BLS

PROVIDER MANUAL

Basic Life Support Table of Contents

Basic Life Support Table of Contents .......................................................................................................... 1
Table of Figures ........................................................................................................................................... 2
General Concepts of Basic Life Support ...................................................................................................... 3
Initiating the Chain of Survival ................................................................................................................ 3
2010 BLS Guidelines Changes ................................................................................................................. 4
BLS for Adults .............................................................................................................................................. 6
One Rescuer Adult BLS ............................................................................................................................ 6
One Rescuer CPR ..................................................................................................................................... 7
Two Rescuer Adult BLS/CPR .................................................................................................................... 8
Adult Mouth-to-Mask Ventilation .......................................................................................................... 8
Adult Bag-Mask Ventilation in 2-Rescuer CPR ........................................................................................ 8
Use of the Automated External Defibrillator (AED) .................................................................................... 9
AED Use for Infants and Children ............................................................................................................. 10
BLS for Children (Age 1 to Puberty) .......................................................................................................... 10
One Rescuer BLS for Children ............................................................................................................... 11
Two Rescuer BLS for Children ............................................................................................................... 12
Child Ventilation.................................................................................................................................... 12
BLS for Infants (0 to 12 months old) ......................................................................................................... 12
One Rescuer BLS for Infants.................................................................................................................. 13
Two Rescuer BLS for Infants ................................................................................................................. 14
CPR with an Advanced Airway .................................................................................................................. 14
Mouth-to-Mouth Rescue Breathing ......................................................................................................... 15
Adult and Older Children Mouth-to-Mouth ......................................................................................... 15
Infant Mouth-to-Mouth or Mouth-to-Nose ......................................................................................... 16
Rescue Breathing .................................................................................................................................. 16
Relief of Choking ....................................................................................................................................... 17
Choking in an Adult or Child Older than One Year ............................................................................... 17
Choking in Infants (Less than one year old) .......................................................................................... 19

Table of Figures
Figure 1: Adult Chain of Survival ................................................................................................................. 3
Figure 2: Pediatric Chain of Survival ........................................................................................................... 4
Figure 3: 2010 BLS Changes ........................................................................................................................ 4
Figure 4: Adult BLS ...................................................................................................................................... 6
Figure 5: One Rescuer CPR .......................................................................................................................... 7
Figure 6: Using an AED for Adults ............................................................................................................... 9
Figure 7: Differences in BLS for Adults and Children ................................................................................ 10
Figure 8: One Rescuer BLS for Children .................................................................................................... 11
Figure 9: One Rescuer Infant BLS .............................................................................................................. 13
Figure 10: Compression to Breath Ratios with/without Advanced Airway .............................................. 14
Figure 11: Adult & Older Child Mouth to Mouth ...................................................................................... 15
Figure 12: Rescue Breathing ..................................................................................................................... 16
Figure 13: Adult and Child Airway Obstruction ........................................................................................ 17
Figure 14: Abdominal Thrusts for Adult/Child Choking ............................................................................ 18
Figure 15: Infant Airway Obstruction ....................................................................................................... 19
Figure 16: Back Blows/Chest Thrusts for Choking Infant.......................................................................... 20

General Concepts of Basic Life Support

The American Heart Association (AHA) Basic Life Support (BLS) course has changed dramatically over
the years to make it more accessible to the general public and more effective for the victim of cardiac
arrest. Cardiac arrest is the leading cause of death in the world. Providers of BLS can intervene early
and possibly prevent a death associated with sudden cardiac arrest. The elements of BLS are:
Initiating the chain of survival as soon as a possible problem is identified;
Initiating early and high quality chest compressions for any victim;
Providing early defibrillation with an Automated External Defibrillator (AED) when one is
available;
Initiating rescue breathing when respiration are inadequate;
Performing BLS as a team; and
Relieving a choking episode.

Initiating the Chain of Survival

Research shows that BLS can increase the rate of survival for certain victims of cardiac arrest. It is
critical that the Adult Chain of Survival is initiated quickly and performed at a high level of quality.
Activate the
Emergency
Response
System

Early and High

Quality CPR

Rapid
Defibrillation

Effective
Advanced Life
Support

Post Cardiac
Arrest Care

Figure 1: Adult Chain of Survival

Typically, pediatric victims begin the collapse process after suffering dehydration or respiratory
problems. This population will rarely have a primary cardiac arrest. If respiratory events and
dehydration can be prevented, cardiac arrest can often be avoided. Therefore, it is critical to prevent
the need for resuscitation in infants and children.
Prevent the
need for
resuscitation

Perform High
Quality CPR

Call 911 to
activate the
emergency
system

Provide
Advanced Life
Support

Provide Post
Cardiac Arrest
Care

Figure 2: Pediatric Chain of Survival

2010 BLS Guidelines Changes

In 2010, the American Heart Association (AHA) made some important changes to the BLS Guidelines.
These revisions are:
Guideline
Steps in the
process
Look, listen
and feel for
breathing
CPR
Cricoid
Pressure
Pulse Check

Old Guideline
ABC (airway, breathing,
compressions)
"Look, listen and feel" for breathing
with two rescue breaths
Slower rate, less depth
Ofte used during difficult intubation
For at least 15 seconds

Use of AED in Not recommended

Infants
Figure 3: 2010 BLS Changes

2010 Guideline
CAB (compressions, airway, breathing)
Begin CPR if the victim is unresponsive,
pulseless, and not breathing or if the
breathing is gasping
High Quality CPR (see definition below)
No longer recommended during the
advanced care of the victim
10 seconds or less and start CPR if not
certain that pulse is present
Use an AED as soon as it is available for
all ages

 Research shows that beginning compressions early increases the chance of survival so the
sequence has been changed from ABC to CAB (Chest Compressions, Airway, Breathing).
The importance of high-quality CPR is stressed. High quality CPR includes:
o Perform compressions at a rate of AT LEAST 100 per minute regardless of the age of the
victim;
o Increase the compression depth to AT LEAST 2 inches for adults and children over the
age of one, and 1.5 inches for infants (under the age of 1 year old);
o Allow the chest to completely recoil between compressions to ensure that the heart can
completely refill;
o Do not interrupt compressions except to use an AED or change providers even at
those times, perform the actions quickly to minimize interruptions;
o Prevent over-inflation of the lungs by avoiding rapid ventilations;
o Perform CPR as a team to perform activities more quickly and to ensure the victim
receives definitive care as quickly as possible.
The time for pulse checks has been shortened since it is not always possible to know if you can
feel a pulse. Do not delay CPR for more than 10 seconds if you are not sure that a pulse is
present.
A manual defibrillator is preferred for infants, but if one is not available an AED should be used.
If a pediatric dose attenuator is available on the AED, use it. If the dose attenuator is not
available, use an adult AED for a victim of any age.

BLS for Adults

The BLS process for adults teaches one rescuer CPR but also recognizes that there may be more
rescuers available to help. In the BLS course, students learn both one and two rescuer CPR. The steps
for BLS for adults will depend on whether or not

One Rescuer Adult BLS

Pull victim out of water
or trac

Secure the scene

Unresponsive and abnormal

respirations

No respirations or
Only grasping breathing

Activate the Emergency

System

Get AED

Pulse
Present?

NO

YES

Continue to Monitor

Perform CPR

Perform cycle of
30 compressions
And 2 breaths
Every 2 minutes

Connect to AED; shock

when indicated

Figure 4: Adult BLS

One Rescuer CPR

Once the assessment is complete and you have determined that the victim is not
responsive, does not have a pulse and is not breathing, it is important to start CPR.
Victim should be face up
on a at hard surface

If head or neck injury is

possible, keep the head and
neck in alignment

Kneel at victims side

Position the heels of your hands

one on top of the other on the
lower half of the breastbone

Rate = At least 100

per minute
Depth = At least 2 inches

With your arms straight,

push hard and fast

Allow chest to recoil between

each compression

Head Tilt - Chin lift for jaw (thrust)

and deliver 2 slow breaths
over 1 second each

Each round of CPR

consists of
30 compressions
And 2 breaths

Resume compressions

Figure 5: One Rescuer CPR

Do not interrupt
compressions until
AED is available

Two Rescuer Adult BLS/CPR

With the 2010 BLS guidelines, it is recognized that often there will be more than one person available
to perform CPR. The steps of CPR do not change, but the tasks can be shared by the team. If a second
person is available:Many times, there will be a second person available who can act as a second team
member. Send this person to call EMS and find an AED while you begin CPR. When the second rescuer
returns, the CPR tasks can be shared:
Send the second person to activate the emergency response system and retrieve an AED if one
is readily available. At the same time, the first rescuer begins CPR.
When the second rescuer returns, have them prepare the AED for use. The first person
continues CPR counting compressions out loud.
When the AED is open and ready, stop CPR long enough to apply the pads (see the AED section
below).
The second rescuer ensures that the victims airway is open then gives 2 rescue breaths over 1
second each.
The rescuers should switch positions every 2 minutes (5 cycles of 30 compressions and 2
breaths).
Once the AED is prepared, stop CPR long enough for the AED to analyze the rhythm. (See the
AED section below)

Adult Mouth-to-Mask Ventilation

When performing one rescuer CPR, rescue breaths should be supplied using a mask if available.
1. Perform 30 high quality compressions at least 100 per minute and 2 inches deep.
2. Seal the mask against the victim's face by forming your hand in a C shape and pressing down
on the top and bottom edges of the mask.
3. Unless you think the victim may have a neck injury, open the airway using the head tilt/chin lift.
4. Give two slow deep breaths over 1 second each and watch for the rise of the victims chest.

Adult Bag-Mask Ventilation in 2-Rescuer CPR

If two or more rescuers are available with a bag-mask device, one rescuer should continue
compressions while the second rescuer seals the mask over the victims face and delivers two rescue
breaths after every 30 compressions.

Use of the Automated External Debrillator (AED)

One of the most common causes of cardiac arrest is ventricular brillation. The
Automated External Debrillator (AED) is the most eective treatment for this
disorder. The AED analyzes the heart rhythm and advises a shock only when it is
appropriate based on what is happening in the heart. The AED is safe for anyone to
use since it will talk you through the process and will not allow you to make a mistake.
All AEDs work in very much the same way, so learning the algorithm below will ensure
that you can safely use any AED.
Get the AED and turn it on;
Listen to and follow the
verbal instructions

Feel for hard lumps in the

upper chest; do not place the
pads over these lumps

Peel the backing o the

pads and apply to the
victims chest

Place one pad on the upper

right chest;
Place the 2nd pad under the left
armpit by the left nipple

Ensure that the pads are

attached to the AED box

Clear everyone away from the victim;

Allow AED to analyze rhythm

YES

Call out Clear and

press shock button

Shock
Advised?

NO

Continue CPR for 2 minutes

Figure 6: Using an AED for Adults

AED Use for Infants and Children

Research indicates that an AED should be used as early as possible in any arrest situation for any age.
If the AED has pediatric pads and a pediatric attenuator, that is ideal for an infant or child. If these
pediatric pads are not available, adult pads can be used as long as they are applied so that they do not
touch each other. If the AED has a pediatric attenuator available, use it for children less than 8 years
old. Typically, you will see an adult/pediatric switch if the attenuator is available. If this switch is not
available, use the AED to deliver an adult shock.

BLS for Children (Age 1 to Puberty)

BLS for children and adults is very similar but there are differences. The primary differences are:
Guideline
Compression to breath ratio
for 2 rescuers
Compression to breath ratio
for 1 rescuer
CPR
Compression depth
Activate the Emergency
Response System in
unwitnessed arrest
Activate the Emergency
Response System in witnessed
arrest

Adult
30 compressions: 2
breaths
30 compressions: 2
breaths
Always use 2 hands for
compressions
At least 2 inches

Child
15 compressions : 2 breaths
30 compressions: 2 breaths

Immediately

For small children, may use one

hand for compressions
1/3 of the depth of the chest
(usually about 1 to 2 inches)
After performing CPR for 2 minutes

Immediately

Immediately

Figure 7: Differences in BLS for Adults and Children

One Rescuer BLS for Children

If you are alone and a child older than 1 year old is unresponsive, follow the one rescuer algorithm for
children:

Pull victim out of water

or trac

Secure the scene

Unresponsive and abnormal

respirations

No respirations or
Only grasping breathing

Yell for help

Pulse Present
and greater than
60/minute?

Feel for
Carotid or
Femoral pulse

YES

NO

Perform CPR
For 2 minutes

Continue to Monitor

If help is not available, leave

the child to get help and an AED

Perform cycle of
30 compressions
And 2 breaths
Every 2 minutes

Connect to AED; shock

when indicated

Figure 8: One Rescuer BLS for Children

Two Rescuer BLS for Children

If two rescuers are available, use the same algorithm as for one rescuer BLS with the following
exceptions:
As soon as it is determined that the child is not breathing and responsive, the second rescuer
should immediately activate the Emergency Response System and go to find an AED.
As soon as another rescuer arrives, change the compression to ventilation ratio from 30:1 to 15:
2 (i.e., give 2 breaths after every 15 compressions)

Child Ventilation
Adult masks should not be used for small children. If the mask covers the eyes or chin of the child, it is
too big and ventilations will not be optimal. Breaths for a child will typically not be as deep, but should
be over 1 second each and should result in a visible rise of the childs chest. Unless a neck injury is
suspected, open the airway using the head tilt/chin lift technique.

BLS for Infants (0 to 12 months old)

BLS for children and infants is similar but there are differences. The primary differences are:
Guideline
Checking the pulse
CPR

Compression depth

Activate the Emergency

Response System in
unwitnessed arrest
Activate the Emergency
Response System in witnessed
arrest

Child
Carotid or femoral artery

Infant (0 to 12 months)
Brachial artery on inside of upper
arm
For small children, may use May use 2 fingers or 2 thumbs by
one hand for compressions the encircling hands technique if
your hands are big enough to circle
the infants chest
1/3 of the depth of the
1/3 of the depth of the chest
chest (usually about 1 to (usually about 1 inches)
2 inches)
After performing CPR for 2 After performing CPR for 2 minutes
minutes
Immediately

Immediately

One Rescuer BLS for Infants

If you are the only rescuer of an infant, follow the one rescuer algorithm:
Pull victim out of water
or trac

Secure the scene

Unresponsive and abnormal

respirations

No respirations or
Only grasping breathing

Yell for help

Pulse Present
and greater than
60/minute?

Feel for
brachial pulse

NO

YES

Perform CPR
For 2 minutes

Continue to Monitor

If help is not available, leave

the child to get help and an AED

Perform cycle of
30 compressions
And 2 breaths
Every 2 minutes

Connect to AED; shock

when indicated

Figure 9: One Rescuer Infant BLS

Two Rescuer BLS for Infants

If two rescuers are available, use the same algorithm as for one rescuer BLS with the following
exceptions:
As soon as it is determined that the infant is not breathing and responsive, the second rescuer
should immediately activate the Emergency Response System and go to find an AED.
As soon as another rescuer arrives, change the compression to ventilation ratio from 30:1 to 15:
2 (i.e., give 2 breaths after every 15 compressions)

CPR with an Advanced Airway

An advanced airway includes supraglottic airways, laryngeal mask airways, or endotracheal tubes.
These airways should be initiated as soon as available since they provide a better way of providing
ventilations for any age. If these advanced airways are not available, continue to use mouth-to-mouth,
mouth-to-mask, or bag-mask for breathing in an arrest situation. If an advanced airway is in place, the
compression/breath ratio should be as below.
Guideline
Adult Compression to Breath
Ratio
Child or Infant Compression to
Breath Ratio

No Advanced Airway
30 compressions : 2
breaths
15 compressions : 2
breaths

With Advanced Airway

Continue CPR without pausing;
deliver 1 breath every 6 8
seconds (8-10 breaths per minute)

Figure 10: Compression to Breath Ratios with/without Advanced Airway

Mouth-to-Mouth Rescue Breathing

If a mask or advanced airway is not available, be ready to provide mouth-to-mouth
rescue breathing during CPR. Avoid over-ventilation which can ll the stomach with air
and prevent proper lung expansion.

Adult and Older Children Mouth-to-Mouth

Do not give breaths too rapidly or too forcefully; doing this may cause air to be forced into the stomach
resulting in distention and less room for lung expansion.
Open the airway using
the head tilt/chin lift
technique

Close the victims nose

by pinching it closed

If head or neck injury is

possible, keep the head and
neck in alignment and use the
Jaw thrust technique

Place your mouth over the

victims mouth and form
a tight seal

Blow into the victims mouth

for 1 full second and watch
for chest rise

NO

Reposition victims head

Chest rises?

YES

Give 2nd breath

Resume compressions

Figure 11: Adult & Older Child Mouth to Mouth

Infant Mouth-to-Mouth or Mouth-to-Nose

Ventilation techniques for an infant is exactly like for children and adults with the following exceptions:
If the infant is small enough and you can cover the nose and mouth with your mouth and create
a good seal, you do not have to pinch the nose.
Be aware that an infants lungs are very small so a smaller volume of air will be necessary to
inflate the infants lungs. Every breath should still be given over 1 second but the volume will
be less.

Rescue Breathing
Early recognition of and intervention for respiratory distress may prevent deterioration into cardiac
arrest. During assessment, if the victim has a strong pulse but has ineffective breathing, open the
airway using the head tilt/chin lift technique and begin rescue breathing.
Victim Age
Adult
Child or Infant

Breathing Rate
Every 5-6 Seconds
Every 3-5 Seconds

# Breaths/Minute Lenth of Breath

10-12 per Minute Each breath
12-20 per Minute should be given
over 1 second

Figure 12: Rescue Breathing

Evaluation
Check for chest
rise and
breathing;
Check pulse and
begin CPR if
victim becomes
pulseless

Relief of Choking
If a victim is choking, the condition may deteriorate into respiratory arrest and cardiac arrest. Early
and proper intervention can prevent this series of events. Proper intervention depends on the age of
the victim and the amount of obstruction of the airways.

Choking in an Adult or Child Older than One Year

Amount of
Airway
Obstruction
Mild

Symptoms

Severe

Breathing may be
accompanied by wheezing
Coughing and making noise
Exhibiting universal sign of
choking (holding neck and
throat)
Weak or absent cough
May be making highpitched noise but unable to
talk
Ineffective or no breathing
Skin may be blue around
lips and finger tips

Recommended Actions

Remain with victim and continue to

monitor
Encourage the victim to cough
Call EMS if choking gets worse
Attempt abdominal thrusts to
relieve obstruction
If you see the obstruction in the
victims mouth and can remove it,
do so. Do not perform blind
sweeps of the mouth.
Call EMS
Begin CPR if victim is unresponsive
and pulseless

Figure 13: Adult and Child Airway Obstruction

Abdominal Thrusts (Heimlich Maneuver)

If the choking victim older than one-year-old is responsive, perform abdominal thrusts in an attempt to
relieve choking.
Stand behind the choking
victim
Do not use this technique
if the victim is not responsive
Wrap your arms around
the victims waist

Place the st of one hand

in the middle of the victims abdomen
above the navel.

Hold your st with the other hand

and exert pressure into the victims
belly up toward his chest

NO

Obstruction
Relieved?

YES

Monitor Victim

Figure 14 : Abdominal Thrusts for Adult/Child Choking

Choking in Infants (Less than one year old)

Amount of
Airway
Obstruction
Mild

Symptoms

Breathing may be
accompanied by wheezing
Coughing and making noise

Recommended Actions

Severe

Exhibiting universal sign of

choking (holding neck and
throat)
Weak or absent cough
May be making highpitched noise but unable to
talk
Ineffective or no breathing
Skin may be blue around
lips and finger tips

Remain with infant and continue to

monitor
Do not do a blind finger sweep in
an attempt to remove an
obstruction
Call EMS if infant begins to
deteriorate
Attempt back blows/chest thrusts
to relieve obstruction
If you see the obstruction in the
victims mouth and can remove it,
do so. Do not perform blind
sweeps of the mouth.
Call EMS
Begin CPR if infant becomes
unresponsive and pulseless

Figure 15: Infant Airway Obstruction

In an infant less than 12 months old who is choking but responsive, attempt to use back blows and
chest thrusts to relieve an obstruction.

Sit with the infant

in your lap

Do not use this technique

if the victim is not responsive

With your forearm resting on your thigh,

rest the infant face down on your forearm
His head should be lower than his chest

Avoid pressure on the

infants throat; support
the infants head
and neck

Deliver 5 back blows

between the infants
shoulder blades

Turn the infant face up on your other forearm

with his head lower than his chest

Using 2 ngers of your free hand, deliver

5 chest thrusts over the bottom half
of the breastbone

NO

Obstruction
Relieved?

YES

Monitor Victim

Figure 16: Back Blows/Chest Thrusts for Choking Infant