3 HOURS
Continuing Education
Overview: Survival rates for cardiac arrests
that occur in hospitals and outside them con-
tinue to be low (17% and 6%, respectively),
and fewer than one-third of patients who
have an out-of-hospital cardiac arrest receive
cardiopulmonary resuscitation (CPR).
Consequently, a number of changes were
made to the 2005 American Heart
Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular
Care. The changes were intended to simplify
CPR in order to increase its use and effective-
ness by both clinicians and nonprofessionals.
This article summarizes the primary changes
to the recommendations, including a univer-
sal 30-to-2 compression-to-ventilation ratio for
all lone rescuers, the need for compressions
of sufficient depth and number, and the
replacement of the three-shock model of ini-
tial defibrillation with one that recommends a
single shock, now seen as an adequate pre-
cursor to CPR.
60 AJN ▼ January 2007 ▼ Vol. 107, No. 1
A review of the latest changes to the
American Heart Association’s cardio-
pulmonary resuscitation and emergency
cardiovascular care guidelines.
“
W
hy do they keep updating these guidelines? Didn’t they make
changes just last year?” It does seem so. In 2005 the
American Heart Association (AHA) published another ver-
sion of its Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care,1 but it had been five
years since the last published revisions. The AHA first established guide-
lines for cardiopulmonary resuscitation (CPR) in 1974 and has revised
them five times since, in 1980, 1986, 1992, 2000, and 2005. The 2005
guidelines cover all aspects of emergency cardiac care; at the same time,
they represent an attempt to simplify CPR procedures so that more
health care professionals and lay rescuers might learn them and perform
them correctly. (The complete guidelines are available online at
http://circ.ahajournals.org/content/vol112/24_suppl.)
Much is at stake. Despite decades of efforts to promote CPR, the sur-
vival rate for out-of-hospital cardiac arrest remains low worldwide,
averaging 6% or less.2, 3 In the United States, sudden cardiac arrest is a
leading cause of death,4-6 resulting in an estimated 330,000 out-of-hospital
Linda Mutchner is an infusion nurse at Frederick Memorial Hospital in Frederick, MD.
She also is a coowner of Core Training Consultants, Taneytown, MD, which offers
courses in cardiopulmonary resuscitation, first aid, infusion, and chemotherapy. Contact
author: lmutchner@msn.com. The author of this article has no significant ties, financial
or otherwise, to any company that might have an interest in the publication of this edu-
cational activity.
Much of this article is adapted from the 2005 American Heart Association Guidelines
for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published in
the December 13, 2005, Circulation supplement: Circulation 2005 Dec 13;112(24
Suppl):IV1-203.
http://www.nursingcenter.com
 By Linda Mutchner, BSN, RN, CRNI, OCN
deaths annually.7 Ventricular fibrillation plays a role
in most cases of sudden cardiac arrest,3, 5, 8 and defib-
rillation in the first five minutes after collapse
greatly increases the chances of survival.9 Too often,
however, the time to defibrillation exceeds five min-
utes.2 Casinos, airlines, airports, and police forces
that have “first-responder programs” involving the
use of automated external defibrillators (AEDs)
show survival rates to hospital discharge of 49% to
80%,10-13 but survival rates decrease 7% to 10% for
each minute between collapse and defibrillation
when CPR is not provided.14 When initiated as soon
as possible after a patient’s collapse, CPR performed
correctly and followed by defibrillation is a central
aspect of the “chain of survival” for those who have
a sudden cardiac arrest.15 Fewer than one-third of
patients who have an out-of-hospital cardiac arrest
receive CPR,15, 16 suggesting a need for better and
more widespread training of nonprofessionals.
And hospital nurses and physicians do not
always perform CPR effectively.17, 18 The new AHA
guidelines warn clinicians against hyperventilating
patients (providing too many breaths at too great a
tidal volume), interrupting compressions too often
or for too long, and compressing the chest too
slowly and too shallowly, with a resulting drop in
coronary perfusion. At the same time, advanced
interventions such as endotracheal intubation don’t
make a significant difference in survival rates;
according to one multisite, observational study, only
17% of patients who experience in-hospital cardiac
arrest survive to discharge.19
INTERNATIONAL CONSENSUS
The 2000 AHA guidelines resulted from a process
begun in 1993, when the International Liaison
ajn@wolterskluwer.com
Committee on Resuscitation (ILCOR) was formed to
identify, review, and reconcile international research
and practice related to CPR and emergency cardio-
vascular care. ILCOR’s founding member organiza-
tions were the AHA, the European Resuscitation
Council, the Heart and Stroke Foundation of Canada,
the Resuscitation Council of Southern Africa, and the
Australian Resuscitation Council, later joined by
the Consejo Latino-Americano de Resuscitación
and the New Zealand Resuscitation Council.
Since 1993 representatives from the ILCOR
member councils have been evaluating research find-
ings and working toward developing resuscitation
guidelines, meeting 22 times. The AHA hosted the
first ILCOR conference in 1999, recommendations
from which were published in 2000.20 Researchers
from the ILCOR member councils continued to eval-
uate research findings, in a process that culminated
in the 2005 International Consensus Conference
on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science with Treatment Recom-
mendations (hereafter referred to as the 2005 con-
sensus conference). The conferees undertook the
most extensive review to date of international scien-
tific evidence on CPR, using a carefully structured
process of ongoing disclosure and management of
potential conflicts of interest. They paid particular
attention to streamlining the guidelines in order to
reduce the amount of information that rescuers need
to remember and to clarifying the fundamental tasks
that rescuers should perform.
More than 280 international experts were
divided into six task forces, on basic life support,
advanced life support, acute coronary syndromes,
pediatric life support, neonatal life support, and
overlapping topics such as education. (Additional
AJN ▼ January 2007 ▼ Vol. 107, No. 1 61
 task forces—separate from the ILCOR process,
although findings are summarized in the guide-
lines—were created to consider stroke and first-aid.)
The task forces proposed hypotheses; one or two
international experts were appointed to review
research on each topic, determine levels of evidence,
and develop a draft of recommendations for treat-
ment. At the 2005 consensus conference such a
draft was discussed, with a special focus on the
quality of evidence and issues of financial disclosure
and conflict of interest. The wording was refined, and
prior to publication, the final document was approved
by all ILCOR members and by an international edi-
torial board.
While universally applicable international guide-
lines may not be an achievable short-term goal—
because of regional differences in health care and
contradictory or weak evidence available on some
topics—many treatment recommendations have been
agreed upon and simplified in ways that should make
the training of professionals and nonprofessionals
more efficient and the delivery of CPR more effective.
What follows is a look at changes in the guidelines as
well as the scientific reasoning behind them.
ADULT BASIC LIFE SUPPORT
Major recommendations in the 2005 AHA guide-
lines were assigned to “classes” meant to reflect the
level of current evidence found to support them and
the weight they should be given in practice, with the
caveat that much of the evidence we have currently
is derived not from clinical trials but from non-
randomized or retrospective trials or from animal
models. These are as follows (and appear through-
out the text to indicate the strength of particular
recommendations):
• Class I: the benefit clearly outweighs the risk; the
procedure, treatment, or assessment should be
performed.
• Class IIa: the benefit is likely to outweigh the risk.
It’s reasonable to follow the recommendation.
• Class IIb: the benefit is greater than or equal to
the risk. Following the recommendation may be
considered.
• Class III: the risk is greater than or equal to the
benefit. The procedure, treatment, or assessment
is not helpful, may be harmful, and should not be
performed.
• Class indeterminate: research has not begun or is
ongoing. No recommendations can be made at
this time.
Recommendations were also distinguished accord-
ing to whether they were meant for health care
providers, for lay rescuers, or for both. The follow-
ing is a summary of changes in the guidelines for
adult basic life support.
62 AJN ▼ January 2007 ▼ Vol. 107, No. 1
Recognition and “activation”: avoid delays.
Early recognition of sudden cardiac arrest is the key
to increasing the chances of survival. For lay rescuers,
checking the carotid pulse is an inaccurate method of
confirming the presence or absence of circulation;
according to research, they fail to recognize the
absence of a pulse in 10% of pulseless victims (poor
sensitivity) and fail to detect a pulse in 40% of victims
with a pulse (poor specificity).20 Health care providers
also often take too long in checking for a pulse and
inaccurately assess its presence or absence.21, 22 There
is no evidence that checking for movement, breath-
ing, or coughing is any more reliable than checking
for a pulse as a method of recognizing the signs of cir-
culation. Taking too much time to check for a pulse
delays the rescuer’s initiation of chest compressions
(class IIb). Agonal respiration is common in the early
stages of cardiac arrest and can mislead a rescuer into
thinking that CPR isn’t required.
Recommendations
• If the person is unconscious (unresponsive), not
moving, and not breathing (or has agonal breath-
ing), lay rescuers shouldn’t check for pulse; they
should dial 911, obtain an AED if one is avail-
able, perform CPR for two minutes (or approxi-
mately five cycles, with one cycle defined as 30
compressions and two ventilations), and then use
an AED if they are trained to use one. (There are
two types of AEDs—those sold before 2003 tend
to be monophasic, delivering just one shock at a
time, while the newer biphasic models deliver a
dual shock of lower energy.) If an AED is not
available, lay rescuers should continue CPR with-
out interruption until emergency help arrives.
• Clinicians should check for the absence of nor-
mal, adequate breathing and pulse (taking no
more than 10 seconds to do so) before beginning
CPR (class IIa).
• Clinicians should adapt the sequence of rescue
actions to the probable cause of arrest. If a lone
health care provider sees someone collapse sud-
denly, the arrest is likely to be cardiac in origin and
the provider should dial 911, obtain and use an
AED (class I), and then provide CPR for two min-
utes (five cycles) before rechecking the rhythm. If
an AED is not available, she or he should continue
CPR until emergency medical services arrive.
• If the lone health care provider did not witness
the person’s collapse, she or he should perform
CPR for two minutes and then use an AED, if
available (class IIb). If the provider aids a victim
of likely asphyxial (usually respiratory) arrest of
any age, she or he should give five cycles of CPR
before leaving the victim to dial 911 (class IIa).
Airway: keep it simple. Maintaining the airway
and providing adequate ventilation are crucial dur-
http://www.nursingcenter.com
Table 1. Summary of Basic Life Support ABCD Maneuvers for Infants, Children, and Adults
MANEUVER ADULT CHILD INFANT
(Maneuvers performed only by health (For lay rescuers, adults are defined as those 8 years (For lay rescuers, children are those 1–8 (For all rescuers, infants are defined
care providers are indicated by “HCP”) of age or older; for HCPs, adolescent or older) years of age; for HCPs, 1 year to adolescent) as those under 1 year of age)

Activate (Call) Call when victim is found un- Call after performing 5 cycles of CPR
emergency response num- responsive
ber (lone rescuer) HCP: if asphyxial arrest is likely, call For sudden, witnessed collapse, call after verifying
after 5 cycles (2 minutes) of CPR that victim is unresponsive

AIRWAY Head tilt–chin lift (HCP: if trauma suspected, use jaw thrust)
BREATHS 2 effective breaths at 1 second 2 effective breaths at 1 second per breath
per breath
HCP: rescue breathing 10 to 12 breaths per minute 12 to 20 breaths per minute (1 breath every 3 to 5
without chest compressions (1 breath every 5 to 6 seconds) seconds)

HCP: rescue breathing for 8 to 10 breaths per minute (1 breath every 6 to 8 seconds)
CPR with advanced airway

Foreign-body airway Abdominal thrusts Back slaps and chest thrusts

obstruction

CIRCULATION
HCP: pulse check Carotid artery Brachial or femoral
(10 seconds or less) (HCP can use femoral artery in child) artery

Compression landmarks Center of chest, between nipples Just below nipple line

Compression method: 2 hands: heel of 1 hand, other 2 hands: heel of 1 hand 1 rescuer: 2 fingers
• push hard and fast hand on top with second on top or HCP, 2 rescuers: 2-
• allow complete recoil 1 hand: heel of 1 hand thumb–encircling-hands
only technique

Compression depth 11/2 to 2 inches Approximately 1/3 to 1/2 the depth of the chest

Compression rate Approximately 100 per minute

Compression-to-ventilation 30 to 2 (1 or 2 rescuers) 30 to 2 (single rescuer)

ratio HCP: 15 to 2 (2 rescuers)

DEFIBRILLATION
Automatic external defibril- Use adult pads. Do not use child HCP: use AED as soon as No recommendation for
lator (AED) pads or a child system. possible for sudden and in- infants less than 1 year
HCP: for out-of-hospital response, hospital collapse.
you may provide 5 cycles (2 min- All: after 5 cycles of CPR (out
utes) of CPR before shock if of hospital). Use child pads
response time is longer than 4 to and system for child 1 to 8
5 minutes and arrest was not wit- years old if available. If child
nessed. pads and system are not
available, use adult AED
and pads.
Note: information appropriate for use in newborns is not included.
Used with permission from American Heart Association. Currents in Emergency Cardiovascular Care 2005–2006;16(4)15.

ajn@wolterskluwer.com AJN ▼ January 2007 ▼ Vol. 107, No. 1 63

 ing CPR (class I). The best method of opening an
airway is the head tilt–chin lift maneuver (class IIa).
The rescuer should reposition the head if the first
ventilation does not cause the chest to rise. All such
repositionings cause spinal movement, and studies
in cadavers have shown that chin lifts (with or with-
out head tilts) and jaw thrusts cause substantial
movement of the cervical vertebrae,23 but no studies
have evaluated the effects of these movements on
people with suspected spinal injuries. When spinal
injury is suspected, manual spinal motion restriction
should be employed while the jaw thrust maneuver
is used to open the airway. This is safer than using
immobilization devices, which may interfere with
the airway during CPR (class IIb).
Recommendations
• Lay rescuers should be taught only the head
tilt–chin lift technique for both injured and unin-
jured people (class IIa). (The jaw thrust maneuver
is considered too difficult for nonprofessionals to
learn and perform.)
• Clinicians should use the jaw thrust maneuver if
injury to the cervical spine is suspected (class IIb);
if that does not open the airway, the head
tilt–chin lift technique should be used. If two
health care professionals are present, one can
manually stabilize the head and neck while the
other performs CPR.
Ventilation: practice moderation. After cardiac
arrest with ventricular fibrillation, diminished car-
diac output causes myocardial and cerebral ischemia,
but the blood oxygen level remains high for the first
several minutes. Therefore, administering breaths is
not at first as important as administering chest com-
pressions. During CPR, blood flow to the lungs is
reduced to 25% to 35%, and achieving adequate
oxygenation requires a lower tidal volume and
fewer ventilations.24 Hyperventilation is unneces-
sary and even harmful; it increases intrathoracic
pressure, decreases venous return to the heart, and
diminishes cardiac output. Hyperventilation can
also cause gastric distention leading to regurgitation
and aspiration and can elevate the diaphragm,
restricting lung movement and elasticity. It may,
however, be necessary to provide high pressures to
ventilate patients with an obstructed airway or poor
lung compliance.
Recommendations
• Two rescue breaths, one second each (class IIa),
should be given with enough volume to see the
chest rise (class IIa).
• Rapid or forceful breaths should be avoided.
• For a victim with a pulse, 10 to 12 breaths per
minute (one breath every five to six seconds)
should be given; more can be dangerous (class
IIa).
64 AJN ▼ January 2007 ▼ Vol. 107, No. 1
Chest compressions: “push hard, push fast.”
Effective chest compressions are essential (class I).
The new guidelines strongly emphasize that com-
pressions should be given at a rate of about 100 per
minute, with a depth of 1.5 to 2 in., over the lower
half of the sternum, allowing the chest to completely
recoil (equal compression and relaxation time). (The
guidelines state that the “compression rate refers to
the speed of compressions, not the actual number of
compressions.”) Studies have suggested that in
almost 40% of cases, in-hospital chest compressions
may be too shallow.17 Incomplete recoil of the chest
and inadequate depth and rate of compressions may
result from rescuer fatigue.25 Incomplete recoil is also
associated with higher intrathoracic pressure,
decreased coronary perfusion, and decreased cere-
bral perfusion.26 When chest compression is 20% to
50% of the total combined chest compression and
relaxation time, coronary and cerebral perfusion
increases, as shown in animal studies.27, 28
Studies involving clinicians performing CPR show
that chest compressions may not be provided for as
much as half of the total arrest time.17, 18, 29 In animal
studies, interrupted chest compressions were associ-
ated with reduced coronary artery perfusion pressure,
reduced return of spontaneous circulation, reduced
survival rates, and reduced postresuscitation myocar-
dial function.30-32
Recommendations
• Chest compressions should be performed at a
rate of 100 per minute, over the lower half of the
sternum, at a depth of 1.5 to 2 in. (class IIa).
• Complete recoil of the chest should be allowed
between compressions; a duty cycle of 50% (that
is, equal time given to chest compression and
relaxation) is recommended because it is easy to
achieve with practice.33
• CPR should be interrupted as infrequently as
possible; interruptions should last no longer than
10 seconds, except for the performance of inter-
ventions such as defibrillation (class IIa).
• Lay rescuers should be instructed not to stop
CPR to check for signs of circulation.
Compression and ventilation: a new ratio.
Animal studies and theoretical calculations have been
used to determine the compression-to-ventilation ratio
most likely to increase the number of compressions
given, reduce the likelihood of hyperventilation, mini-
mize interruptions, and simplify instruction.34, 35 While
more study is needed, a consensus has been reached
in the current guidelines that a 30-to-2 ratio best
meets these criteria. This ratio is, however, demand-
ing to maintain; although rescuers may deny fatigue
for up to five minutes of performing CPR, after one
minute they often give compressions that are too
shallow.25
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Recommendations
• All rescuers should use acompression-to-ventilation
ratio of 30 to 2—that is, giving 30 compressions
for every two ventilations (class IIa).
• During two-person CPR, compressions should
be paused briefly to provide ventilations; in
mechanically ventilated patients, eight to 10 ven-
tilations per minute (one every six to eight sec-
onds) should be given without a pause in
compressions (class IIa).
• When two rescuers are present, compressors
should change every two minutes, switching in
less than five seconds, if possible (class IIb).
• Lay rescuers should be instructed to use only
compressions if they are not willing or able to
deliver rescue breaths (class IIa).
DEFIBRILLATION: ADULTS
Immediate defibrillation is the first and best response
to witnessed cardiac arrest with a short time to inter-
vention (class I). In cases of sudden cardiac arrest with
prolonged ventricular fibrillation, survival rates are
highest when CPR is provided immediately and defib-
rillation begins within three to five minutes.10, 14, 15, 36
Chest compressions generate a small but critical
amount of blood flow and consequently oxygen to
the brain and myocardium. Two studies found that
when emergency providers’ time to arrival was four
or five minutes or longer, victims who received one
and a half to three minutes of CPR before defibrilla-
tion had increased rates of initial resuscitation, sur-
vival to hospital discharge, and one-year survival
than did those who received immediate defibrilla-
tion.37, 38 But one randomized trial found no improve-
ment in outcomes when 90 seconds of CPR was
performed before defibrillation in patients with ven-
tricular fibrillation or tachycardia.39
When ventricular fibrillation is present for sev-
eral minutes, the heart consumes most of the oxy-
gen and electrolytes it needs to contract effectively.
Even if a shock does terminate ventricular fibrilla-
tion, the heart probably won’t pump effectively for
several minutes because of the inadequate oxygen
supply. Data obtained from a Seattle first-responder
team equipped with AEDs showed survival rates
actually decreased as a result of a focus on initiating
defibrillation instead of CPR.37 A period of CPR
before shock delivery will provide some oxygen to
cardiac muscle, thus making a shock more likely to
convert it to a normal rhythm.
At the time of the consensus conference there had
been no studies comparing a one-shock protocol
with a protocol of three stacked shocks. Animal
studies, however, strongly suggest that interruptions
in the administration of compressions are associated
with a decreased probability that ventricular fibrilla-
ajn@wolterskluwer.com
tion will convert.31, 40 Analysis of AED data shows
that a three-shock sequence delays delivery of chest
compressions by up to 37 seconds (from delivery of
the first shock to administration of the first post-
shock compression).32 This delay was found difficult
to justify in light of the fact that the first shock using
either biphasic or monophasic defibrillators has been
found to convert ventricular fibrillation more than
90% of the time.41, 42 If one shock fails to eliminate
ventricular fibrillation, the incremental benefits of
another shock are low and resuming CPR is likely to
lead to greater efficacy from subsequent shocks
because it will provide needed oxygen to the heart.
Recommendations
• Clinicians should ensure an efficient coordina-
tion between CPR and defibrillation (class IIa).
• For witnessed out-of-hospital cardiac arrest, the
clinician and trained rescuer should use the AED
as soon as it is available, giving just one shock
followed by five cycles of CPR (class IIb).
• When ventricular fibrillation is present and the
arrest is unwitnessed, the lone rescuer should
give five cycles of CPR, deliver just one shock,
and then immediately resume CPR, beginning
with chest compressions (class IIa). There should
be no delays or interruptions to check for pulse
or rhythm.
• When two rescuers are on hand, the rescuer
operating the AED should be prepared to deliver
a first shock as soon as the compressor removes
her or his hands and the “all clear” is given.
When possible, the compressor should continue
with chest compressions while the other rescuer
is attaching the AED. After five cycles of CPR,
the AED should be used to analyze the rhythm
and deliver another shock, if indicated (class IIb).
• If the AED detects a rhythm other than ventricu-
lar fibrillation, it may instruct the rescuer to
resume CPR immediately, beginning with chest
compressions (class IIb), although some AEDs
may only instruct the rescuer to reassess the vic-
tim and determine whether CPR is needed.
Concerns that chest compressions might provoke
recurrent ventricular fibrillation in the presence
of a postshock organized rhythm do not appear
to have a basis.43
FOREIGN-BODY AIRWAY OBSTRUCTION: ADULTS
Early recognition of foreign-body airway obstruc-
tion is crucial. Signs of severe airway obstruction,
such as difficulty breathing, silent cough, cyanosis,
or the inability to speak, should prompt an immedi-
ate response. The use of back slaps, abdominal
thrusts, and chest thrusts are all effective ways of
relieving an obstruction, but about half of obstruc-
tions aren’t relieved by a single technique.44 A com-
AJN ▼ January 2007 ▼ Vol. 107, No. 1 65
 bination of back slaps, abdominal thrusts, and chest
thrusts increases the chances of success.44
In cases of foreign-body airway obstruction, CPR
should be performed when the person is uncon-
scious. Studies of cadavers and anesthetized volun-
teers show that higher sustained airway pressures
can be generated using chest thrusts instead of
abdominal thrusts.45, 46
Initiating cardiopulmonary resusci-
tation before dialing 911 remains
the best approach to responding to
an unresponsive child.
Recommendations
• For simplification of training, a rapid sequence of
abdominal thrusts is advised for the conscious
victim of foreign-body airway obstruction until
the obstruction is relieved (except for infants
under one year of age) (class IIb).
• Chest thrusts should be used for obese victims or
those in the late stages of pregnancy (class IIb).
• If the victim is unconscious, the rescuer should first
dial 911 and then begin CPR (using the 30-to-2
compression-to-ventilation ratio), having looked
for and removed the object (only if it is clearly
visible) before ventilation (class indeterminate).
CPR should not be interrupted to search the air-
way for a foreign body.
PEDIATRIC BASIC LIFE SUPPORT
Recognition. Because hypoxia–ischemia resulting
from asphyxia is the most common cause of cardiac
arrest in infants and children—and ventricular fibril-
lation is the cause in just 5% to 15% of pediatric
cases47, 48—the rescuer’s actions should be determined
by the cause of the arrest, not the age of the victim.
Initiating CPR before dialing 911 remains the best
approach to responding to an unresponsive child.
Recommendations
• All rescuers should respond according to the cause
of the arrest. In children whose collapse is unwit-
nessed or not sudden, CPR should be initiated
immediately and performed for five cycles before
911 is dialed. In the case of a witnessed, sudden
collapse—for example, during an athletic event—
the cause is likely to be ventricular fibrillation
and the rescuer should phone for help, get and use
the AED (if trained to do so), and begin CPR.
Airway. No new evidence was obtained to merit
changes to the recommendation for pediatric air-
66 AJN ▼ January 2007 ▼ Vol. 107, No. 1
way management (other than those made for
adults). Several points, however, were emphasized.
Rescuers who have difficulty obtaining an adequate
seal over an infant’s mouth and nose should provide
mouth-to-mouth ventilations while pinching the
nose closed. Adequate ventilation remains the prior-
ity, even when spinal injury is suspected. The health
care provider should use the jaw thrust maneuver,
as with the adult victim, if adequate ventilations can
be achieved. If not, the head tilt–chin lift technique
should be used. Nonprofessionals should use the
head tilt–chin lift technique only.
Ventilation. There are no recommended changes
to the 2000 guidelines concerning ventilation tech-
niques. The 2005 guidelines do note, however, that
when rescuers are using a mask system, they should
make sure the mask size is appropriate to the infant
or child; ensuring a tight seal can take time away
from CPR and requires training and periodic
retraining. Hyperventilation should be avoided with
the infant and child as it is with the adult.
Recommendations
• Two rescue breaths of one second each should be
given (class IIa), with enough volume to see the
chest rise (class IIa). Rapid or forceful breaths
should be avoided.
• Rescuers should deliver 12 to 20 rescue breaths
per minute (one breath every three to five sec-
onds) when the victim has a pulse greater than or
equal to 60 beats per minute (only professionals
should attempt to palpate the pulse) and signs of
adequate perfusion, such as improved color or
warmness to the touch (class IIa).
Chest compressions. Profound bradycardia
(heart rate lower than 60 beats per minute) in the
presence of poor perfusion (pallor or cyanosis) indi-
cates that cardiac arrest may soon follow; chest
compressions should begin immediately. A heart
rate at which chest compressions should be initiated
in children hasn’t been identified; the guidelines rec-
ommend starting compressions at a rate of fewer
than 60 beats per minute with signs of poor perfu-
sion because it’s easy to teach and remember.
Infants. The two-thumb–encircling-hands tech-
nique—performed by encircling the infant’s chest
with both hands, spreading the fingers around the
thorax, and placing the thumbs over the lower half
of the sternum—is recommended for health care
providers when two rescuers are present. The
thumbs compress the sternum; the fingers provide
counterpressure on the infant’s back (class IIa).
Studies using animals and mechanical models show
that the two-thumb–encircling-hands technique
produces higher coronary perfusion pressures and
more consistently correct depth and force of com-
pressions than the two-finger technique does.49-52 Lay
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rescuers or a lone rescuer should use the two-finger
technique, placing the fingers just below the inter-
mammary line (since it’s impossible to encircle the
infant’s chest, compress the chest with two fingers,
and provide ventilations at the recommended rate).
Children. No new data show the superiority of the
one-hand over the two-hand compression technique
(class indeterminate). Most important are that the
depth of compressions be about one-third to one-half
the depth of the chest and that there be complete
recoil and minimal interruptions, as with adults.
Recommendations
• The two-finger technique is considered best for
the lone rescuer to decrease the time between
compressions and ventilations and to minimize
interruptions in compressions. The two-thumb–
encircling-hands technique should be used when
there are two rescuers.
• Both the one-hand and two-hand techniques for
chest compressions in children are acceptable;
rescuers can be taught the same technique (two-
hand) for both the adult and child victims.
• As with the adult, compressions should be per-
formed at a rate of 100 per minute for both the
infant and the child, to a depth of one-third to
one-half of the chest. Complete chest recoil
should be allowed, with equal time for compres-
sion and release.
Compression-to-ventilation ratio. In a study using
pediatric manikins, “rescuers” were told to adhere
to a compression-to-ventilation ratio of 5 to 1 and
a compression rate of 100 per minute; however
fewer than 60 compressions per minute were per-
formed, although these were ideal circumstances.53
Interruptions in compressions for ventilation and
attachment of the AED can result in a significant
decrease in cardiac-perfusion pressure.40 Animal stud-
ies, manikin studies, and mathematical models have
examined various ratios (15 to 2, 5 to 1, and others)
and failed to provide adequate data to identify an
optimal compression-to-ventilation ratio for infants
and children.34, 40, 54
Recommendations
• Lone rescuers should use a compression-to-
ventilation ratio of 30 to 2 for all age groups.
• When health care providers are rescuing, they
should use a compression-to-ventilation ratio of
15 to 2.
• Interruptions in CPR should be as infrequent as
possible and limited to no longer than 10 sec-
onds, except for specific interventions such as
intubation.
• When two rescuers are present, compressors
should switch every two minutes, doing so in less
than five seconds, if possible. When there is no
advanced airway, a short pause must be taken to
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allow for ventilations. For patients with an
advanced airway such as an endotracheal tube,
eight to 10 ventilations should be given per
minute, without attempting to synchronize with
compressions.
DEFIBRILLATION: CHILDREN AND INFANTS
Children whose sudden collapse is witnessed (as can
occur during an athletic event) are likely to have ven-
tricular fibrillation or pulseless ventricular tachycar-
dia and require immediate CPR and defibrillation.
Institutions that care for children and have an AED
program should have an AED capable of recognizing
shockable rhythms in children and a pediatric “dose-
attenuating system”—a feature that automatically
adjusts the dose the device delivers. Data show that
AEDs can be used safely and effectively in children
one to eight years of age.55-57 If an AED with a pedi-
atric dose-attenuating system is not available in an
emergency, a standard AED should be used.
A standard adult AED should be used for chil-
dren older than age eight and for those weighing
more than 25 kg (55 lbs.). Standard AEDs may also
come equipped with adult and pediatric pads and
cables or contain a key or switch system for select-
ing a lower dose.
As with adults, there’s insufficient evidence to
support a one-shock protocol over a three-stacked-
shocks protocol for children; however, one shock is
recommended.
Recommendations
• When rescuers witness the sudden collapse of a
child, they should dial 911, get and use an AED
if trained to do so, and then perform CPR if
needed.
• For the unwitnessed collapse of a child, the res-
cuer should perform five cycles of CPR, then dial
911 and obtain an AED, if available.
• There is insufficient evidence to make a recom-
mendation for or against using any AED in infants
less than one year of age (class indeterminate).55, 56
• Coordination between CPR and defibrillation is
important to reduce interruptions, and CPR
should be resumed immediately after defibrilla-
tion without checking for pulse.
FOREIGN-BODY AIRWAY OBSTRUCTION: CHILDREN AND
INFANTS
No new recommendations have been made for the
management of foreign-body airway obstruction in
the child and infant. For the child, abdominal
thrusts should be performed until the object is
removed or the victim becomes unconscious. For
the infant, administer five back slaps and five chest
thrusts until the object is removed or the victim
becomes unconscious. When the infant becomes
AJN ▼ January 2007 ▼ Vol. 107, No. 1 67
 unconscious, initiate CPR at a ratio of 30 to 2 when
the rescuer is alone and 15 to 2 if two health care
professionals are present; look for the object and
remove it if it can be seen prior to ventilation. Do
not interrupt CPR to check for the object.
FUTURE DIRECTIONS
Continuous quality improvement is one way of
monitoring the quality of CPR delivered and of
tracking outcomes up to hospital discharge. In an
effort to compile more accurate statistics on out-
comes, the Centers for Disease Control and
Prevention has begun collecting data that include
survival to hospital discharge and whether or not
the patient is mentally intact. Defibrillators
equipped to collect data on compression rate, depth
of compression, and ventilation rate will help to
improve outcomes of cardiac arrest.
The science of resuscitation is evolving rapidly
and it would not be in patients’ best interest for
providers to wait another five years to make
changes to their practice. ILCOR members will con-
tinue to review new research and, when necessary,
publish interim advisory statements to update the
guidelines. ▼
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