What is the recommended cardiopulmonary resuscitation (CPR) protocol for an unresponsive adult who is not breathing normally?

CPR Protocol for Unresponsive Adults

For an unresponsive adult who is not breathing normally, immediately begin high-quality CPR with 30 chest compressions followed by 2 rescue breaths, continuing this cycle until advanced help arrives or the patient shows signs of life. 1

Initial Assessment and Activation (First 10 Seconds)

1. Verify scene safety - ensure the environment poses no danger to you or the patient
2. Check responsiveness - tap shoulders and shout loudly
3. Simultaneously assess breathing and pulse - look for absent or only gasping respirations while checking the carotid pulse for no more than 10 seconds 1, 2
4. Immediately call for help - activate emergency medical services (call 911/119) and request an automated external defibrillator (AED) before proceeding further 2

Critical pitfall: Do not waste time with prolonged pulse checks. If you cannot definitively feel a pulse within 10 seconds, assume cardiac arrest and begin CPR immediately.

High-Quality Chest Compressions

Compression technique is the cornerstone of effective CPR - poor quality compressions are associated with worse outcomes. 1, 3

Proper positioning and execution:

• Hand placement: Heel of palm on the lower half of the sternum (center of chest)
• Body mechanics: Arms fully extended, elbows locked, shoulders positioned directly vertical over the patient's chest
• Depth: Compress at least 2 inches (5 cm) for adults - push hard 1, 4
• Rate: 100-120 compressions per minute - push fast 1, 4
• Recoil: Allow complete chest recoil between compressions - lift hands slightly but maintain contact
• Minimize interruptions: Limit pauses to less than 10 seconds 3

Compression-to-Ventilation Ratio: 30:2

Perform 30 chest compressions followed by 2 rescue breaths. This interrupted CPR strategy with ventilation pauses is superior to continuous compressions for healthcare providers and trained lay rescuers. 1

Rescue breathing technique:

• Open airway: Head tilt-chin lift maneuver
• Deliver 2 breaths: Each breath should be 1 second in duration with 400-600 mL tidal volume
• Watch for chest rise: Visible chest rise confirms adequate ventilation 1, 5
• Complete both breaths within 6 seconds to minimize interruption of compressions 5

Important nuance: The 2025 AHA guidelines emphasize that 30:2 CPR allows monitoring of chest rise during ventilations, which is impossible with continuous compressions. Recent evidence shows ventilations are often inadequate during resuscitation, making this visual confirmation critical. 1

For lay rescuers unable or unwilling to perform rescue breathing:

• Compression-only CPR is acceptable - continuous chest compressions at 100-120/minute without ventilations 2, 4
• This is particularly appropriate for dispatcher-instructed CPR or untrained bystanders 2, 6

Automated External Defibrillator (AED) Use

Apply the AED as soon as it becomes available - early defibrillation is critical for shockable rhythms. 1, 2

AED protocol:

1. Turn on the AED and follow voice prompts
2. Attach pads: Use anterolateral positioning (one pad on right upper chest, one on left lower chest) - this is the priority method for ease of application 2
3. Ensure no one is touching the patient during rhythm analysis
4. If shock advised: Deliver shock immediately, then resume CPR for 2 minutes before next rhythm check
5. If no shock advised: Resume CPR immediately for 2 minutes before next rhythm check

Continue CPR-rhythm check-shock cycles until the patient shows signs of life, advanced providers take over, or you are physically unable to continue. 1

Rescuer Fatigue Management

• Change compressors every 2 minutes (or sooner if fatigued) to maintain compression quality 1
• Fatigue significantly degrades compression depth and rate, directly impacting survival

Special Consideration: Patients with Pulse but No Breathing

If the patient has a definite pulse but is not breathing or breathing ineffectively (e.g., opioid overdose, post-cardiac arrest):

• Provide rescue breathing only: 1 breath every 5-6 seconds (10-12 breaths per minute for adults)
• Recheck pulse every 2 minutes - if pulse is lost, immediately begin full CPR 1
• Critical timing: Oxygen saturation drops to dangerously low levels (mean 62%) within just 90 seconds of apnea, making rapid effective ventilation essential 1

Healthcare Provider Modifications

For healthcare workers with advanced training:

• Maintain the 30:2 ratio until an advanced airway is placed
• Once advanced airway secured: provide continuous compressions at 100-120/minute with asynchronous ventilations at 1 breath every 6 seconds (10 breaths/minute) 1
• Use waveform capnography to confirm airway placement and monitor ventilation adequacy
• For suspected high-risk pathogen infections: maintain 30:2 CPR with appropriate PPE (N95/respirator, gloves, gown, eye protection) 2

The evidence strongly supports that survival depends on immediate recognition, high-quality compressions with minimal interruptions, and rapid defibrillation when indicated. 1, 3