American Heart Association 2010 Guidelines for BLS / CPR
The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-quality CPR, including:
• A compression depth of at least 2 inches in adults and a compression depth of at least one third of the anterior/posterior diameter of the chest in infants and children (approximately 1.5 inches in infants and 2 inches in children). The range of 1. to 2 inches is no longer used for adults, and the absolute depth specified for children and infants is deeper than in previous versions of the AHA Guidelines.
A Change From A-B-C to C-A-B
The 2010 AHA Guidelines for CPR and ECC recommend a change in the BLS sequence of steps from A-B-C (Airway,Breathing, Chest compressions) to C-A-B (Chest compressions, Airway, Breathing) for adults, children, and infants (excluding the newly born). This fundamental change in CPR sequence will require reeducation of everyone who has ever learned CPR, but the consensus of the authors and experts involved in the creation of the 2010 AHA Guidelines for CPR and ECC is that the benefit will justify the effort.
Why: The vast majority of cardiac arrests occur in adults, and the highest survival rates from cardiac arrest are reported among patients of all ages who have a witnessed arrest and an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). In these patients, the critical initial elements of BLS 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, retrieves a barrier device, or gathers and assembles ventilation equipment. By changing the sequence to C-A-B, chest compressions will be initiated sooner and the delay in ventilation should be minimal (ie, only the time required to deliver the first cycle of 30 chest compressions, or approximately 18 seconds; when 2 rescuers are present for resuscitation of the infant or child, the delay will be even shorter). Most victims of out-of-hospital cardiac arrest do not receive any 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, namely, opening the airway and delivering breaths. Starting with chest compressions might encourage more rescuers to begin CPR. Basic life support is usually described as a sequence of actions, and this continues to be true for the lone rescuer.
Most healthcare providers, however, work in teams, and team members typically perform BLS actions simultaneously. For example, one rescuer immediately initiates chest compressions while another rescuer gets an automated external defibrillator (AED) and calls for help, and a third rescuer opens the airway and provides ventilations. Healthcare providers are again encouraged to tailor rescue actions to the most likely cause of arrest. For example, if a lone healthcare provider witnesses a victim suddenly collapse, the provider may assume that the victim has had a primary cardiac arrest with a shockable rhythm and should immediately activate the emergency response system, retrieve an AED, and return to the victim to provide CPR and use the AED. But for a presumed victim of asphyxial arrest such as drowning, the priority would be to provide chest compressions with rescue breathing for about 5 cycles (approximately 2 minutes) before activating the emergency response system.
AHA ECC Adult Chain of Survival
The links in the new AHA ECC Adult Chain of Survival are as follows:
1. Immediate recognition of cardiac arrest and activation of the emergency response system
2. Early CPR with an emphasis on chest compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post–cardiac arrest care
Simplified Adult BLS
Unresponsive, No breathing or no normal breathing (only gasping)
Chest Compression Depth*
2010 (New): The adult sternum should be depressed at least 2 inches.
Number of Compressions Delivered Affected by Compression Rate and by Interruptions
The total number of compressions delivered during resuscitation is an important determinant of survival from cardiac arrest. The number of compressions delivered is affected by the compression rate and by the compression fraction (the portion of total CPR time during which compressions are performed); increases in compression rate and fraction increase the total compressions delivered, whereas decreases in compression rate or compression fraction decrease the total compressions delivered. Compression fraction is improved if you reduce the number and length of any interruptions in compressions, and it is reduced by frequent or long interruptions in chest compressions. An analogy can be found in automobile travel. When you travel in an automobile, the number of miles you travel in a day is affected not only by the speed that you drive (your rate of travel) but also by the number and duration of any stops you make (interruptions in travel). During CPR, you want to deliver effective compressions at an appropriate rate (at least 100/min) and depth, while minimizing the number and duration of interruptions in chest compressions. Additional components of high-quality CPR include allowing complete chest recoil after each compression and avoiding excessive ventilation. Rescuers often do not compress the chest enough despite recommendations to “push hard.” In addition, the available science suggests that compressions of at least 2 inches are more effective than compressions of 1½ inches. For this reason the 2010 AHA Guidelines for CPR and ECC recommend a single minimum depth for compression of the adult chest.
HEALTHCARE PROVIDER BLS
Key issues and major changes in the 2010 AHA Guidelines
for CPR and ECC recommendations for healthcare providers include the following:
• Because cardiac arrest victims may present with a short period of seizure-like activity or agonal gasps that may confuse potential rescuers, dispatchers should be specifically trained to identify these presentations of cardiac arrest to improve cardiac arrest recognition.
• Dispatchers should instruct untrained lay rescuers to provide Hands-Only CPR for adults with sudden cardiac arrest.
• Refinements have been made to recommendations for immediate recognition and activation of the emergency response system once the healthcare provider identifies the adult victim who is unresponsive with no breathing or no normal breathing (ie, only gasping). The healthcare provider briefly checks for no breathing or no normal breathing (ie, no breathing or only gasping) when the provider checks responsiveness. The provider then activates the emergency response system and retrieves the AED (or sends someone to do so). The healthcare provider should not spend more than 10 seconds checking for a pulse, and if a pulse is not definitely felt within 10 seconds, should begin CPR and use the AED when available.
• Increased emphasis has been placed on high-quality CPR (compressions of adequate rate and depth, allowing complete chest recoil between compressions, minimizing interruptions in compressions, and avoiding excessive ventilation).
• Use of cricoid pressure during ventilations is generally not recommended.
• Rescuers should initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). Beginning CPR with 30 compressions rather than 2 ventilations leads to a shorter delay to first compression.
• Compression rate is modified to at least 100/min from approximately 100/min.
• Compression depth for adults has been slightly altered to at least 2 inches (about 5 cm) from the previous recommended range of about 1½ to 2 inches (4 to 5 cm).
• Continued emphasis has been placed on the need to reduce the time between the last compression and shock delivery and the time between shock delivery and resumption of compressions immediately after shock delivery.
• There is an increased focus on using a team approach during CPR.
Emphasis on Chest Compressions*
2010 (New): Chest compressions are emphasized forboth trained and untrained rescuers. If a bystander is not trained in CPR, the bystander should provide Hands Only (compression-only) CPR for the adult who suddenly collapses, with an emphasis to “push hard and fast” on the center of the chest, or follow the directions of the emergency medical dispatcher. The rescuer should continue Hands-Only CPR until an AED arrives and is ready for use or EMS providers take over care of the victim. Optimally all healthcare providers should be trained in BLS. In this trained population, it is reasonable for both EMS and inhospital professional rescuers to provide chest compressions and rescue breaths for cardiac arrest victims.