Adult and Child CPR 2017

CPR Training (Adult and Child)

The 2005 AHA Guidelines for CPR and ECC emphasized the importance of high-quality chest compressions (compressing at an adequate rate and depth, allowing complete chest recoil after each compression, and minimizing interruptions in chest compressions). Studies published before and since 2005 have demonstrated that (1) the quality of chest compressions continues to require improvement, although implementation of the 2005 AHA Guidelines for CPR and ECC has been associated with better CPR quality and greater survival; (2) there is considerable variation in survival from out-of-hospital cardiac arrest across emergency medical services (EMS) systems; and (3) most victims of out-of-hospital sudden cardiac arrest do not receive any bystander CPR. The changes recommended in the 2010 AHA Guidelines for CPR and ECC attempt to address these issues and also make recommendations to improve outcome from cardiac arrest through a new emphasis on post–cardiac arrest care.


Continued Emphasis on High-Quality CPR

The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-quality CPR, including

A compression rate of at least 100/min (a change from “approximately” 100/min)

A compression depth of at least 2 inches (5 cm) in adults and a compression depth of at least one third of the anteriorposterior diameter of the chest in infants and children (approximately 1.5 inches [4 cm] in infants and 2 inches [5 cm] in children). Note that 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 for CPR and ECC.

Allowing for complete chest recoil after each compression

Minimizing interruptions in chest compressions

Avoiding excessive ventilation

There has been no change in the recommendation for a compression-to-ventilation ratio of 30:2 for single rescuers of adults, children, and infants (excluding newly born infants). The 2010 AHA Guidelines for CPR and ECC continue to recommend that rescue breaths be given in approximately 1 second. Once an advanced airway is in place, chest compressions can be continuous (at a rate of at least 100/min) and no longer cycled with ventilations. Rescue breaths can then be provided at about 1 breath every 6 to 8 seconds (about 8 to 10 breaths per minute). Excessive ventilation should be avoided.


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; see Neonatal Resuscitation section). 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.


Two new parts in the 2010 AHA Guidelines for CPR and ECC are Post–Cardiac Arrest Care and Education, Implementation, and Teams. The importance of post–cardiac arrest care is emphasized by the addition of a new fifth link in the AHA ECC Adult Chain of Survival.


Chain of Survival

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

 
Summary of Key Issues and Major Changes

Key issues and major changes for the 2010 AHA Guidelines for CPR and ECC recommendations for lay rescuer adult CPR are the following:

The simplified universal adult BLS algorithm has been created.

Refinements have been made to recommendations for immediate recognition and activation of the emergency response system based on signs of unresponsiveness, as well as initiation of CPR if the victim is unresponsive with no breathing or no normal breathing (ie, victim is only gasping).

“Look, listen, and feel for breathing” has been removed from the algorithm.

Continued emphasis has been placed on high-quality CPR (with chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in compressions, and avoiding excessive ventilation).

There has been a change in the recommended sequence for the lone rescuer to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). The lone rescuer should begin CPR with 30 compressions rather than 2 ventilations to reduce delay to first compression.

Compression rate should be at least 100/min (rather than “approximately” 100/min).

Compression depth for adults has been changed from the range of 1. to 2 inches to at least 2 inches (5 cm).

 
These changes are designed to simplify lay rescuer training and to continue to emphasize the need to provide early chest compressions for the victim of a sudden cardiac arrest.

 
Emphasis on Chest Compressions*

2010 (New): If a bystander is not trained in CPR, the bystander should provide Hands-Only™ (compression-only) CPR for the adult victim who suddenly collapses, with an emphasis to “push hard and fast” on the center of the chest, or follow the directions of the EMS dispatcher. The rescuer should continue Hands-Only CPR until an AED arrives and is ready for use or EMS providers or other responders take over care of the victim.

All trained lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest. In addition, if the trained lay rescuer is able to perform rescue breaths, compressions and breaths should be provided in a ratio of 30 compressions to 2 breaths. The rescuer should continue CPR until an AED arrives and is ready for use or EMS providers take over care of the victim.

 
2005 (Old): The 2005 AHA Guidelines for CPR and ECC did not provide different recommendations for trained versus

untrained rescuers but did recommend that dispatchers provide compression-only CPR instructions to untrained bystanders.

The 2005 AHA Guidelines for CPR and ECC did note that if the rescuer was unwilling or unable to provide ventilations, the rescuer should provide chest compressions only.

 
Why: Hands-Only (compression-only) CPR is easier for an untrained rescuer to perform and can be more readily guided by dispatchers over the telephone. In addition, survival rates from cardiac arrests of cardiac etiology are similar with either Hands-Only CPR or CPR with both compressions and rescue breaths. However, for the trained lay rescuer who is able, the recommendation remains for the rescuer to perform both compressions and ventilations.

 
Change in CPR Sequence: C-A-B Rather Than A-B-C*

2010 (New): Initiate chest compressions before ventilations.

2005 (Old): The sequence of adult CPR began with opening of the airway, checking for normal breathing, and then delivery of 2 rescue breaths followed by cycles of 30 chest compressions and 2 breaths.

Why: Although no published human or animal evidence demonstrates that starting CPR with 30 compressions rather than 2 ventilations leads to improved outcome, chest compressions provide vital blood flow to the heart and brain, and studies of out-of-hospital adult cardiac arrest showed that survival was higher when bystanders made some attempt rather than no attempt to provide CPR. Animal data demonstrated that delays or interruptions in chest compressions reduced survival, so such delays or interruptions should be minimized throughout the entire resuscitation. Chest compressions can be started almost immediately, whereas positioning the head and achieving a seal for mouth-to-mouth or bag-mask rescue breathing all take time. The delay in initiation of compressions can be reduced if 2 rescuers are present: the first rescuer begins chest compressions, and the second rescuer opens the airway and is prepared to deliver breaths as soon as the first rescuer has completed the first set of 30 chest compressions. Whether 1 or more rescuers are present, initiation of CPR with chest compressions ensures that the victim receives this critical intervention early, and any delay in rescue breaths should be brief.

 
Elimination of “Look, Listen, and Feel for Breathing”*

2010 (New): “Look, listen, and feel” was removed from the CPR sequence. After delivery of 30 compressions, the lone rescuer opens the victim’s airway and delivers 2 breaths.

2005 (Old): “Look, listen, and feel” was used to assess breathing after the airway was opened.

Why: With the new “chest compressions first” sequence, CPR is performed if the adult is unresponsive and not breathing

or not breathing normally (as noted above, lay rescuers will be taught to provide CPR if the unresponsive victim is “not breathing or only gasping”). The CPR sequence begins with compressions (C-A-B sequence). Therefore, breathing is briefly checked as part of a check for cardiac arrest; after the first set of chest compressions, the airway is opened, and the rescuer delivers 2 breaths.

 
Chest Compression Rate: At Least 100 per Minute*

2010 (New): It is reasonable for lay rescuers and healthcare providers to perform chest compressions at a rate of at least

100/min.

2005 (Old): Compress at a rate of about 100/min.

Why: The number of chest compressions delivered per minute during CPR is an important determinant of return of spontaneous circulation (ROSC) and survival with good neurologic function. The actual number of chest compressions delivered per minute is determined by the rate of chest compressions and the number and duration of interruptions in compressions (eg, to open the airway, deliver rescue breaths, or allow AED analysis). In most studies, more compressions are associated with higher survival rates, and fewer compressions are associated with lower survival rates. Provision of adequate chest compressions requires an emphasis not only on an adequate compression rate but also on minimizing interruptions to this critical component of CPR. An inadequate compression rate or frequent interruptions (or both) will reduce the total number of compressions delivered per minute.

 
Chest Compression Depth*

2010 (New): The adult sternum should be depressed at least 2 inches (5 cm).

2005 (Old): The adult sternum should be depressed approximately 1. to 2 inches (approximately 4 to 5 cm).

Why: Compressions create blood flow primarily by increasing intrathoracic pressure and directly compressing the heart.

Compressions generate critical blood flow and oxygen and energy delivery to the heart and brain. Confusion may result when a range of depth is recommended, so 1 compression depth is now recommended. 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 1. inches. For this reason the 2010 AHA Guidelines for CPR and ECC recommend a single minimum depth for compression of the adult chest.

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