Vince Mosesso, MD
CPR No Longer A-B-C But Still Easy as 1-2-3
For years the steps to performing cardiopulmonary resuscitation (CPR) followed a simple mnemonic process commonly known as A-B-C. After dialing 9-1-1, bystanders and professional responders first focused on the patient’s Airway, then Breathing followed by chest Compression.
Revised this fall, the American Heart Association’s (AHA) 2010 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care call for a change in performing CPR, citing research that indicates chest compressions are just as effective as rescue breathing and compressions combined. Now, after dialing 9-1-1, responders are recommended to perform chest Compressions first, then adjust the patient’s Airway and provide rescue Breaths.
In addition to the data showing the effectiveness of stand-alone chest compressions, medical experts hope these new changes will increase survival outcomes due to increased bystander assistance. Since most out-of-hospital cardiac arrests are not witnessed and only five to seven percent of SCA patients survive, experts continue to stress the need for bystander assistance. Eliminating the need for rescue breaths could attract more good Samaritans who might otherwise have been uncomfortable coming to the aid of a person experiencing a heart attack or cardiac arrest.
To help explain the guidelines and how they might impact the public, SCAA interviewed Dr. Vince Mosesso, associate professor of emergency medicine at the University of Pittsburgh.
SCAA: What’s the next step for these new guidelines? Do they become law? Do other medical organizations need to adopt these before they are put into practice by emergency responders?
Dr. Mosesso: No, these are not law, but rather guidelines and recommendations developed through an extensive review of the literature supplemented by expert opinion. Many physicians and organizations do use the guidelines to develop protocols and guide care, but new scientific evidence and the specifics of each clinical situation must be considered as well.
SCAA: If a bystander performs the “old” method of CPR – not realizing that newer guidelines have been published – can that Good Samaritan be held legally responsible if the patient does not survive?
Dr. Mosesso: We often hear that bystanders who do not intervene are afraid they might break a rib or cause more damage and thereby increase the possibility of litigation. It is unfortunate that legal liability always raises concerns, and Good Samaritan laws do vary from state to state. However, there is extremely little exposure risk for bystanders who start CPR and/or use an AED and act in “good faith.” As an aside, a recent study found that injuries from CPR are extremely rare.
SCAA: If a patient isn’t responding to chest compressions only, should the bystander switch gears and perform the traditional method of CPR?
Dr. Mosesso: In general, for persons who suddenly collapse, it is probably best for a lay bystander to continue to do chest compressions only, making the best effort to do them well:
- at a rate of 100 compressions per minute;
- depth of 2 inches;
- ensuring the patient’s chest fully recoils after each compression;
- allowing for no interruptions except for an AED to analyze the heart’s rhythm.
However, if it was learned that the patient was potentially drowning or choking, then it would be reasonable to switch to a 30:2 compression-ventilation ratio and attempt to give ventilations. So, for every 30 compressions, the bystander would provide two breaths. Regardless of the type of CPR being performed, CPR is most effective when applied continuously. Lapses can reduce the quality and quantity of oxygen rich blood flowing through the body. Performing CPR can be physically exhausting, and this is why it’s so important to have more than one bystander assist.
SCAA: Traditional CPR varies slightly when performed on adults versus children and infants. Does this new method apply to children as well?
Dr. Mosesso: Since breathing problems are often the cause of cardiac arrest in infants and children, the guidelines suggest doing both chest compressions and ventilations, but using the new C-A-B order. However, untrained bystanders are encouraged to do chest compressions only. The depth of compressions in children is 2 inches and in infants (first year of life) is 1 ½ inches.