Emphasis on Action

CPR is important enough that we spend millions of dollars a year teaching it not only to healthcare providers, but to lay citizens too. That's good for saving lives, but it also means changing how it's performed, even in the face of strong evidence, isn't something done lightly.

When the American Heart Association announced its new CPR guidelines in October, it posed EMS leaders the challenge of reeducating not only their own providers, but their communities as well. The AHA acknowledged as much, noting that its change in recommended BLS sequence from A-B-C (airway, breathing, compressions/circulation) to C-A-B (putting compressions first) "will require reeducation of everyone who has ever learned CPR."

Put that way, it's an imposing challenge. But the good news is, it doesn't have to happen overnight.

"It's certainly a daunting task when you consider the millions of people who have been trained with mouth-to-mouth as the first step," says resuscitation expert Mickey Eisenberg, MD, PhD, medical director for King Co. (WA) EMS and a professor of medicine at the University of Washington. "Is it critical that people make this change immediately? That's the recommendation, but I think whether it takes more or less time to retrain all those people is less critical than the fact that people still just take action in the setting of a cardiac arrest."

The important thing, in other words, is that people just do something--and an A-B-C approach is better than standing idle. As they work to disseminate the new C-A-B guidelines, that's a message for EMS systems to keep in mind. The new sequence is better, but the old sequence is better than nothing.

"That A-B-C approach has served us well for a long time," Eisenberg notes. "We hope and expect this modification will do even better. But it's certainly saved an awful lot of people in the past."

What's Changed

There's no doubt compressions are among the most important components in helping a sudden cardiac arrest victim survive. The new guidelines instruct rescuers to start pushing the chest immediately on those who are unresponsive and not breathing normally. Previously, you opened the airway first; looked, listened and felt for normal breathing; then delivered two rescue breaths before starting compressions.

Professional rescuers should now perform a quick check for abnormal or no breathing as they they check responsiveness. They should spend no more than 10 seconds checking for a pulse before starting CPR, then use a defibrillator when it's available. For all trained rescuers, the previously recommended ratio of 30 compressions to two breaths hasn't changed; the compressions just come first.

"That will get blood circulating faster, which presumably has some oxygen content in it," says Eisenberg. "In that regard, you're doing what you can to prevent cell death in the brain and heart and other vital organs."

In other changes, the recommended compression rate is now at least 100 a minute, instead of approximately 100 a minute, and the recommended compression depth is now at least 2 inches (5 cm) in adults, instead of 1½-2 inches. The new guidelines also contain increased emphasis on integrated post-cardiac arrest care and education.

Reach and Teach

King County EMS's 2010 annual summary, released in September, reported a survival rate for witnessed ventricular fibrillation arrests of 46%. This is a system that knows what it's doing with respect to SCAs.

It began incorporating the new CPR by training its trainers. King County has around 400 of those, between various regional fire departments and other organizations. The training will involve roughly two dozen meetings over November and December, plus information disseminated through the system's training website. Most EMTs should be up to speed by January 1.

To reach the public, one mechanism is through citizen advisory boards, a concept touted by Eisenberg in his 2009 book Resuscitate! How Your Community Can Improve Survival From Sudden Cardiac Arrest. These panels of interested, willing civic-minded types can help devise ways to reach and teach community members.

"The more of those kinds of citizen boards and philanthropic-type foundations that exist within communities," Eisenberg notes, "the more you can tap into the energies of people of good will wanting to encourage this training."

The Seattle/King County area also has the benefit of its Medic One Foundation. This privately supported complement to the area's Medic One emergency medical services provides funding to train paramedics, offers independent medical review, sponsors research and helps equip providers. It's also worked to place AEDs in schools and other public venues within the region and train people in CPR and AED use.

"It's a wonderful prototype," says Eisenberg, a member of its board of directors. "Relying solely on donations, they help facilitate training not only of paramedics, but of the general public as well. That's a perfect kind of vehicle to try to move this training forward."

The Medic One Foundation welcomes inquiries from communities interested in setting up something comparable.