From MedscapeCME Clinical Briefs

From MedscapeCME Clinical Briefs
2010 AHA Guidelines: The ABCs of CPR Rearranged to "CAB"

CME/CE
News Author: Emma Hitt, PhD
CME Author: Laurie Barclay, MD
Authors and Disclosures
CME/CE Released: 10/27/2010; Valid for credit through 10/27/2011
Learning Objectives
Upon completion of this activity, participants will be able to:
1. Describe changes in the A-B-Cs (Airway-Breathing-Compressions) of cardiopulmonary resuscitation for basic life support,
as now recommended by the American Heart Association.
2. Describe key guidelines recommendations for healthcare professionals directing cardiopulmonary resuscitation, as
endorsed by the American Heart Association.
Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

Family Physicians - maximum of 0.25 AAFP Prescribed credit(s)
Nurses - 0.50 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)
All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.
October 20, 2010 — Chest compressions should be the first step in addressing cardiac arrest. Therefore, the
American Heart Association (AHA) now recommends that the A-B-Cs (Airway-Breathing-Compressions) of
cardiopulmonary resuscitation (CPR) be changed to C-A-B (Compressions-Airway-Breathing).
The changes were documented in the 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care, published in the November 2 supplemental issue of
Circulation: Journal of the American Heart Association, and represent an update to previous guidelines issued
in 2005.
"The 2010 AHA Guidelines for CPR and ECC [Emergency Cardiovascular Care] are based on the most current
and comprehensive review of resuscitation literature ever published," note the authors in the executive
summary. The new research includes information from "356 resuscitation experts from 29 countries who
reviewed, analyzed, evaluated, debated, and discussed research and hypotheses through in-person meetings,
teleconferences, and online sessions ('webinars') during the 36-month period before the 2010 Consensus
Conference."
According to the AHA, chest compressions should be started immediately on anyone who is unresponsive and
is not breathing normally. Oxygen will be present in the lungs and bloodstream within the first few minutes, so
initiating chest compressions first will facilitate distribution of that oxygen into the brain and heart sooner.
Previously, starting with "A" (airway) rather than "C" (compressions) caused significant delays of approximately
30 seconds.
"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," noted Michael R. Sayre, MD, coauthor and chairman of the AHA's Emergency
Cardiovascular Care Committee, in an AHA written release. "This approach was causing significant delays in
starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body,"
he added.
The new guidelines also recommend that during CPR, rescuers increase the speed of chest compressions to a
rate of at least 100 times a minute. In addition, compressions should be made more deeply into the chest, to a
depth of at least 2 inches in adults and children and 1.5 inches in infants.
Persons performing CPR should also avoid leaning on the chest so that it can return to its starting position, and
compression should be continued as long as possible without the use of excessive ventilation.
9-1-1 centers are now directed to deliver instructions assertively so that chest compressions can be started
when cardiac arrest is suspected.
The new guidelines also recommend more strongly that dispatchers instruct untrained lay rescuers to provide
Hands-Only CPR (chest compression only) for adults who are unresponsive, with no breathing or no normal
breathing.
Other Key Recommendations
Other key recommendations for healthcare professionals performing CPR include the following:
• Effective teamwork techniques should be learned and practiced regularly.

• Quantitative waveform capnography, used to measure carbon dioxide output, should be used to
confirm intubation and monitor CPR quality.
• Therapeutic hypothermia should be part of an overall interdisciplinary system of care after
resuscitation from cardiac arrest.
• Atropine is no longer recommended for routine use in managing and treating pulseless electrical
activity or asystole.
Pediatric advanced life support guidelines emphasize organizing care around 2-minute periods of continuous
CPR. The new guidelines also discuss resuscitation of infants and children with various congenital heart
diseases and pulmonary hypertension.
The authors of the guidelines have disclosed no relevant financial relationships.
Circulation. 2010;122[suppl 3]:S640-S656.
Additional Resource
The 2010 AHA guidelines for CPR and emergency cardiovascular care are available on the AHA Web site.
Clinical Context
When the AHA established the first resuscitation guidelines in 1966, the original "A-B-Cs" of CPR were to open
the victim's Airway by tilting the head back; pinching the nose and Breathing into the victim's mouth, and then
giving chest Compressions. However, this sequence resulted in significant delays (approximately 30 seconds)
in starting chest compressions needed to maintain circulation of oxygenated blood.
In its 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care, the AHA has therefore rearranged the steps of CPR from "A-B-C" to "C-A-B" for adults
and children, allowing all rescuers to begin chest compressions immediately. Since 2008, the AHA has
recommended that untrained bystanders use Hands-Only CPR, or CPR without breaths, for an adult who
suddenly collapses. The new guidelines also contain other recommendations, based primarily on evidence
published since the previous AHA resuscitation guidelines were issued in 2005.
Study Highlights
• The AHA has rearranged the A-B-Cs (Airway-Breathing-Compressions) of CPR to C-A-B

(Compressions-Airway-Breathing).
• Chest compressions are therefore the first step for lay and professional rescuers to revive an individual
with sudden cardiac arrest.
• This change in CPR sequence applies to adults, children, and infants, but excludes newborns.
• "Look, Listen and Feel" has been removed from the basic life support algorithm.
• Other changes in CPR recommendations for basic life support include the following:
o Rate of chest compressions should be at least 100 times a minute.
o Rescuers should push deeper on the chest, resulting in compressions of at least 2 inches in
adults and children and 1.5 inches in infants.
o Between each compression, rescuers should avoid leaning on the chest so that it can return
to the starting position.
o Rescuers should avoid stopping chest compressions and avoid excessive ventilation.
o All 9-1-1 centers should assertively give telephone instructions to start chest compressions
(Hands-Only CPR) when cardiac arrest is suspected in adults who are unresponsive, with no
breathing or no normal breathing.
• Dispatchers should provide instructions in conventional CPR for individuals who have presumably
drowned or have had other likely asphyxial arrest.
• For attempted defibrillation with an automated external defibrillator of children 1 to 8 years old, the
rescuer should use a pediatric dose-attenuator system if one is available, or a standard automated
external defibrillator if the pediatric dose-attenuator system is not available.
• A manual defibrillator is preferred for infants younger than 1 year.
• Key guidelines recommendations for healthcare professionals include the following:
o Effective teamwork techniques should be learned and practiced regularly.
o To confirm intubation and monitor CPR quality, professional rescuers should use quantitative
waveform capnography to measure and monitor carbon dioxide output.
o Therapeutic hypothermia should be incorporated into the overall interdisciplinary system of
care after resuscitation from cardiac arrest.
o For management and treatment of pulseless electrical activity (asystole), atropine is no longer
recommended for routine use.
• The new guidelines do not recommend routine use of cricoid pressure in cardiac arrest.
• For the initial diagnosis and treatment of stable, undifferentiated regular, monomorphic wide-complex
tachycardia, adenosine is recommended.
• Pediatric advanced life support guidelines offer new strategies for resuscitating infants and children
with certain congenital heart diseases and pulmonary hypertension.
• The pediatric advanced life support guidelines emphasize organizing care around 2-minute periods of
uninterrupted CPR.
Clinical Implications
• In its latest guidelines, the AHA has rearranged the A-B-Cs of CPR to C-A-B. This change in CPR
sequence applies to adults, children, and infants, but excludes newborns.
• Key guidelines recommendations for healthcare professionals include focus on effective teamwork
techniques, use of quantitative waveform capnography, and incorporation of therapeutic hypothermia
into the overall interdisciplinary system of care. Atropine is no longer recommended for routine use for
management of pulseless electrical activity (asystole).
CME Test
According to the AHA updated CPR guidelines, which of the following statements about CPR is
correct?
Rate of chest compressions should be approximately 60 times a minute
Shallow compressions are recommended
Rescuers should avoid stopping chest compressions and avoid excessive ventilation
9-1-1 centers should give telephone instructions to start CPR by clearing the airway and initiating
mouth-to-mouth breathing
According to the AHA updated CPR guidelines, which of the following is not recommended for
healthcare professionals directing CPR?
Learn effective teamwork techniques and practice them regularly
Use quantitative waveform capnography to confirm intubation and monitor CPR quality
Incorporate therapeutic hypothermia into the overall interdisciplinary system of care
Use atropine routinely to treat pulseless electrical activity

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From MedscapeCME Clinical Briefs

2010 AHA Guidelines: The ABCs of CPR Rearranged to "CAB"

Upon completion of this activity, participants will be able to:

Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

Other Key Recommendations

• Effective teamwork techniques should be learned and practiced regularly.

The authors of the guidelines have disclosed no relevant financial relationships.

Circulation. 2010;122[suppl 3]:S640-S656.

• The AHA has rearranged the A-B-Cs (Airway-Breathing-Compressions) of CPR to C-A-B

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