Cardiopulmonary Resuscitation (CPR)

1. Introduction

Actualisation according to ERC Guidelines 2021.

CPR is a complex of relatively simple and logical ‘step by step’ procedures which should immediately restore the flow of oxygenated blood to the brain. CPR is only likely to be effective if commenced within short period after the blood flow stops. Already in as little as 4-5 min after the oxygenated blood flow stops brain cells become irreversibly damaged. Even if medical professionals are able to restore an effective circulation later on, cortical cerebral functions are often permanently damaged and the quality of patient’ s life would be never the same as before. This is the main reason why is so vitally important to educate broad community in the first aid and pre-hospital CPR.

2. History of CPR

History of Cardiopulmonary Resuscitation (CPR)

The desire to bring people back to life is very old. In the Bible is described a story discerning a similarity to artificial ventilation in a passage from the Books of Kings (Bible, 2 Kings, IV, 34.). This first resuscitation effort described was Prophet Elisha's mouth to mouth method

"...And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child; and the flesh of the child waxed warm."

Very early in our history, people realized that the body became cold when lifeless and connected heat with life. In order to prevent death from taking the person, the body was warmed. The use of warm ashes, burning excrement, or hot water placed directly on the body were all employed in an attempt to restore life. In the early ages, the would-be rescuers would actually whip the victim in an attempt to stimulate some type of response.

1550 Bellows

In the 1500's it was recommended to use a bellows from a fireplace to blow hot air and smoke into the victim's mouth, a method that was used for almost 300 years. However, the lack of anatomical and physiological knowledge reduced its efficacy significantly. In 1829, Leroy d'Etiolles demonstrated that overdistension of the lungs by bellows could kill an animal, so this practice was discontinued.

In the 1700's a new method of resuscitation was used. This "new" procedure involved blowing tobacco smoke into the victim's rectum. According to the literature, smoke was first blown into an animal bladder, then into the victim's rectum. It was used successfully by North American Indians and American colonists an introduced in England in 1767. This practice was abandoned in 1811 after research by Benjamin Brodie when he demonstrated that four ounces of tobacco would kill a dog and one ounce would kill a cat.

1770 - Inversion Method

Other methods were developed in the 1700's in response to the leading cause of sudden death of that time, drowning. Inversion was originally practiced in Egypt almost 3,500 years before and it again became popular in Europe. This method involved hanging the victim by his feet, with chest pressure to aid in expiration and pressure release to aid inspiration.

In response to the increasing numbers of drowning during this time period, societies were formed to organize efforts in resuscitation. England's Royal Humane Society was founded in 1774. Although it was the most famous, it was not the first. It was preceded by the Dutch Society for Recovery of Drowned Persons, established in 1767. The Dutch recommendations included:

  1. Warming the victim (which sometimes required transporting the body to a different location) by lighting afire near the victim, burying him in warm sand, placing the body in a warm bath, or placing in a bed with one or two volunteers;

  2. Removing swallowed or aspirated water by positioning the victim head lower than his feet and applying manual pressure to the abdomen, vomiting was induced by tickling the back of the throat with a feather

  3. Stimulation of the victim, especially the lungs, stomach and intestines by such means as rectal fumigation with tobacco smoke, or the use of strong odours

  4. Restoring breathing with a bellows

  5. Bloodletting.

These and other methods had been applied for years as documented in the report of Anne Green's hanging, resuscitation and recovery in 1650. Other methods included physical and tactile stimulation in an attempt to "wake up" the victim. Yelling, slapping, even whipping were used to attempt to resuscitate.

1773 - Barrel Method

In an effort to force air in and out of the victim's chest cavity, the rescuer would hoist the Victim onto a large wine barrel and alternately roll him back and forth. This action would result in a compression of the victim's chest cavity, forcing air out, and then a release of pressure which would allow the chest to expand resulting in air being drawn in.

1812 - Trotting Horse Method

In 1812 Lifeguards were equipped with a horse which was tied to the Lifeguard station. When a victim was rescued and removed from the water, the Lifeguard would hoist the victim onto his horse and run the horse up and down the beach. This resulted in an alternate compression and relaxation of the chest cavity as a result of the bouncing of the body on the horse. This procedure as banned across the United States in 1815 as a result of complaints by "Citizens for Clean Beaches".

1856 - Roll Method

As late as 1856, manual ventilation was given low priority, concentration was on maintaining body heat. These were the same recommendations as provided by the Dutch nearly 100 years earlier. A significant change in priorities occurred when Marshall Hall challenged the conventional wisdom of the Society. His contention that time was lost transporting the victim; that the restoration of warmth without some type of ventilation was detrimental; that fresh air was beneficial; and that if left in the supine position, the victim's tongue would fallback and occlude the airway.

Because the bellows were no longer an option, Marshall Hall developed a manual method in which the victim was rolled from stomach to side 16 times a minute. In addition, pressure was applied to the victim's back while the victim was prone (expiratory phase). Tidal volumes of 300 ml to 500 ml were achieved and soon became adopted by the Royal Humane Society.

Other methods still used included stretching the rectum, rubbing the body, tickling the throat with a feather, waving strong salts, such as ammonia, under the victim's nose.

Late 1892 - Tongue stretching

In 1892, French authors recommended tongue stretching. This procedure was described as holding the victim's mouth open while pulling the tongue forcefully and rhythmically.

1858 – The Silvester Method of Ventilation

Henry Robert Silvester attended the King’s College in London. He became a member of the Royal College of Surgeons in 1853 and in 1855 obtained his medical doctorate at the University of London. In 1858, he described a method of artificial ventilation: the patient lies on his or her back, with arms raised to the sides of the head, held there temporarily, then brought down and pressed against the chest. Movement repeated 16 times per minute. In 1883 he received the golden Fothergill medal (worth 50 Guineas) from the Royal Humane Society. For detailed description see

1911 - Holger Nielsen Technique

A second technique, called the Holger Nielsen technique, described in the first edition of the Boy Scout Handbook in the United States in 1911, described a form of artificial respiration where the person was laid on their front, with their head to the side, and a process of lifting their arms and pressing on their back was utilized, essentially the Silvester Method with the patient flipped over.

1932 - Eve's Rocking Method of Artificial Respiration

In 1932 Dr. Frank C. Eve published in the Lancet the method consisting of laying the victim of respiratory arrest on a stretcher, which was pivoted about its middle on a trestle and rocking up and down rhythmically so that the weight of the viscera pushes the flaccid diaphragm alternately up and down. This technique was officially adopted and endorsed by the Royal Navy during the Second World War for resuscitation of nearly drowned. Like all other methods of manual artificial respiration, it was supplanted by mouth-to-mouth respiration.

1957 - Mouth-to-Mouth Resuscitation

It was not until the middle of the 20th century that the wider medical community started to recognize and promote resuscitation following cardiac arrest. Peter Safar wrote the book ABC of resuscitation in 1957. Peter Safar (born April 12, 1924 in Vienna; died August 2, 2003 in Mount Lebanon, Pennsylvania) was an Austrian physician of Czech descent. He is credited with pioneering cardiopulmonary resuscitation. Together with James Elam, he rediscovered the airway, head tilt, chin lift (Step A) and the mouth-to-mouth breathing (Step B) components of CPR and influenced Norwegian doll maker Asmund Laerdal of Laerdal company to design and manufacture mannequins for CPR training called Resusci Anne®. Safar, who began to work on cardiopulmonary resuscitation (CPR) in 1956 demonstrated in a series of experiments on paralyzed human volunteers that rescuer exhaled air mouth-to-mouth breathing could maintain satisfactory oxygen levels in the non-breathing victim, and showed that even lay people could effectively perform mouth-to-mouth breathing to save lives. He combined the A (Airway) and the B (Breathing) of CPR with the C (chest compressions), and wrote the book ABC of Resuscitation in 1957, which established the basis for mass training of CPR. This A-B-C system for CPR training of the public was later adopted by the American Heart Association, which promulgated standards for CPR in [1973]. See

1960 - Cardiac Massage

The next major step in resuscitation was closed chest massage which was introduced in the 1960's by Dr. Kouwenhoven, Dr. Jude and a young engineer Knickerbocker. The crucial aspect of this technique is that the patient receives oxygen which is transported to the brain by the development of a minimal blood circulation. On this basis many national and international guidelines to perform CPR came out. Kouwenhoven's studies inspired Division of Anesthesiology researchers James Elam and Peter Safar, who would go on in the 1940s to perfect the emergency mouth-to-mouth method of lung ventilation, crucial for oxygenating the blood when the heart stops.

1961 - Cardiopulmonary resuscitation

The combination of both methods was described in 1961 by Safar as a cardiopulmonary resuscitation. During the Vietnam War the US army introduced CPR to the people for the first time. Then, in 1973 the American Red Cross and the American Heart Association (AHA) began a big campaign to teach the American population this method. 1992 ILCOR (International Liaison Committee on resuscitation) was founded, the representative organ for Europe is ERC (European Resuscitation Council). European Council evaluates roughly every five years new scientific publications and accordingly modifies its guidelines for CPR. The recommendations were last time up-dated in 2021. 

2021 - European Resuscitation Council Guidelines for Resuscitation


3. Basic life support in adults

Basic life support in adults

ERC Guidelines 2015 remained unchanged. Basic life support consists of the following steps:

  1. Make sure you, the victim and any bystanders are safe.

  2. Check the victim for a response: gently shake his shoulders and ask loudly: ‘‘Are you all right?’’ Do not use painful stimulation.

  3. If he responds


    leave him in the position in which you found him provided there is no further danger


    try to find out what is wrong with him and get help if needed


    reassess him regularly

    Basic life support in adults by ERC

    If he does not respond


    Shout for help


    Turn the victim onto his back and then open the airway. The most common cause of airway obstruction is that the tongue falls backwards and obstructs the airway. Tongue is anatomically connected to the jaw is position is dependant on the tension of masseter muscle. If one is conscious or even asleep, the airway is patent. If the patient is unconscious, muscle tension decreases, lower jaw collapses and the tongue may obstruct the airway. The simplest manoeuvre how to open the airway is an application of head tilt and chin lift. place your hand on his forehead and gently tilt his head back keeping your thumb and index finger free to close his nose if rescue breathing is required or with your fingertips under the point of the victim’s chin, lift the chin to open the airway

  4. Breathing

    Keeping the airway open, look, listen and feel for normal breathing.


    Look for chest movement.


    Listen at the victim’s mouth for breath sounds.


    Feel for air on your cheek.

    In the first few minutes after cardiac arrest, a victim may be barely breathing, or taking infrequent noisy gasps. Important: do not confuse this with normal breathing! Look, listen, and feel for no more than 10 s to determine whether the victim is breathing normally. If you have any doubt whether breathing is normal, act as if it is not normal.

  5. If he is breathing normally


    turn him into the recovery position


    send or go for help/call for an ambulance


    check for continued breathing

    If he is not breathing normally, suppose cardiac arrest. Pulsation on large vessels is not checked routinely, finding that patient’s breathing is not effective should be sufficient.

  6. Send someone for help or, if you are on your own, leave the victim and alert the ambulance service (in the Czech Republic 155 or less conveniently 112). Switch the phone to a loud mode, if possible. Let bring defibrillator (AED) according to dispatcher advice.

    Return and start chest compression as follows:


    kneel by the side of the victim


    place the heel of one hand in the centre of the victim’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 victim’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 victim’s chest and, with your arms straight, between your hands and the sternum; press down hard only the sternum 5 – 6 cm. For adults receiving chest compressions, rescuers should place their hands on the lower half of the sternum (place the heel of one hand in the centre of the chest with the other hand on top). This should limit a risk of artificial rib fractures.

    After each compression, release all the pressure on the chest without losing contact. During relaxation phase, both heart and lungs are perfused. After each compression, all the pressure on sternum should be released. Even low pressure applied on sternum during relaxation phase decreases an efficacy of chest compressions.

    Repeat at a rate at least 100/min, maximum 120/min  e.g. nearly 2 compressions per second. These manoeuvres are able to maintain artificially the circulation mainly to the heart, lungs and brain. It is vitally important that chest compressions must be performed quickly, and without unnecessary interruptions. Compression and release should take equal amounts of time.

  7. Combine chest compression with rescue breaths. After 30 compressions open the airway again using head tilt and chin lift. During cardiac arrest is necessary to combine chest compressions with rescue breaths. Generally, one can perform two types of artificial breathing – ‘mouth-to-mouth’ or ‘mouth-to-nose’.


    Mouth to mouth ventilation

    1. Pinch the soft part of the nose closed, using the index finger and thumb of your hand on the forehead.

    2. Allow the mouth to open, but maintain chin lift.

    3. Take a normal breath and place your lips around his the mouth, making sure that you have a good seal.

    4. Blow steadily into the mouth while watching for the chest to rise, taking about 1 s as in normal breathing; this is an effective rescue breath. The volume is approximately 500-600 mL (this is normal single breath volume at rest). Slight resistance is felt while the patient’s lungs are inflated.  

    5. Maintaining head tilt and chin lift, take your mouth away from the victim and watch for the chest to fall as air passes out

    6. Take another normal breath and blow into the victim’s mouth once more, to achieve a total of two effective rescue breaths. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions.


    Mouth to nose ventilation

    1. The lips of rescuer are placed around victim’s nose and his mouth is closed with the thumb of rescuer’s hand which is placed on his chin. One should take his mouth away during expiration phase and open the mouth of the patient. His chest falls down automatically and expiration is done.

    2. Take another normal breath and blow into the victim’s nose once more, to achieve a total of two effective rescue breaths. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions

  8. Continue with chest compressions and rescue breaths in a ratio of 30:2.

    Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation.

    If your initial rescue breath does not make the chest rise as in normal breathing, then before your next attempt:


    check the victim’s mouth and remove any obstruction


    recheck that there is adequate head tilt and chin lift

    Do not attempt more than two breaths each time before returning to chest compressions.

    Chest-compression-only CPR may be used as follows


    If you are not able or are unwilling to give rescue breaths, give chest compressions only.


    If chest compressions only are given, these should be continuous, at a rate of 100 min-1.

  9. After AED is available, follow AED voice prompts.

  10. Continue resuscitation until


    qualified help arrives and takes over


    the victim starts breathing normally


    you become exhausted victims.

    Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation.

  11. If there is more than one rescuer present, another should take over CPR every 1—2 min to prevent fatigue. Ensure the minimum of delay during the changeover of rescuers. The recovering rescuer may maintain in the meantime the airway of the victim patent during chest compressions.

The use of Resuscitation Face Shield

Resuscitation face shield

Resuscitation face shield is a simple device used for artificial breathing to prevent transmission of infection from the victim and to eliminate reluctance to perform mouth-to mouth ventilation. Air-proof polyethylene membrane and one-way valve reduce both aversion and risk of cross infection. Shield is placed easily on the face of victim and artificial breathing may be performed. Pressure on the shield must be released during expiration phase.

4. The use of Automated External Defibrillator (AED)

Automated external defibrillator (AED)

An automated external defibrillator (AED) is a portable device that checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm. Early defibrillation is critical to survival from cardiac arrest for several reasons: (1) the most frequent initial rhythm in witnessed sudden cardiac arrest is ventriculat fibrillation (VF); (2) the most effective treatment for VF is electrical defibrillation; (3) the probability of successful defibrillation diminishes rapidly over time; and (4) VF tends to convert to asystole within a few minutes. Early defibrillation with an AED has established benefit. The principle of early defibrillation suggests that the first person to arrive at the scene of a cardiac arrest should have a defibrillator. AEDs are user-friendly devices that can be used by trained or even untrained bystanders to save the life of cardiac arrest victims.

As soon as AED arrives, switch on the device and follow the spoken/visual information. Attach the electrodes to the victim´s bare chest. Ensure that nobody is touching the victim while AED is analysing the rhythm, deliver shock if indicated and immediately restart CPR as directed by the prompts from the device.

Automated external defibrillators (AEDs) are safe to use. There are no reports of AEDs harming bystanders or users. Also, there are no reports of AEDs delivering inappropriate shocks.

5. Paediatric CPR

In the children between 1-15 years of age, the cardiac arrest is usually secondary, because of asphyxia. The sequence of steps is similar to the adult CPR; however a slightly modified approach is used to recover respiration as soon as possible.

The main differences between adult and paediatric CPR

Basic Life Support of Babies and Children

It is preferable to modify adult BLS and perform five initial breaths followed by 1 min of CPR before going for help (see adult CPR). Advice for determining the landmarks for infant compression is now the same as for older children. Infant compression technique remains the same: two-finger compression for single rescuers and two-thumb, encircling technique for two or more rescuers, but for older children there is no division between the one- or two-hand technique. The emphasis is on achieving an adequate depth of compression with minimal interruptions, using one or two hands according to rescuer preference.

The paediatric CPR algorithm 2021

  1. Make sure you, the victim and any bystanders are safe.

  2. Check the victim for response

  3. Shout for help

  4. Turn the victim onto his back

  5. Open the airway

  6. Check normal breathing

  7. If absent, start CPR. When more than one rescuer is available, one starts resuscitation while another rescuer goes for assistance. Give 5 rescue breaths. Take a breath and cover the mouth and nose of the infant with your mouth, making sure you have a good seal. If the nose and mouth cannot be covered in the older infant, the rescuer may attempt to seal only the infant’s nose or mouth with his mouth (if the nose is used, close the lips to prevent air escape). Identify effectiveness by seeing that the child’s chest has risen and fallen in a similar fashion to the movement produced by a normal breath.

    A) A single rescuer with a phone

  8. If still unresponsive, call EMS and continue with chest compression and rescue breaths (see points 9 and 10)

    B) A single rescuer without a phone

  9. If still unresponsive, start chest compressions. In infants, use a two-thumb encircling technique for chest compression. To perform chest compression in children, compress the lower half of the sternum. Lift the fingers to ensure that pressure is not applied over the child’s ribs. In larger children or for small rescuers, this is achieved most easily by using both hands with the fingers interlocked. Compress the sternum to depress it by approximately one third of the depth of the chest. The frequency should be 100-120/min.

  10. Combine chest compressions with rescue breathing. The ratio is 15 : 2

  11. After 1 minute of basic life support (rescue breaths and chest compressions) go to find a phone and call emergency medical services (ambulance).

  12. Continue with CPR until the AED arrives. Attach the AED and follow the instructions. For 1–8 year old, use paediatric electrodes and pads if available. If not, use and adult AED.

  13. CPR is again fully continued until qualified help arrives and take over or the child starts breathing normally, or rescuer is absolutely exhausted.

6. Resuscitation of babies at birth

First Aid, study material
First Aid, study material
See chapter 15.8. Resuscitation of a newborn at

7. Dealing with trapped casualties

Dealing with trapped casualties

Accident scenes are dangerous places and one should protect himself in many ways. Technical first aid is an important part of initial action. High visibility jackets and warning triangles should be used. An ignition of the crashed car should be switched off, protect the crashed vehicle from further movement. Check the condition and number of victims, activate integrate rescue service and start first aid. Use surgical gloves for manipulating with victims if possible. See

The risk of spine injury

There is always a suspicion of head and spine trauma. Spine with its bone structures protects spinal cord against injury. Spinal trauma, mainly unstable vertebral fractures, can cause spinal cord injury during manipulation and dislocation by the rescuer. That is why we manipulate with the car crash victim only if there is another life-threatening situation like thread of fire, coma or serious trauma.

Pulling casualties from a car

Level of consciousness should be noted. If the victim is e.g. only drunken and is able to response, careful whole-body examination is made and, in case of need, we allow him to leave the car on his own.

If the victim is unconscious, we have to open his airway. His head is maintained in strictly neutral position to minimize cervical spinal cord injury. If the victim starts to breathe spontaneously and there is no need for emergency hauling out of car, we shout wait for a professional help.

In the case that breathing of the victim is not effective, one should initiate emergency hauling out of car and start CPR immediately. The most optimal way of pulling out is to use more people. One person is responsible for the victim’s head while the others try to extract his body. Rautek’s manoeuvre is usually applied: The first step is to free up his feet if they are stuck, and approach the person from behind, slipping arms of the rescuer under victim’s armpits. With both hands grab the victim uninjured forearm, so that the body of the victim is supported by rescuer chest. Move the victim slowly and pull him from the car maintaining as much as possible a straight line between his head and body, forming a sort of block. A thread of fire is a situation that justify pulling out an injured person as soon as possible without waiting for a help.

8. Foreign body airway obstruction

Foreign body airway obstruction

Foreign body obstruction is an acute, life-threatening situation occurring in both children and adults. The adults often aspirate food particles, mainly if they are drunken, while children most commonly aspirate a part of their toys or nuts. The vocal cords are the narrowest part of airway in adults, while in children it is a level of cricoid cartilage. Distally to that narrowest part, the airways are getting broader (the internal diameter of trachea is about 20mm in an adult). A foreign body obstruction is usually even worsened by concurrent laryngeal spasm.

Foreign body obstruction (FBP) treatment varies according to the severity of obstruction. The symptoms of FBO with a partial obstruction are cough and stridor within inspiration. If the victim is able to breathe, no further action is performed because it can make situation worse. If the obstruction is complete, the victim cannot breathe or cough and after short time is getting unconscious. Emergency medical services are contacted immediately. All manoeuvres are based on the principle of intra-thoracic pressure rise so that foreign body is expulsed by the stream of expired gas.

  1. Series of back blows is the safest approach. Both abdominal thrust and chest compressions could lead to a serious injury of intra-abdominal organs. Therefore back blows are indicated as a method of choice in pregnant women, extremely obese people and infants. Apply up to five back blows as follows:


    Stand to the side and slightly behind the victim.


    Support the chest with one hand and lean the victim well forwards so that when the obstructing object is dislodged it comes out of the mouth rather than goes further down the airway.


    Give up to five sharp blows between the shoulder blades with the heel of your other hand

  2. Heimlich manoeuvre consists of forceful pressure on upper abdomen which pushes diaphragm upwards rapidly. If the victim is still conscious, we stand behind him and put both arms round the upper part of his abdomen and pull our hands sharply upwards and downwards. This is repeated up to 5 times. Even if the foreign body is expulsed, the patient should be always examined by a physician because of risk for intra-abdominal organ damage.


    Stand behind the victim and put both arms round the upper part of his abdomen.


    Lean the victim forwards.


    Clench your fist and place it between the umbilicus and xiphisternum.


    Grasp this hand with your other hand and pull sharply inwards and upwards.


    Repeat up to five time

  3. The same effect is achieved by chest compression. We stand behind the victim and put both arms round his chest and press him against our chest. This is repeated up to 5 times.

  4. If the victim is already unconscious, full basic life support with CPR is initiated. In terminal stadium, laryngospasm sometimes relieves and foreign body is expulsed.

Foreign body obstruction in infants

The infants are placed face down over rescuer’s forearm with head and neck supported. Forceful back blows are delivered. In unconscious infant, emergency CPR is started.

This programme was supported by Project FRVS No 1372//2007, 208/2010 and internal grant of the 3FM CU 2017 and 2021

Authors: J. Málek, J. Knor, P. Michálek, A. Dvořák , A. Kurzová

English translalation: J. Malek, M. Sukhanenko, WP. Kirk, A. Wthitley

Video production: TM Studio, executive manager M. Jantač

Copyright © Third Faculty of Medicine, Charles University, 2007, 2010, 2017, 2021

Last change: May 4, 2023 14:20 
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