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Basic life support

Basic life support (BLS) is a standardized sequence of emergency medical actions designed to sustain oxygenated blood flow to vital organs in individuals experiencing cardiac arrest or respiratory failure, using minimal or no equipment, until advanced life support can be provided.^[1] It forms the foundational level of care in the chain of survival for out-of-hospital cardiac arrest and is essential for improving outcomes in life-threatening situations.^[1] The history of BLS traces back to the 18th century, when mouth-to-mouth resuscitation was recommended for drowning victims by the Paris Academy of Sciences in 1740. Early techniques evolved through the 19th century with manual methods like chest pressure, but modern BLS emerged in the mid-20th century. In 1960, closed-chest cardiac massage was developed, and the American Heart Association (AHA) began promoting standardized CPR training in 1963. The International Liaison Committee on Resuscitation (ILCOR), formed in 1992, now coordinates global evidence-based consensus on resuscitation guidelines.^[2]^[3] The primary components of BLS begin with prompt recognition of cardiac arrest, which involves assessing for unresponsiveness and checking for the absence of normal breathing or only gasping respirations.^[1] This is immediately followed by activation of the emergency response system, such as calling 911, and retrieval of an automated external defibrillator (AED) if available.^[1] High-quality cardiopulmonary resuscitation (CPR) is then initiated, emphasizing chest compressions at a rate of 100 to 120 per minute and a depth of 2 to 2.4 inches (5 to 6 cm) for adults, with full chest recoil between compressions and minimal interruptions.^[1] Airway management, such as the head-tilt/chin-lift maneuver, and delivery of rescue breaths (if trained and able) are integrated, typically in a ratio of 30 compressions to 2 breaths.^[1] BLS protocols also incorporate the use of an AED as soon as possible to analyze heart rhythm and deliver a shock if indicated, significantly increasing survival rates when applied early.^[4] For healthcare settings, BLS training extends to team dynamics in multirescuer scenarios and relief of foreign-body airway obstruction (choking) in adults, children, and infants.^[4] Based on international consensus from ILCOR and adopted by organizations like the American Heart Association, the guidelines were updated in October 2025 to reflect evidence-based practices that prioritize compression-only CPR for untrained bystanders and enhanced integration of technology, such as real-time feedback devices, in professional responses.^[1]

Introduction

Definition and purpose

Basic life support (BLS) is defined as a standardized sequence of non-invasive actions designed to preserve life by addressing the critical elements of airway, breathing, and circulation during life-threatening emergencies such as cardiac arrest.^[1] This approach focuses on immediate interventions to maintain oxygenation and blood flow to vital organs until professional medical help arrives.^[5] The primary purpose of BLS is to serve as a vital bridge to advanced life support, significantly enhancing survival outcomes in out-of-hospital cardiac arrest scenarios. When initiated promptly by bystanders, BLS, particularly cardiopulmonary resuscitation (CPR), can double or triple the chances of survival compared to no intervention.^[6] It forms an essential early link in the chain of survival, emphasizing rapid action to prevent irreversible damage from hypoxia.^[7] Core components of BLS include high-quality chest compressions to restore circulation, rescue breaths or ventilations to support oxygenation, and the use of automated external defibrillators (AEDs) when available to address shockable rhythms.^[4] These interventions are tailored for both lay rescuers and trained healthcare providers, requiring minimal equipment and no advanced skills.^[8] In distinction from advanced life support (ALS), BLS excludes pharmacological agents, invasive procedures such as intubation, or specialized equipment, relying instead solely on manual techniques to sustain life temporarily.^[7] This simplicity enables widespread application in community settings, prioritizing accessibility over complexity.^[1]

Historical development

The origins of basic life support (BLS) trace back to early 18th-century efforts to revive drowning victims, with the Paris Academy of Sciences recommending mouth-to-mouth resuscitation in 1740, marking one of the first formalized attempts at artificial ventilation.^[2] Around the same time, rudimentary closed-chest massage experiments emerged as part of manual compression techniques to stimulate circulation, though these methods were inconsistent and not widely adopted.^[9] By the early 20th century, isolated cases of closed-chest cardiac massage were reported, such as George Crile's successful application in 1904, but invasive open-chest methods dominated clinical practice until mid-century innovations.^[2] In the 1950s, modern BLS foundations solidified with the rediscovery and formalization of mouth-to-mouth ventilation. James Elam demonstrated in 1954 that exhaled air contained sufficient oxygen for effective resuscitation, paving the way for non-invasive techniques.^[10] Peter Safar built on this in 1958 by validating the head-tilt chin-lift maneuver to open the airway, combining it with positive-pressure ventilation to create reliable breathing support protocols.^[2] The 1960s brought pivotal advancements in circulation management, with William Kouwenhoven, James Jude, and Guy Knickerbocker discovering external chest compressions in 1960 during animal studies at Johns Hopkins, leading to the first human applications that year.^[11] Their seminal JAMA publication described closed-chest massage as a non-invasive alternative to open thoracotomy, dramatically improving outcomes for cardiac arrest.^[12] This innovation merged with Safar's ventilation techniques to form the core of cardiopulmonary resuscitation (CPR). In 1963, the American Heart Association (AHA), founded in 1924 but newly focused on emergency care, endorsed CPR and established its first guidelines through a dedicated committee led by Leonard Scherlis, initiating standardized training for healthcare providers.^[2] From the 1970s to 1980s, BLS evolved through institutional collaboration and guideline refinement. The AHA launched widespread public CPR training in 1973 in collaboration with organizations like the American Red Cross, with programs such as Seattle's Medic II training over 100,000 people in its first two years and hundreds of thousands more by the end of the decade; national conferences in 1973 and 1979 refined protocols based on emerging evidence.^[2]^[13] The European Resuscitation Council (ERC) formed in 1988 to adapt guidelines for Europe, followed by the International Liaison Committee on Resuscitation (ILCOR) in 1992, which coordinated global consensus among organizations like the AHA, ERC, and Red Cross to harmonize BLS standards.^[14]^[15] ILCOR's first consensus conference in 1992 produced unified recommendations, emphasizing evidence-based updates.^[16] In the 21st century, BLS protocols shifted to prioritize rapid circulation, with the AHA's 2010 guidelines changing the sequence from ABC (airway, breathing, circulation) to CAB (circulation, airway, breathing) to minimize delays in compressions for trained rescuers.^[17] For lay rescuers, compression-only CPR gained emphasis starting in the late 2000s, supported by studies showing equivalent or superior survival rates compared to conventional methods with ventilations, particularly for adult out-of-hospital cardiac arrests of cardiac origin.^[18] Concurrently, automated external defibrillators (AEDs) integrated into BLS post-1990s, with FDA approval for layperson use in 1996 enabling public access defibrillation programs that boosted bystander intervention rates.^[1] These developments, refined through ongoing ILCOR reviews, culminated in the 2025 AHA guidelines maintaining CAB and compression-only emphases while incorporating new evidence on high-quality compressions.^[19]

Guidelines and Evidence Base

International standards

The International Liaison Committee on Resuscitation (ILCOR) serves as the primary global body coordinating evidence-based reviews and consensus development for resuscitation practices, including basic life support (BLS). Established to harmonize guidelines across nations, ILCOR facilitates systematic evaluations of scientific literature through task forces, producing Consensus on Science with Treatment Recommendations (CoSTR) documents that synthesize international research. The 2025 CoSTR, for instance, underscores the importance of high-quality CPR—characterized by prompt initiation of chest compressions, minimal interruptions, and a compression-to-ventilation ratio of 30:2—and early defibrillation to optimize outcomes in out-of-hospital cardiac arrest (OHCA).^[20]^[21] Central to ILCOR's framework is the Chain of Survival, a conceptual model outlining sequential interventions to improve cardiac arrest survival rates. For OHCA, this chain comprises five key links: early recognition of cardiac arrest and activation of the emergency response system; immediate high-quality CPR by bystanders; rapid defibrillation; effective advanced life support; and integrated post-cardiac arrest care. BLS protocols primarily address the initial three links—recognition and activation, CPR, and defibrillation—aiming to bridge the critical gap before professional help arrives.^[22]^[23] The evidence base supporting these standards derives from rigorous systematic reviews demonstrating that bystander-initiated CPR significantly enhances survival. Meta-analyses indicate that bystander CPR approximately doubles the odds of survival to hospital discharge compared to no bystander intervention, with odds ratios ranging from 1.72 to 2.4 across large cohorts of OHCA cases. ILCOR guidelines emphasize simplicity for lay rescuers to maximize bystander participation, prioritizing compression-only CPR in untrained scenarios to reduce barriers like fear of harm or procedural complexity.^[24]^[25]^[20] ILCOR's harmonized recommendations are widely adopted and adapted by major national and regional organizations, ensuring consistent BLS practices globally while allowing for local contextualization. For example, the American Heart Association (AHA) and European Resuscitation Council (ERC) integrate ILCOR CoSTR findings into their respective guidelines, promoting uniform training and implementation. Regional variations, such as adjustments for resource availability in low-income settings, build on this core framework without altering foundational principles.^[26]^[27]^[3]

Key updates in 2025

In 2025, the American Heart Association (AHA) and European Resuscitation Council (ERC) updated their Basic Life Support (BLS) guidelines based on the International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations (CoSTR) from 2020 to 2025, incorporating real-world survival data from registries such as the Cardiac Arrest Registry to Enhance Survival (CARES).^[28]^[29]^[20] The AHA 2025 guidelines integrate naloxone administration for suspected opioid overdoses, recommending that lay rescuers possess and use naloxone with legal immunity to reduce overdose mortality, and that it may be administered during cardiac arrest if it does not interfere with CPR.^[28] They reaffirm the 30:2 compression-to-ventilation ratio as reasonable before advanced airway placement, based on moderate-certainty evidence showing no superiority of alternatives.^[28]^[20] The guidelines continue to recommend compression-only CPR for lay and untrained rescuers, while reaffirming the 30:2 compression-to-ventilation ratio for trained rescuers before advanced airway placement, based on evidence showing both approaches support high-quality resuscitation.^[28] The ERC 2025 guidelines place stronger emphasis on minimizing pauses in chest compressions, recommending a chest compression fraction of at least 60% with hands-off time limited to less than 10 seconds where possible, supported by ILCOR reviews showing improved return of spontaneous circulation (adjusted odds ratio 2.91; 95% CI 1.09–7.8).^[29]^[20] They also update foreign body airway obstruction (FBAO) algorithms based on ILCOR evidence reviews, relocating detailed protocols to first aid guidance while advising sequences of 5 back blows followed by 5 abdominal thrusts for adults and children, or 5 chest thrusts for infants.^[29]^[28] Common updates across AHA and ERC include shortening pulse checks to 10 seconds or less to avoid prolonging interruptions and reducing chest compression fraction, as observational data indicate checks often exceed this duration.^[1] Both reinforce automated external defibrillator (AED) prompts and use for all ages without age-based restrictions, promoting community access to improve bystander intervention rates. Both AHA and ERC guidelines strengthen recommendations for dispatcher-assisted CPR, including prompt instructions to bystanders, to improve recognition and initiation of CPR, supported by low-certainty evidence showing increased survival.^[28]^[29]^[20] Considerations for obesity remain unchanged, advising standard CPR techniques without modifications, as ILCOR scoping reviews found no evidence supporting alterations despite variable neurological outcomes in obese patients.^[28]^[29]^[20]

Initial Assessment and Activation

Scene safety and danger assessment

In basic life support (BLS), the initial step of the primary survey emphasizes ensuring the safety of the rescuer, bystanders, and the potential victim before any intervention begins. This requires rescuers to evaluate the environment for immediate threats that could endanger lives or complicate the response.^[1]^[30] Rescuers must scan the scene from a safe distance to identify and mitigate hazards, approaching only if the area is secure; if dangers persist, they should wait for emergency professionals rather than risk further harm. Common hazards include traffic on roadways, fire or smoke, electrical risks such as live wires or powerlines, structural instability, chemical spills, or potential violence.^[31]^[30] To mitigate these, rescuers should isolate the threat where possible—for instance, by turning off power sources, moving bystanders away, or alerting authorities—and don personal protective equipment (PPE) like gloves or masks if available to guard against infectious or environmental risks.^[32]^[19] Legal protections under Good Samaritan laws encourage bystander intervention by shielding rescuers from civil liability when providing aid in good faith, provided they act reasonably and without gross negligence; these laws vary by jurisdiction but generally apply to non-professional volunteers in emergencies like cardiac arrest.^[33] Once the scene is deemed safe, the rescuer may proceed to assess the victim's responsiveness.^[34]

Responsiveness check and calling for help

After ensuring the scene is safe, the rescuer approaches the victim to assess responsiveness as the initial step in basic life support.^[1] This involves tapping the victim's shoulders firmly and asking or shouting, "Are you okay?" to elicit a verbal or physical response.^[1]^[32] If the victim is unresponsive, the rescuer immediately shouts for help to alert nearby bystanders and activates the emergency response system, including sending someone to retrieve an automated external defibrillator (AED) if available.^[1] Emergency services should be called without delay using the local number, such as 911 in the United States or 112 in Europe, providing the dispatcher's instructions on the victim's location and condition.^[1]^[35] For a solo rescuer, the call to emergency services and retrieval of an AED (if nearby) takes priority before further actions, whereas if bystanders are present, one is delegated to make the call and get the AED while the rescuer remains with the victim.^[1]^[32] To facilitate dispatcher-assisted guidance, the call should be placed on speakerphone, allowing the telecommunicator to provide real-time instructions for the situation.^[28] This activation is essential immediately upon identifying an unresponsive victim, as early professional intervention and defibrillation improve outcomes in cardiac arrest scenarios.^[1]^[35]

Airway and Breathing Support

Airway opening techniques

In basic life support (BLS), establishing a patent airway is essential to facilitate effective oxygenation and ventilation, particularly in unresponsive individuals without suspected trauma. The primary techniques prioritize simple manual maneuvers that can be performed by lay rescuers or trained providers using no advanced equipment. These methods aim to relieve upper airway obstruction caused by the tongue or soft tissues while minimizing risks such as cervical spine injury. Head-tilt chin-lift maneuver is the standard technique for opening the airway in non-trauma cases. It involves placing one hand on the victim's forehead to gently tilt the head backward while using the fingers of the other hand to lift the chin upward, thereby displacing the tongue from the posterior pharynx. This method, first described in seminal work demonstrating its efficacy in overcoming tongue obstruction, remains a cornerstone of BLS protocols due to its simplicity and effectiveness in achieving airway patency.^[36]^[19] Jaw thrust maneuver serves as an alternative when cervical spine injury is suspected, as it avoids head extension. The rescuer places the fingers behind the angles of the lower jaw and lifts it forward toward the victim's ears, displacing the mandible anteriorly to open the airway without tilting the head. This technique produces less movement of the head and neck compared to the head-tilt chin-lift, making it preferable in trauma scenarios, though it may require two rescuers for optimal execution. If the jaw thrust proves ineffective, rescuers may revert to the head-tilt chin-lift to prioritize oxygenation.^[19] The recovery position is indicated for unconscious victims who are breathing normally but unresponsive, to maintain airway patency and prevent aspiration of secretions or vomit. The victim is gently rolled onto their side with the upper leg bent for stability, the head supported in a neutral position, and the mouth downward to allow drainage. This lateral decubitus positioning reduces the risk of airway obstruction and aspiration, and it is recommended until advanced help arrives, provided there are no signs of trauma that contraindicate movement.^[37]^[38] Common errors in these techniques can compromise airway management and overall resuscitation success. In the head-tilt chin-lift, rescuers often fail to tilt sufficiently or overextend the neck, particularly in trauma cases, which may exacerbate spinal injuries or fail to relieve obstruction. For the jaw thrust, inadequate forward displacement of the mandible can leave the airway partially occluded, while visual inspection for obstructions like foreign bodies is frequently overlooked across all maneuvers. Additionally, improper application of manual techniques without confirming chest rise during subsequent breathing assessment can lead to ineffective ventilation. To mitigate these, training emphasizes gentle, controlled movements and immediate verification of airway patency.^[19]^[38]

Breathing assessment and rescue breaths

In basic life support (BLS), breathing assessment follows confirmation of unresponsiveness and airway patency, as part of the airway and breathing components following the circulation check in the CAB (Circulation, Airway, Breathing) sequence. Rescuers evaluate respiratory effort by looking for chest rise, listening for breath sounds at the mouth, and feeling for air movement on the cheek, typically for no more than 10 seconds to minimize delays in intervention.^[1]^[19] Normal breathing is characterized by regular, effective respirations, whereas absent breathing or agonal gasps—irregular, slow, and labored efforts seen in 40% to 60% of out-of-hospital cardiac arrests—indicate the need for immediate ventilatory support, as they do not provide adequate oxygenation.^[19] If breathing is inadequate or absent but a pulse is present, rescuers provide rescue breaths to support oxygenation. The technique involves maintaining a head-tilt chin-lift maneuver to keep the airway open, pinching the nostrils shut to prevent air escape, creating a complete seal over the victim's mouth with the rescuer's mouth, and delivering two initial breaths, each lasting about 1 second with sufficient volume—approximately 5 to 7 mL/kg ideal body weight or enough to produce visible chest rise—without excessive force.^[1]^[19] These breaths should be given at a rate of 10 per minute (one every 6 seconds) for adults in respiratory arrest, reassessing the pulse every 2 minutes.^[19] For lay rescuers untrained in or unwilling to perform rescue breaths due to concerns such as infection risk, hands-only CPR—continuous chest compressions without ventilations—is a viable alternative that has demonstrated comparable survival outcomes in adult cardiac arrest scenarios.^[19] To mitigate transmission risks during mouth-to-mouth ventilation, barrier devices like pocket masks or face shields are recommended, as they facilitate effective seal formation and reduce exposure to bodily fluids.^[19] A key complication of rescue breaths is gastric insufflation, where excessive pressure or volume forces air into the stomach, potentially leading to regurgitation, aspiration, and compromised ventilation; this risk is minimized by using controlled tidal volumes that just achieve chest rise and avoiding overinflation.^[19] The 2025 American Heart Association guidelines reaffirm these techniques with no major revisions from prior iterations, emphasizing rapid assessment and ventilation to improve outcomes in respiratory failure or arrest.^[19]

Circulation Management and CPR

Circulation assessment

In basic life support (BLS), circulation assessment is a critical component of the initial evaluation to determine if cardiac arrest has occurred, guiding the decision to initiate cardiopulmonary resuscitation (CPR). This step, often referred to as the "C" in the traditional ABC (Airway, Breathing, Circulation) sequence, involves a rapid check for signs of effective blood flow, particularly in unresponsive individuals with abnormal or absent breathing. The assessment aims to minimize delays, as prompt CPR initiation significantly improves survival outcomes in out-of-hospital cardiac arrest.^[19] For healthcare professionals, circulation is primarily assessed by palpating the carotid pulse for no more than 10 seconds; if no pulse is definitively felt or if there is uncertainty, cardiac arrest should be assumed, and CPR should begin immediately with chest compressions. This brief time limit is emphasized to avoid prolonging the evaluation, as studies indicate that delays beyond 10 seconds reduce the chances of return of spontaneous circulation. Lay rescuers are not recommended to perform routine pulse checks due to the high rate of inaccurate detection, instead proceeding directly to compressions if the victim is unresponsive and not breathing normally. Signs of poor circulation that may accompany this assessment include cyanosis (bluish discoloration of the skin, lips, or nails due to inadequate oxygenation) and cool, clammy skin, which indicate inadequate perfusion even before a full arrest.^[19]^[1]^[39] The 2025 American Heart Association (AHA) guidelines reinforce prioritizing chest compressions over extended circulation checks, building on evidence that rapid action—without hesitation for confirmation—enhances resuscitation success rates, particularly in the first minutes of arrest. This update aligns with International Liaison Committee on Resuscitation (ILCOR) consensus, stressing high-quality compressions from the outset. Integration with prior airway and breathing assessments is seamless: if no pulse is detected alongside absent or abnormal breathing (such as agonal gasps), CPR commences without further delay, transitioning directly to the compression phase.^[19]^[40]

Chest compression technique

Chest compressions are a critical component of basic life support performed immediately following the identification of absent or inadequate circulation in an unresponsive victim, aiming to manually restore blood flow to vital organs.^[19] Proper hand positioning ensures effective force transmission to the heart without causing injury. The rescuer places the heel of one hand on the center of the lower half of the sternum, between the nipples, while positioning the other hand directly on top and interlocking the fingers to keep them off the chest.^[19] This technique, recommended by international guidelines, optimizes compression over the left ventricle and avoids the xiphoid process to minimize risks such as rib fractures or abdominal injury.^[20] Compressions should be delivered at a rate of 100 to 120 per minute, equivalent to the tempo of the song "Stayin' Alive" by the Bee Gees, to mimic normal cardiac output.^[19] The depth must reach at least 5 cm (2 inches) but not exceed 6 cm (2.4 inches) in adults, as shallower compressions fail to generate sufficient perfusion pressure, while excessive depth increases injury risk without proportional benefit.^[19] Full chest recoil between compressions is essential, allowing the heart to refill with blood; rescuers must avoid leaning on the chest, as this reduces venous return and coronary perfusion.^[38] High-quality compressions require minimizing interruptions to less than 10 seconds, aiming for a chest compression fraction of at least 60% of the total resuscitation time, as prolonged pauses correlate with decreased survival rates.^[19] To combat rescuer fatigue, which can degrade compression depth and rate after 90 to 120 seconds, rescuers should switch roles every 2 minutes or use real-time feedback devices if available to monitor and maintain quality metrics.^[20]

Compression-ventilation ratios

In basic life support (BLS) for adults, the standard compression-ventilation ratio for a single rescuer performing conventional CPR is 30 chest compressions followed by 2 rescue breaths (30:2), which allows for assessment of ventilation effectiveness while minimizing interruptions in compressions.^[19] This ratio is recommended to maintain adequate oxygenation and circulation during cardiac arrest, with compressions delivered at a rate of 100 to 120 per minute.^[28] For two-rescuer BLS in adults, the 30:2 ratio is also employed, with one rescuer providing compressions and the other delivering ventilations using a bag-mask device to ensure visible chest rise, facilitating coordinated and effective CPR without altering the sequence.^[19] Once an advanced airway (such as an endotracheal tube or supraglottic device) is placed, the approach shifts to continuous chest compressions at the same rate, with asynchronous ventilations provided at 1 breath every 6 seconds (approximately 10 per minute) to avoid pauses.^[41] A hands-only CPR variant, consisting of continuous chest compressions without rescue breaths, is recommended for untrained lay rescuers or those unwilling to provide ventilations, particularly in cases of witnessed cardiac arrest where an AED is available or expected soon, as it simplifies the process and sustains circulation.^[19] The 2025 American Heart Association (AHA) guidelines reaffirm the 30:2 ratio based on systematic reviews showing no significant survival benefit from switching to continuous compressions without ventilations in most out-of-hospital cardiac arrest scenarios for trained rescuers, though ventilations delivered during the 30:2 pauses are often inadequate if chest rise is not confirmed.^[28] Evidence indicates that the 30:2 approach enables better monitoring of ventilation quality compared to uninterrupted compressions, supporting its continued use in BLS protocols.^[20]

Automated External Defibrillation

AED usage procedure

The automated external defibrillator (AED) is a portable device designed to analyze cardiac rhythm and deliver an electric shock if a shockable rhythm is detected, as part of basic life support for sudden cardiac arrest.^[1] In BLS protocols, rescuers activate the AED as soon as it is available after confirming unresponsiveness and absence of normal breathing, while a bystander calls emergency services.^[42] The standard procedure begins with powering on the AED by pressing the power button, which initiates voice and visual prompts to guide the user.^[1] Expose the patient's chest by removing or cutting clothing to ensure good skin contact, and if the chest is wet, wipe it dry to improve pad adhesion.^[42] Attach the self-adhesive defibrillation pads to the bare chest: place one pad directly below the right collarbone and the other on the left side of the chest, below the armpit at the mid-axillary line (anterior-lateral placement).^[1] If the anterior-lateral pads might overlap or if the patient has a pacemaker or implantable device, position one pad at least 2.5 cm (1 inch) away from the device bulge and consider anterior-posterior placement with one pad on the center of the chest and the other on the back between the shoulder blades.^[43] Plug the pad connector into the AED if not pre-connected, then stand clear of the patient and ensure no one is touching the patient or bed.^[42] Follow the device's prompts to allow rhythm analysis; the AED will advise whether a shock is needed based on detection of ventricular fibrillation or pulseless ventricular tachycardia.^[1] If a shock is indicated, loudly announce "Clear!" to confirm safety, then press the shock button to deliver the energy dose, typically 120-200 J for biphasic waveforms in adults.^[44] Immediately resume chest compressions after the shock or if no shock is advised, minimizing interruptions.^[1] Continue following prompts for subsequent analyses and shocks every 2 minutes during CPR cycles.^[45] For pediatric patients under 8 years of age or weighing less than 25 kg (55 lbs), select the pediatric mode if available on the device, which reduces the energy dose via an attenuator, or use pediatric-sized pads that attenuate the shock to approximately 2-4 J/kg.^[44] If pediatric pads or mode are unavailable, adult pads and mode may be used cautiously, with anterior-posterior placement preferred to avoid overlap on smaller chests.^[44] Manual override is not part of BLS and is reserved for advanced providers.^[1] AED maintenance involves monthly visual inspections to verify battery status, pad integrity, and device functionality, as well as replacing pads and batteries according to manufacturer guidelines, typically every 2-5 years.^[46] Rescuers should receive training on specific AED models to familiarize themselves with unique features like voice prompts or self-tests.^[47]

Integration with CPR

In basic life support (BLS), the integration of automated external defibrillation (AED) with cardiopulmonary resuscitation (CPR) follows a structured sequence designed to minimize interruptions in chest compressions while allowing for timely rhythm analysis and shock delivery when indicated. The AED is applied as soon as it becomes available, with rescuers pausing CPR only briefly to attach the device and follow its voice prompts for rhythm assessment. This approach ensures that high-quality CPR continues to support circulation until defibrillation can be attempted, as prolonged pauses reduce the chances of successful resuscitation.^[1] In out-of-hospital adult cardiac arrest, rescuers apply the AED and analyze the rhythm as soon as the device is available, whether the arrest was witnessed or unwitnessed, to optimize outcomes by minimizing the time to potential defibrillation. These protocols prioritize early AED use without requiring advanced monitoring.^[1]^[7] During CPR cycles, rhythm checks occur every 2 minutes, coinciding with the end of each 2-minute CPR interval, during which rescuers pause compressions for the AED to analyze the cardiac rhythm. The AED automatically determines if the rhythm is shockable, such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), or non-shockable, like asystole or pulseless electrical activity; in BLS settings, rescuers do not manually interpret the rhythm and must follow the device's prompts exclusively. If a shockable rhythm is detected, a single shock is delivered, after which CPR resumes immediately without checking for a pulse or signs of circulation. This cycle repeats until advanced help arrives or the victim shows signs of life.^[1]^[7] Post-shock management emphasizes seamless resumption of CPR to maintain perfusion, regardless of the monitored rhythm. Immediately after delivering a shock, rescuers perform 2 full minutes of high-quality CPR—starting with chest compressions—before the next rhythm analysis, avoiding any unnecessary delays that could compromise coronary and cerebral blood flow. This protocol applies uniformly after each shock, promoting a rhythmic alternation between CPR and defibrillation attempts to sustain the chain of survival in out-of-hospital settings.^[1]

Specific Indications

Cardiac arrest

Cardiac arrest represents the sudden cessation of effective cardiac output, leading to immediate loss of consciousness and, if untreated, death within minutes. It is primarily recognized in basic life support (BLS) protocols when an individual is found unresponsive, exhibits no normal breathing (or only gasping, known as agonal respirations), and has no detectable pulse upon rapid assessment. Common underlying causes include myocardial infarction, which disrupts blood flow to the heart muscle, and life-threatening arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia, which prevent coordinated heart contractions. These signs prompt immediate action, as delaying intervention reduces the window for successful resuscitation.^[1]^[48] In BLS, the primary role during cardiac arrest is to initiate high-quality cardiopulmonary resuscitation (CPR) immediately to restore circulation and oxygenation, followed by the prompt application of an automated external defibrillator (AED) if available, to address shockable rhythms. This sequence aligns with the early links of the chain of survival, emphasizing rapid bystander response to prevent irreversible brain damage from hypoxia. Survival rates for out-of-hospital cardiac arrest (OHCA) are approximately 10% without bystander intervention, reflecting delays in professional care, but can reach up to 50% in settings where early CPR and defibrillation occur within 3-5 minutes of collapse, particularly for shockable rhythms. These interventions are critical, as each minute without CPR reduces survival chances by 7-10%.^[19]^[49] For suspected opioid-associated cardiac arrest, which may present with respiratory depression progressing to circulatory collapse, BLS guidelines recommend administering an opioid antagonist such as naloxone if available, alongside continuing standard CPR without interruption. This 2025 update integrates naloxone into the adult BLS algorithm to reverse opioid-induced respiratory arrest before or during cardiac arrest, potentially improving outcomes in overdose scenarios, though CPR remains the cornerstone regardless of response to the antagonist. Bystander intervention, including calling emergency services and starting CPR, is pivotal in the chain of survival, as it bridges the gap to advanced care and has been shown to double or triple survival odds in OHCA.^[19]^[6]

Respiratory arrest and failure

Respiratory arrest refers to the cessation of effective breathing with a detectable pulse present, distinguishing it from full cardiac arrest where circulation also fails. The patient may initially be responsive or become unresponsive as hypoxia progresses. It is recognized in BLS when an unresponsive person exhibits no normal breathing; healthcare providers should confirm the presence of a pulse within 10 seconds while assessing breathing, whereas lay rescuers may assume cardiac arrest in such scenarios and initiate compressions if untrained in pulse checks.^[19] Common causes of respiratory arrest in adults include opioid overdose, which depresses the respiratory drive, and trauma such as head injuries that impair brainstem function controlling ventilation. Other etiologies encompass drowning, severe asthma exacerbations, or neurological events like stroke, leading to inadequate oxygenation and potential progression to hypercarbia if untreated. Early identification is critical, as untreated respiratory arrest can rapidly evolve into cardiac arrest due to hypoxia.^[50]^[51]^[19] In basic life support for respiratory arrest with a confirmed pulse, rescuers should immediately open the airway using the head-tilt chin-lift maneuver (or jaw thrust if cervical spine injury is suspected) to ensure patency. Rescue breaths are then administered at a rate of 1 breath every 6 seconds, equivalent to 10 breaths per minute, with each breath lasting about 1 second and sufficient to produce visible chest rise (tidal volume of 5-7 mL/kg, or 362-406 mL in adults). Ventilation can be delivered via mouth-to-mouth, mouth-to-mask, or bag-mask device if available, with two rescuers preferred for bag-mask to optimize seal and delivery. Continuous monitoring of the pulse every 2 minutes is essential to detect deterioration in circulation.^[19]^[1] If spontaneous breathing resumes, the patient should be placed in the recovery position—a lateral recumbent posture—to maintain airway patency, facilitate drainage of secretions, and minimize aspiration risk, provided no suspected spinal injury exists. Supplemental oxygen, if equipment and training are available, may be administered via nasal cannula or mask to target SpO2 of 94% or higher, though this is not a core component of BLS and ventilations alone suffice for initial support. Rescuers must remain vigilant for signs of clinical decline.^[19]^[51] Should the pulse become absent during monitoring, rescuers must immediately transition to full cardiopulmonary resuscitation, initiating chest compressions at a rate of 100-120 per minute with a 30:2 compression-to-ventilation ratio. This seamless shift underscores the continuum between respiratory and cardiac arrest in BLS protocols.^[19]

Foreign body airway obstruction

Foreign body airway obstruction (FBAO), often referred to as choking, is an acute emergency where a foreign object lodges in the airway, impairing airflow and potentially leading to hypoxia if not addressed immediately. In the context of basic life support (BLS), management focuses on rapid recognition and mechanical dislodgement techniques to restore ventilation, as untreated FBAO can progress to respiratory arrest or cardiac arrest. The 2025 American Heart Association (AHA) guidelines emphasize evidence-based maneuvers that balance effectiveness with safety, prioritizing non-invasive methods for conscious victims.^[19] Recognition of FBAO relies on assessing the victim's responsiveness and airway patency. Mild FBAO is indicated by a forceful cough, ability to speak or cry, and normal skin color, where the victim can often clear the obstruction independently through vigorous coughing. Severe FBAO, requiring intervention, presents with signs such as weak or absent cough, inability to speak or breathe, cyanosis (bluish skin discoloration), altered mental status, or apnea; victims may also display the universal choking sign by clutching their throat. Bystanders should verify scene safety, activate the emergency response system, and confirm responsiveness before proceeding.^[1]^[19]^[52] For a conscious adult with severe FBAO, rescuers position themselves behind the victim, leaning them slightly forward, and deliver 5 firm back blows between the shoulder blades using the heel of the hand to create upward force. If the object is not expelled, immediately follow with 5 abdominal thrusts (Heimlich maneuver), placing a fist above the navel and grasping it with the other hand to deliver inward and upward thrusts. These cycles of 5 back blows alternated with 5 abdominal thrusts are repeated until the object is dislodged, the victim becomes unresponsive, or advanced help arrives. For pregnant or obese individuals where the abdomen cannot be encircled, chest thrusts replace abdominal thrusts, applied in the center of the chest. In mild cases, rescuers observe closely while encouraging continued coughing to facilitate self-clearance, without performing thrusts. The 2025 AHA guidelines reaffirm this sequence without substantive changes from prior recommendations, highlighting its efficacy in expelling obstructions while minimizing complications.^[52]^[19]^[1] If the conscious victim becomes unresponsive during intervention, the rescuer lowers them to a firm surface, activates the emergency response if not already done, and initiates standard BLS CPR starting with 30 chest compressions. Before attempting rescue breaths, the rescuer opens the airway and visually inspects the mouth, removing any visible foreign object with a finger sweep only if it can be grasped without pushing it deeper. Cycles of 30 compressions followed by 2 breaths continue, with mouth checks before each breath attempt, until the object is expelled, the victim shows signs of life, or emergency medical services arrive. This integrates FBAO relief with overall BLS airway management to support oxygenation.^[52]^[19]

Variations and Special Populations

Regional technique differences

Basic life support (BLS) protocols exhibit variations across regions, primarily due to adaptations of international consensus recommendations to local emergency systems, cultural factors, and legal frameworks, while striving for global alignment. The International Liaison Committee on Resuscitation (ILCOR) plays a central role in harmonizing these approaches through its periodic consensus on science with treatment recommendations (CoSTR), which emphasize evidence-based practices such as the 30:2 compression-to-ventilation ratio for adult CPR and a compression-first (CAB) sequence to expedite interventions.^[20] These efforts minimize procedural differences, though regional guidelines incorporate specific emergency response numbers, sequence acronyms, and emphases tailored to bystander capabilities and infrastructure. In the United States, the American Heart Association (AHA) 2025 guidelines recommend the CAB sequence—starting with chest compressions, followed by airway management and breathing—for healthcare providers, enabling faster initiation of compressions compared to traditional ABC approaches.^[19] For lay rescuers, hands-only CPR (continuous compressions without ventilations) is strongly encouraged to simplify the process and boost bystander participation, particularly in non-asphyxial cardiac arrests, with activation of the 911 emergency number prioritized early by lone rescuers.^[19] This focus addresses regional disparities in bystander CPR rates, which vary significantly by demographics and location within the U.S.^[19] European protocols, as outlined in the European Resuscitation Council (ERC) 2025 guidelines, utilize the DRABC sequence (Danger, Response, Airway, Breathing, Circulation), placing a strong emphasis on immediate activation of the 112 emergency number for any unresponsive individual to facilitate dispatcher-assisted CPR instructions.^[29] While aligning with the 30:2 ratio, these guidelines highlight the importance of ventilations for trained rescuers, recommending just sufficient tidal volume to cause chest rise, and support continuous compressions for untrained bystanders, reflecting a balanced approach to ventilation in contexts with higher training penetration.^[29] In Australia and New Zealand, the Australian and New Zealand Committee on Resuscitation (ANZCOR) employs the DRSABCD action plan (Danger, Response, Send for help, Airway, Breathing, CPR, Defibrillation), which integrates early emergency activation—typically via 000—and prioritizes defibrillation access, adapting ILCOR standards to the region's dispersed geography and public access defibrillator networks.^[53] Asian variations, such as those from the Japanese Resuscitation Council (JRC) 2025 guidelines, closely follow ILCOR but incorporate local enhancements like community AED mapping to improve device accessibility in urban and rural settings, alongside the standard 30:2 ratio and CAB initiation for bystanders.^[54] Overall, ILCOR's 2025 recommendations promote uniformity in core elements like compression quality and ratios to enhance survival outcomes, while regional differences often stem from emergency numbering systems and liability protections under good Samaritan laws, which vary by jurisdiction to encourage bystander intervention without fear of legal repercussions.^[20]

Adaptations for pregnant patients

Basic life support (BLS) for pregnant patients must account for pregnancy-related physiological changes, particularly aortocaval compression caused by the gravid uterus, which can reduce cardiac output by up to 25% in the supine position and impair resuscitation efforts.^[55] To optimize maternal and fetal outcomes, rescuers should prioritize relieving this compression through manual left uterine displacement (LUD) while performing standard BLS maneuvers.^[56] LUD involves continuously displacing the uterus manually to the left using one or two hands (e.g., cupping and lifting from the patient's left side or using a two-handed technique from the right), ideally by a dedicated rescuer to avoid interrupting chest compressions.^[55] This adaptation enhances venous return, increases preload, and facilitates effective CPR without requiring patient repositioning, which could delay care.^[55] Airway management and ventilation techniques in pregnant patients follow standard BLS protocols, including head-tilt chin-lift or jaw thrust for opening the airway and bag-mask ventilation at a 30:2 compression-to-ventilation ratio for healthcare providers.^[55] However, pregnancy increases the risk of difficult airway due to reduced functional residual capacity and edema, so early advanced airway intervention (e.g., supraglottic device or endotracheal intubation) by experienced personnel is recommended if bag-mask ventilation proves inadequate.^[56] LUD should be maintained during these procedures to prevent hemodynamic compromise.^[55] Chest compressions during CPR for pregnant patients require high-quality delivery at a rate of 100-120 per minute and depth of 5-6 cm, allowing full chest recoil, but with hands positioned on the upper half of the sternum (slightly higher than in non-pregnant adults) to avoid compressing the uterus and account for diaphragmatic elevation in later gestation.^[55] This modification, classified as a Class IIa recommendation (Level of Evidence C-LD, based on limited data and expert consensus), improves compression efficacy and maternal circulation without altering the overall compression-ventilation ratio.^[55] If LUD is not feasible (e.g., due to limited rescuers), a 30-degree left lateral tilt may be used as an alternative, though it can reduce compression quality and is less preferred.^[55] Defibrillation in pregnant patients is safe and follows standard BLS protocols, with pads placed according to manufacturer guidelines (e.g., anterolateral or anteroposterior positions) and no energy adjustments needed, as the uterus does not significantly alter transthoracic impedance.^[55] Rescuers must ensure LUD is maintained during pad application and shock delivery to avoid compromising displacement.^[56] There is no evidence of harm to the fetus from defibrillation, and prompt delivery of shocks remains critical for shockable rhythms.^[55] For patients beyond 20 weeks gestation, if return of spontaneous circulation is not achieved after 4 minutes of effective BLS, rescuers should initiate perimortem cesarean delivery (PMCD) within 5 minutes of arrest to relieve aortocaval compression, potentially improving maternal venous return and cardiac output by up to 25%.^[56] This intervention, a Class I recommendation (Level of Evidence C-LD), prioritizes maternal resuscitation while offering fetal viability if performed promptly, and should be considered even without fetal monitoring; a scalpel or similar tool can be used for a rapid hysterotomy at or above the umbilicus.^[55] PMCD does not interrupt CPR, which should continue simultaneously.^[55]

Considerations for obese individuals

Basic life support (BLS) for obese individuals adheres to standard adult protocols, as recommended by the 2025 American Heart Association (AHA) guidelines, which state that CPR should be performed using the same techniques as for patients of average weight without routine modifications. A 2024 International Liaison Committee on Resuscitation (ILCOR) scoping review of 36 studies confirmed that no evidence supports altering standard BLS methods for obese adults, though anatomical factors like increased chest wall thickness can pose challenges to achieving optimal outcomes. These considerations focus on ensuring effective compressions, airway patency, and defibrillation while minimizing delays in care. Chest compressions in obese patients require greater force to attain the recommended depth of 5 to 6 cm, owing to thicker chest walls and adipose tissue that reduce compliance. The 2025 AHA guidelines emphasize performing compressions on a firm surface, such as activating the CPR mode on a hospital bed or using a firm mattress, to facilitate adequate depth and recoil without unnecessary patient repositioning, as moving obese individuals to the floor may delay initiation of CPR. Although backboards are occasionally employed to stabilize the surface, evidence from in-hospital cardiac arrest studies shows they provide no benefit over standard firm surfaces and are not routinely recommended.^[19] Airway management follows conventional BLS maneuvers, but obese patients' excess neck and pharyngeal fat may impede the head-tilt/chin-lift technique, potentially necessitating the jaw thrust to improve retroglossal airway patency. Additionally, the higher prevalence of gastroesophageal reflux disease in obese individuals elevates the general risk of regurgitation and aspiration during resuscitation, underscoring the need for prompt airway control to mitigate complications.^[19]^[57] For automated external defibrillator (AED) use, standard anterolateral pad placement is applied, with no adjustments to analysis time or rhythm detection algorithms required, as studies indicate equivalent shock success rates and defibrillation efficacy between obese and non-obese patients. In cases where body habitus prevents proper anterolateral adhesion, manufacturers' instructions may permit anterior-posterior placement or larger pads if available, but the 2025 AHA and ILCOR reviews affirm that overall AED performance remains unaffected by obesity.^[19]^[58]

Pediatric and infant modifications

Basic life support (BLS) for pediatric patients requires modifications from adult protocols to account for smaller body size, anatomical differences, and the higher prevalence of respiratory causes of arrest compared to cardiac ones in adults. Recognition of cardiac arrest in children follows similar criteria—unresponsiveness and absence of normal breathing or only gasping—but rescuers should be aware that pediatric arrests are more often due to hypoxia from respiratory failure or shock, emphasizing the need for early ventilations.^[44] For children aged 1 to 8 years (or puberty, whichever comes first), chest compressions use the heel of one hand placed on the lower half of the sternum, with the option of two hands if a single hand does not achieve adequate depth; the rate is 100 to 120 compressions per minute, depth is at least one-third the anterior-posterior chest diameter (approximately 5 cm or 2 inches), allowing full chest recoil between compressions. The compression-to-ventilation ratio is 30:2 for single-rescuer CPR, consistent with adult guidelines but scaled for efficacy in smaller chests. Ventilations involve smaller puffs of air sufficient to produce visible chest rise, avoiding excessive volume to prevent gastric inflation.^[44]^[59] In infants younger than 1 year, compressions are performed using two fingers (for single rescuer) on the lower sternum just below the intermammary line, or the encircling thumbs technique (thumbs on the sternum with fingers encircling the chest) for two rescuers to improve depth control; the rate remains 100 to 120 per minute, with depth of about 4 cm (1.5 inches) or one-third the chest diameter, ensuring complete recoil. The ratio is 30:2 for single-rescuer CPR but 15:2 for two rescuers to prioritize ventilations given the respiratory etiology of most infant arrests. Rescue breaths are gentle puffs that cause visible chest rise, delivered after compressions with minimal interruptions.^[44]^[59] Automated external defibrillator (AED) use in pediatric and infant BLS incorporates pediatric-dose attenuator pads or a pediatric mode if available for those under 8 years to deliver appropriate energy levels (2-4 J/kg); if unavailable, adult pads in anterior-posterior placement are acceptable, but manual defibrillation is preferred when possible. These modifications aim to optimize circulation and oxygenation while minimizing risks like rib fractures in fragile structures.^[44]^[59]

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