Knowing exactly when do you call 911 during CPR is the single most important decision a bystander makes during a cardiac emergency, and current 2026 guidelines from the American Heart Association are unambiguous: call immediately after recognizing unresponsiveness and abnormal breathing, before you begin compressions if you are alone with an adult, and after two minutes of CPR if you are alone with an infant or child. This timing difference reflects the underlying cause of arrest, which is usually cardiac in adults and respiratory in pediatrics. Understanding the why behind every step transforms hesitation into action.
CPR procedure guidelines have evolved significantly over the past decade, shaped by clinical evidence, registry data from the American Heart Association, and refinements published through the national cpr foundation and the International Liaison Committee on Resuscitation. The current chain of survival emphasizes early recognition, high-quality chest compressions, rapid defibrillation, and seamless integration with advanced life support. Each link is measurable, and each weak link cuts survival probability roughly in half. That is why memorizing the sequence is not enough; you must rehearse it until execution becomes automatic.
The foundational rhythm of modern CPR is 30 compressions to 2 breaths for one-rescuer adult, child, and infant resuscitation, performed at a rate of 100 to 120 compressions per minute. Compression depth is at least two inches for adults, about two inches for children, and roughly one and a half inches for infants. These numbers are not arbitrary; they reflect the depth required to generate adequate stroke volume and coronary perfusion pressure. Shallow compressions look like CPR but accomplish very little physiologically, and they are one of the most common errors observed during code reviews.
This guide walks you through the complete procedure for every age group, integrates AED use, addresses special circumstances such as drowning and opioid overdose, and explains how the basic life support sequence flows into the acls algorithm used by paramedics and hospital teams. We will also cover the recovery position, post-arrest care, and the documentation that follows every real-world resuscitation. Whether you are a parent learning infant cpr, a healthcare worker preparing for pals certification, or a workplace responder, the principles are identical and the standards are universal.
The data tells a sobering story. Roughly 350,000 out-of-hospital cardiac arrests happen in the United States every year, and survival to hospital discharge hovers near ten percent. Yet when bystander CPR is started within the first minute, survival can triple. When an AED is applied within three minutes, survival can exceed seventy percent in witnessed shockable arrests. The difference between a fatal event and a complete neurological recovery often comes down to a stranger willing to push hard, push fast, and stay calm until professional help arrives.
One persistent myth deserves a direct answer: you cannot make a clinically dead person worse. Broken ribs heal, bruised sternums fade, and the legal protections under Good Samaritan laws cover lay rescuers who act in good faith. The only true failure is doing nothing. With that mindset established, let us move through the modern CPR procedure step by step, beginning with scene safety and ending with handoff to emergency medical services.
Throughout this guide, you will see references to compression-only CPR, conventional CPR with rescue breaths, and special considerations for pregnant patients, hypothermia, and electrocution. Each variation exists for a clinical reason, and each is taught in detail by certifying bodies. By the end, you will have a clear, actionable framework that aligns with the latest 2025-2026 consensus statements and prepares you for both real emergencies and certification testing.
Survey the area for hazards such as traffic, electrical sources, or fire. Tap the victim's shoulders and shout. If no response, the resuscitation sequence begins immediately. Wearing gloves and a barrier device is ideal but never delay care.
For an unresponsive adult with no normal breathing, call 911 immediately and request an AED. If alone, place the phone on speaker. If a second person is present, send them to call and retrieve the AED while you begin compressions without delay.
Place the heel of one hand on the lower half of the sternum, the other hand on top, lock elbows, and compress at least 2 inches deep at 100-120 per minute. Allow complete chest recoil between compressions to maximize venous return.
After 30 compressions, open the airway using head-tilt chin-lift, pinch the nose, and deliver two breaths over one second each. Each breath should produce visible chest rise. Resume compressions immediately after the second breath.
Power on the AED, attach pads as illustrated, and follow voice prompts. Clear the patient for analysis and shock delivery. Resume compressions immediately after any shock or no-shock advisory until EMS takes over.
Continue cycles of 30 compressions and 2 breaths until the patient shows signs of life, an AED instructs you to stop, EMS personnel take over, or you are too exhausted to continue effective compressions.
High-quality chest compressions are the single most powerful intervention in cardiac arrest, more important than ventilation, medications, or even early intubation in the first minutes. The five measurable metrics of high-quality CPR are rate, depth, recoil, chest compression fraction, and minimal interruption. Every aspect of the modern procedure exists to optimize one or more of these variables. Even with perfect technique, external compressions generate only about 25-30% of normal cardiac output, which is why interruptions longer than 10 seconds are devastating to coronary perfusion pressure and significantly reduce return of spontaneous circulation.
The 30:2 ratio applies to all single-rescuer scenarios across every age group. When two trained rescuers respond to a child or infant, the ratio shifts to 15:2 because pediatric arrest is more often respiratory in origin, and ventilation matters more. For adults with two rescuers, the ratio remains 30:2 until an advanced airway is in place, at which point compressions become continuous at 100-120 per minute and ventilations are delivered every 6 seconds, or about 10 breaths per minute, matching the normal respiratory rate of a resting adult.
Hand placement varies subtly but meaningfully by age. For adults, two hands sit on the lower half of the sternum. For children roughly 1 to 8 years old, either one or two hands may be used depending on the rescuer's strength and the child's size. For infants under one year, two fingers are used just below the nipple line during single-rescuer CPR, while the two-thumb encircling-hands technique is preferred when two rescuers are present because it generates higher coronary perfusion pressure and more consistent depth.
Allowing full chest recoil between compressions is widely under-appreciated. Leaning on the chest, even slightly, prevents the heart from refilling during the relaxation phase and slashes effective cardiac output. Rescuers should lift their hands just enough to release pressure while maintaining contact with the chest wall, preserving hand position for the next downstroke. Many CPR training mannequins now provide real-time feedback on recoil because instructors found that even experienced providers leaned without realizing it during prolonged events.
Compression fraction, the percentage of time during a cardiac arrest spent actively compressing the chest, should exceed 60%, and many high-performing systems target 80% or higher. Interruptions for rhythm checks, pulse checks, intubation attempts, and rescuer switches all reduce fraction. Modern protocols therefore limit pulse checks to no more than 10 seconds, encourage compressions during defibrillator charging, and rotate compressors every two minutes during a rhythm analysis to maintain freshness without unnecessary downtime.
Ventilation technique matters too. Each rescue breath should be delivered over approximately one second and produce visible chest rise. Over-ventilation is harmful because it increases intrathoracic pressure, reduces venous return, and decreases cardiac output. Avoid forcing air, avoid blowing too fast, and avoid blowing for too long. If chest rise is not visible on the first breath, reposition the head and try again before continuing to compressions. Two failed breaths still mean you return to compressions and try again on the next cycle.
Finally, fatigue is real and predictable. Studies show compression depth declines noticeably after about 90 seconds even in trained rescuers who do not perceive themselves as tired. That is why guidelines call for switching compressors every two minutes, ideally during rhythm analysis to avoid interrupting the compression fraction. If you are alone, push through, knowing that even degraded compressions are better than none, and that EMS arrival will allow you to step back and recover.
Adult CPR begins at puberty and continues throughout adulthood. The compression depth is at least two inches but no more than 2.4 inches, the rate is 100-120 per minute, and the ratio is 30:2 with one or two rescuers until an advanced airway is placed. Hand placement is two hands on the lower half of the sternum, elbows locked, shoulders directly over the patient.
Adult arrest is most commonly cardiac in origin, which is why immediate activation of EMS and rapid AED application are emphasized before rescue breaths. Compression-only CPR is acceptable for untrained or unwilling bystanders and is associated with similar outcomes in witnessed adult arrest. The acls algorithm takes over once paramedics arrive with monitor-defibrillators, IV access, and medications.
Child CPR applies from age one through the onset of puberty. Compression depth is about two inches or roughly one third the depth of the chest, the rate matches adult CPR at 100-120 per minute, and one or two hands may be used depending on the child's size. The compression-to-breath ratio is 30:2 for one rescuer and 15:2 for two rescuers.
Because pediatric arrest is more often respiratory than cardiac, rescue breaths matter more, and the lone rescuer should perform two minutes of CPR before leaving the child to call 911 if no phone is available. Always check for foreign body airway obstruction in any sudden pediatric collapse, and prepare to integrate with pals certification protocols when EMS arrives.
Infant cpr covers children under one year of age, excluding newborns immediately after birth. Compression depth is about 1.5 inches or one third the depth of the chest. Single-rescuer technique uses two fingers just below the nipple line; two-rescuer technique uses the two-thumb encircling-hands method, which generates better perfusion pressure and is the preferred technique whenever a second responder is available.
Open the airway using a neutral or slightly sniffing position rather than the deep head-tilt used in adults, as over-extension can occlude the soft infant trachea. Deliver gentle puffs of air rather than full breaths, watching for chest rise. Infant arrest is almost always respiratory, so prioritize ventilation and oxygenation alongside compressions.
Across thousands of recorded resuscitations, the most common high-impact error is compressing at less than the recommended depth. Even trained rescuers consistently under-compress when they rely on perceived effort rather than visual or device feedback. Push hard enough that you feel uncomfortable doing it — that is usually about right. If a rib fractures, keep going; survival matters more than skeletal integrity.
The automated external defibrillator is the single most powerful tool a bystander can use during sudden cardiac arrest, and integrating it seamlessly into your CPR procedure is essential. So what does aed stand for, and why does it matter? AED stands for Automated External Defibrillator — a device that analyzes the heart's electrical rhythm, determines whether a shock is indicated, and delivers that shock through adhesive pads placed on the chest. AEDs are designed to be used by laypeople with minimal training because clear voice prompts guide every step.
The moment an AED arrives, power it on. Most AEDs begin speaking immediately, instructing you to attach the pads. For adults, place one pad on the upper right chest just below the collarbone and the other on the lower left side along the mid-axillary line. For children under eight or under 55 pounds, use pediatric pads if available; if not, adult pads are acceptable but should be placed front-and-back to avoid overlap. Skin must be dry, bare, and free of medication patches or implanted device bulges.
Once pads are attached, the AED will analyze the rhythm. During analysis, no one may touch the patient, and compressions must briefly pause. If the device advises a shock, ensure the area is clear, announce loudly, and press the shock button. Immediately after the shock, resume compressions for two full minutes before the AED re-analyzes. If no shock is advised, resume compressions immediately. Most AEDs cycle through analysis every two minutes, providing a natural rhythm-check interval.
Shockable rhythms include ventricular fibrillation and pulseless ventricular tachycardia, the rhythms most commonly seen in witnessed sudden cardiac arrest. Non-shockable rhythms include asystole and pulseless electrical activity, which require continued CPR and advanced interventions delivered by paramedics. Either way, the AED's role is straightforward — analyze, advise, deliver if needed, and step out of the way so high-quality CPR can resume with minimal interruption.
Common pitfalls include placing pads over wet skin, failing to remove transdermal medication patches, attempting to use an adult AED on an infant under one year without manual override capability, and prolonged pauses in compressions during analysis. Modern devices include sensors that detect impedance and skin contact issues, so listen for any warning prompts. If multiple shocks are advised over consecutive cycles, you are dealing with refractory ventricular fibrillation, and the case will require advanced life support medications and possibly extracorporeal resuscitation.
Public access defibrillation programs have transformed survival in airports, casinos, schools, and gyms by placing AEDs within a three-minute walk of any area. When integrated with bystander CPR, witnessed arrest survival in these locations exceeds 50%, and complete neurological recovery is the norm rather than the exception. Knowing where AEDs are located at your workplace, gym, child's school, and place of worship is a high-leverage piece of preparedness that takes only minutes to inventory.
Special situations require subtle adjustments. For drowning, dry the chest thoroughly before applying pads. For pregnancy, place pads as usual; the fetus is not at meaningful risk from defibrillation. For implanted pacemakers or ICDs, place pads at least one inch from the device bulge. For hairy chests, the AED may instruct you to press firmly on the pads or to shave the area with the razor included in most public AED cabinets. Each scenario has a workaround that does not delay shock delivery.
The transition from bystander CPR to advanced life support is the most fragile moment of any resuscitation, and seamless handoff dramatically affects outcomes. When paramedics arrive, they bring the acls algorithm, IV access, advanced airways, capnography, and medications such as epinephrine and amiodarone. Your job as a lay rescuer is to keep compressions going until the paramedic places a hand on the chest to take over, then step back and provide a concise verbal report. Do not stop until explicitly relieved.
An effective handoff report uses the SAMPLE or AMPLE format: when the patient collapsed, what they were doing, how long CPR has been in progress, how many shocks the AED has delivered, what medications the patient takes if known, and any relevant medical history. If you witnessed the arrest, that detail alone can change the resuscitation strategy because witnessed arrests with bystander CPR have dramatically higher survival rates than unwitnessed events. Bystanders should also note time of collapse to the minute if possible.
Advanced life support introduces additional interventions that build on your foundation. Paramedics secure an advanced airway, attach a continuous waveform capnograph, establish intravenous or intraosseous access, and administer epinephrine every 3-5 minutes. For shockable rhythms refractory to defibrillation, they add amiodarone or lidocaine. Throughout, compressions continue uninterrupted at 100-120 per minute, with mechanical compression devices sometimes deployed to provide consistent, fatigue-free compressions during transport.
Return of spontaneous circulation, or ROSC, is the immediate goal but not the final one. Post-arrest care includes targeted temperature management, hemodynamic optimization, identification and treatment of the underlying cause, and neuroprognostication after 72 hours. Survival to hospital discharge with good neurologic outcome is the meaningful endpoint, and it depends on every link in the chain — bystander CPR, AED use, EMS response, and hospital-based critical care working together as a system.
Once the patient is transported, your role as a bystander is complete, but documentation matters. Note the time you began CPR, the time the AED was applied, how many shocks were delivered, when EMS arrived, and any other relevant details. This information may be valuable for the EMS report, hospital admission, and any subsequent investigation. Many CPR-trained workplaces require a brief incident report; this is not punitive, it is a learning tool to improve future response. For comprehensive review, see this CPR - Cardiopulmonary Resuscitation: Complete Study Guide 2026.
Once the patient is stable enough to breathe spontaneously and circulation has returned, the recovery position becomes relevant. Place the patient on their side with the top knee bent forward, the head tilted back to maintain an open airway, and the lower arm extended for support. Position recovery technique prevents aspiration of vomit or saliva while you wait for advanced help, and it is appropriate for any unconscious patient who is breathing normally — including post-arrest, seizure, intoxication, or syncope cases. Monitor breathing continuously and be prepared to return to CPR if respiration ceases.
The emotional aftermath of performing CPR is often overlooked. Even successful resuscitations are intensely stressful, and unsuccessful ones can trigger guilt, intrusive memories, or sleep disruption. Most EMS systems and many employers offer critical incident stress debriefing for bystanders who participated in a resuscitation. Accepting that support is a sign of strength, not weakness. You did something most people never do — you stepped forward and gave a stranger a fighting chance.
Practical preparation matters as much as theoretical knowledge. The best CPR procedure guidelines in the world are worthless if your hands freeze during the real event. Hands-on training with a qualified instructor, ideally every two years, builds the muscle memory that takes over when adrenaline floods your system. Online refreshers and video review are helpful supplements but cannot replace the tactile feedback of pushing on a real mannequin while an instructor critiques your depth, rate, and recoil in real time. Repetition is the only path to automaticity.
Consider where you are most likely to encounter a cardiac emergency and rehearse mentally. Parents should rehearse infant cpr in the nursery. Lifeguards should rehearse drowning protocols at the pool. Office workers should know where the AED is in their building and how to access it after hours. Coaches should rehearse pediatric arrest on the field. Every environment has unique constraints — locked doors, narrow stairwells, crowded rooms — and visualizing the response under those conditions accelerates real-world execution dramatically.
Build a small personal CPR kit if you can. A pocket-sized one-way valve barrier device, a pair of nitrile gloves, and a small flashlight fit easily in a glove box or bag and dramatically improve your willingness and ability to act. Many lay rescuers hesitate because of disease transmission concerns; a $5 barrier device eliminates that hesitation. Some kits also include trauma shears for clothing removal, which speeds AED pad placement significantly. None of this gear is required, but each piece reduces friction in the critical first minute.
Refresh your certification on schedule. Lay rescuer certifications through the American Heart Association, American Red Cross, and national cpr foundation are valid for two years. Healthcare provider BLS, ACLS, and pals certification have the same renewal cycle. Skills decay measurably within months, especially compression depth and ratio adherence, so even informal practice on a home mannequin between formal courses preserves competence. Many employers cover certification costs because trained employees reduce liability and improve workplace safety outcomes considerably.
Stay current with guideline changes. Major updates from the American Heart Association are released every five years, with focused updates published in between as new evidence emerges. The 2025 focused update refined recommendations on dispatcher-assisted CPR, opioid overdose response, and post-arrest care. Subscribe to one reliable source — the AHA's Circulation journal, the national cpr foundation newsletter, or a reputable EMS publication — so you do not rely on outdated training that may have been current when you certified five years ago.
Avoid distractions during real or simulated events. Cell phones should be on speaker rather than held against the ear, freeing both hands for compressions. Do not pause to film or photograph the event. Do not pause to retrieve personal items. The CPR procedure demands singular focus, and unrelated tasks like searching for cpr cell phone repair stores or scrolling through cpr phone repair listings have no place in an active resuscitation. Stay on the chest, stay on the rhythm, and stay on the patient until relief arrives.
Finally, talk about CPR with your family, coworkers, and friends. Most cardiac arrests happen at home, and the person most likely to save your life is someone you live with. Encourage spouses, adult children, parents, and roommates to take a basic CPR course. Identify AED locations in your community. Discuss what to do if a family member collapses, including who calls 911, who starts compressions, and who retrieves the AED. The few minutes spent on this conversation can be the difference between a saved life and a preventable death.