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

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.

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'sAirway by tilting the head back; pinching the nose and Breathing into the victim's mouth, and then giving chestCompressions. 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:
  • Rate of chest compressions should be at least 100 times a minute.
  • 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.
  • Between each compression, rescuers should avoid leaning on the chest so that it can return to the starting position.
  • Rescuers should avoid stopping chest compressions and avoid excessive ventilation.
  • 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:
  • Effective teamwork techniques should be learned and practiced regularly.
  • To confirm intubation and monitor CPR quality, professional rescuers should use quantitative waveform capnography to measure and monitor carbon dioxide output.
  • Therapeutic hypothermia should be incorporated into the overall interdisciplinary system of care after resuscitation from cardiac arrest.
  • 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).

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