According to the studies by American Heart Association, out-of-hospital cardiac arrest can affect more than 300,000 people in the United States every year. Three minutes after the attack, a lack of blood flow starts to damage the cardiac arrest patient's brain, and after 10 minutes, the survival rate is close to zero. However, when someone goes into sudden cardiac arrest outside of a health care facility (out of hospital cardiac arrest), there is a specific sequence of events that can significantly improve their chances of survival and recovery if performed thoroughly and efficiently. This is known as the Out-of-Hospital Chain of Survival. 

What is the Chain of Survival?

The term Chain of Survival provides a helpful metaphor for the Emergency Cardiovascular Care systems concept elements. When the Chain of Survival was first created and described, it included early recognition, early access, CPR, defibrillation, and advanced life support. This concept was later adopted by the American Heart Association and other health organizations like International Liaison Committee on Resuscitation. Afterward, the Chain of Survival was reevaluated to emphasize the importance of early recognition and response. As aftercare options expanded to include mild therapeutic hypothermia and other treatments, integrated post-cardiac arrest care was added to the Chain of Survival. Today's latest version includes the recovery link, which emphasizes cardiac arrest patients and their caregivers' physical, social, and emotional needs after survivors leave the hospital.

What are the Steps of the Out-of-Hospital Chain of Survival?

The Chain of Survival represents the crucial actions required to treat life-threatening emergencies such as heart attack, cardiac arrest, stroke, and choking or foreign body airway obstruction. The links in the American Heart Association Chain of Survival are:

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

Bystanders can help save a victim's life by addressing the first three links in the AHA Chain of Survival. Action steps that bystanders can follow are explained below.

Prevention for Pediatric Patient

Prevention measures matter to everyone. In fact, prevention has become very effective in hospitals. Therefore, the American Heart Association recommends mirroring that work in adult care. For pediatrics, prevention measures include safety initiatives. These address specific issues that affect children—for example, bicycle helmet laws and SIDS prevention. The goal is to increase bystander rescuer capacity. As a result, we can decrease emergency response times for victims ahead of any actual emergency. 

Immediate Recognition and Emergency Response Activation

The Chain of Survival is based on a significant fact: Every minute a person does not receive care after sudden cardiac arrest, their chance of surviving decreases. Therefore, the goal is to have the fastest possible response, both by lay rescuers and emergency medical services. Someone must recognize the cardiac arrest as it occurs. Once they do, they should assign another bystander (if any) to call 911 before taking any other rescue steps. 

Unfortunately, many persons experiencing symptoms that may lead to a cardiac arrest ignore these warning symptoms or, recognizing these warning symptoms correctly, fail to activate the EMS system, preferring to contact relatives instead.

Early, High-Quality CPR (Emphasis on Chest Compressions)

The immediate initiation of bystander CPR can quadruple the chances of survival from out-of-hospital cardiac arrest. If untrained, bystanders can perform Hands-only CPR or chest compressions-only CPR. One of the most common misconceptions about CPR is the number of breaths a victim needs. Any more than two breaths after 30 compressions isn't much help. Therefore, it's much more important that an AED or Automated External Defibrillator be used as soon as possible. Rescuers should start CPR just as quickly if one is not available. It must be performed fast and hard enough.

According to the American Heart Association, the primary components of high-quality CPR are:

  1. The adequate chest compression depth for adults is 2-2.4 inches, 2 inches for children, and 1.5 for infants.
  2. The optimal chest compression rate is 100-120 compressions per minute.
  3. Minimizing interruptions in CPR. If you're slowing down, switch with a fresh rescuer.
  4. Allowing full chest recoil between compressions
  5. Avoiding excessive ventilation (rescue breathing)

Rapid Defibrillation

Rapid defibrillation is considered the most critical link in the Chain of survival. It involves using an Automated External Defibrillator to shock the victim's heart. If regular heart function can be restored before the existing in-bloodstream oxygen is depleted, the chances of survival can be much higher. Defibrillation within 3–5 mins of collapse can produce a survival rate as high as 50–70%. So if an Automated External Defibrillator is available, rescuers must use it as soon as possible. 

Advanced Resuscitation by Healthcare Providers

It's imperative to get advanced life support intervention as soon as possible. Likewise, it is equally vital to get professional or advanced care at the earliest possible moment. The victim needs to be assessed for various possible sudden cardiac arrest problems, which must be addressed immediately. For this reason, this is why activation of EMS comes before performing Cardiopulmonary Resuscitation. 

Post-Cardiac Arrest Care

By this phase, medical care has been taken over by medical professionals and advanced life support will be provided. History and research have taught some particular lessons. We have learned that medical care can improve patient outcomes for different people suffering sudden cardiac arrest for various reasons. Therefore, aftercare is still a critical component of ensuring a lasting recovery. 


According to the American Heart Association, Accurate neurological prognostication in brain-injured cardiac arrest survivors is critical. This ensures that cardiac arrest patient with significant potential for recovery is not destined for certain poor outcomes due to care withdrawal. This added step asks care teams to plan to investigate both the causes and the secondary effects of the cardiac arrest and ensure treatment continues.

The American Heart Association is committed to supporting research. Likewise, they are dedicated to updating both in and out-of-hospital rescue guidelines. Consequently, this means that the Chain of Survival is likely to be improved again in time. The current version still provides a strong outline for thinking about care. It also reminds us that having a bank of knowledgeable, certified lay-person rescuers is supremely important.

What's a Bystander's Role in the Chain of Survival?

The first three steps of the Chain must often be performed by bystanders, whether or not they know the cardiac arrest patient. If nothing else, it's vital to understand when a sudden cardiac arrest occurs and call 911.

But performing Cardiopulmonary Resuscitation as soon as possible is key to improving outcomes. According to data from 2014, almost 45 percent of people who suffer from out-of-hospital cardiac arrest survived when bystander CPR was performed. And because about 70 percent of cardiac arrests occur in the home, the life you save may be that of a family member.

Why did the American Heart Association's Chain of Survival change?

The American Heart Association reports that sudden cardiac arrest survival improved around 2012. However, there haven't been substantive survival increases since. Recently, the American Heart Association determined that one major factor in surviving sudden cardiac arrest was missing, the aftercare received after hospital discharge. As a result, recovery in the Chain of Survival was added. It's now included in the adult and pediatric in-hospital and out-of-hospital chains of survival. In addition, almost 500 other recommendations were made to increase survival rates.

These changes accompany other notable researched-based changes. For example, the ABC/CAB swap several years ago. Until 2015, the American Heart Association reviewed and updated guidance for CPR every five years. Starting in 2015, the organization changed to a more continuous update model. This allows change in guidance as research reveals new, important science. Therefore, we don't have to wait for the next revision period to arrive.

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