What are the steps of cardiopulmonary resuscitation for an unresponsive person not breathing normally, regardless of age?

CPR Procedure

For any unresponsive person not breathing normally, immediately begin high-quality chest compressions at 100-120 compressions per minute with a depth of at least 2 inches (5 cm) in adults, ensuring complete chest recoil between compressions, while simultaneously activating emergency services. 1

Initial Assessment and Activation

Scene safety must be verified first before approaching any victim to prevent becoming a second casualty. 2

Once the scene is safe, the rescuer should:

• Check for responsiveness by tapping the victim's shoulder and shouting "Are you all right?" 1
• Shout for nearby help immediately upon finding an unresponsive victim 1
• Activate the emergency response system (call 9-1-1) as the next priority action 1
• Simultaneously assess breathing and pulse (healthcare providers only) within 10 seconds, looking specifically for no breathing or only gasping 1

Lay rescuers should NOT check for a pulse - they should proceed directly to CPR if the victim is unresponsive and not breathing normally. 1 Healthcare providers may check the pulse simultaneously with breathing assessment, but this must be completed within 10 seconds to avoid delaying compressions. 1

Recognition of Cardiac Arrest

A victim should be presumed to be in cardiac arrest if they are unresponsive with no breathing or only gasping. 1 Agonal gasps are commonly mistaken for normal breathing by bystanders and emergency dispatchers, leading to failure to initiate CPR. 1 Brief generalized seizures may also be the first manifestation of cardiac arrest. 1

High-Quality Chest Compressions

Chest compressions are the single most critical component of CPR and must be started immediately - the 2010 Guidelines changed the sequence from A-B-C to C-A-B (compressions-airway-breathing) to minimize time to first compression. 1, 2

Proper Compression Technique:

• Hand position: Center of the chest (lower half of sternum) on a firm surface 2
• Compression depth: At least 2 inches (5 cm) in adults 1, 2
• Compression rate: 100-120 compressions per minute 1, 2
• Complete chest recoil: Allow full recoil between compressions without leaning on the chest 2
• Minimize interruptions: Keep pauses to less than 10 seconds 2
• Compression-to-ventilation ratio: 30 compressions to 2 breaths for both single and two-rescuer adult CPR 1

The rescuer should push hard and fast with arms outstretched and perpendicular to the patient's chest. 2 Inadequate compression depth or rate significantly reduces CPR effectiveness. 2

Rescue Breathing

For trained lay rescuers, it is reasonable to provide rescue breaths in addition to chest compressions using a 30:2 ratio. 1 However, all lay rescuers should, at minimum, provide chest compressions even if they are unwilling or unable to perform rescue breaths. 1

For untrained bystanders or those unwilling to perform mouth-to-mouth, compression-only CPR is acceptable and has been shown to provide equivalent survival outcomes, particularly in the first several minutes of cardiac arrest. 3, 4 Emergency dispatchers should guide untrained callers to perform chest compressions only. 5

Healthcare providers should provide both compressions and ventilations at a 30:2 ratio until an advanced airway is placed. 1

Early Defibrillation

An AED should be retrieved and applied as soon as it becomes available without delaying the initiation of chest compressions. 1, 2 When two rescuers are present, one should begin compressions while the second activates emergency services and retrieves the AED. 1

AED Use Sequence:

• Turn on the AED and follow voice prompts 1
• Check rhythm to determine if shockable (ventricular fibrillation or pulseless ventricular tachycardia) 1
• If shockable: Deliver one shock and immediately resume CPR for 2 minutes before rechecking rhythm 1
• If non-shockable: Resume CPR immediately for 2 minutes 1

Chest compressions should be resumed immediately after shock delivery to minimize interruptions. 1, 2

Special Considerations

If Pulse Present But No Normal Breathing:

Healthcare providers should provide rescue breathing at 1 breath every 6 seconds (10 breaths per minute) and recheck the pulse every 2 minutes. 1 If no pulse is detected at any point, immediately begin chest compressions. 1

Pediatric Modifications:

• Start CPR if heart rate is less than 60 beats per minute with signs of poor perfusion 1, 6
• Use 30:2 ratio for single rescuer, 15:2 ratio for two or more rescuers 1, 2
• Compression depth should be at least one-third of the anterior-posterior diameter of the chest 1, 7

Suspected Opioid Overdose:

Administer naloxone if available while continuing CPR, but do not delay compressions to obtain or administer naloxone. 1

Critical Pitfalls to Avoid

• Do NOT delay compressions to check for a pulse beyond 10 seconds - if uncertain, start CPR immediately 1, 2
• Do NOT provide inadequate compression depth - compressions must be at least 2 inches deep in adults 2
• Do NOT lean on the chest between compressions - this prevents adequate cardiac refilling 2
• Do NOT interrupt compressions for prolonged periods - keep all pauses under 10 seconds 2
• Do NOT mistake agonal gasps for normal breathing - gasping indicates cardiac arrest 1
• Do NOT provide excessive ventilations - this increases intrathoracic pressure and reduces venous return 1

Duration and Termination

Continue CPR until:

• Advanced life support providers arrive and take over 1
• The victim shows signs of movement or recovery 1
• The rescuer is too exhausted to continue 2
• A valid Do Not Attempt Resuscitation order is presented 2

Early initiation of CPR by bystanders significantly improves survival, particularly when started within 4-6 minutes of collapse and followed by advanced life support within 10-12 minutes. 8 Bystander CPR can improve survival rates two-fold to three-fold compared to no bystander intervention. 3, 8