What is the immediate recommendation for a person experiencing cardiac arrest who is unresponsive and not breathing?

Immediate Management of Cardiac Arrest

For any person who is unresponsive and not breathing (or only gasping), immediately begin high-quality chest compressions at a rate of 100-120 compressions per minute with a depth of at least 2 inches (5 cm), while simultaneously activating the emergency response system and retrieving an AED. 1, 2

Recognition and Activation

Scene safety must be verified first before approaching the victim to avoid becoming a second casualty. 2, 3

Check for responsiveness by shouting at and tapping the victim on the shoulder. 1 If the victim is unresponsive:

• Immediately activate the emergency response system (call 911 or your local emergency number). 1
• If two rescuers are present, one should start CPR immediately while the other activates emergency services and retrieves the AED. 1
• For lay rescuers: The phone should remain at the victim's side on speaker to receive dispatcher instructions. 1

Simultaneously assess breathing and pulse within 10 seconds maximum. 1 Look for absent or abnormal breathing (only gasping counts as absent breathing). 1, 2

Critical Recognition Point: Agonal Gasps

Agonal gasps are present in 40-60% of cardiac arrest victims and are commonly misinterpreted as normal breathing. 1 These slow, irregular gasping respirations are ineffective for ventilation and should be treated as absent breathing. 1 Dispatchers and rescuers must be educated to recognize that gasping equals cardiac arrest. 1

Pulse Check (Healthcare Providers Only)

Healthcare providers should check for a carotid pulse, but limit this to no more than 10 seconds. 1 If no definite pulse is felt within 10 seconds, assume cardiac arrest and begin CPR immediately. 1 Research demonstrates that even trained healthcare providers have difficulty detecting pulses accurately, with sensitivity approaching only 90% and specificity of 55%. 4 Lay rescuers should not check for a pulse. 1

Immediate CPR Initiation

Begin chest compressions immediately—do not delay for any reason. 1, 2 The 2010 guidelines changed the sequence from A-B-C (airway-breathing-compressions) to C-A-B (compressions-airway-breathing) specifically to minimize time to first compression. 1

High-Quality Chest Compression Technique

Compression rate: 100-120 compressions per minute. 1, 2, 5

Compression depth: At least 2 inches (5 cm) in adults. 1, 2, 5

Hand position: Center of the chest on the lower half of the sternum. 2

Complete chest recoil: Allow full chest recoil between compressions without leaning on the chest—incomplete recoil prevents adequate cardiac refilling and is a critical error. 2, 5, 3

Minimize interruptions: Keep pauses in compressions to less than 10 seconds. 1, 2, 3 Every interruption causes coronary perfusion pressure to drop, requiring several compressions to restore it. 1

Compression-to-ventilation ratio: 30 compressions followed by 2 breaths for both single and two-rescuer CPR in adults. 1, 2, 5

For Untrained or Compression-Only CPR

All lay rescuers should, at minimum, provide chest compressions. 1, 5 For untrained rescuers or those unwilling to provide ventilations, compression-only (Hands-Only) CPR is acceptable and strongly encouraged over no CPR. 1, 5, 3 The benefit of providing CPR to someone in cardiac arrest far outweighs the minimal risk of providing compressions to someone who is unconscious but not in arrest (injury rates: chest pain 8.7%, rib/clavicle fracture 1.7%, no visceral injuries). 1

For Trained Rescuers

Trained lay rescuers should provide both compressions and ventilations using the 30:2 ratio. 1, 5 After 30 compressions, open the airway with head tilt-chin lift and deliver 2 breaths (each over 1 second, sufficient to produce visible chest rise). 1

Early Defibrillation

Use the AED as soon as it becomes available—apply it immediately without delaying ongoing CPR. 1, 2, 3 Early bystander CPR provides an essential bridge to successful defibrillation, with survival rates of 37% when bystander CPR is provided versus 29% without it for ventricular fibrillation arrests. 6

AED sequence:

1. Turn the AED on. 1
2. Apply pads (ideally without interrupting compressions). 1
3. Follow AED prompts for rhythm analysis. 1, 2
4. If shockable rhythm (VF/pulseless VT): Clear the victim, deliver one shock, and immediately resume CPR for 2 minutes before reassessing rhythm. 1, 2, 3
5. If non-shockable rhythm: Immediately resume CPR for 2 minutes. 2

Check rhythm every 2 minutes during ongoing CPR. 2, 5

Dispatcher-Assisted CPR

Emergency dispatchers should determine if the patient is unresponsive with abnormal breathing and assume cardiac arrest if present. 1 Dispatcher CPR instructions substantially increase the likelihood of bystander CPR performance and improve survival. 1, 7 Dispatchers must be educated to identify agonal gasps across various descriptions. 1

Advanced Life Support (Healthcare Providers)

Once advanced providers arrive:

• Establish IV/IO access without interrupting compressions. 2
• Administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms. 2, 5, 3
• For refractory VF/pulseless VT: Consider amiodarone 300 mg IV/IO or lidocaine 1-1.5 mg/kg IV/IO. 2, 5, 3
• Airway management: Initially use bag-mask ventilation with 100% oxygen; consider advanced airway if needed. 2

Critical Pitfalls to Avoid

Do not delay compressions to obtain history or perform prolonged assessments. 2, 3 Time to first compression is the most critical determinant of survival—early CPR initiated within 1.9 minutes yields 32% survival versus 22% when delayed to 5.7 minutes. 6

Do not perform prolonged pulse checks. 5, 3 Healthcare providers often take too long (median 24 seconds, up to 30 seconds when no pulse is found), far exceeding the 10-second maximum. 4 If uncertain after 10 seconds, start CPR. 1, 3

Do not provide inadequate compression depth or rate. 2, 3 Compressions must be hard (at least 2 inches) and fast (100-120/min) to generate adequate perfusion pressure. 1, 2

Do not lean on the chest between compressions. 2, 3 This prevents complete recoil and adequate venous return to the heart. 2, 5

Do not confuse agonal gasps with normal breathing. 1 This is the most common reason bystanders fail to recognize cardiac arrest and initiate CPR. 1

Do not continue CPR indefinitely without response. While each case requires individual assessment, if CPR continues beyond 30 minutes without return of spontaneous circulation, there are essentially no survivors. 8 However, continue CPR until advanced life support arrives or the victim shows signs of life. 1