The following are the highlighted recommendations from the 2010 CPR Guidelines, directly derived from the 2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, as published in the journal Circulation.
(if you wish to access the full journal, click on the link at the end of this article). Learn about all the highlights and changes in the new guidelines during the CPR Sessions at the 18th ASEAN Congress of Cardiology, this December 1, 2010 at the Waterfront Hotel, Cebu City.
The Change From “A-B-C” to “C-A-B”
The newest development in the 2010 AHA Guidelines for CPR and ECC is a change in the basic life support (BLS) sequence of steps from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adults and pediatric patients (children and infants, excluding newly borns). Although the experts agreed that it is important to reduce time to first chest compressions, they were aware that a change in something as established as the A-B-C sequence would require re-education of everyone who has ever learned CPR. The 2010 AHA Guidelines for CPR and ECC recommend this change for the following reasons:
The vast majority of cardiac arrests occur in adults, and the highest survival rates from cardiac arrest are reported among patients of all ages with witnessed arrest and a rhythm of VF or pulseless ventricular tachycardia (VT). In these patients the critical initial elements of CPR are chest compressions and early defibrillation.
● In the A-B-C sequence chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths or retrieves a barrier device or other ventilation equipment. By changing the sequence to C-A-B, chest compressions will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions (30 compressions should be accomplished in approximately 18 seconds).
● Fewer than 50% of persons in cardiac arrest receive bystander CPR. There are probably many reasons for this, but one impediment may be the A-B-C sequence, which starts with the procedures that rescuers find most difficult: opening the airway and delivering rescue breaths. Starting with chest compressions might ensure that more victims receive CPR and that rescuers who are unable or unwilling to provide ventilations will at least perform chest compressions.
● It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrest. For example, if a lone healthcare provider sees a victim suddenly collapse, the provider may assume that the victim has suffered a sudden VF cardiac arrest; once the provider has verified that the victim is unresponsive and not breathing or is only gasping, the provider should immediately activate the emergency response system, get and use an AED, and give CPR. But for a presumed victim of drowning or other likely asphyxial arrest the priority would be to provide about 5 cycles (about 2 minutes) of conventional CPR (including rescue breathing) before activating the emergency response system. Also, in newly born infants, arrest is more likely to be of a respiratory etiology, and resuscitation should be attempted with the A-B-C sequence unless there is a known cardiac etiology.
Basic Life Support (BLS)
BLS is the foundation for saving lives following cardiac arrest. Fundamental aspects of adult BLS include immediate recognition of sudden cardiac arrest and activation of the emergency response system, early performance of highquality CPR, and rapid defibrillation when appropriate. The 2010 AHA Guidelines for CPR and ECC contain several important changes but also have areas of continued emphasis based on evidence presented in prior years.
Key Changes in the 2010 AHA Guidelines for CPR and ECC
● The BLS algorithm has been simplified, and “Look, Listen and Feel” has been removed from the algorithm. Performance of these steps is inconsistent and time consuming. For this reason the 2010 AHA Guidelines for CPR and ECC stress immediate activation of the emergency response system and starting chest compressions for any unresponsive adult victim with no breathing or no normal breathing (ie, only gasps).
Encourage Hands-Only (compression only) CPR for the untrained lay rescuer. Hands-Only CPR is easier to perform by those with no training and can be more readily guided by dispatchers over the telephone.
● Initiate chest compressions before giving rescue breaths (CA-B rather than A-B-C). Chest compressions can be started immediately, whereas positioning the head, attaining a seal for mouth-to-mouth rescue breathing, or obtaining or assembling a bag-mask device for rescue breathing all take time. Beginning CPR with 30 compressions rather than 2 ventilations leads to a shorter delay to first compression.
● There is an increased focus on methods to ensure that high-quality CPR is performed. Adequate chest compressions require that compressions be provided at the appropriate depth and rate, allowing complete recoil of the chest after each compression and an emphasis on minimizing any pauses in compressions and avoiding excessive ventilation. Training should focus on ensuring that chest compressions are performed correctly. The recommended depth of compression for adult victims has increased from a depth of 11⁄2 to 2 inches to a depth of at least 2 inches.
● Many tasks performed by healthcare providers during resuscitation attempts, such as chest compressions, airway management, rescue breathing, rhythm detection, shock delivery, and drug administration (if appropriate), can be performed concurrently by an integrated team of highly trained rescuers in appropriate settings. Some resuscitations start with a lone rescuer who calls for help, resulting in the arrival of additional team members. Healthcare provider training should focus on building the team as each member arrives or quickly delegating roles if multiple rescuers are present. As additional personnel arrive, responsibilities for tasks that would ordinarily be performed sequentially by fewer rescuers may now be delegated to a team of providers who should perform them simultaneously.
Key Points of Continued Emphasis for the 2010 AHA Guidelines for CPR and ECC
● Early recognition of sudden cardiac arrest in adults is based on assessing responsiveness and the absence of normal breathing. Victims of cardiac arrest may initially have gasping respirations or even appear to be having a seizure. These atypical presentations may confuse a rescuer, causing a delay in calling for help or beginning CPR. Training should focus on alerting potential rescuers to the unusual presentations of sudden cardiac arrest.
● Minimize interruptions in effective chest compressions until ROSC or termination of resuscitative efforts. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness.
● Minimize the importance of pulse checks by healthcare providers. Detection of a pulse can be difficult, and even highly trained healthcare providers often incorrectly assess the presence or absence of a pulse when blood pressure is abnormally low or absent. Healthcare providers should take no more than 10 seconds to determine if a pulse is present. Chest compressions delivered to patients subsequently found not to be in cardiac arrest rarely lead to significant injury. The lay rescuer should activate the emergency response system if he or she finds an unresponsive adult. The lay rescuer should not attempt to check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses, is unresponsive, and is not breathing or not breathing normally (ie, only gasping).
From Field JM et al. Executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S640 –S656.