The Chain of Survival (2024)

The concept was later adopted by the American Heart Association (Cummins R, 1991) and other health organizations. Subsequently, the Chain of Survival was revisited to emphasize the importance of early recognition and response (Newman M, Bahr R, 1998).

As post-resuscitation care options expanded to include mild therapeutic hypothermia and other treatments, another link, integrated post-cardiac arrest care, was added to the Chain (Hazinski M, 2010).

Today, the links in the American Heart Association version of the Chain of Survival are:

1. Immediate recognition of cardiac arrest and activation of the emergency response system
2. Early CPR with an emphasis on chest compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care.

Bystanders can help save lives by addressing the first three links in the Chain of Survival. Action steps for bystanders are described below.

BYSTANDERS

1. Immediate recognition of cardiac arrest and activation of the emergency response system

Action steps

• Recognize the emergency and decide to act.
• Call 9-1-1 or the local emergency number, activate the on-site emergency response system (e.g., by phone or text), and send someone to retrieve the nearest automated external defibrillator (AED). If the rescuer is alone, he or she should retrieve the AED immediately.

Notes

• A medical emergency can be ambiguous, confusing and frightening, which can delay effective action (Braslow A). Nevertheless, it is critical to make the decision to help and take action immediately.
• If the victim is unresponsive, not breathing or not breathing normally, he or she could be in cardiac arrest. The SCA victim may experience several seconds of seizure activity and agonal breathing, or gasping. The rescuer should suspect cardiac arrest if the victim is not breathing normally or only gasping.

2. Early CPR with an emphasis on chest compressions

Action steps

• Start CPR immediately.

Notes

• Decreasing the time between cardiac arrest onset and the first chest compression is critical to survival (Graham, 2015).
• If the bystander is not trained in CPR, he or she should provide hands-onlyor compression-only CPR by pushing hard and fast on the center of the chest at a rate of at least 100 compressions per minute.
• For adult victims, the compression depth should be at least two inches. For young victims (age 1-8) the compression depth should be about two inches, or about one-third the diameter of the chest.
• The rescuer should allow the chest to recoil completely between compressions.
• The rescuer should continue CPR until an AED is ready for use or EMS providers take over care of the victim.
• In the event the bystander is trained and proficient in CPR, he or she should provide 30 compressions followed by two breaths and repeat this cycle until an AED is ready for use or EMS providers take over care of the victim.
• Emergency dispatchers in many EMS systemswill coach bystandersin their efforts to save lives. They will guiderescuers through compression-only CPR, and in the event of an asphyxial arrest such as drowning, dispatchers will also provide guidance on rescue breathing.

3. Rapid defibrillation

Action steps

• As soon as an AED is available, the rescuer should position the device next to the patient, turn it on, and follow visual and voice prompts. He or she should then attach the electrode pads to the victim’s bare chest as shown in thediagram on the pads. If a shock is advised, the rescuer should be sure no one is touching the victimand then press the shock button.

Notes

• If a shock is needed, the device will instruct the rescuer to press the shock button. In fully automaticdevices, the shock will be delivered automatically.
• AEDs are designed for use by untrained laypersons. They are safe, effective, and intuitive devices that will not shock a victim unless a shock is needed to restore a normal heartbeat. They cannot harm the victim.
• AEDs are safe for use with children. If the child is age 1-8 and a pediatric dose-attenuator is available,the rescuer should use it. If this adapter is not available, the rescuer should use a standard AED.

EMERGENCY RESPONDERS

The two remaining links in the Chain of Survival refer to actions that should be taken by professional responders. They include advanced life support and integrated post-cardiac arrest care.

4. Effective advanced life support

Advanced life support refers to high-quality CPR, early defibrillation, and use of devices and drugs.

5.Integrated post-cardiac arrest care

Integrated post-cardiac arrest care refers to a comprehensive, multidisciplinary system of care including mild therapeutic hypothermia and other treatments.

SUMMARY

Cardiac arrest treatment is a community issue requiring a wide range of people to be prepared to act—including bystanders, family members, first responders, emergency medical personnel, and other healthcare providers. Bystander CPR and AED use can significantly improve outcomes from cardiac arrest (Graham, 2015).

-Mary M. Newman, MS

References