Guidelines: Adult basic life support and

automated external defibrillation

Authors
Gavin Perkins
Mick Colquhoun
Charles Deakin
Anthony Handley
Chris Smith
Michael Smyth

1. The guideline process

The process used to produce the Resuscitation Council UK Guidelines 2015 has
been accredited by the National Institute for Health and Care Excellence. The
guidelines process includes:

Systematic reviews with grading of the quality of evidence and strength of

recommendations. This led to the 2015 International Liaison Committee on
Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science with Treatment Recommendations.
1,2

The involvement of stakeholders from around the world including members

of the public and cardiac arrest survivors.
Details of the guidelines development process can be found in the
Resuscitation Council UK Guidelines Development Process Manual.
These Resuscitation Council UK Guidelines have been peer reviewed by the
Executive Committee of Resuscitation Council UK, which comprises 25
individuals and includes lay representation and representation of the key
stakeholder groups.

2. Summary of changes in basic life support and

automated external defibrillation since the
2010 Guidelines

Guidelines 2015 highlights the critical importance of the interactions

between the emergency medical dispatcher, the bystander who provides
cardiopulmonary resuscitation (CPR) and the timely deployment of an
automated external defibrillator (AED). An effective, co-ordinated
community response that draws these elements together is key to
improving survival from out-of-hospital cardiac arrest.
The emergency medical dispatcher plays an important role in the early
diagnosis of cardiac arrest, the provision of dispatcher-assisted CPR (also
known as telephone CPR), and the location and dispatch of an AED. The
sooner the emergency services are called, the earlier appropriate treatment
can be initiated and supported.
The knowledge, skills and confidence of bystanders will vary according to
the circumstances, of the arrest, level of training and prior experience. The
bystander who is trained and able should assess the collapsed victim rapidly
to determine if the victim is unresponsive and not breathing normally and
then immediately alert the emergency services. Whenever possible, alert
the emergency services without leaving the victim.
The victim who is unresponsive and not breathing normally is in cardiac
arrest and requires CPR. Immediately following cardiac arrest blood flow to
the brain is reduced to virtually zero, which may cause seizure-like episodes
that may be confused with epilepsy. Bystanders and emergency medical
dispatchers should be suspicious of cardiac arrest in any patient presenting
with seizures and carefully assess whether the victim is breathing normally.

3. Introduction

The community response to cardiac arrest is critical to saving lives. Each year,
UK ambulance services respond to approximately 60,000 cases of suspected
cardiac arrest. Resuscitation is attempted by ambulance services in less than half
of these cases (approximately 28,000).3 The main reasons are that either the
victim has been dead for several hours or has not received bystander CPR so by
the time the emergency services arrive the person has died. Even when
resuscitation is attempted, less than one in ten victims survive to go home from
hospital. Strengthening the community response to cardiac arrest by training and
empowering more bystanders to perform CPR and by increasing the use of
automated external defibrillators (AEDs) at least doubles the chances of survival
and could save thousands of lives each year.4,5

This guideline is based on the International Liaison Committee on Resuscitation

(ILCOR) 2015 Consensus on Science and Treatment Recommendations (CoSTR)
for Basic Life Support and Automated External Defibrillation and the European
Resuscitation Council Guidelines for Resuscitation 2015 Section 2 Adult basic life
support and automated external defibrillation.2,6 These contain all the reference
material for this section.

4. Chain of Survival

The Chain of Survival (Figure 1) describes four key, inter-related steps, which if
delivered effectively and in sequence, optimise survival from out-of-hospital
cardiac arrest.7

Figure 1. Chain of Survival

1: Early recognition and call for help

If untreated, cardiac arrest occurs in a quarter to a third of patients with

myocardial ischaemia within the first hour after onset of chest pain. Once cardiac
arrest has occurred, early recognition is critical to enable rapid activation of the
ambulance service and prompt initiation of bystander CPR.

2: Early bystander CPR

The immediate initiation of bystander CPR can double or quadruple survival from
out-of-hospital cardiac arrest.5,8-13 Despite this compelling evidence, only 40%
of victims receive bystander CPR in the UK.14

3: Early defibrillation

Defibrillation within 3–5 min of collapse can produce survival rates as high as
50–70%.15 This can be achieved through public access defibrillation, when a
bystander uses a nearby AED to deliver the first shock.4,15-17 Each minute of
delay to defibrillation reduces the probability of survival to hospital discharge by
10%. In the UK, fewer than 2% of victims have an AED deployed before the
ambulance arrives.18

4: Early advanced life support and standardised post-

resuscitation care

Advanced life support with airway management, drugs and the correction of
causal factors may be needed if initial attempts at resuscitation are unsuccessful.
The quality of treatment during the post-resuscitation phase affects outcome and
is addressed in the Adult advanced life support and Post-resuscitation care
sections.19

5. Improving survival from out-of-hospital

cardiac arrest

Resuscitation Council UK recommends that to improve survival from cardiac

arrest:

1. All school children are taught CPR and how to use an AED.
2. Everyone who is able to should learn CPR.
3. Defibrillators are available in places where there are large numbers of
people (e.g. airports, railway stations, shopping centres, sports stadiums),
increased risk of cardiac arrest (e.g. gyms, sports facilities) or where access
to emergency services can be delayed (e.g. aircraft and other remote
locations).
4. Owners of defibrillators should register the location and availability of
devices with their local ambulance services.
5. Systems are implemented to enable ambulance services to identify and
deploy the nearest available defibrillator to the scene of a suspected cardiac
arrest.
6. All out-of-hospital cardiac arrest resuscitation attempts are reported to the
National Out-of-Hospital Cardiac Arrest Audit. www.warwick.ac.uk/ohcao.

6. Resuscitation Council UK’s BLS/AED

guidelines

The remainder of this section contains guidance on the initial resuscitation of an

adult cardiac arrest victim where the cardiac arrest occurs outside a hospital.
This includes basic life support (BLS: airway, breathing and circulation support
without the use of equipment other than a protective barrier device) and the use
of an automated external defibrillator (AED). Simple techniques used in the
management of choking (i.e. foreign body airway obstruction) are also included.
Guidelines for the use of manual defibrillators and starting in-hospital
resuscitation are found in Advanced life support guidelines section.

The guidelines are based on the ILCOR 2015 Consensus on Science and
Treatment Recommendations (CoSTR) for BLS/AED and European Resuscitation
Council Guidelines for BLS/AED.2,6

7. Key messages from Guidelines 2015

Ensure it is safe to approach the victim.

Promptly assess the unresponsive victim to determine if they are breathing
normally.
Be suspicious of cardiac arrest in any patient presenting with seizures and
carefully assess whether the victim is breathing normally.
For the victim who is unresponsive and not breathing normally:
Dial 999 and ask for an ambulance. If possible stay with the victim and
get someone else to make the emergency call.
Start CPR and send for an AED as soon as possible.
If trained and able, combine chest compressions and rescue breaths,
otherwise provide compression-only CPR.
If an AED arrives, switch it on and follow the instructions.
Minimise interruptions to CPR when attaching the AED pads to the
victim.
Do not stop CPR unless you are certain the victim has recovered and is
breathing normally or a health professional tells you to stop
Treat the victim who is choking by encouraging them to cough. If the victim
deteriorates, give up to 5 back slaps followed by up to 5 abdominal thrusts.
If the victim becomes unconscious – start CPR.
The same steps can be followed for resuscitation of children by those who
are not specifically trained in resuscitation for children – it is far better to
 use the adult BLS sequence for resuscitation of a child than to do nothing.

8. Adult BLS Sequence

The sequence of steps for the initial assessment and treatment of the
unresponsive victim are summarised in Figure 2. Further technical information on
each of the steps is presented in Table 1 and below.

The sequence of steps takes the reader through recognition of cardiac arrest,
calling an ambulance, starting CPR and using an AED. The number of steps has
been reduced to focus on the key actions. The intent of the revised algorithm is
to present the steps in a logical and concise manner that is easy for all types of
rescuers to learn, remember and perform CPR and use an AED.

Figure 2. Adult basic life support algorithm

Table 1. BLS/AED detailed sequence of steps

SEQUENCE Technical Description

SAFETY Make sure you, the victim and any bystanders are safe

Check the victim for a response

Gently shake their shoulders and ask loudly: “Are you all
right?"
RESPONSE
If they respond, leave them in the position in which you
find them, provided there is no further danger; try to find
out what is wrong with the person and get help if needed;
reassess them regularly

Open the airway

Turn the victim onto their back

AIRWAY
Place your hand on their forehead and gently tilt their
head back; with your fingertips under the point of the
victim's chin, lift the chin to open the airway
 SEQUENCE Technical Description

Look, listen and feel for normal breathing for no

more than 10 seconds
In the first few minutes after cardiac arrest, a victim may
BREATHING be barely breathing, or taking infrequent, slow and noisy
gasps. Do not confuse this with normal breathing. If you
have any doubt whether breathing is normal, act as if they
are not breathing normally and prepare to start CPR

Call an ambulance (999)

Ask a helper to call if possible; otherwise call them

yourself
DIAL 999
Stay with the victim when making the call if possible

Activate the speaker function on the phone to aid

communication with the ambulance service

Send someone to get an AED if available

SEND FOR AED
If you are on your own, do not leave the victim, start CPR
 SEQUENCE Technical Description

Start chest compressions

Kneel by the side of the victim

Place the heel of one hand in the centre of the victim’s

chest (which is the lower half of the victim’s breastbone
(sternum))

Place the heel of your other hand on top of the first hand

Interlock the fingers of your hands and ensure that

pressure is not applied over the victim's ribs

CIRCULATION Keep your arms straight

Do not apply any pressure over the upper abdomen or the

bottom end of the bony sternum (breastbone)

Position your shoulders vertically above the victim's chest

and press down on the sternum to a depth of 5–6 cm

After each compression, release all the pressure on the

chest without losing contact between your hands and the
sternum;

Repeat at a rate of 100–120 min-1

 SEQUENCE Technical Description

After 30 compressions open the airway again using

head tilt and chin lift and give 2 rescue breaths

Pinch the soft part of the nose closed, using the index
finger and thumb of your hand on the forehead

Allow the mouth to open, but maintain chin lift

Take a normal breath and place your lips around their

mouth, making sure that you have a good seal

Blow steadily into the mouth while watching for the chest
to rise, taking about 1 second as in normal breathing; this
is an effective rescue breath

Maintaining head tilt and chin lift, take your mouth away
GIVE RESCUE
from the victim and watch for the chest to fall as air comes
BREATHS
out

Take another normal breath and blow into the victim’s

mouth once more to achieve a total of two effective rescue
breaths. Do not interrupt compressions by more than 10
seconds to deliver two breaths. Then return your hands
without delay to the correct position on the sternum and
give a further 30 chest compressions

Continue with chest compressions and rescue breaths in a

ratio of 30:2

If you are untrained or unable to do rescue breaths, give

chest compression only CPR (i.e. continuous compressions
at a rate of at least 100–120 min-1)
 SEQUENCE Technical Description

Switch on the AED

Attach the electrode pads on the victim’s bare chest

If more than one rescuer is present, CPR should be

continued while electrode pads are being attached to the
chest

Follow the spoken/visual directions

Ensure that nobody is touching the victim while the AED is

analysing the rhythm

IF AN AED If a shock is indicated, deliver shock

ARRIVES
Ensure that nobody is touching the victim

Push shock button as directed (fully automatic AEDs will

deliver the shock automatically)

Immediately restart CPR at a ratio of 30:2

Continue as directed by the voice/visual prompts

If no shock is indicated, continue CPR

Immediately resume CPR

Continue as directed by the voice/visual prompts

Do not interrupt resuscitation until:

A health professional tells you to stop

You become exhausted

CONTINUE CPR
The victim is definitely waking up, moving, opening eyes
and breathing normally

It is rare for CPR alone to restart the heart. Unless you are
certain the person has recovered, continue CPR
 SEQUENCE Technical Description

If you are certain the victim is breathing normally

but is still unresponsive, place in the recovery
position

Remove the victim’s glasses, if worn

Kneel beside the victim and make sure that both their legs
are straight

Place the arm nearest to you out at right angles to his

body, elbow bent with the hand palm-up

Bring the far arm across the chest, and hold the back of
the hand against the victim’s cheek nearest to you

With your other hand, grasp the far leg just above the
knee and pull it up, keeping the foot on the ground
THE RECOVERY
POSITION Keeping their hand pressed against his cheek, pull on the
far leg to roll the victim towards you on to their side

Adjust the upper leg so that both the hip and knee are
bent at right angles

Tilt the head back to make sure that the airway remains
open

If necessary, adjust the hand under the cheek to keep the

head tilted and facing downwards to allow liquid material
to drain from the mouth

Check breathing regularly

Be prepared to restart CPR immediately if the

victim deteriorates or stops breathing normally
Initial assessment

For clarity, the algorithm is presented as a linear sequence of steps. It is

recognised that the early steps of ensuring the scene is safe, checking for a
response, opening the airway, checking for breathing and calling the ambulance
may be accomplished simultaneously or in rapid succession.

Airway

Open the airway using the head tilt and chin lift technique whilst assessing
whether the person is breathing normally. Do not delay assessment by checking
for obstructions in the airway. The jaw thrust and finger sweep are not
recommended for the lay provider.

Breathing

Agonal breaths are irregular, slow and deep breaths, frequently accompanied by
a characteristic snoring sound. They originate from the brain stem, which
remains functioning for some minutes even when deprived of oxygen. The
presence of agonal breathing can be interpreted incorrectly as evidence of a
circulation and that CPR is not needed. Agonal breathing may be present in up to
40% of victims in the first minutes after cardiac arrest and, if correctly identified
as a sign of cardiac arrest, is associated with higher survival rates.20-29 The
significance of agonal breathing should be emphasised during basic life support
training. Bystanders should suspect cardiac arrest and start CPR if the victim is
unresponsive and not breathing normally.

Immediately following cardiac arrest, blood flow to the brain is reduced to

virtually zero. This may cause a seizure-like episode that can be confused with
epilepsy. Bystanders should be suspicious of cardiac arrest in any patient
presenting with seizures. Although bystanders who have witnessed cardiac arrest
events report changes in the victims’ skin colour, notably pallor and bluish
changes associated with cyanosis, these changes are not diagnostic of cardiac
arrest.

Checking the carotid pulse (or any other pulse) is an inaccurate method for
confirming the presence or absence of circulation.
30-34

Dial 999

Early contact with the ambulance service will facilitate dispatcher assistance in
the recognition of cardiac arrest, telephone instruction on how to perform CPR
and locating and dispatching the nearest AED.

If possible, stay with the victim while calling the ambulance. If the phone has a
speaker facility, switch it to speaker mode as this will facilitate continuous
dialogue with the dispatcher including (if required) CPR instructions.6 It seems
reasonable that CPR training should include how to activate the speaker phone.
Additional bystanders may be used to call the ambulance service.

Circulation

In adults needing CPR, there is a high probability of a primary cardiac cause for
their cardiac arrest. 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, start CPR with chest compressions rather than
initial ventilations.

Deliver compressions ‘in the centre of the chest’

Experimental studies show better haemodynamic responses when chest

compressions are performed on the lower half of the sternum. Teach this location
simply, such as, “place the heel of your hand in the centre of the chest with the
other hand on top”. Accompany this instruction by a demonstration of placing the
hands on the lower half of the sternum.

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.

Compress the chest to a depth of 5–6 cm

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.35-38 Resuscitation Council UK
endorses the ILCOR recommendation that it is reasonable to aim for a chest
compression depth of approximately 5 cm but not more than 6 cm in the average
sized adult.2,6 In making this recommendation, Resuscitation Council UK
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. Training should continue to prioritise achieving adequate compression
depth.

Compress the chest at a rate of 100–120 per minute (min-1)

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-1.6 Very high
chest compression rates were associated with declining chest compression
depths.39,40 Resuscitation Council UK therefore recommends that chest
compressions are performed at a rate of 100–120 min-1.

Minimise pauses in chest compressions

Delivery of rescue breaths, defibrillation shocks, ventilations and rhythm analysis

lead to pauses in chest compressions. Pre- and post-shock pauses of less than 10
seconds, and minimising interruptions in chest compressions are associated with
improved outcomes.41-45 Pauses in chest compressions should be minimised and
training should emphasise the importance of close co-operation between CPR
providers to achieve this.

Chest recoil

Leaning on the chest preventing full chest wall recoil is common during CPR.46,47
Allowing complete recoil of the chest after each compression results in better
venous return to the chest and may improve the effectiveness of CPR.46,48-50
CPR providers should, therefore, take care to avoid leaning forward after each
chest compression.

Duty cycle

The proportion of a chest compression spent in compression compared to

relaxation is referred to as the duty cycle. There is very little evidence to
recommend any specific duty cycle and, therefore, insufficient new evidence to
prompt a change from the currently recommended ratio of 50%.

Feedback on compression technique

CPR feedback and prompt devices (e.g. voice prompts, metronomes, visual dials,
numerical displays, waveforms, verbal prompts, and visual alarms) should be
used when possible during CPR training. Their use during clinical practice should
be integrated with comprehensive CPR quality improvement initiatives rather
than as an isolated intervention.51,52

CPR provider fatigue

Chest compression depth can decrease as soon as two minutes after starting
chest compressions. If there are sufficiently trained CPR providers, they should
change over approximately every two minutes to prevent a decrease in
compression quality. Changing CPR providers should not interrupt chest
compressions.

Rescue breaths

CPR providers should give rescue breaths with an inflation duration of 1 second
and provide sufficient volume to make the victim’s chest rise. Avoid rapid or
forceful breaths. The maximum interruption in chest compression to give two
breaths should not exceed 10 seconds.53

Mouth-to-nose ventilation

Mouth-to-nose ventilation is an acceptable alternative to mouth-to-mouth

ventilation. 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.

Barrier devices for use with rescue breaths

Barrier devices decrease transmission of bacteria during rescue breathing in

controlled laboratory settings. Their effectiveness in clinical practice is unknown.

If a barrier device is used, care should be taken to avoid unnecessary

interruptions in CPR. Manikin studies indicate that the quality of CPR is improved
when a pocket mask is used, compared to a bag-mask or simple face shield
during basic life support.

Compression-only CPR

CPR providers trained and able to perform rescue breaths should perform chest
compressions and rescue breaths as this may provide additional benefit for
children and those who sustain an asphyxial cardiac arrest or where the EMS
response interval is prolonged.54-57 Only if rescuers are unable to give rescue
breaths should they do compression-only CPR.

Resuscitation Council UK has carefully considered the balance between potential

benefit and harm from compression-only CPR compared to standard CPR that
includes ventilation. Our confidence in the equivalence between chest-
compression-only and standard CPR is not sufficient to change current practice.
Resuscitation Council UK, therefore, endorses the ILCOR and ERC
recommendations that CPR providers should perform chest compressions for all
patients in cardiac arrest. CPR providers trained and able to perform rescue
breaths should perform chest compressions and rescue breaths as this may
provide additional benefit for children and those who sustain an asphyxial
cardiac arrest or where the EMS response interval is prolonged.

When an untrained bystander dials 999, the ambulance dispatcher should

instruct them to give chest-compression-only CPR while awaiting the arrival of
trained help. Further guidance on dispatcher-assisted CPR is given in the
Prehospital resuscitation guidelines.

9. Use of an automated external defibrillator

AEDs are safe and effective when used by laypeople, including if they have had
minimal or no training.58 AEDs may make it possible to defibrillate many minutes
before professional help arrives. CPR providers should continue CPR with minimal
interruption to chest compressions both while attaching an AED and during its
use. CPR providers should concentrate on following the voice prompts,
particularly when instructed to resume CPR, and minimising interruptions in
chest compression.

Public access defibrillation (PAD) programmes

Public access AED programmes should be actively implemented in public places

with a high density and movement of people such as airports, railway stations,
bus terminals, sport facilities, shopping malls, stadiums, centres, offices, and
casinos – where cardiac arrests are frequently witnessed and trained CPR
providers can quickly be on scene.15,59-62 AEDs should also be provided in
remote locations where an emergency ambulance response would be likely to be
delayed (e.g. aircraft, ferries and off-shore locations). The potential benefits of
AEDs being placed in schools as a method to raise awareness and familiarity with
this lifesaving equipment is highlighted in the Education and implementation of
resuscitation section.

Registration of defibrillators with the local ambulance services is highly desirable

so that dispatchers can direct CPR providers to the nearest AED.63

When implementing an AED programme, community and programme leaders

should consider factors such as the development of a team with responsibility for
monitoring and maintaining the devices, training and retraining individuals who
are likely to use the AED, and identification of a group of volunteer individuals
who are committed to using the AED in victims of cardiac arrest.64 Funds must
be allocated on a permanent basis to maintain the programme.

Resuscitation Council UK and British Heart Foundation have produced

information endorsed by the National Ambulance Service Medical Directors
Group about AEDs and how they can be deployed in the community – A guide to
Automated External Defibrillators.

Risks to recipients of CPR

It is extremely rare for bystander CPR to cause serious harm in victims who are
eventually found not to be in cardiac arrest. Those who are in cardiac arrest and
exposed to longer durations of CPR are likely to sustain rib and sternal fractures.
Damage to internal organs can occur but is rare.65 The balance of benefits from
bystander CPR far outweighs the risks. CPR providers should not, therefore, be
reluctant to start CPR because of the concern of causing harm.

Risks to the CPR provider

CPR training and actual performance is safe in most circumstances. Although

rare occurrences of muscle strain, back symptoms, shortness of breath,
hyperventilation, pneumothorax, chest pain, myocardial infarction and nerve
injury have been described in rescuers, the incidence of these events is
extremely low. Individuals undertaking CPR training should be advised of the
nature and extent of the physical activity required during the training
programme. Learners and CPR providers who develop significant symptoms (e.g.
chest pain or severe shortness of breath) during CPR training should be advised
to stop and seek medical attention.

Although injury to the CPR provider from a defibrillator shock is extremely rare,
standard surgical or clinical gloves do not provide adequate electrical protection.
CPR providers, therefore, should not continue manual chest compressions during
shock delivery. Avoid direct contact between the CPR provider and the victim
when defibrillation is performed. Implantable cardioverter defibrillators (ICDs)
can discharge without warning during CPR and rescuers may therefore be in
contact with the patient when this occurs. However the current reaching the
rescuer from the ICD is minimal and harm to the rescuer is unlikely.

Adverse psychological effects after performing CPR are relatively rare. If

symptoms do occur the CPR provider should consult their general practitioner.

10. Choking

Choking is an uncommon but potentially treatable cause of accidental death. As

most choking events are associated with eating, they are commonly witnessed.
As victims are initially conscious and responsive, early interventions can be life-
saving.

Recognition

Recognition of airway obstruction is the key to successful outcome, so do not

confuse this emergency with fainting, myocardial infarction, seizure or other
conditions that may cause sudden respiratory distress, cyanosis or loss of
consciousness. Choking usually occurs while the victim is eating or drinking.
People at increased risk of choking include those with reduced consciousness,
drug and/or alcohol intoxication, neurological impairment with reduced
swallowing and cough reflexes (e.g. stroke, Parkinson’s disease), respiratory
disease, mental impairment, dementia, poor dentition and older age.66

Table 2 and Figure 3 present the treatment for the adult with choking. Foreign
bodies may cause either mild or severe airway obstruction. It is important to ask
the conscious victim “Are you choking?” The victim that is able to speak, cough
and breathe has mild obstruction. The victim that is unable to speak, has a
weakening cough, is struggling or unable to breathe, has severe airway
obstruction.

Table 2: Sequence of steps for managing the adult victim who is choking

SEQUENCE TECHNICAL DESCRIPTION

SUSPECT
Be alert to choking particularly if victim is eating
CHOKING

ENCOURAGE TO
Instruct victim to cough
COUGH

If cough becomes ineffective give up to 5 back blows

Stand to the side and slightly behind the victim

Support the chest with one hand and lean the victim
GIVE BACK BLOWS well forwards so that when the obstructing object is
dislodged it comes out of the mouth rather than
goes further down the airway
Give five sharp blows between the shoulder blades
with the heel of your other hand
 SEQUENCE TECHNICAL DESCRIPTION

If back blows are ineffective give up to 5 abdominal

thrusts

Stand behind the victim and put both arms round

the upper part of the abdomen
Lean the victim forwards
GIVE ABDOMINAL Clench your fist and place it between the umbilicus
THRUSTS (navel) and the ribcage
Grasp this hand with your other hand and pull
sharply inwards and upwards
Repeat up to five times
If the obstruction is still not relieved, continue
alternating five back blows with five abdominal
thrusts

Start CPR if the victim becomes unresponsive

START CPR Support the victim carefully to the ground

Immediately activate the ambulance service
Begin CPR with chest compressions
Figure 3. Adult choking algorithm

Treatment for mild airway obstruction

Coughing generates high and sustained airway pressures and may expel the
foreign body. Aggressive treatment with back blows, abdominal thrusts and chest
compressions at this stage may cause harm and can worsen the airway
obstruction. These treatments are reserved for victims who have signs of severe
airway obstruction. Victims with mild airway obstruction should remain under
continuous observation until they improve, as severe airway obstruction may
subsequently develop.

Treatment for severe airway obstruction

The clinical data on choking is largely retrospective and anecdotal. For conscious
adults and children over one year of age with complete airway obstruction, case
reports show the effectiveness of back blows or ‘slaps’ and abdominal thrusts.
Approximately half of cases of airway obstruction are not relieved by a single
technique. The likelihood of success is increased when combinations of back
blows or slaps, and abdominal and chest thrusts are used.

Treatment of choking in an unresponsive victim

Higher airway pressures can be generated using chest thrusts compared with
abdominal thrusts. Bystander initiation of chest compressions for unresponsive or
unconscious victims of choking is associated with improved outcomes. Therefore,
start chest compressions promptly if the victim becomes unresponsive or
unconscious. After 30 compressions, attempt 2 rescue breaths, and continue CPR
until the victim recovers and starts to breathe normally.

Aftercare and referral for medical review

Following successful treatment of choking, foreign material may nevertheless

remain in the upper or lower airways and cause complications later. Victims with
a persistent cough, difficulty swallowing or the sensation of an object being still
stuck in the throat should, therefore, seek medical advice. Abdominal thrusts and
chest compressions can potentially cause serious internal injuries and all victims
successfully treated with these measures should be examined afterwards for
injury. Patients receiving antiplatelet and/or anticoagulant drugs are at increased
risk of intra-abdominal haemorrhage and we suggest a low threshold for
obtaining a senior clinical opinion and thoracoabdominal CT scan if a thoraco-
abdominal injury is suspected.

11. Resuscitation of children and victims of

drowning
Many children do not receive resuscitation because potential CPR providers fear
causing harm if they are not specifically trained in resuscitation for children. This
fear is unfounded: it is far better to use the adult BLS sequence for resuscitation
of a child than to do nothing. For ease of teaching and retention, laypeople are
taught that the adult sequence may also be used for children who are not
responsive and not breathing normally. The following minor modifications to the
adult sequence will make it even more suitable for use in children:

Give 5 initial rescue breaths before starting chest compressions.

If you are on your own, perform CPR for 1 minute before going for help.
Compress the chest by at least one third of its depth, approximately 4 cm
for the infant and approximately 5 cm for an older child. Use two fingers for
an infant under 1 year; use one or two hands as needed for a child over 1
year to achieve an adequate depth of compression.

The same modifications of 5 initial breaths and 1 minute of CPR by the lone CPR
provider before getting help may improve outcome for victims of drowning. This
modification should be taught only to those who have a specific duty of care to
potential drowning victims (e.g. lifeguards).

12. Acknowledgements

These guidelines have been adapted from the European Resuscitation Council
2015 Guidelines. We acknowledge and thank the authors of the ERC Guidelines
for Adult basic life support and automated external defibrillation: Gavin D
Perkins, Anthony J Handley, Rudolph W. Koster, Maaret Castrén, Michael A Smyth,
Theresa Olasveengen, Koenraad G. Monsieurs, Violetta Raffay, Jan-Thorsten
Gräsner, Volker Wenzel, Giuseppe Ristagno, Jasmeet Soar.

Accreditation of the 2015 Guidelines

NICE has accredited the process used by Resuscitation Council UK to produce its
Guidelines development Process Manual. Accreditation is valid for 5 years from
March 2015. More information on accreditation can be viewed at
https://www.nice.org.uk/about/what-we-do/accreditation.
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