolsPeete eee con oma lei Personal protective equipment (PPE) helps protect rescuers from health or safety risks. PPE will vary based on situations and protocols. It can include a combination of items, such as medical gloves, eye protection, gowns/tull-body suits, nigh-visibilty clothing, safety footwear, and safety helmets ‘Ask your local health authority or regulatory body about the PPE protocols for your role. Me Pe CL Read your BLS Provider Manual carefully. Study the skills and lifesaving sequences. During the course, you'll apply this knowledge as a rescuer in simulated emergency scenarios. Your BLS Provider Manual can serve as a resource long afler you complete your course. Age Definitions In this course, age definitions are as follows: «Infants: younger than 1 year of age (excluding newly born infants in the delivery room) + Children: 4 year of age to puberty (signs of puberty are chest or underarm hair in males; any breast development in termales) ‘+ Adults: adolescents (je, after the onset of puberty) and older Callout Boxes This manual includes Critical Concepts boxes that call attention to specific content. Critical Goncepts ‘These boxes contain important information you must know, including specific risks associated with certain interventions and additional background on key topics Review Questions ‘Answer the review questions provided at the end of each Part. You may use these to confirm your understanding of important BLS concepts.Part 2: The Chain of Survival For many years, the American Heart Association has adopted, supported, and helped develop the concept of emergency cardiovascular care. The term Chair of Survival provides a useful metaphor for the elements of the emergency cardiovascular care systems-of-care concept. The Chain of Survival shows the actions that must take place to give the cardiac arrest victim the best chance of survival. Each link is independent, yet connected, to the links before and after. If any link is broken, the chance for a good outcome decreases. Learning Objectives At the end of this Part, you will be able to + Deseribe the importance of high-quality CPR and its impact on survivat + Describe all of the steps in the Chain of Survival + Apply the BLS concepts of the Chain of Survival Cardiac arrest can happen anywhere—on the street, at home, or in a hospital emergency department (ED), inpatient bed, or intensive care unit. Elements in the system of care and order of actions in the Chain of Survival differ based on the situation. Care will depend on whether the victim has the arrest outside the hospital or inside the hospital. Care also depends on whether the victim is an adult, child, or infant Actions in the Chain of Survival differ according to setting (in-hospital vs out-of-hospital) and age group. Here are the specific Chains of Survival (Figure 1) «Pediatric in-nospital cardiac arrest + Pediatric out-of-hospital cardiac arrest + Adult in-hospital cardiac arrest + Adult out-of hospital cardiac arrest SGooeo Figure 14. The American Heart ‘Association 2020 ‘Chains of Survival. Links in the Chain of ‘Survival will differ based on whether the arrest occurs in or out ‘of the hospital and the age of the victim. A, Pediatric In-Hospital ‘Chain of Survival, 6GoceoFigure 18. Pediatric ‘Out-of-Hospital Chain of Survival. @GGGEeo Figure 1C, Adult In- Hospital Chain of Survival, eooces Figure 10. Adult Out-of- Hospital Chain of Survival . ee area Although there are slight differences in the Chains of Survival based on the age of the victim and the location of the cardiac arrest, each includes the following elements: * Prevention and preparedness + Activating the emergency response system * High-quality CPR, including early defibritation + Advanced resuscitation interventions © Post-cardiae arrest care + Recovery Prevention and Preparedness Prevention and preparedness are the foundation of early recognition of cardiac arrest and rapid response, ‘Out-of-hospital. Most out-of-hospital adult cardiac arrests are unexpected and happen at home. Successful outcomes depend on early high-quality CPR and rapid defibriliation in the first fev minutes after the arrest. Organized community programs that prepare the public to respond quickly to a cardiac arrest are critical to improving outcomes. Prevention includes measures to improve the health of individuals and communities. Preparedness includes public awareness programs and training to help people recognize the signs of a heart attack and cardiac arrest and take effective action. Community CPR training and emergency response system development are important. Emergency telecommunicators (ie, call takers, dispatchers) who give CPR instructions help increase rates of bystander CPR and improve outcomes. This telecommunicator-assisted CPR (T-CPR) enables the general public to perform high-quality CPR and early defibrillation. Mobile phone apps or text messages can be used fo summon members of the public who are trained in CPR. Mobile phone apps/mapping can help rescuers locate the nearest AED. Widespread AED availability supports early defibrillation and saves lives. Public access defibrillation (PAD) programs are designed to reduce the time to defibrillation by placing AEDs in public places and training laypeople to use themIn-hospital. In the hospital setting, preparedness includes early recognition and rapid response to the patient who may need resuscitation. For adult patients in the hospital, cardiac arrest usually happens as a result of serious respiratory or circulatory conditions that get worse. Healthcare providers can predict and prevent many of these arrests by careful observation, preventive care, and early treatment of prearrest conditions Once a provider recognizes cardiac arrest, immediate activation of the emergency response system. early high-quality CPR, and rapid defibrillation are essential. Many institutions conduct ongoing training in resuscitation response. Some maintain rapid response teams or medical emergency teams. Activating the Emergency Response System Out-of-hospital. Activating the emergency response system usually means shouting for nearby help and phoning 8-1-1 or the local emergency response number. In the workplace, every employee should know how to activate the emergency response system in their setting (Figure 24). The sooner a rescuer activates the emergency response system, the sooner the next level of care will arrive. ~ Figure 2A. Activate the emergency response ‘system in your setting. A, Qut-of-hospital setting in the workplace. In-hospital. Activation of the emergency response system in the hospital setting is specific to each institution (Figure 2B). A provider may activate a code, summon the rapid response team or medical emergency team, or ask someone else to do it. The sooner a provider activates the emergency response system, the sooner the next level of care will arrive. Figure 2B, In-hospital setting. High-Quality GPR, Including Early Defibrillation Out-of-hospital and in-hospital. High-quality CPR with minimal interruptions and early defibrilation are the actions most closely related to good resuscitation outcomes. High-quality GPR started immediately after cardiac arrest combined with early defibrillation can double or triple the chances of survival. These time-sensitive interventions can be provided both by members of the public and by healthcare providers. Bystanders who are not trained in CPR should at least provide chest compressions (also called Hands-Onty CPR), Even withaut training, bystanders can perform chest compressions with guidance from emergency telecommunicators aver the phone (T-CPR) Advanced Resuscitation Interventions ‘Out-of-hospital and in-hospital. Advanced interventions may be performed by medically trained providers during a resuscitation attempt. Some advanced interventions are obtaining vascular access,giving medications, and placing an advanced ainvay. Others are obtaining a 12-lead electrocardiogram (EGG) or starting advanced cardiac monitoring. In both settings, high-quality CPR and defibrillation are key interventions that are the foundation of a successful outcome. Out-of-hospital. Lay rescuers provide high-quality CPR and defibrillation with an AED until a multirescuer team takes over the resuscitation attempt. This high-performance team will continue high+ quality CPR and defibrillation and may perform advanced interventions, in-hospital. The high-performance team in a hospital may include physicians, nurses, respiratory therapists, pharmacists, and others. In addition to advanced interventions, extracorporeal CPR may be usad in certain resuscitation situations Post-Cardiac Arrest Care Out-of-hospital. After return of spontaneous circulation (ROSC), all cardiac arrest victims receive post-cardiac arrest care. Post-cardiac arrest care includes routine critical care support, such as artificial ventilation and blood pressure management. This care begins in the field and continues during transport to a medical facility. in-hospital. A multidisciplinary team provides this advanced level of care. Providers focus on preventing the return of cardiac arrest and tailor specific therapies to improve long-term survival. Post— cardiac arrest care may occur in the ED, cardiac catheterization lab (cath lab), intensive care unit, or coronary care unit The patient may undergo a cardiac catheterization procedure. During this procedure, a catheter is inserted in an artery (most frequently the groin or wrist) and threaded through the blood vessels to the Patient's heart to evaluate heart function and blood flow. Some cardiac problems, such as a blocked artery, may be fixed or other problems diagnosed. Recovery Recovery from cardiac arrest continues long after hospital discharge. Depending on the outcome, the survivor of cardiac arrest may need specific interventions. Interventions may be needed to address the underlying cause of cardiac arrest or to provide cardiac rehabilitation. Some patients need rehabiltation focused on neurological recovery. Psychological support for the patient and family are important during the recovery period. Rescuers also may benefit frem psychological support. Comparison of the In-Hospital and Out-of-Hospital Chains of Survival Five key elements affect all Chains of Survival (Table 1). Those elements are initial support resuscitation teams, available resources, resuscitation constraints, and level of complexity. Table 1 shows key differences in initial support, resuscitation teams, and available resources between the in- hospital and out-of-hospital settings. Resuscitation constraints and level of complexity are the same in both settings. Table 1. Comparison of 5 Key Elements in the Chains of Survival aud eee eee rea eee ern Initial support | Depends on an in-hospital system of Depends on community and EMS appropriate surveillance, monitoring, and | providers for support prevention vith responsive primary provider teamsAvailable Depending on the facility, in-hospital Available resources may be limited in the resources multidisciplinary teams may have out-of-hospital settings: immediate access to additional personnel as |» AED access: AEDs may be available ‘well as resources of the ED, cardiac cath ‘through a local PAD program or lab, and intensive care unit. included in emergency or first aid ‘equipment Untrained rescuers: T-CPR helps untrained rescuers perform high- ‘quality GPR. EMS high-performance teams: The ‘only resources may be those they ‘brought with them. Additional ‘backup resources and equipment may take some time to arrive, Level of Resuscitation attempts, both in and out of the hospital, are typically complex. They require complexity | teamwork and coordination between rescuers and care providers. eee aPC a ka emer mel hep In adults, cardiac arrestis offen sudden and frequently results from a cardiac cause. In children however, cardiac arrest is offen secondary to respiratory failure or shock. Both respiratory failure and ‘shock can be life-threatening. Prevention of cardiac arrest is the first link in the pediatric Chains of Survival (Figures 1A and B), Early identification of respiratory or circulatory problems and appropriate treatment may prevent progression to cardiac arrest. Early identification also may maximize survival. eT eles 1. Im which locations do most out-of-hospital cardiac arrests occur? a. Healthcare clinics b. Homes c. Recreational facilities d. Shopping centers 2. Which is the most common cause of cardiac arrest in children? a. Cardiac problem . Congenital or acquired heart defect c. Respiratory failure or shock d. Infection and sepsis3. What is the third link in the adult out-of-hospital Chain of Survival? a. Advanced life support b. High-quality CPR ¢. Prevention ¢. Defibrillation Show Answ See Answers to Review Question:Part 3: BLS for Adults This section describes BLS for adults. You will learn to perform high-quality CPR skills, both as a single rescuer and as a member of a multirescuer team. Use adult BLS skills for victims who are adolescents (le, after the onset of puberty) and older Pee aie ele) Cathy In this Part, you will learn to * Recognize the signs of someone needing CPR + Perform high-quality CPR for an adult + Provide effective ventilation with a barrier device Basic Framework for CPR Anyone can be a lifesaving rescuer for a cardiac arrest victim (Figure 3). The particular CPR skills & rescuer uses depend on several variables, such as level of training, experience, and confidence (le, rescuer proficiency). Other variables are the type of victim (child vs adult), available equipment, and other rescuers. A single rescuer with limited training or who has training but limited equipment can do Hands-Only CPR. Arescuer with more training can do 30:2 CPR. When several rescuers are present, they can perform multirescuer-coordinated CPR. Figure 3. Building blocks of CPR. Here are some examples: + Hands-Only CPR. A single rescuer with little training and no equipment who witnesses a cardiac arrest in a middle-aged man might provide only chest compressions until help arrives. + 30:2 CPR. A police officer trained in BLS who finds an adolescent in cardiac arrest will provide both chest compressions and breaths by using a ratio of 30 compressions to 2 breaths. + High-performance team. Three emergency responders who are called to assist a woman in cardiac arrest will perform multirescuer-coordinated CPR: rescuer 1 performs chest compressions: rescuer 2 gives breaths with a bag-mask device; rescuer 3 uses the AED. Rescuer 3 also assumes the role of CPR Coach. A CPR Coach helps team members perform high-quality CPR and minimize ‘pauses in chest compressions. Teeter me (oy Coordinated efforts by several rescuers during CPR may increase the chances for a successful resuscitation. High-performance teams divide tasks among team members during a resuscitation attempt,As a team member, you will want to perform high-quality CPR skills to make your maximum contribution to each resuscitation team effort. See Part § for more about team performance. Main Components of CPR The main components of CPR are + Chest compressions * ainvay = Breathing ‘You will learn about each of these throughout this course. Adult BLS Algorithm for Healthcare Providers ‘The Adult BLS Algorithm for Healthcare Providers outlines steps for single rescuers and multiple Tescuers of an unresponsive adult (Figure 4). Once you learn the skills presented in this Part, use this algorithm as @ quick reference for providing high-quality CPR te an adult whe is in cardiac arrest. Figure 4, Adult BLS Algorithm for Healthcare Providers. ‘Arescuer who arrives at the side of a potential car steps on the algorithm: flac arrest victim should follow these sequential Step 1: Verify scene safety. Make sure that the scene is safe for you and the victim. ‘Step 2: Check for responsiveness, Tap the victim's shoulders. Shout, “Are you OK? If the victim is not responsive, activate the emergency response system via mobile device. Get the AED or send someone to doso. Step 3: Assess for breathing and a pulse. Check for a pulse to determine next actions. To minimize delay in staring CPR, you should assess breathing and pulse at the same time. This should take no more than 10 seconds. Steps 3a and 3b: Determine next actions based on whether breathing is normal and if a pulse is felt: «Ifthe victim is breathing normally and a pulse is felt, monitor the victim. = Ifthe victim is not breathing normally but a pulse is felt:— Provide rescue breathing at a rate of 1 breath every 6 seconds, or 10 breaths per minute. — Check for @ pulse about every 2 minutes. Perform high-quality CPR if you do not feel a pulse. - Ifyou suspect opioid use, give naloxone if available and follow your local protocols. «Ifthe victim is not breathing normally or is only gasping and has no pulse, begin high-quality CPR (Step 4). Step 4: Start high-quality CPR, with 30 chest compressions followed by 2 breaths. Use an AED as soon as itis available. Steps 5 and 6: Use the AED as soon as its available. Follow the AED directions to check the rhythm. Step 7; Ifthe AED detects a shockable rhythm, give 1 shock, Resume CPR immediately until prompted by the AED to allow a rhythm check, about every 2 minutes. Continue CPR and using the AED until advanced life support providers take over or the victim begins to breathe, move, or otherwise react. Step 8: ifthe AED detects a nonshockable rhythm, resume high-quality CPR until prompted by the ‘AED to allow a rhythm check, about every 2 minutes. Continue CPR and using the AED until advanced life support providers take over or the victim begins to breathe, move, or otherwise react. Fora complete explanation of each step, see the Adull 1-Rescuer BLS Sequence in the Acpendix Learning the skills in this section will prepare you to provide high-quality CPR to adults uality CPR Skills: Adults Assess for Breathing and a Pulse Assess the victim for normal breathing and a pulse (Figure 5). This will help you determine the next appropriate actions. Figure 5. Check for breathing and a pulse at the same time. To minimize delay in starting CPR, you should assess breathing at the same time as you check the pulse. This should take at least 5 seconds but no more than 40 seconds. Breathing To check for breathing, scan the victim's chest fer rise and fall for no. more than #0 seconds. + Ifthe victim is breathing: Monitor the victim until additional help arrives. + Ifthe victim is not breathing or is only gasping: Be prepared to begin high-quality CPR. Gasping is not normal breathing and is a sign of cardiac arrest. Critical Concepts: Agonal Gasps Agonal gasps may be present in the first minutes after sudden cardiac arrest. Agonal gasps are not normal breathing.‘A person who gasps usually appears to be drawing air in very quickly. The mouth may be open, and the Jaw, head, or neck may move with gasps. Gasps may appear forceful or weak. Some time may pass between gasps because they usually happen at a siow, irregular rate. The gasp may sound like a snort, snore, or groan. Gasping is not normal breathing. It is @ sign of cardiac arrest. Checking for the Carotid Pulse on an Aduit To perform a pulse check on an adult, feel for a carotid pulse (Figure 5). Ifyou do not definitely fees a pulse within 40 seconds, begin high-quality CPR, starting with chest compressions. Follow these steps to find and feel for the carotid pulse= + Locate the trachea (on the side closest to you), using 2 or 3 fingers (Figure 6A) + Slide those fingers into the groove between the trachea and the muscles at the side of the neck, where you can feel the carotid pulse (Figure 68) + Feel for a pulse for at ieast 5 but. no mare than 10 seconds. If you do not definitely feel a pulse, begin CPR, starting with chest compressions. Figure 6A. Finding the carotid pulse. A, Locate the trachea, Figure 6B. Gently fee! for the carotid pulse. In all scenarios, by the time @ breathing-and-pulse check indicates cardiac arrest, the following should already be happening. «Someone has activated the emergency response system. + Someone has gone to get the AED. Pr Ua eel meee eC Cleat The foundation of CPR is high-quality chest compressions. Compressing the chest during CPR pumps blood from the heart to the brain and then to the rest of the body. Each time you stop chest compressions, the blood flow trom the heart to the brain and other organs decreases significantly. Once you resume compressions, it takes several compressions to bring the blood flow back up to the levels present before the interruption. Thus, the more often you interrupt chest compressions and the longer the interruptions are, the lower the blood supply to the brain and critical organs.