Push It Real Good: New CPR Guidelines Put Compressions First

The American Heart Association's long-awaited new guidelines for CPR reflect what the resuscitation community has learned in recent years: that fast, high-quality compressions, started quickly and sustained, are among the most vital components to helping a sudden cardiac arrest victim survive.

In its new 2010 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, just published in the AHA journal Circulation, the organization reorders the traditional A-B-C of care to put the C, for circulation, first. Now, responder or lay person, you call a C-A-B.

"For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim's airway by tilting their head back, pinching the nose and breathing into the victim's mouth, and only then giving chest compressions," guidelines coauthor Michael Sayre, MD, chair of the AHA's Emergency Cardiovascular Care Committee, said of the change. "This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body. Changing the sequence from A-B-C to C-A-B for adults and children allows all rescuers to begin chest compressions right away."

Previously, the guidelines instructed rescuers to open the airway, then look, listen and feel for normal breathing, and to deliver two rescue breaths before starting compressions on an unresponsive patient. Now, conversely, they should start compressing immediately on those who are unresponsive and not breathing normally.

The reason: In the initial moments after an arrest-precipitated collapse, victims still have oxygen in their lungs and bloodstream, and the faster compressions begin, the faster that oxygen can be moved along to the brain and heart. With airway as the top priority, rescuers may instead delay to deliver breaths, retrieve a mouth barrier or collect and prepare ventilation equipment. Rescuers who pause to open the airway, research suggests, can take up to 30 seconds longer to start pushing the chest.

With that in mind, professional rescuers should now perform a quick check for abnormal or no breathing when they check responsiveness. Providers should spend no more than 10 seconds checking for a pulse before starting CPR, then use a defibrillator when it's available.

For trained rescuers, the previously recommended ratio of 30 compressions to two breaths has not changed; the compressions just come first. As before, rescue breaths should be given in approximately one second. Trained lay rescuers should continue this cycle until a rescue professional takes over. Once an advanced airway is in place, professional rescuers can revert to continuous compressions and no longer cycle with ventilations.

Other important changes and aspects:

  • The recommended compression rate is now at least 100 a minute, instead of approximately 100 a minute. The Bee Gees song "Stayin' Alive" is still a good pacing aid.
  • The recommended compression depth is now at least 2 inches (5 cm) in adults, instead of 1½ to 2 inches. For infants and children, compress at least one third of the anterior-posterior diameter of the chest, or approximately 1½ inches (4 cm) in infants and 2 inches (5 cm) in children.
  • Allow full chest recoil after each compression. Avoid leaning on the chest between compressions.
  • Minimize interruptions to compressions.
  • Avoid excessive ventilation.
  • Use of cricoid pressure during ventilations is generally not recommended.
Bystander Benefit

SCA survival rates are highest among those who experience witnessed arrests and initial rhythms of ventricular fibrillation or pulseless ventricular tachycardia. The C-A-B change is also expected to benefit the critical element of bystander CPR. Instead of being asked to open the airway and provide breaths, lay rescuers now need only start pushing.

"By simplifying the initial assessment and starting with chest compressions, these guidelines should increase the rate and effectiveness of bystander CPR," says Angelo Salvucci, Jr., MD, FACEP, EMS medical director in California's Ventura and Santa Barbara counties.

"We have asked our dispatchers to focus on getting bystanders to perform compressions for several years, and have seen increased compliance with prearrival instructions as a result," notes Michael Dailey, MD, FACEP, assistant professor in the Department of Emergency Medicine at New York's Albany Medical College and medical director for Colonie, NY, EMS. "In Colonie--the IAFC HeartSafe Community award winner for small communities--it certainly seems to help. Frankly, the changes in this release are more validations of the seemingly radical ideas of the 2005 guidelines than huge new ideas.

"I think these changes and clarifications will continue the trend to increased survival nationwide," Dailey adds. "This will be easier to learn."

Additional Points

The AHA notes that professionals should tailor their interventions to the most likely cause of a victim's arrest. For a collapse witnessed by a lone provider, for instance, the provider should assume the cause is a cardiac arrest with a shockable rhythm, and expediently 1) activate the emergency-response system, 2) retrieve an AED if available, and 3) provide CPR and use the AED. However, for a victim of presumed asphyxial arrest (e.g., drowning), they should provide compressions with rescue breathing for about five cycles (around two minutes) before activating the emergency-response system.

The new guidelines also contain new emphasis on integrated post-cardiac arrest care and education, as represented by the addition to the Chain of Survival of a fifth link representing it.

More best practices:

  • 9-1-1 centers should give telephone instructions to get hands-only CPR started when a cardiac arrest is suspected.
  • To identify victims with agonal gasps, dispatchers should ask about adult victims' responsiveness, whether they're breathing and whether they're breathing normally.
  • Professional rescuers should learn and practice effective teamwork on resuscitation calls.
  • Qualified providers should also use quantitative waveform capnography to confirm intubation and monitor CPR quality.
  • Therapeutic hypothermia should be part of an overall interdisciplinary system of care after cardiac arrest resuscitation.
  • Atropine is no longer recommended for routine use in managing and treating PEA or asystole.

For Professionals

The new CPR guidelines for professional BLS rescuers:

  • "Look, listen and feel" has been removed from the algorithm. Simultaneously check for no breathing or no normal breathing (i.e., agonal gasps) as you check for responsiveness.
  • Activate the emergency response system and retrieve an AED (or send someone to get one).
  • Do not spend more than 10 seconds checking for a pulse. If a pulse is not felt within 10 seconds, begin CPR and use the AED when it's available.
  • Initiate chest compressions before giving rescue breaths.
  • Use of cricoid pressure during ventilations is generally not recommended.
For Nonprofessionals

The new CPR guidelines for nonprofessional rescuers:

  • Shake the victim to determine responsiveness.
  • If a victim is unresponsive and not breathing normally, yell for someone to call 9-1-1 and get an AED, if one is available.
  • If an AED is available, follow its voice prompts.
  • If no AED is available, start CPR immediately, beginning with compressions.
  • Those without CPR training should continue compressing until an AED arrives or a trained rescuer takes over.
  • Those with CPR training should, after 30 compressions, open the airway with a head tilt/chin lift, then pinch the nose and deliver two rescue breaths.
  • Alternate the 30:2 cycle until an AED arrives or a rescue professional takes over.