When should CPR be initiated on an unresponsive person with no normal breathing or detectable pulse?

When to Initiate CPR

Start CPR immediately on any unresponsive person who has no normal breathing (or only gasping) and no detectable pulse within 10 seconds of checking. 1, 2

Recognition Algorithm for All Rescuers

Step 1: Scene Safety and Responsiveness

• Ensure the scene is safe before approaching 2
• Tap the victim's shoulder and shout "Are you all right?" to check responsiveness 1, 3

Step 2: Simultaneous Assessment (Healthcare Providers)

Healthcare providers must assess both breathing and pulse simultaneously within a strict 10-second window 1, 2:

• Look for absent breathing or only gasping (not normal breathing) 1
• Check for a pulse at the carotid artery 1, 3
• If you cannot definitively feel a pulse within 10 seconds, start CPR immediately 1, 2

Step 3: Simplified Assessment (Lay Rescuers)

Lay rescuers should NOT check for a pulse 1, 3:

• Start CPR on any unresponsive victim who is not breathing normally 1, 3
• Ignore occasional gasps—these indicate cardiac arrest, not adequate breathing 1

Critical Decision Points

Unresponsive + No Normal Breathing + No Pulse (or Uncertain)

Begin chest compressions immediately 1, 2:

• Activate emergency response system 1, 3
• Start with 30 compressions followed by 2 breaths 1, 3
• Continue cycles of 30:2 until help arrives 1, 3

Unresponsive + No Normal Breathing + Definite Pulse Present

Provide rescue breathing only 1, 3:

• Give 1 breath every 5-6 seconds (approximately 10 breaths per minute) 1, 3
• Recheck pulse every 2 minutes 1, 3
• If pulse disappears, immediately begin full CPR 1

Special Consideration: Pediatric Patients

For infants and children, start CPR when heart rate is <60 beats per minute AND signs of poor perfusion are present 2, 4:

• Signs of poor perfusion include mottled/pale skin, weak pulses, altered mental status 4
• If heart rate <60 but perfusion appears adequate, provide rescue breathing only and reassess frequently 2, 4
• Use 30:2 ratio for single rescuer, 15:2 ratio for two rescuers in pediatric arrests 2, 4

Why the 10-Second Rule Matters

Healthcare providers detect pulses correctly only 78% of the time and average 20 seconds checking for a pulse, which significantly delays life-saving compressions 2. The evidence is clear: initiating CPR within approximately 2 minutes of collapse doubles to triples survival compared with initiation at 6 minutes 2. Every second counts.

Recognizing Agonal Gasping

Agonal gasps are NOT normal breathing and indicate cardiac arrest 1:

• These are occasional, irregular gasps that occur in the first minutes after cardiac arrest 1
• Rescuers frequently mistake gasping for adequate breathing 1
• Treat any victim with only gasping as if they are not breathing at all 1

Common Pitfalls to Avoid

• Do not extend pulse checks beyond 10 seconds—if uncertain, start compressions 1, 2
• Do not mistake agonal gasping for normal breathing—gasping equals cardiac arrest 1, 2
• Do not delay CPR to obtain history or establish IV access—compressions are the absolute priority 2, 3
• Do not perform prolonged assessments—the combination of unresponsiveness plus abnormal breathing is sufficient to trigger CPR 1, 2
• For lay rescuers: do not attempt pulse checks—pulse accuracy for untrained individuals is only 47% at 5 seconds 2