Who does this guideline apply to?

This guideline applies to all persons who are unresponsive and not breathing normally.

Who is the audience for this guideline?

This guideline is for use by bystanders, first aiders or first aid providers, first responders and health professionals.

Recommendations

The Australian and New Zealand Committee on Resuscitation (ANZCOR) makes the following recommendations:

1. All rescuers should perform chest compressions for all persons who are unresponsive and not breathing normally.
2. Interruptions to chest compressions should be minimised.
3. Those who are trained and willing to give rescue breaths do so for all persons who are unresponsive and not breathing normally. 

All rescuers should perform chest compressions for all persons who are unresponsive and not breathing normally.^1,2 [Strong recommendation, moderate certainty of evidence] ANZCOR suggests that those who are trained and willing to give rescue breaths do so for all who are  in cardiac arrest.^1,2  [Weak recommendation, very-low-certainty evidence]

All rescuers, including health care professionals, should use unresponsiveness and absence of normal breathing to identify the need for resuscitation.^1-4 [Good practice statement] Palpation of a pulse is unreliable and should not be performed to confirm the need for resuscitation.^5-8 [Good practice statement]

ANZCOR suggests performing chest compressions on the lower half of the sternum.^1,2,4,9 [CoSTR 2015/2020, weak recommendation, very-low-certainty evidence] In making this recommendation, we place a high value on consistency with current treatment recommendations in the absence of compelling data suggesting the need to change the recommended approach.^1,2,4,9  Place the heel of their hand in the centre of the chest with the other hand on top (Figure 1). [Good practice statement]

Avoid compression beyond the lower limit of the sternum. Compression applied too high is ineffective and if applied too low may cause regurgitation and/or damage to internal organs. [Good practice statement]

Figure 1: Location of chest compressions

The lower half of the sternum should be depressed approximately one third of the depth of the chest with each compression. This equates to more than 5cm in adults,^1,2,4,9,11 approximately 5cm in children^5,6,12,13 and 4 cm in infants.^5,6,12,13 [2015/2020 CoSTR, weak recommendation, very-low-certainty evidence] ANZCOR places greater importance on adequate compression depth. Although there is some evidence suggesting detriment with compression depths greater than 6cm, the clinical reality of being able to tell the difference between 5 or 6 cm and adjust compressions accordingly is questionable. Inadequate compression depth is definitely associated with poor outcomes. ANZCOR has elected not to put an upper limit on compression depth as the risk of too shallow compressions outweighs the risk of compressions that are too deep.^3,4 [Good practice statement]

Rescuers should perform chest compressions for all ages at a rate of 100 to 120 compressions per minute (almost 2 compressions/second).^1,2,4,9,11 [CoSTR 2015/2020, strong recommendation, very-low-certainty evidence]  This does not imply that 100-120 compressions will be delivered each minute since the number will be reduced by interruptions for breaths given by rescue breathing. ANZCOR acknowledges that compression rates will vary between and within providers and survival rates are optimised at compressions rates of 100-120 compressions per minute. There is some evidence that compressions rates less than 100 or greater than 140 compressions per minute are associated with lower rates of survival.^1,2,4,9,11

The compression rate and depth is variable among rescuers and compressions may be worse in the first 5 minutes of the arrest.¹⁴ One manikin study of rescuer CPR showed that compressions became shallow within one minute, but providers became aware of fatigue only after 5 min.⁷ When performing compressions, if feasible, change rescuers at least every two minutes to prevent rescuer fatigue and deterioration in chest compression quality, particularly depth.^1,2,15-17 [Good practice statement] Changing rescuers performing chest compressions should be done with a minimum of interruptions to compressions.^14,17

There is no high level evidence that the use of CPR feedback devices during real time CPR improves survival or return of spontaneous circulation.^1-4 CPR prompt / feedback devices may be considered for clinical use to provide data as part of an overall strategy to improve quality of CPR at a systems level.^1-4 [CoSTR 2015/2020, weak recommendation, very-low-certainty evidence]. ANZCOR places a higher value on resource allocation and cost effectiveness than widespread implementation of a technology with uncertain effectiveness during real time CPR. We acknowledge that data provided by CPR feedback devices may benefit other victims as part of a broader quality improvement system.^1-4

Rib fractures and other injuries are common but acceptable consequences of CPR given the alternative of death.¹⁵ [Good practice statement] CPR should be initiated for presumed cardiac arrest without concerns of harm to patients not in cardiac arrest.^3,4 [CoSTR 2015, strong recommendation, very-low-certainty evidence] In making this recommendation, ANZCOR places a higher value on the survival benefit of CPR initiated by laypersons for patients in cardiac arrest against the low risk of injury in patients not in cardiac arrest.^3,4

1. Olasveengen TM, Mancini ME, Perkins GD, et al. Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142(16_suppl_1): S41-S91.
2. Olasveengen TM, Mancini ME, Perkins GD, et al. Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156: A35-A79.
3. Perkins GD, Travers AH, Berg RA, et al. Part 3: Adult basic life support and automated external defibrillation. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2015; 95: e43-e69.
4. Travers AH, Perkins GD, Berg RA, et al. Part 3: Adult Basic Life Support and Automated External Defibrillation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2015; 132(16 suppl 1): S51-S83.
5. Maconochie IK, Aickin R, Hazinski MF, et al. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142(16_suppl_1): S140-S84.
6. Maconochie IK, Aickin R, Hazinski MF, et al. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156: A120-A55.
7. de Caen AR, Kleinman ME, Chameides L, et al. Part 10: Paediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010; 81(1): e213-e59.
8. Kleinman ME, De Caen AR, Chameides L, et al. Part 10: Pediatric Basic and Advanced Life Support 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122(16 suppl 2): S466-S515.
9. Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015; 95: 81-99.
10. Holt J, Ward A, Mohamed T-Y, et al. The optimal surface for delivery of CPR: A systematic review and meta-analysis. Resuscitation 2020; 155: 159-64.
11. Considine J, Gazmuri RJ, Perkins GD, et al. Chest compression components (rate, depth, chest wall recoil and leaning): A scoping review. Resuscitation 2020; 146(Jan): 188-202.
12. Maconochie IK, de Caen AR, Aickin R, et al. Part 6: Pediatric basic life support and pediatric advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2015; 95: e147-e68.
13. De Caen AR, Maconochie IK, Aickin R, et al. Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support. Circulation 2015; 132(16 suppl 1): S177-S203.
14. Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. Jama 2005; 293(3): 299-304.
15. Koster RW, Sayre MR, Botha M, et al. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010; 81(1): e48-e70.
16. Sayre MR, Koster RW, Botha M, et al. Part 5: adult basic life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010; 122(16_suppl_2): S298-S324.
17. International Liaison Committee on Resuscitation. Part 2. Adult basic life support. 2005 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2005; 67: 187-200.