BASIC CARDIAC LIFE

SUPPORT
(BCLS) MODULE
A Comprehensive Training Guide

Covering CPR · BLS for Adults · AED · Chain of Survival

Prepared for: Nursing / Paramedic / First Responder Training

Classification: Educational | Pages: 30

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 Table of Contents
Module Topic Page

1 Introduction – General Concept of BCLS 3

• Introduction of BCLS

• Definition of BCLS (3 definitions)

• Purpose of BCLS

• Principle of BCLS

2 Introduction to CPR 8

• Introduction, Definition, Purpose, Principle

• Indication & Contraindication

• Equipment, Components, Medication of CPR

• Initiating Chain of Survival

3 BLS for Adults 18

• Definition, Principle, Purpose, Indication

• Contraindication, Main Components

• Algorithm, One & Two Rescuer CPR Steps

• Mouth-to-Mask & Bag-Mask Ventilation

4 Automated External Defibrillator (AED) 26

• Introduction, Definition, Parts

• Use of AED & Steps

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 MODULE 1

INTRODUCTION: GENERAL CONCEPT OF

BCLS
Foundations of Basic Cardiac Life Support

1.1 Introduction of BCLS

Basic Cardiac Life Support (BCLS) is a fundamental set of life-saving procedures performed when a
person experiences cardiac arrest, respiratory failure, or airway obstruction. It serves as the first-line
intervention in an emergency before advanced medical help arrives. BCLS skills are taught to both
healthcare providers and lay responders to maximize survival rates after sudden cardiac arrest
(SCA).

Cardiac arrest can occur anywhere — in hospitals, at home, or in public places. Studies consistently
show that immediate, high-quality BCLS significantly improves the chance of survival and reduces
brain damage caused by lack of oxygen. Every minute without CPR after cardiac arrest reduces the
survival rate by 7–10%.

1.2 Definition of BCLS

BCLS is defined by multiple authoritative bodies:

BCLS is a level of medical care used for victims of life-threatening illnesses or injuries
AHA 2020 until they can be given full medical care by advanced life support providers. It
encompasses CPR, airway management, and defibrillation.

Basic Cardiac Life Support refers to the maintenance of the airway, breathing, and
WHO circulation (ABC) without the use of equipment other than a protective device, performed
until definitive treatment can be provided.

BCLS consists of a series of actions that, when performed in sequence, give a cardiac
ERC 2021 arrest victim the best chance of survival, including recognition of cardiac arrest, activation
of emergency services, early CPR, and rapid defibrillation.

1.3 Purpose of BCLS

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Key Purposes of BCLS
• Maintain oxygenated blood flow to the brain and vital organs during cardiac arrest.
• Prevent biological death by sustaining circulation until advanced care is available.
• Restore spontaneous circulation through early defibrillation when indicated.
• Provide airway management to prevent hypoxic brain injury.
• Train healthcare professionals and bystanders to respond effectively in emergencies.
• Reduce morbidity and mortality associated with sudden cardiac arrest.

1.4 Principle of BCLS

The principles of BCLS are built around the concept of early, systematic, and high-quality
intervention. The core guiding principles include:

• Early Recognition: Rapid identification of cardiac arrest or respiratory failure is critical. Rescuers
must quickly assess unresponsiveness, absence of normal breathing, and pulselessness.
• Early Activation: Immediate activation of the Emergency Medical System (EMS) ensures that
advanced help is on its way while basic support is being provided.
• Early CPR: High-quality chest compressions maintain perfusion pressure to the heart and brain,
bridging the victim until defibrillation or advanced care is available.
• Early Defibrillation: For shockable rhythms (ventricular fibrillation, pulseless VT), early
defibrillation is the single most important intervention.
• Minimal Interruptions: Chest compressions should be interrupted as little as possible,
maintaining a compression fraction of ≥ 60%.

■ IMPORTANT: Never delay CPR to search for equipment. Begin compressions immediately upon confirming
unresponsiveness and absence of normal breathing.

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 MODULE 2

INTRODUCTION TO CPR
Cardiopulmonary Resuscitation — Theory & Practice

Fig 2.1 — Correct hand positioning for adult chest compressions

2.1 Introduction
Cardiopulmonary Resuscitation (CPR) is an emergency procedure combining chest compressions
and rescue breathing to manually maintain brain circulation and oxygenation during cardiac arrest.
CPR was first described by Dr. W.B. Kouwenhoven and colleagues in 1960, and has since evolved
into a cornerstone of emergency medicine. Modern CPR guidelines emphasize high-quality
compressions, minimal interruptions, and prompt defibrillation.

2.2 Definition of CPR

CPR is an emergency procedure performed in an effort to manually preserve intact brain

AHA 2020 function until further measures are taken to restore spontaneous blood circulation and
breathing in a person who is in cardiac arrest.

Resuscitation of the heart and/or lungs by mouth-to-mouth resuscitation, external cardiac

MeSH / NLM massage, or both combined. It is used in the event of CARDIAC ARREST without
apparent underlying disease.

CPR is a set of emergency techniques used to pump the heart and supply oxygen to the
WHO
lungs of a person whose heart has stopped beating, preventing brain damage and death.

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 2.3 Purpose of CPR

Why CPR is Performed

• To maintain partial flow of oxygenated blood to the brain and heart.
• To buy time until a defibrillator or advanced life support is available.
• To prevent irreversible brain damage (occurs within 4–6 minutes without circulation).
• To potentially restore a perfusing cardiac rhythm.
• To improve survival rates following out-of-hospital cardiac arrest (OHCA).

2.4 Principle of CPR

CPR works through two main physiological mechanisms:

• Cardiac Pump Theory: Direct compression of the heart between the sternum and spine squeezes
blood out of the ventricles into the aorta and pulmonary artery.
• Thoracic Pump Theory: Overall increase in intrathoracic pressure during compressions drives
blood out of the chest; the heart acts as a conduit rather than a pump.
In practice, both mechanisms contribute. CPR generates approximately 25–30% of normal cardiac
output — enough to maintain viability until definitive treatment.

2.5 Indication and Contraindication

INDICATIONS CONTRAINDICATIONS

• Cardiac arrest (any rhythm) • Valid Do-Not-Resuscitate (DNR) order

• Respiratory arrest • Obvious signs of irreversible death
• Pulseless electrical activity (PEA) (rigor mortis, decapitation, lividity)
• Ventricular fibrillation / pulseless VT • Unsafe scene / environmental hazard
• Asystole • Open chest wound (relative)
• Near-drowning with cardiac arrest • Severe trauma incompatible with life
• Drug/toxin-induced cardiac arrest • Terminal illness — documented patient wish

2.6 Equipment for CPR

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 Essential CPR Equipment
• Personal Protective Equipment (PPE): gloves, face shield, eye protection
• Pocket face mask / CPR barrier device for rescue breathing
• Bag-Valve-Mask (BVM) with oxygen reservoir
• Automated External Defibrillator (AED)
• Supplemental oxygen supply (cylinder, regulator, mask)
• Oropharyngeal Airway (OPA) / Nasopharyngeal Airway (NPA)
• Suction device for airway clearance
• IV access supplies (for medication administration if available)

Fig 2.2 — CPR being performed on an adult mannequin during training

2.7 Components of CPR

Component Description Rate / Depth

Chest Compressions Rhythmic external cardiac compression 100–120/min; 5–6 cm depth

Rescue Breaths Mouth-to-mouth or BVM ventilation 1 breath per 5–6 sec (adult)

Airway Opening Head-tilt chin-lift or jaw thrust As needed before ventilation

Defibrillation Electrical shock via AED/manual defib As soon as available

Compression-Ventilation Ratio
30:2 (single rescuer adult) Minimize interruptions

2.8 Medication in CPR

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 Medications in CPR are administered by advanced providers (ALS team). The primary drugs used
during cardiac arrest resuscitation include:

Drug Indication Dose (Adult)

Epinephrine (Adrenaline) All cardiac arrest rhythms 1 mg IV/IO every 3–5 min

Amiodarone Shock-refractory VF/pVT 300 mg IV/IO (first dose)

Lidocaine Shock-refractory VF/pVT (alternative) 1–1.5 mg/kg IV/IO

Sodium Bicarbonate Severe acidosis, hyperkalemia 1 mEq/kg IV (if indicated)

Atropine Symptomatic bradycardia 0.5 mg IV (NOT in arrest)

Vasopressin Alternative to epinephrine 40 units IV/IO (one-time dose)

2.9 Initiating the Chain of Survival

The Chain of Survival is a metaphor used to describe the sequence of critical actions that must be
taken to maximize survival from sudden cardiac arrest. Each link in the chain is equally important:

Recognition & Emergency Activation

Recognise signs of cardiac arrest (unresponsiveness, no normal breathing) and immediately
1
activate EMS (call 108/911). Early activation brings advanced help faster.

Early High-Quality CPR

Begin chest compressions at 100–120/min with a depth of 5–6 cm. Allow full chest recoil.
2
Minimize interruptions. Compression fraction ≥ 60%.

Rapid Defibrillation
Apply AED or manual defibrillator as soon as possible. Each minute of delay reduces survival by
3
7–10%. Shock shockable rhythms (VF/pVT) without delay.

Advanced Resuscitation
ALS providers manage the airway (intubation/supraglottic airway), administer IV/IO medications,
4
and treat reversible causes (4 H's and 4 T's).

Post-Cardiac Arrest Care

After ROSC: targeted temperature management, PCI if indicated, ICU monitoring,
5
neuroprognostication, and rehabilitation support.

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 Fig 2.3 — Chain of Survival training — early CPR and defibrillation

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 MODULE 3

BLS FOR ADULTS

One-Rescuer & Two-Rescuer CPR · Airway Management

Fig 3.1 — BLS training session for adult cardiac arrest management

3.1 Introduction
BLS for Adults focuses on the systematic approach to managing adult cardiac arrest. An adult is
defined as any individual who has gone through puberty (approximately ≥ 8 years old). The adult BLS
algorithm differs from pediatric BLS in compression depth, compression-to-ventilation ratio, and
defibrillation energy levels.

3.2 Definition of BLS for Adults

Adult BLS is the foundational emergency care for cardiac arrest that includes recognizing
AHA 2020 cardiac arrest, activating EMS, performing high-quality CPR, and using an AED, all
without requiring advanced airway devices or intravenous medications.

BLS for adults encompasses the skills of cardiopulmonary resuscitation and use of an
ERC 2021 AED in persons from adolescence onward, emphasising a compression rate of
100–120/min, depth of 5–6 cm, and 30:2 compression-to-ventilation ratio.

Adult basic life support refers to the combination of recognition of cardiac arrest and
ILCOR activation of the emergency response system, early high-quality CPR, and rapid
defibrillation, forming the first three links of the Chain of Survival.

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 3.3 Principle of Adult BLS
Adult BLS is governed by the following core principles:

• Safety First: Ensure the scene is safe for both the victim and rescuer before approaching.
• Systematic Assessment: Use the C-A-B sequence (Compressions → Airway → Breathing) as
recommended by AHA.
• High-Quality Compressions: Rate 100–120/min, depth 5–6 cm, full recoil, minimal interruptions.
• Adequate Ventilation: 1 breath over 1 second, visible chest rise, 30:2 ratio.
• Early Defibrillation: Use AED at the earliest opportunity for shockable rhythms.
• Teamwork: In two-rescuer CPR, rotate compressor every 2 minutes to prevent fatigue.

3.4 Purpose of BLS for Adults

Objectives of Adult BLS

• Restore and maintain oxygenation to the brain and myocardium.
• Bridge the victim to advanced cardiac life support (ACLS) interventions.
• Improve neurological outcomes post-resuscitation.
• Empower trained rescuers (lay and professional) to act confidently in emergencies.
• Standardize resuscitation practices across healthcare systems globally.

3.5 Indication and Contraindication

Indications for Adult BLS:

• Unresponsive adult victim

• Absent or abnormal breathing (gasping counts)
• No detectable pulse (check carotid, ≤ 10 seconds)
• Witnessed cardiac arrest
• Near-drowning, electrocution, drug overdose leading to cardiac arrest
Contraindications:

• Valid DNR / POLST order in place

• Obvious signs of irreversible death (rigor mortis)
• Unsafe environment presenting life threat to rescuer
• Documented terminal illness with advance directive refusing resuscitation

3.6 Main Components of CPR in Adults

Parameter Adult Standard

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Compression Rate 100 – 120 per minute

Compression Depth 5 – 6 cm (2 – 2.4 inches)

Hand Position Heel of hand on lower half of sternum (centre of chest)

Chest Recoil Allow complete recoil between compressions

Interruptions Less than 10 seconds (for rhythm check, shock)

Compression Fraction ≥ 60% of total resuscitation time

Ventilation Ratio 30 compressions : 2 breaths (no advanced airway)

Ventilation Rate (with advanced airway) 1 breath every 6 seconds (10 breaths/min)

Tidal Volume ~500 mL — enough for visible chest rise

Defibrillation Minimise pre-shock pause to < 10 seconds

3.7 Adult BLS Algorithm

SCENE SAFETY
Ensure the environment is safe for you and the victim. Don personal protective equipment
1
(gloves, face shield).

ASSESS RESPONSIVENESS
2 Tap shoulders firmly and shout 'Are you okay?' If no response, call for help immediately.

ACTIVATE EMS
3 Call 108 / 911 or direct a bystander to call. Request an AED if available. Note the time.

CHECK BREATHING & PULSE

Look for normal breathing (< 10 sec). Simultaneously palpate carotid pulse (< 10 sec). Gasping
4
= not normal.

BEGIN CPR (30:2)

Position yourself at victim's side. Place heel of dominant hand on lower sternum, interlace
5 fingers. Compress 5–6 cm at 100–120/min. After 30 compressions, open airway (head-tilt
chin-lift) and give 2 breaths.

APPLY AED
As soon as the AED arrives, power on and attach pads. Follow prompts. Minimize CPR
6
interruption for rhythm analysis.

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 SHOCK / RESUME CPR
If shock advised: ensure no one touches victim, deliver shock, immediately resume CPR for 2
7
minutes. If no shock advised: resume CPR immediately.

REASSESS EVERY 2 MINUTES

After each 2-minute CPR cycle, briefly reassess pulse/breathing. Rotate compressor to prevent
8
fatigue.

CONTINUE UNTIL…
ROSC achieved, qualified ALS team takes over, victim begins normal breathing, scene becomes
9
unsafe, or rescuer is exhausted.

3.8 One-Rescuer BCLS/CPR for Adults

When a single rescuer is available, the following sequence is performed:
• Confirm unresponsiveness, call EMS, retrieve AED.
• Begin chest compressions immediately — 30 compressions at 100–120/min, 5–6 cm depth.
• Open airway using head-tilt chin-lift manoeuvre.
• Give 2 rescue breaths (each ~1 second), observe chest rise.
• Continue 30:2 cycle until AED arrives or help comes.
• Attach AED pads and follow voice prompts as soon as device arrives.

■ IMPORTANT: In single-rescuer scenarios, calling EMS before starting CPR is recommended for adults (in
children and drowning victims, give 5 cycles of CPR first, then call).

3.9 Two-Rescuer BCLS/CPR for Adults

Two-rescuer CPR improves quality by allowing role specialization and compressor rotation:

Rescuer 1 (Compressor) Rescuer 2 (Ventilator / AED)

Perform uninterrupted chest compressions at 100–120/minMaintain open airway; deliver ventilations after every 30 compress

Compress 5–6 cm depth; allow full chest recoil Use BVM or pocket mask with supplemental oxygen

Count aloud to coordinate with ventilator Set up and operate AED; attach pads when available

Switch roles every 2 minutes (at rhythm check) Monitor compression quality; guide rate/depth verbally

3.10 Adults Mouth-to-Mask Ventilation

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 Mouth-to-mask ventilation uses a pocket face mask to deliver rescue breaths while protecting the
rescuer from direct contact. It is more effective than mouth-to-mouth as it allows a better seal and, if
equipped, supplemental oxygen delivery.

Steps for Mouth-to-Mask Ventilation

• Position the mask on the victim's face — narrow end on the nose, wider end on the chin.
• Seal the mask against the face using both thumbs on the top and fingers along the jaw.
• Tilt the head back (or use jaw thrust if spinal injury suspected) to open the airway.
• Take a normal breath, then blow steadily into the valve for ~1 second.
• Watch for visible chest rise — if no rise, reposition the airway and retry.
• Allow passive exhalation before delivering the second breath.
• Maintain compression-to-ventilation ratio of 30:2.

3.11 Adult Bag-Mask Ventilation in Two-Rescuer CPR

Bag-Valve-Mask (BVM) ventilation in two-rescuer CPR is the preferred method for delivering rescue
breaths with higher tidal volumes and oxygen concentration:

• Rescuer 2 selects the correct mask size and connects to oxygen at 10–15 L/min.
• Apply mask using EC-clamp technique: fingers form 'E' on jaw; thumb and forefinger form 'C' over
mask.
• Maintain head-tilt chin-lift while sealing the mask firmly.
• Rescuer 1 continues compressions at 100–120/min.
• After every 30 compressions, Rescuer 2 delivers 2 breaths (1 sec each) — squeeze bag gently.
• With advanced airway in place (ETT/LMA), ventilate at 1 breath every 6 seconds continuously.
• Watch for equal bilateral chest rise; avoid overventilation.

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 Fig 3.2 — Bag-valve-mask ventilation technique in two-rescuer CPR

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 MODULE 4

AUTOMATED EXTERNAL DEFIBRILLATOR

(AED)
Recognition · Operation · Clinical Use

Fig 4.1 — Automated External Defibrillator (AED) device

4.1 Introduction to AED

An Automated External Defibrillator (AED) is a portable, battery-powered medical device that
automatically analyses the heart's rhythm and, if necessary, delivers an electrical shock
(defibrillation) to restore a normal rhythm. AEDs are designed for use by both trained rescuers and
untrained bystanders, guided by clear audio and visual prompts. They are found in airports, schools,
shopping centres, and other public locations.

Early defibrillation combined with high-quality CPR is the most effective treatment for ventricular
fibrillation (VF) — the most common initial rhythm in sudden cardiac arrest. Every minute of delay in
defibrillation decreases the likelihood of survival by approximately 7–10%.

4.2 Definition of AED

An AED is a computerised medical device that checks the heart rhythm and can send an
electric shock to the heart to try to restore a normal rhythm. AEDs are used to treat
AHA 2020
sudden cardiac arrest — a medical condition in which the heart suddenly and
unexpectedly stops beating.

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 A portable automatic device that delivers an electrical shock to the heart to stop the
irregular contractions of the cardiac muscle and allow them to resume coordinated
FDA / MeSH
beating, suitable for use by non-medical personnel in public access defibrillation
programs.

Automated external defibrillators are safe, reliable defibrillators designed for use by lay
ERC 2021 rescuers who have received minimal training; they provide spoken and visual prompts
and analyse the heart rhythm to determine whether a shock is required.

4.3 Parts of an AED

Component Function

On/Off Button Activates the device and initiates the voice guidance system

ECG Electrode Pads (× 2) Self-adhesive pads placed on the bare chest to sense rhythm and deliver shock

Pad Connector Cable Connects the electrode pads to the AED main unit

LCD / LED Display Screen Shows ECG rhythm trace, prompts, shock count, and device status

Shock Button Delivers the defibrillating shock when instructed (semi-auto AEDs only)

Speaker / Audio Module Provides step-by-step voice instructions to guide the rescuer

Battery Powers the device; must be regularly checked for charge status

Memory / Data Card Records ECG, shock times, and CPR metrics for post-event review

Paediatric Key / Pad Attenuator Reduces energy for use in children under 8 years or < 25 kg

Fig 4.2 — AED wall-mounted cabinet in a public access location

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 4.4 Use of AED
AEDs are indicated for use in cardiac arrest caused by shockable rhythms. The device automatically
differentiates shockable from non-shockable rhythms:

Shockable Rhythms (AED WILL advise shock) Non-Shockable Rhythms (AED will NOT advise
shock)

• Ventricular Fibrillation (VF) • Asystole (flat line)

• Pulseless Ventricular Tachycardia (pVT) • Pulseless Electrical Activity (PEA)
• Normal sinus rhythm

Special Considerations for AED Use

• Wet chest: dry the chest thoroughly before applying pads — water conducts electricity and impairs pad
adhesion.
• Implanted pacemaker / ICD: place the pad at least 8 cm away from the device.
• Medication patches (e.g., nitroglycerine): remove patches and wipe area clean before pad placement.
• Children (< 8 yr or < 25 kg): use paediatric pads or a paediatric key/attenuator; if unavailable, use adult pads.
• Hairy chest: if pads don't adhere, shave area rapidly using the razor in the AED kit.
• Pregnancy: use AED normally — defibrillation is safe and necessary for both mother and foetus.

4.5 Steps of AED Use

POWER ON THE AED

Press the power button or open the lid (some models auto-power on). Listen for voice prompts
1
and follow instructions throughout the procedure.

ATTACH THE ELECTRODE PADS

Expose the victim's bare chest. Peel the backing off the pads. Place Pad 1 (right/white) below
2 the right collarbone. Place Pad 2 (left/red) on the lower-left side of the chest, below and to the
left of the nipple.

PLUG IN THE CONNECTOR

Insert the pad connector cable into the AED port if not pre-connected. Ensure firm contact of
3
both pads with the skin.

ANALYSE THE RHYTHM

Stand clear — do not touch the victim. Press 'Analyse' (if prompted). The AED will assess the
4
cardiac rhythm for approximately 5–10 seconds.

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 DELIVER SHOCK (if advised)
If shock is advised: warn everyone loudly — 'STAND CLEAR!' — visually confirm no contact,
5
then press the flashing Shock button. Energy delivered: 150–360 J biphasic (AED-determined).

RESUME CPR IMMEDIATELY

Regardless of the outcome, immediately resume high-quality CPR starting with chest
6
compressions. Do NOT check pulse immediately after shock.

REPEAT ANALYSIS EVERY 2 MINUTES

After every 2-minute CPR cycle, the AED will prompt to stop CPR and re-analyse. Continue until
7
ROSC, ALS arrival, or rescuer exhaustion.

■ IMPORTANT: Always minimise the pre-shock pause. The goal is < 10 seconds from last compression to
shock delivery. Resume compressions within 10 seconds of shock.

MODULE 5

SPECIAL POPULATIONS IN BLS

Paediatric · Drowning · Pregnancy · Trauma

5.1 Paediatric BLS (Infants & Children)

Paediatric BLS differs from adult BLS in compression depth, hand technique,
compression-to-ventilation ratio, and the priority of ventilation over defibrillation.

Parameter Infant (< 1 year) Child (1 yr – puberty)

Compression site Just below nipple line (sternum) Lower half of sternum

Compression technique 2 fingers OR 2-thumb encircling Heel of one or two hands

Compression depth 4 cm (1.5 inches) 5 cm (2 inches)

Compression rate 100–120 / min 100–120 / min

C:V ratio (1 rescuer) 30:2 30:2

C:V ratio (2 rescuers) 15:2 15:2

AED Use paediatric pads/key < 8 yr Paediatric pads if available

Call EMS After 5 cycles of CPR (2 min) if alone After 5 cycles (2 min) if alone

5.2 BLS in Drowning Victims

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 Drowning-related cardiac arrest is primarily a hypoxic event; therefore, ventilation takes priority over
compressions.

Key Points for Drowning BLS

• Remove victim from water safely — do not risk your own life.
• Begin 5 rescue breaths first if pulse is absent or uncertain.
• Continue 30:2 CPR as per standard adult BLS algorithm.
• Assume cervical spine injury only if there is evidence of head/neck trauma or diving.
• Do not use the Heimlich manoeuvre to remove water from the airway.
• Hypothermic drowning victims: 'not dead until warm and dead' — continue CPR aggressively.
• AED use is appropriate once the victim is out of water and the chest is dry.

5.3 BLS in Pregnancy

Cardiac arrest in pregnancy requires standard BLS with key modifications to account for physiological
changes and the presence of the foetus:

• Perform standard high-quality CPR — do NOT withhold CPR due to pregnancy.

• Manual left uterine displacement (LUD): push the uterus to the left to relieve aorto-caval
compression.
• Defibrillation energy and pad placement remain the same.
• Target a perimortem caesarean delivery within 5 minutes of cardiac arrest if ROSC not achieved.
• Airway management may be more difficult due to airway oedema — prepare for difficult airway.

5.4 Traumatic Cardiac Arrest

Traumatic cardiac arrest (TCA) requires addressing reversible causes simultaneously with CPR (the
4 T's of trauma):

4 H's (Medical) 4 T's (Trauma/Other)

Hypoxia Tension Pneumothorax

Hypovolaemia Tamponade (cardiac)

Hypo/Hyperkalaemia & metabolic Toxins / drug overdose

Hypothermia Thrombosis (PE or coronary)

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 MODULE 6

POST-RESUSCITATION CARE
Care After Return of Spontaneous Circulation (ROSC)

6.1 Return of Spontaneous Circulation (ROSC)

ROSC is defined as the restoration of a sustained perfusing cardiac rhythm, evidenced by

Definition a palpable pulse, measurable blood pressure, or a rise in end-tidal CO2 (ETCO2 > 40
mmHg).

Signs of ROSC include:

• Palpable carotid or femoral pulse

• Sudden rise in ETCO2 on capnography (> 40 mmHg)
• Spontaneous breathing or coughing
• Purposeful movement or eye opening
• Return of blood pressure on arterial line / NIBP

6.2 Immediate Post-ROSC Actions (ABCDE Approach)

AIRWAY
Maintain a patent airway. If not already intubated, consider advanced airway management.
1
Confirm ETT position with ETCO2, chest auscultation, and chest X-ray.

BREATHING
Target SpO2 of 94–98%. Avoid hyperoxia. Titrate FiO2 accordingly. Target normocarbia: PaCO2
2
35–45 mmHg. Avoid hyperventilation.

CIRCULATION
Target SBP ≥ 90 mmHg / MAP ≥ 65 mmHg. Obtain 12-lead ECG. If STEMI or suspected
3
coronary occlusion → activate cath lab for emergent PCI.

DISABILITY (Neuro)
Assess GCS, pupils, and neurological status. Implement Targeted Temperature Management
4
(TTM): 32–36°C for 24 hours in comatose patients to minimize neurological injury.

EXPOSURE / INVESTIGATIONS
Blood gases, electrolytes, lactate, glucose, troponin, CBC, coagulation studies, bedside echo,
5
chest X-ray, CT head/chest as indicated.

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 6.3 Targeted Temperature Management (TTM)
TTM is recommended for adult comatose survivors of cardiac arrest regardless of initial rhythm. The
goal is to prevent secondary brain injury from reperfusion and metabolic disturbances.

TTM Protocol Summary

• Indication: comatose adult (GCS < 8) after ROSC from cardiac arrest.
• Target temperature: 32–36°C (most centres target 36°C based on TTM2 trial, 2021).
• Duration: maintain target for 24 hours, then rewarm at ≤ 0.25°C/hour.
• Methods: surface cooling devices, endovascular cooling catheters, cold IV fluids (initial).
• Avoid: fever (≥ 37.8°C) for at least 72 hours post-arrest.
• Monitor: core temperature continuously (oesophageal, bladder, or PA catheter).

6.4 Neuroprognostication
Neurological outcome prediction is performed ≥ 72 hours after ROSC (and ≥ 72 h after normothermia
in TTM patients) using a multimodal approach:

• Clinical examination: pupillary light reflex, corneal reflex, GCS motor response.
• Electroencephalography (EEG): absent background activity, status epilepticus are poor signs.
• Somatosensory evoked potentials (SSEP): bilateral absence of N20 responses indicates poor
outcome.
• Biomarkers: serum NSE (neuron-specific enolase) > 60 mcg/L at 48–72 h suggests poor outcome.
• Brain imaging: CT/MRI for diffuse anoxic injury, sulcal effacement, or loss of grey-white
differentiation.

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 MODULE 7

CPR QUALITY METRICS & TRAINING

Measuring & Improving Resuscitation Performance

7.1 Metrics of High-Quality CPR

Metric Target Why It Matters

Compression Rate 100–120 / min Optimal coronary perfusion pressure

Compression Depth 5–6 cm (adults) Adequate stroke volume generation

Full Chest Recoil Complete between compressions

Allows ventricular filling

No Leaning < 2.5 kg residual force Prevents impaired venous return

Compression Fraction ≥ 60% Maximises total perfusion time

Pre-Shock Pause < 10 seconds Reduces loss of coronary perfusion

Post-Shock Resume < 10 seconds Maintains myocardial blood flow

Ventilation Rate 10 breaths/min (advanced airway)

Prevents hyperventilation

≥ 10 mmHg; sudden rise = ROSC

ETCO2 (waveform capnography) Real-time CPR quality feedback

7.2 Common CPR Errors and Corrections

Common Error Consequence Correction

Too slow (< 100/min) Inadequate perfusion pressure Use metronome or CPR feedback device

Too fast (> 120/min) Insufficient diastolic filling Count aloud; use feedback device

Insufficient depth (< 5 cm) Low cardiac output Depress firmly; lock elbows straight

Leaning between compressions

Impaired venous return Fully lift hands between compressions

Excessive ventilation Air trapping; impairs return 1 breath/5–6 sec; visible chest rise only

Prolonged interruptions (> 10 s)

Loss of coronary perfusion Minimise pulse checks; smooth rhythm check

Rescuer fatigue Compressions deteriorate > 2 minRotate compressor every 2 minutes

Wrong hand position Rib fractures; ineffective output Heel of hand on lower half of sternum

7.3 CPR Certification & Training

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 Regular BLS training and certification are essential for maintaining competency. Skills deteriorate
significantly within 3–6 months without practice:

BLS Training Requirements

• Initial BLS Certification: typically 4–8 hours of combined classroom/hands-on training.
• Renewal: every 2 years (AHA, ERC, and most international standards).
• High-Fidelity Simulation: manikin-based training with CPR feedback devices improves skill retention.
• Dispatcher-Assisted CPR: telecommunication-guided CPR improves bystander CPR rates.
• Mass CPR Training: community programmes significantly improve OHCA survival (e.g., 'Hands-Only CPR'
campaigns).
• Online components: blended learning (e-learning + skills session) is equally effective for CPR skills.

■ IMPORTANT: BLS certification does NOT expire immediately. However, providers should refresh skills and
update knowledge every 2 years or whenever major guideline updates occur.

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 MODULE 8

QUICK REFERENCE SUMMARY

Adult BLS at a Glance

Adult BLS Quick Reference Card

Step Action Key Number

1 Scene Safety Always first

2 Check responsiveness Tap & shout

3 Call EMS / Get AED 108 / 911

4 Check breathing & pulse ≤ 10 seconds

5 Begin chest compressions 100–120 / min

6 Compression depth 5–6 cm

7 Allow full recoil 100% recoil

8 Give rescue breaths 30:2 ratio

9 Attach AED ASAP

10 Shock (if advised) Stand clear!

11 Resume CPR Immediately post-shock

12 Rotate compressor Every 2 minutes

Key Numbers to Remember

Parameter Value

Compression Rate (adults) 100 – 120 / minute

Compression Depth (adults) 5 – 6 cm

Compression Depth (children) ≈ 5 cm (1/3 chest AP diameter)

Compression Depth (infants) ≈ 4 cm (1/3 chest AP diameter)

Ventilation rate (advanced airway) 10 breaths / minute (1 every 6 sec)

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C:V ratio — adult 1-rescuer 30 : 2

C:V ratio — child/infant 2-rescuer 15 : 2

Pre-shock pause < 10 seconds

Time to death of brain cells 4 – 6 minutes without blood flow

Survival drop per minute without CPR 7 – 10 %

AED energy (biphasic) 150 – 360 J (device-specific)

Epinephrine dose in cardiac arrest 1 mg IV/IO every 3 – 5 min

Amiodarone (first dose, VF/pVT) 300 mg IV/IO bolus

TTM target temperature 32 – 36 °C for 24 hours

BLS recertification interval Every 2 years

MODULE 9

AIRWAY MANAGEMENT IN BLS

Techniques · Adjuncts · Ventilation Strategies

9.1 Introduction to Airway Management

Airway management is a critical component of BLS. An unobstructed airway is essential for effective
ventilation and oxygenation. In unconscious patients, the tongue and soft tissues of the pharynx are
the most common causes of airway obstruction. BLS providers must be proficient in basic airway
manoeuvres before considering adjunct devices.

9.2 Basic Airway Opening Techniques

Head-Tilt Chin-Lift
Place one hand on the victim's forehead and tilt the head back. Place the fingertips of the other
1 hand under the bony part of the lower jaw and lift the chin upward. This is the standard technique
for all non-trauma arrests.

Jaw Thrust (Trauma)

Position yourself at the top of the victim's head. Place fingers behind the angles of the mandible
2 and push the jaw forward without tilting the head. Use when cervical spine injury is suspected. If
it fails to open the airway, switch to head-tilt chin-lift.

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 Suction
If visible secretions, blood, or vomit are present, use a rigid suction catheter (Yankauer). Suction
3
for no more than 10 seconds at a time. Resume CPR/ventilation immediately after.

9.3 Airway Adjuncts

Device Description Sizing / Insertion

Oropharyngeal Airway (OPA)

Curved plastic device that prevents the tongue fromMeasure:
occluding
corner
the airway.
of mouth
Only
to for
earlobe.
unconscious
Insert rotated
patients
18

Nasopharyngeal Airway (NPA)

Soft rubber tube inserted into one nostril to maintain
Measure:
pharyngeal
tip of
patency.
nose toCan
earlobe.
be used
Lubricate
in semi-conscious
and insert b

Supraglottic Airway (LMA Sits

/ i-gel)
above the glottis, providing a more secure airway
Sizethan
by weight.
BVM. Allows
Insert hands-free
blindly along
continuous
the hard palate
compress
cur

Endotracheal Tube (ETT)Gold standard advanced airway — cuffed tube passed

Adultthrough
female:the
7.0-7.5
vocalmm;
cords.
Adult
Allows
male:
continuous
7.5-8.5 mm.
compr
Co

9.4 Oxygen Delivery Systems

Device Flow Rate FiO2 Delivered

Nasal Cannula 1-6 L/min 24-44%

Simple Face Mask 6-10 L/min 35-55%

Non-Rebreather Mask 10-15 L/min 60-80%

BVM without O2 - 21% (room air)

BVM with O2 reservoir 10-15 L/min 85-100%

ETT / LMA with 100% O2 10-15 L/min ~100%

■ IMPORTANT: After ROSC, titrate oxygen to maintain SpO2 94-98%. Hyperoxia (SpO2 > 99% with 100%
FiO2) is associated with worse neurological outcomes and should be avoided.

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 MODULE 10

FOREIGN BODY AIRWAY OBSTRUCTION

Recognition · Management · Choking Relief Techniques

10.1 Introduction and Definitions

Foreign Body Airway Obstruction (FBAO) occurs when a foreign object lodges in the
AHA 2020 airway, partially or completely blocking airflow. It is a life-threatening emergency that can
rapidly lead to hypoxia, loss of consciousness, and cardiac arrest if untreated.

Choking is an acute emergency defined as mechanical obstruction of the upper airway by

WHO a foreign body, most commonly food in adults and small objects in children, requiring
immediate manual intervention to restore patency.

FBAO is classified as mild (victim can cough effectively) or severe (victim cannot speak,
ERC 2021 cough, or breathe adequately), and requires immediate graded intervention including
back blows, abdominal thrusts, and CPR if the victim becomes unconscious.

10.2 Mild vs Severe Obstruction

Mild Obstruction Severe Obstruction

Able to speak, cry, or cough forcefully Cannot speak, cry, or cough effectively

Noisy breathing but some airflow Silent or high-pitched stridor

Skin colour normal or slightly flushed Cyanosis: blue lips and fingertips

Conscious and alert Panic, distress; hands clasped at throat

ACTION: Encourage coughing; do NOT interfere ACTION: Immediate back blows and abdominal thrusts

10.3 Management of FBAO in Conscious Adult

BACK BLOWS (5 times)

Stand to the side and slightly behind the victim. Support the chest with one hand. Lean the victim
1 forward so the object can exit through the mouth. Give 5 firm back blows between the shoulder
blades with the heel of your hand.

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 ABDOMINAL THRUSTS (Heimlich, 5 times)
Stand behind the victim. Make a fist and place it thumb-side against the abdomen between the
2 navel and lower sternum. Grasp your fist with the other hand and give 5 sharp
inward-and-upward thrusts.

ALTERNATE 5+5 UNTIL RELIEVED

Continue alternating 5 back blows and 5 abdominal thrusts until the object is expelled, the victim
3
can breathe or cough forcefully, or the victim loses consciousness.

IF VICTIM BECOMES UNCONSCIOUS

Lower the victim carefully to the ground. Call EMS. Begin CPR starting with chest compressions.
4 Before rescue breaths, look in the mouth; if you see the foreign body, remove it. Never perform
blind finger sweeps.

FBAO in Special Situations

• Obese or pregnant victims: use CHEST thrusts instead of abdominal thrusts.
• Infant (under 1 year): 5 back blows alternated with 5 chest thrusts. Never use abdominal thrusts.
• Self-administered: thrust fist into own abdomen, or thrust abdomen against a hard edge.
• Healthcare setting: laryngoscopy and Magill forceps for direct removal is ideal.

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 MODULE 11

ETHICAL AND LEGAL ASPECTS OF BLS

DNR · Good Samaritan · When to Stop CPR

11.1 Do-Not-Resuscitate (DNR) Orders

A DNR order is a legally binding medical directive instructing healthcare providers not to perform CPR
if the patient's heart or breathing stops. It reflects the patient's autonomous decision, often made in
the context of terminal illness or poor quality of life.

Key Points About DNR

• A valid DNR must be written, signed by the patient or legal surrogate, and countersigned by a physician.
• DNR does NOT mean do not treat — comfort care, pain management, and other treatments continue.
• DNR orders should be readily accessible at the bedside, on the patient, and in medical records.
• POLST (Physician Orders for Life-Sustaining Treatment) is a more comprehensive document.
• If uncertain about a DNR's validity in an emergency, begin CPR and clarify simultaneously.
• Healthcare providers who honour a valid DNR are legally protected from liability.

11.2 When to Withhold or Terminate CPR

Withhold CPR (do not start):

• Valid DNR/POLST order present and accessible.

• Obvious signs of irreversible death: rigor mortis, dependent lividity, decapitation.
• Scene is immediately dangerous to rescuers and cannot be made safe.
• Injuries clearly incompatible with life.
Terminate CPR (stop ongoing resuscitation):

• ROSC is achieved — transfer to post-resuscitation care.

• Valid DNR is found after CPR has already been initiated.
• ALS team determines resuscitation is futile — prolonged arrest with no reversible cause.
• Rescuer physical exhaustion with no relief available.
• Scene becomes unsafe during resuscitation.

11.3 Good Samaritan Laws

• Good Samaritan laws protect bystanders who provide emergency assistance in good faith from
legal liability.
• Protection applies when care is given voluntarily, without expectation of payment.

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 • The rescuer must act in good faith and not be grossly negligent.
• Coverage varies by country and state — most jurisdictions protect trained and untrained
bystanders.
• AED use by laypersons is specifically protected in most countries with public access defibrillation
programmes.

Consent in Emergencies
• Implied consent: applied when the victim is unconscious and cannot provide express consent.
• Express consent: required when the patient is conscious — explain what you are doing.
• Surrogate consent: family members or legal guardians may consent for incapacitated patients.
• Withdrawal of consent: a conscious patient has the right to refuse CPR at any time.
• Children: parental consent is implied in emergencies; do not delay treatment to seek consent.

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 MODULE 12

MOCK SCENARIOS AND SELF-ASSESSMENT

Practice Cases and Review Questions

12.1 Scenario 1 — Out-of-Hospital Cardiac Arrest

SCENARIO: You are in a shopping mall and witness a 58-year-old man suddenly collapse. He is
unresponsive, not breathing normally, and you cannot detect a pulse. An AED is available 30 metres
away. You are alone. What do you do?

Scene safety
1 Check for hazards before approaching.

Assess responsiveness
2 Tap shoulders, shout 'Are you okay?' — no response.

Shout for help

3 Direct one person to call 108 and another to get the AED.

Check breathing and pulse

4 Simultaneously, less than 10 seconds — absent.

Begin 30:2 CPR

5 100-120/min, 5-6 cm depth, rescue breaths every 30 compressions.

Apply AED
6 Power on, attach pads, analyse rhythm, deliver shock if advised.

Resume CPR immediately

7 Continue until EMS arrives; rotate compressor every 2 minutes.

12.2 Self-Assessment MCQs

Q1. Recommended adult CPR compression rate?

A. 80-100/min B. 100-120/min C. 60-80/min D. 120-140/min

Answer: B — 100-120 per minute (AHA 2020).

Q2. Correct compression depth for an adult?

A. 3-4 cm B. 4-5 cm C. 5-6 cm D. 6-7 cm

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 Answer: C — 5-6 cm (2-2.4 inches).

Q3. Which rhythm does NOT receive a shock from the AED?
A. Ventricular Fibrillation B. Pulseless VT C. Asystole D. Coarse VF

Answer: C — Asystole is non-shockable; resume CPR immediately.

Q4. C:V ratio for two-rescuer paediatric CPR?

A. 30:2 B. 15:2 C. 5:1 D. 3:1

Answer: B — 15:2 for two-rescuer child or infant CPR.

Q5. Post-ROSC SpO2 target?

A. 88-92% B. 100% C. 94-98% D. 90-95%

Answer: C — 94-98% to avoid both hypoxia and hyperoxia.

Q6. How often should compressors rotate in two-rescuer CPR?

A. Every 5 min B. Every 3 min C. Every 2 min D. When fatigued only

Answer: C — Every 2 minutes at the rhythm check pause.

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 MODULE 13

GLOSSARY OF BCLS TERMS

Key Terminology and Abbreviations

Term Definition

AED Automated External Defibrillator — portable device that analyses cardiac rhythm and
delivers shocks.

AHA American Heart Association — authority on cardiovascular resuscitation guidelines.

ALS/ACLS Advanced (Cardiac) Life Support — resuscitation using medications and advanced
airways.

Asystole Complete absence of cardiac electrical activity; flat line on ECG; non-shockable.

BLS Basic Life Support — foundational resuscitation skills (CPR + AED) without advanced
interventions.

BCLS Basic Cardiac Life Support — equivalent term to BLS, used in nursing and paramedic
curricula.

BVM Bag-Valve-Mask — manual device for positive-pressure ventilation.

Cardiac Arrest Sudden cessation of effective cardiac mechanical activity resulting in loss of circulation.

Chain of Survival Sequential five-link model of care for optimising cardiac arrest outcomes.

CPR Cardiopulmonary Resuscitation — external cardiac massage combined with rescue

breathing.

Defibrillation Controlled electrical shock to terminate ventricular fibrillation or pulseless VT.

DNR Do-Not-Resuscitate — legal medical directive to withhold CPR.

EMS Emergency Medical Services — pre-hospital ambulance and paramedic systems.

ERC European Resuscitation Council — European body issuing CPR guidelines.

ETCO2 End-Tidal CO2 — capnography used to confirm airway placement and CPR quality.

ETT Endotracheal Tube — tube placed through vocal cords for definitive airway management.

FBAO Foreign Body Airway Obstruction — blockage of the airway by a foreign object.

FiO2 Fraction of Inspired Oxygen — proportion of oxygen in the delivered gas.

ILCOR International Liaison Committee on Resuscitation — global CPR science body.

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LMA Laryngeal Mask Airway — supraglottic airway providing a seal around the larynx.

OPA Oropharyngeal Airway (Guedel) — curved adjunct to prevent tongue obstruction.

PEA Pulseless Electrical Activity — electrical activity without effective contraction;

non-shockable.

ROSC Return of Spontaneous Circulation — restoration of effective cardiac rhythm post-arrest.

SCA Sudden Cardiac Arrest — unexpected loss of cardiac function, consciousness, and
breathing.

SpO2 Peripheral oxygen saturation measured by pulse oximetry.

TTM Targeted Temperature Management — controlled post-ROSC cooling to reduce brain

injury.

VF Ventricular Fibrillation — chaotic ventricular rhythm; most common shockable arrest

rhythm.

pVT Pulseless Ventricular Tachycardia — fast ventricular rhythm without a pulse; shockable.

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 References & Further Reading
• American Heart Association. (2020). 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care.
Circulation, 142(16_suppl_2).
• European Resuscitation Council. (2021). ERC Guidelines 2021. Resuscitation, 161.
• International Liaison Committee on Resuscitation (ILCOR). (2020). Consensus on Science and Treatment
Recommendations.
• World Health Organization. Basic Emergency Care: Approach to the Acutely Ill and Injured. WHO Press, 2018.
• Kouwenhoven, W.B., Jude, J.R., & Knickerbocker, G.G. (1960). Closed-chest cardiac massage. JAMA,
173(10), 1064–1067.
• Berg, R.A., et al. (2020). Part 7: Adult Advanced Cardiovascular Life Support. Circulation, 142, S345–S366.

This BCLS module is for educational purposes. Always follow your institution's current resuscitation protocols and
renew your BLS certification every 2 years.

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