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Cardiac arrest - out of hospital care - Management
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How do I assess someone with a suspected cardiac arrest?

  • Diagnose cardiac arrest if the person is unresponsive and not breathing normally.
  • Ensure that it is safe to approach the person.
  • Check the person for a response — gently shake their shoulders and ask loudly, 'Are you all right?'
  • If there is no response, check whether breathing is normal.
    • Shout for help.
      • Ask anyone who comes to assist to dial 999 and ask for an ambulance, to fetch an automated external defibrillator if available, and then to come back to help.
    • Open the airway by turning the person onto their back, and:
      • Place your hand on the person's forehead and gently tilt their head back.
      • With your fingertips under the point of the person's chin, lift the chin to open the airway.
    • Check whether the person is breathing normally whilst keeping the airway open:
      • Look and feel for chest movement.
      • Listen at the person's mouth for breath sounds.
      • Put your face by their mouth, and feel for air on your cheek.
    • Look, listen, and feel for no more than 10 seconds to determine whether the person is breathing normally. If there is any doubt whether breathing is normal, act as if it is not normal.
      • Agonal gasps (infrequent, irregular breaths) are common in the first few minutes after a sudden cardiac arrest; they should not be considered to be normal breathing.
  • If there is no response and the person is not breathing normally:
    • Call an ambulance if one has not already been called.
      • Ask someone to call for one, or
      • If you are on your own, do this yourself; you may need to leave the person.
    • Start cardiopulmonary resuscitation.
Basis for recommendation

These recommendations are based on guidelines from the Resuscitation Council (UK) [Resusucitation Council, 2010].

  • The absence of breathing in someone who is non-responsive is the main sign of cardiac arrest. Checking the carotid pulse is not recommended, as there is evidence that relying on this to diagnose cardiac arrest is unreliable and time-consuming in both lay people and healthcare professionals without previous cardiopulmonary resuscitation (CPR) training [Bahr et al, 1997; Ochoa et al, 1998].
  • It is important to identify agonal gasps as an indication to start CPR, as studies have shown that agonal gasps are frequently misdiagnosed as normal breathing [Hauff et al, 2003].

How do I perform cardiopulmonary resuscitation?

  • Start chest compressions:
    • Kneel by the side of the person.
    • Place the heel of one hand in the centre of the person's chest.
    • Place the heel of your other hand on top of the first hand.
    • Interlock the fingers of your hands and ensure that pressure is not applied over the person's ribs. Do not apply any pressure over the upper abdomen or the bottom end of the bony sternum (breastbone).
    • Position yourself vertically above the person's chest and, with your arms straight, press the sternum down by 5–6 cm.
    • After each compression, release all the pressure on the chest without losing contact between your hands and the sternum.
    • Repeat at a rate of 100–120 times a minute (about two compressions a second).
    • Compression and release should take an equal amount of time.
    • If a crack is heard or felt during compressions (indicating a fracture to the costal cartilage or ribs) continue with chest compressions, having checked that your hands are in the correct position.
  • Combine chest compressions with rescue breaths:
    • After 30 chest compressions, open the airway again:
      • Place your hand on the person's forehead and gently tilt their head back.
      • With your fingertips under the point of the person's chin, lift the chin to open the airway.
    • Pinch the soft part of the person's nose closed, using the index finger and thumb of the hand on their forehead.
    • Allow their mouth to open, but maintain chin lift.
    • Take a normal breath and place your lips around the mouth, making sure that you have a good seal.
    • Blow steadily into the mouth whilst watching for the chest to rise. Take about 1 second to make the chest rise as in normal breathing; this is an effective rescue breath.
    • Maintaining head tilt and chin lift, take your mouth away and watch for the chest to fall as air comes out.
    • Take another normal breath and blow into the person's mouth once more to give a total of two effective rescue breaths.
    • Without delay, return your hands to the correct position on the sternum and give a further 30 chest compressions.
  • Continue with chest compressions and rescue breaths in a ratio of 30:2.
  • Stop to recheck the person only if they start breathing normally or show other signs of life (such as moving, speaking, opening their eyes); otherwise do not interrupt resuscitation.
Additional information
  • If your rescue breaths do not make the chest rise as in normal breathing, then before your next attempt:
    • Check the person's mouth and remove any easily removable obstruction, taking care not to push it further down.
    • Recheck that there is adequate head tilt and chin lift.
    • Do not attempt more than two breaths each time before returning to chest compressions.
Basis for recommendation

These recommendations are based on guidelines from the Resuscitation Council (UK) [Resusucitation Council, 2010].

  • Expert reviewers agreed that that the benefits of continuing chest compressions outweigh those of a rib injury.
    • No injury to the casualty is likely to occur from fractured costal cartilages, and the alternative is certain death. In the event of successful resuscitation, the chest wall will usually heal quickly.
    • Rib fractures are a known complication of closed chest compressions and do not usually influence the outcome.
    • Several reviewers recommended that the hand position of the rescuer should be checked before continuing compressions.

For how long should I continue CPR?

  • Continue cardiopulmonary resuscitation until:
    • Qualified help arrives and takes over, or
    • The person starts breathing normally or shows other signs of life (such as moving), or
    • You become exhausted.
Basis for recommendation

These recommendations are based on guidelines from the Resuscitation Council (UK) [Resuscitation Council, 2005].

  • The Resuscitation Council (UK) recognizes that delivering chest compressions is tiring and recommends that, where more than one rescuer is present, another should take over the compressions (with a minimum of delay) about every 2 minutes to prevent fatigue and maintain quality.

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