RCP 2010 Resumen - American Heart Association

Highlights of the 2010
A m e r i c a n H e a r t A s s o c i a t i o n
Guidelines for CPR and ECC
Contents
Major Issues Affecting
All Rescuers
1
Lay Rescuer Adult CPR
3
Healthcare Provider BLS
5
Electrical Therapies
9
CPR Techniques and Devices
12
Advanced Cardiovascular
Life Support
13
Acute Coronary Syndromes
17
Stroke
18
Pediatric Basic Life Support
18
Pediatric Advanced Life
Support
20
Neonatal Resuscitation
22
Ethical Issues
24
Education, Implementation,
and Teams
25
First Aid
26
Summary
28

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Editor
Mary Fran Hazinski, RN, MSN
Associate Editors
Leon Chameides, MD
Robin Hemphil , MD, MPH
Ricardo A. Samson, MD
Stephen M. Schexnayder, MD
Elizabeth Sinz, MD
Contributor
Brenda Schoolfield
Guidelines Writing Group Chairs and Cochairs
Michael R. Sayre, MD
Marc D. Berg, MD
Robert A. Berg, MD
Farhan Bhanji, MD
John E. Bil i, MD
Clifton W. Callaway, MD, PhD
Diana M. Cave, RN, MSN, CEN
Brett Cucchiara, MD
Jeffrey D. Ferguson, MD, NREMT-P
Robert W. Hickey, MD
Edward C. Jauch, MD, MS
John Kattwinkel, MD
Monica E. Kleinman, MD
Peter J. Kudenchuk, MD
Mark S. Link, MD
Laurie J. Morrison, MD, MSc
Robert W. Neumar, MD, PhD
Robert E. O’Connor, MD, MPH
Mary Ann Peberdy, MD
Jeffrey M. Perlman, MB, ChB
Thomas D. Rea, MD, MPH
Michael Shuster, MD
Andrew H. Travers, MD, MSc
Terry L. Vanden Hoek, MD
© 2010 American Heart Association

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M A J O R I S S U E S
MAJOR ISSUES AFFECTING
This “Guidelines Highlights” publication summarizes
ALL RESCUERS
the key issues and changes in the 2010
American Heart Association (AHA) Guidelines for
Cardiopulmonary Resuscitation (CPR) and Emergency
This section summarizes major issues in the 2010 AHA
Cardiovascular Care (ECC). It has been developed for
Guidelines for CPR and ECC, primarily those in basic life
resuscitation providers and for AHA instructors to focus on
support (BLS) that affect al rescuers, whether healthcare
resuscitation science and guidelines recommendations that
providers or lay rescuers. The 2005 AHA Guidelines for CPR
are most important or controversial or wil result in changes in
and ECC emphasized the importance of high-quality chest
resuscitation practice or resuscitation training. In addition, it
compressions (compressing at an adequate rate and depth,
provides the rationale for the recommendations.
al owing complete chest recoil after each compression, and
minimizing interruptions in chest compressions). Studies
Because this publication is designed as a summary, it does
published before and since 2005 have demonstrated that (1) the
not reference the supporting published studies and does
quality of chest compressions continues to require improvement,
not list Classes of Recommendations or Levels of Evidence.
although implementation of the 2005 AHA Guidelines for CPR
For more detailed information and references, the reader is
and ECC has been associated with better CPR quality and
encouraged to read the 2010 AHA Guidelines for CPR and
greater survival; (2) there is considerable variation in survival
ECC, including the Executive Summary,1 published online
from out-of-hospital cardiac arrest across emergency medical
in Circulation in October 2010 and to consult the detailed
services (EMS) systems; and (3) most victims of out-of-hospital
summary of resuscitation science in the 2010 International
sudden cardiac arrest do not receive any bystander CPR. The
Consensus on CPR and ECC Science With Treatment
changes recommended in the 2010 AHA Guidelines for CPR
Recommendations, published simultaneously in Circulation2
and ECC attempt to address these issues and also make
and Resuscitation.3
recommendations to improve outcome from cardiac arrest
This year marks the 50th anniversary of the first peer-reviewed through a new emphasis on post–cardiac arrest care.
medical publication documenting survival after closed
Continued Emphasis on High-Quality CPR
chest compression for cardiac arrest,4 and resuscitation
experts and providers remain dedicated to reducing death
and disability from cardiovascular diseases and stroke.
The 2010 AHA Guidelines for CPR and ECC once again
Bystanders, first responders, and healthcare providers all
emphasize the need for high-quality CPR, including
play key roles in providing CPR for victims of cardiac arrest.
• A compression rate of at least 100/min (a change from
In addition, advanced providers can provide excel ent
“approximately” 100/min)
periarrest and postarrest care.
• A compression depth of at least 2 inches (5 cm) in adults
The 2010 AHA Guidelines for CPR and ECC are based on
and a compression depth of at least one third of the anterior-
an international evidence evaluation process that involved
posterior diameter of the chest in infants and children
hundreds of international resuscitation scientists and experts
(approximately 1.5 inches [4 cm] in infants and 2 inches
who evaluated, discussed, and debated thousands of peer-
[5 cm] in children). Note that the range of 1½ to 2 inches is
reviewed publications. Information about the 2010 evidence
no longer used for adults, and the absolute depth specified
evaluation process is contained in Box 1.
for children and infants is deeper than in previous versions of
the AHA Guidelines for CPR and ECC.
BOX 1
Evidence Evaluation Process
The 2010 AHA Guidelines for CPR and ECC are based on an extensive review of resuscitation literature and many debates and
discussions by international resuscitation experts and members of the AHA ECC Committee and Subcommittees. The ILCOR 2010
International Consensus on CPR and ECC Science With Treatment Recommendations, simultaneously published in Circulation2 and
Resuscitation,3 summarizes the international consensus interpreting tens of thousands of peer-reviewed resuscitation studies. This
2010 international evidence evaluation process involved 356 resuscitation experts from 29 countries who analyzed, discussed, and
debated the resuscitation research during in-person meetings, conference calls, and online sessions (“webinars”) over a 36-month
period, including the 2010 International Consensus Conference on CPR and ECC Science With Treatment Recommendations, held
in Dallas, Texas, in early 2010. Worksheet experts produced 411 scientific evidence reviews of 277 topics in resuscitation and ECC.
The process included structured evidence evaluation, analysis, and cataloging of the literature. It also included rigorous disclosure and
management of potential conflicts of interest. The 2010 AHA Guidelines for CPR and ECC1 contain the expert recommendations for
application of the International Consensus on CPR and ECC Science With Treatment Recommendations with consideration of their
effectiveness, ease of teaching and application, and local systems factors.
Highlights of the 2010 AHA Guidelines for CPR and ECC
4
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L A
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• Al owing for complete chest recoil after each compression
required to deliver the first cycle of 30 chest compressions, or
approximately 18 seconds; when 2 rescuers are present for
• Minimizing interruptions in chest compressions
resuscitation of the infant or child, the delay wil be even shorter).
• Avoiding excessive ventilation
Most victims of out-of-hospital cardiac arrest do not receive
There has been no change in the recommendation for a
any bystander CPR. There are probably many reasons for this,
compression-to-ventilation ratio of 30:2 for single rescuers of
but one impediment may be the A-B-C sequence, which starts
adults, children, and infants (excluding newly born infants). The
with the procedures that rescuers find most difficult, namely,
2010 AHA Guidelines for CPR and ECC continue to recommend opening the airway and delivering breaths. Starting with chest
that rescue breaths be given in approximately 1 second. Once
compressions might encourage more rescuers to begin CPR.
an advanced airway is in place, chest compressions can be
Basic life support is usually described as a sequence of
continuous (at a rate of at least 100/min) and no longer cycled
actions, and this continues to be true for the lone rescuer.
with ventilations. Rescue breaths can then be provided at
Most healthcare providers, however, work in teams, and
about 1 breath every 6 to 8 seconds (about 8 to 10 breaths per
team members typically perform BLS actions simultaneously.
minute). Excessive ventilation should be avoided.
For example, one rescuer immediately initiates chest
A Change From A-B-C to C-A-B
compressions while another rescuer gets an automated
external defibrillator (AED) and calls for help, and a third
The 2010 AHA Guidelines for CPR and ECC recommend a
rescuer opens the airway and provides ventilations.
change in the BLS sequence of steps from A-B-C (Airway,
Healthcare providers are again encouraged to tailor rescue
Breathing, Chest compressions) to C-A-B (Chest compressions,
actions to the most likely cause of arrest. For example,
Airway, Breathing) for adults, children, and infants (excluding the
if a lone healthcare provider witnesses a victim suddenly
newly born; see Neonatal Resuscitation section). This fundamental collapse, the provider may assume that the victim has had a
change in CPR sequence wil require reeducation of everyone
primary cardiac arrest with a shockable rhythm and should
who has ever learned CPR, but the consensus of the authors and
immediately activate the emergency response system,
experts involved in the creation of the 2010 AHA Guidelines for
retrieve an AED, and return to the victim to provide CPR
CPR and ECC is that the benefit wil justify the effort.
and use the AED. But for a presumed victim of asphyxial
Why:
arrest such as drowning, the priority would be to provide
The vast majority of cardiac arrests occur in adults,
chest compressions with rescue breathing for about 5 cycles
and the highest survival rates from cardiac arrest are reported
(approximately 2 minutes) before activating the emergency
among patients of al ages who have a witnessed arrest and
response system.
an initial rhythm of ventricular fibril ation (VF) or pulseless
ventricular tachycardia (VT). In these patients, the critical
Two new parts in the 2010 AHA Guidelines for CPR and ECC
initial elements of BLS are chest compressions and early
are Post–Cardiac Arrest Care and Education, Implementation,
defibril ation. In the A-B-C sequence, chest compressions
and Teams. The importance of post–cardiac arrest care is
are often delayed while the responder opens the airway to
emphasized by the addition of a new fifth link in the AHA
give mouth-to-mouth breaths, retrieves a barrier device, or
ECC Adult Chain of Survival (Figure 1). See the sections
gathers and assembles ventilation equipment. By changing the
Post–Cardiac Arrest Care and Education, Implementation,
sequence to C-A-B, chest compressions wil be initiated sooner and Teams in this publication for a summary of key
and the delay in ventilation should be minimal (ie, only the time
recommendations contained in these new parts.
Figure 1
AHA ECC Adult Chain of Survival
The links in the new AHA ECC Adult
Chain of Survival are as fol ows:
1. Immediate recognition of cardiac
arrest and activation of the
emergency response system
2. Early CPR with an emphasis on
chest compressions
3. Rapid defi brillation
4. Effective advanced life support
5. Integrated post–cardiac arrest care
3
2
A m e r i c a n H e a r t A s s o c i a t i o n

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L A Y R E S C U E R A D U LT C P R
LAY RESCUER
Figure 2
ADULT CPR
Simplifi ed Adult BLS Algorithm
Simplified Adult BLS
Summary of Key Issues and Major Changes
Unresponsive
No breathing or
Key issues and major changes for the 2010 AHA Guidelines for
no normal breathing
CPR and ECC recommendations for lay rescuer adult CPR are
(only gasping)
the fol owing:
• The simplified universal adult BLS algorithm has been
Activate
Get
created (Figure 2).
emergency
defibrillator
response
• Refinements have been made to recommendations for
immediate recognition and activation of the emergency
response system based on signs of unresponsiveness, as
wel as initiation of CPR if the victim is unresponsive with no
Start CPR
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
Check rhythm/
(with chest compressions of adequate rate and depth,
shock if
al owing complete chest recoil after each compression,
indicated
minimizing interruptions in compressions, and avoiding
Repeat every 2 minutes
excessive ventilation).
Pus
• There has been a change in the recommended sequence
h
for the lone rescuer to initiate chest compressions before
Har
giving rescue breaths (C-A-B rather than A-B-C). The lone
d • Push Fast
rescuer should begin CPR with 30 compressions rather than
© 2010 American Heart Association
2 ventilations to reduce delay to first compression.
• Compression rate should be at least 100/min (rather than
“approximately” 100/min).
Al trained lay rescuers should, at a minimum, provide chest
compressions for victims of cardiac arrest. In addition, if
• Compression depth for adults has been changed from the
the trained lay rescuer is able to perform rescue breaths,
range of 1½ to 2 inches to at least 2 inches (5 cm).
compressions and breaths should be provided in a ratio of
30 compressions to 2 breaths. The rescuer should continue
These changes are designed to simplify lay rescuer training
CPR until an AED arrives and is ready for use or EMS providers
and to continue to emphasize the need to provide early chest
take over care of the victim.
compressions for the victim of a sudden cardiac arrest. More
2005 (Old): The 2005 AHA Guidelines for CPR and ECC
information about these changes appears below. Note: In the
did not provide different recommendations for trained versus
fol owing topics, changes or points of emphasis for lay rescuers untrained rescuers but did recommend that dispatchers provide
that are similar to those for healthcare providers are noted with
compression-only CPR instructions to untrained bystanders.
an asterisk (*).
The 2005 AHA Guidelines for CPR and ECC did note that if
the rescuer was unwil ing or unable to provide ventilations, the
Emphasis on Chest Compressions*
rescuer should provide chest compressions only.
2010 (New):
Why: Hands-Only (compression-only) CPR is easier for an
If a bystander is not trained in CPR, the bystander untrained rescuer to perform and can be more readily guided
should provide Hands-Only™ (compression-only) CPR for
by dispatchers over the telephone. In addition, survival rates
the adult victim who suddenly col apses, with an emphasis to
from cardiac arrests of cardiac etiology are similar with either
“push hard and fast” on the center of the chest, or fol ow the
Hands-Only CPR or CPR with both compressions and rescue
directions of the EMS dispatcher. The rescuer should continue
breaths. However, for the trained lay rescuer who is able, the
Hands-Only CPR until an AED arrives and is ready for use or
recommendation remains for the rescuer to perform both
EMS providers or other responders take over care of the victim.
compressions and ventilations.
A m e r i c a n H e a r t A s s o c i a t i o n
Highlights of the 2010 AHA Guidelines for CPR and ECC
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L A Y R E S C U E R A D U LT C P R
Change in CPR Sequence: C-A-B Rather
Elimination of “Look, Listen, and Feel
Than A-B-C*
for Breathing”*
2010 (New): Initiate chest compressions before ventilations.
2010 (New): “Look, listen, and feel” was removed from the
2005 (Old): The sequence of adult CPR began with opening of CPR sequence. After delivery of 30 compressions, the lone
the airway, checking for normal breathing, and then delivery of
rescuer opens the victim’s airway and delivers 2 breaths.
2 rescue breaths fol owed by cycles of 30 chest compressions
2005 (Old): “Look, listen, and feel” was used to assess
and 2 breaths.
breathing after the airway was opened.
Why: Although no published human or animal evidence
demonstrates that starting CPR with 30 compressions
Why: With the new “chest compressions first” sequence, CPR
rather than 2 ventilations leads to improved outcome, chest
is performed if the adult is unresponsive and not breathing
compressions provide vital blood flow to the heart and
or not breathing normal y (as noted above, lay rescuers will
brain, and studies of out-of-hospital adult cardiac arrest
be taught to provide CPR if the unresponsive victim is “not
showed that survival was higher when bystanders made
breathing or only gasping”). The CPR sequence begins with
some attempt rather than no attempt to provide CPR. Animal
compressions (C-A-B sequence). Therefore, breathing is briefly
data demonstrated that delays or interruptions in chest
checked as part of a check for cardiac arrest; after the first set
compressions reduced survival, so such delays or interruptions
of chest compressions, the airway is opened, and the rescuer
should be minimized throughout the entire resuscitation. Chest
delivers 2 breaths.
compressions can be started almost immediately, whereas
positioning the head and achieving a seal for mouth-to-mouth
Chest Compression Rate: At Least
or bag-mask rescue breathing al take time. The delay in
100 per Minute*
initiation of compressions can be reduced if 2 rescuers are
present: the first rescuer begins chest compressions, and the
2010 (New): It is reasonable for lay rescuers and healthcare
second rescuer opens the airway and is prepared to deliver
providers to perform chest compressions at a rate of at least
breaths as soon as the first rescuer has completed the first
100/min.
set of 30 chest compressions. Whether 1 or more rescuers are
present, initiation of CPR with chest compressions ensures that 2005 (Old): Compress at a rate of about 100/min.
the victim receives this critical intervention early, and any delay
Why: The number of chest compressions delivered per
in rescue breaths should be brief.
minute during CPR is an important determinant of return
of spontaneous circulation (ROSC) and survival with good
BOX 2
neurologic function. The actual number of chest compressions
delivered per minute is determined by the rate of chest
Number of Compressions Delivered
compressions and the number and duration of interruptions in
Affected by Compression Rate and
compressions (eg, to open the airway, deliver rescue breaths,
by Interruptions
or al ow AED analysis). In most studies, more compressions are
associated with higher survival rates, and fewer compressions
The total number of compressions delivered during resuscitation
is an important determinant of survival from cardiac arrest.
are associated with lower survival rates. Provision of adequate
The number of compressions delivered is affected by the
chest compressions requires an emphasis not only on an
compression rate and by the compression fraction (the portion
adequate compression rate but also on minimizing interruptions
of total CPR time during which compressions are performed);
to this critical component of CPR. An inadequate compression
increases in compression rate and fraction increase the total
rate or frequent interruptions (or both) wil reduce the total
compressions delivered, whereas decreases in compression
number of compressions delivered per minute. For further
rate or compression fraction decrease the total compressions
information, see Box 2.
delivered. Compression fraction is improved if you reduce
the number and length of any interruptions in compressions,
Chest Compression Depth*
and it is reduced by frequent or long interruptions in chest
compressions. An analogy can be found in automobile travel.
2010 (New): The adult sternum should be depressed at least 2
When you travel in an automobile, the number of miles you
inches (5 cm).
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
2005 (Old): The adult sternum should be depressed
stops you make (interruptions in travel). During CPR, you want
approximately 1½ to 2 inches (approximately 4 to 5 cm).
to deliver effective compressions at an appropriate rate (at least
100/min) and depth, while minimizing the number and duration
Why: Compressions create blood flow primarily by increasing
of interruptions in chest compressions. Additional components
intrathoracic pressure and directly compressing the heart.
of high-quality CPR include allowing complete chest recoil after
Compressions generate critical blood flow and oxygen and
each compression and avoiding excessive ventilation.
energy delivery to the heart and brain. Confusion may result
when a range of depth is recommended, so 1 compression
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H E A LT H C A R E P R O V I D E R B L S
depth is now recommended. Rescuers often do not compress
• Compression depth for adults has been slightly altered to at
the chest enough despite recommendations to “push hard.” In
least 2 inches (about 5 cm) from the previous recommended
addition, the available science suggests that compressions of
range of about 1½ to 2 inches (4 to 5 cm).
at least 2 inches are more effective than compressions of
1½ inches. For this reason the 2010 AHA Guidelines for CPR
• Continued emphasis has been placed on the need to reduce
and ECC recommend a single minimum depth for compression
the time between the last compression and shock delivery
of the adult chest.
and the time between shock delivery and resumption of
compressions immediately after shock delivery.
• There is an increased focus on using a team approach
HEALTHCARE PROVIDER BLS
during CPR.
These changes are designed to simplify training for the
healthcare provider and to continue to emphasize the need to
Summary of Key Issues and Major Changes
provide early and high-quality CPR for victims of cardiac arrest.
More information about these changes fol ows. Note: In the
Key issues and major changes in the 2010 AHA Guidelines
fol owing topics for healthcare providers, those that are similar
for CPR and ECC recommendations for healthcare providers
for healthcare providers and lay rescuers are noted with
include the fol owing:
an asterisk (*).
• Because cardiac arrest victims may present with a short
Dispatcher Identification of Agonal Gasps
period of seizure-like activity or agonal gasps that may
confuse potential rescuers, dispatchers should be specifical y Cardiac arrest victims may present with seizure-like activity or
trained to identify these presentations of cardiac arrest to
agonal gasps that may confuse potential rescuers. Dispatchers
improve cardiac arrest recognition.
should be specifical y trained to identify these presentations
• Dispatchers should instruct untrained lay rescuers to provide
of cardiac arrest to improve recognition of cardiac arrest and
Hands-Only CPR for adults with sudden cardiac arrest.
prompt provision of CPR.
• Refinements have been made to recommendations for
2010 (New): To help bystanders recognize cardiac arrest,
immediate recognition and activation of the emergency
dispatchers should ask about an adult victim’s responsiveness,
response system once the healthcare provider identifies the
if the victim is breathing, and if the breathing is normal, in an
adult victim who is unresponsive with no breathing or no
attempt to distinguish victims with agonal gasps (ie, in those
normal breathing (ie, only gasping). The healthcare provider
who need CPR) from victims who are breathing normal y and
briefly checks for no breathing or no normal breathing (ie,
do not need CPR. The lay rescuer should be taught to begin
no breathing or only gasping) when the provider checks
CPR if the victim is “not breathing or only gasping.” The
responsiveness. The provider then activates the emergency
healthcare provider should be taught to begin CPR if the victim
response system and retrieves the AED (or sends someone
has “no breathing or no normal breathing (ie, only gasping).”
to do so). The healthcare provider should not spend more
Therefore, breathing is briefly checked as part of a check for
than 10 seconds checking for a pulse, and if a pulse is not
cardiac arrest before the healthcare provider activates the
definitely felt within 10 seconds, should begin CPR and use
emergency response system and retrieves the AED (or sends
the AED when available.
someone to do so), and then (quickly) checks for a pulse and
begins CPR and uses the AED.
• “Look, listen, and feel for breathing” has been removed from
the algorithm.
2005 (Old): Dispatcher CPR instructions should include
questions to help bystanders identify patients with occasional
• Increased emphasis has been placed on high-quality CPR
gasps as likely victims of cardiac arrest to increase the
(compressions of adequate rate and depth, al owing complete
likelihood of bystander CPR for such victims.
chest recoil between compressions, minimizing interruptions
in compressions, and avoiding excessive ventilation).
Why: There is evidence of considerable regional variation in
the reported incidence and outcome of cardiac arrest in the
• Use of cricoid pressure during ventilations is general y
United States. This variation is further evidence of the need for
not recommended.
communities and systems to accurately identify each instance
• Rescuers should initiate chest compressions before giving
of treated cardiac arrest and measure outcomes. It also
rescue breaths (C-A-B rather than A-B-C). Beginning CPR
suggests additional opportunities for improving survival rates
with 30 compressions rather than 2 ventilations leads to a
in many communities. Previous guidelines have recommended
shorter delay to first compression.
the development of programs to aid in recognition of cardiac
arrest. The 2010 AHA Guidelines for CPR and ECC are more
• Compression rate is modified to at least 100/min from
approximately 100/min.
Highlights of the 2010 AHA Guidelines for CPR and ECC
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H E A LT H C A R E P R O V I D E R B L S
specific about the necessary components of resuscitation
2005 (Old): Cricoid pressure should be used only if the victim
systems. Studies published since 2005 have demonstrated
is deeply unconscious, and it usual y requires a third rescuer
improved outcome from out-of-hospital cardiac arrest,
not involved in rescue breaths or compressions.
particularly from shockable rhythms, and have reaffirmed the
importance of a stronger emphasis on immediate provision
Why: Cricoid pressure is a technique of applying pressure to
of high-quality CPR (compressions of adequate rate and
the victim’s cricoid cartilage to push the trachea posteriorly
depth, al owing complete chest recoil after each compression,
and compress the esophagus against the cervical vertebrae.
minimizing interruptions in chest compressions, and avoiding
Cricoid pressure can prevent gastric inflation and reduce the
excessive ventilation).
risk of regurgitation and aspiration during bag-mask ventilation,
but it may also impede ventilation. Seven randomized studies
To help bystanders immediately recognize cardiac arrest,
showed that cricoid pressure can delay or prevent the
dispatchers should specifical y inquire about an adult
placement of an advanced airway and that some aspiration
victim’s absence of response, if the victim is breathing, and
can stil occur despite application of cricoid pressure. In
if any breathing observed is normal. Dispatchers should be
addition, it is difficult to appropriately train rescuers in use of
specifical y educated in helping bystanders detect agonal
the maneuver. Therefore, the routine use of cricoid pressure in
gasps to improve cardiac arrest recognition.
cardiac arrest is not recommended.
Dispatchers should also be aware that brief generalized
Emphasis on Chest Compressions*
seizures may be the first manifestation of cardiac arrest. In
summary, in addition to activating professional emergency
2010 (New): Chest compressions are emphasized for
responders, the dispatcher should ask straightforward
both trained and untrained rescuers. If a bystander is not
questions about whether the patient is responsive and
trained in CPR, the bystander should provide Hands-Only
breathing normal y to identify patients with possible cardiac
(compression-only) CPR for the adult who suddenly col apses,
arrest. Dispatchers should provide Hands-Only (compression-
with an emphasis to “push hard and fast” on the center of
only) CPR instructions to help untrained bystanders initiate
the chest, or fol ow the directions of the emergency medical
CPR when cardiac arrest is suspected (see below).
dispatcher. The rescuer should continue Hands-Only CPR
Dispatcher Should Provide CPR Instructions
until an AED arrives and is ready for use or EMS providers
take over care of the victim.
2010 (New): The 2010 AHA Guidelines for CPR and ECC more Optimal y al healthcare providers should be trained in BLS. In
strongly recommend that dispatchers should instruct untrained
this trained population, it is reasonable for both EMS and in-
lay rescuers to provide Hands-Only CPR for adults who
hospital professional rescuers to provide chest compressions
are unresponsive with no breathing or no normal breathing.
and rescue breaths for cardiac arrest victims.
Dispatchers should provide instructions in conventional CPR
for victims of likely asphyxial arrest.
2005 (Old): The 2005 AHA Guidelines for CPR and ECC
did not provide different recommendations for trained and
2005 (Old): The 2005 AHA Guidelines for CPR and ECC
untrained rescuers and did not emphasize differences in
noted that telephone instruction in chest compressions alone
instructions provided to lay rescuers versus healthcare
may be preferable.
providers, but did recommend that dispatchers provide
compression-only CPR instructions to untrained bystanders. In
Why: Unfortunately, most adults with out-of-hospital cardiac
addition, the 2005 AHA Guidelines for CPR and ECC noted that
arrest do not receive any bystander CPR. Hands-Only
if the rescuer was unwil ing or unable to provide ventilations,
(compression-only) bystander CPR substantial y improves
the rescuer should provide chest compressions. Note that the
survival after adult out-of-hospital cardiac arrests compared
AHA Hands-Only CPR statement was published in 2008.
with no bystander CPR. Other studies of adults with cardiac
arrest treated by lay rescuers showed similar survival rates
Why: Hands-Only (compression-only) CPR is easier for
among victims receiving Hands-Only CPR versus those
untrained rescuers to perform and can be more readily guided
receiving conventional CPR (ie, with rescue breaths).
by dispatchers over the telephone. However, because the
Importantly, it is easier for dispatchers to instruct untrained
healthcare provider should be trained, the recommendation
rescuers to perform Hands-Only CPR than conventional CPR
remains for the healthcare provider to perform both
for adult victims, so the recommendation is now stronger
compressions and ventilations. If the healthcare provider is
for them to do so, unless the victim is likely to have had an
unable to perform ventilations, the provider should activate the
asphyxial arrest (eg, drowning).
emergency response system and provide chest compressions.
Cricoid Pressure
Activation of Emergency Response System
2010 (New): The routine use of cricoid pressure in cardiac
2010 (New): The healthcare provider should check for
arrest is not recommended.
response while looking at the patient to determine if breathing
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H E A LT H C A R E P R O V I D E R B L S
is absent or not normal. The provider should suspect cardiac
of cardiac arrest. After delivery of 30 compressions, the lone
arrest if the victim is not breathing or only gasping.
rescuer opens the victim’s airway and delivers 2 breaths.
2005 (Old): The healthcare provider activated the emergency
2005 (Old): “Look, listen, and feel for breathing” was used to
response system after finding an unresponsive victim. The
assess breathing after the airway was opened.
provider then returned to the victim and opened the airway and
checked for breathing or abnormal breathing.
Why: With the new chest compression–first sequence, CPR is
performed if the adult victim is unresponsive and not breathing
Why: The healthcare provider should not delay activation of
or not breathing normal y (ie, not breathing or only gasping)
the emergency response system but should obtain 2 pieces of
and begins with compressions (C-A-B sequence). Therefore,
information simultaneously: the provider should check the victim breathing is briefly checked as part of a check for cardiac
for response and check for no breathing or no normal breathing. arrest. After the first set of chest compressions, the airway is
If the victim is unresponsive and is not breathing at al or has no
opened and the rescuer delivers 2 breaths.
normal breathing (ie, only agonal gasps), the provider should
activate the emergency response system and retrieve the AED if Chest Compression Rate: At Least 100 per Minute*
available (or send someone to do so). If the healthcare provider
does not feel a pulse within 10 seconds, the provider should
2010 (New): It is reasonable for lay rescuers and healthcare
begin CPR and use the AED when it is available.
providers to perform chest compressions at a rate of at least
100/min.
Change in CPR Sequence: C-A-B Rather
Than A-B-C*
2005 (Old): Compress at a rate of about 100/min.
Why: The number of chest compressions delivered per
2010 (New): A change in the 2010 AHA Guidelines for CPR
minute during CPR is an important determinant of ROSC and
and ECC is to recommend the initiation of chest compressions
survival with good neurologic function. The actual number of
before ventilations.
chest compressions delivered per minute is determined by the
rate of chest compressions and the number and duration of
2005 (Old): The sequence of adult CPR began with opening
interruptions in compressions (eg, to open the airway, deliver
of the airway, checking for normal breathing, and then delivering
rescue breaths, or al ow AED analysis). In most studies, delivery
2 rescue breaths fol owed by cycles of 30 chest compressions
of more compressions during resuscitation is associated with
and 2 breaths.
better survival, and delivery of fewer compressions is associated
Why: Although no published human or animal evidence
with lower survival. Provision of adequate chest compressions
demonstrates that starting CPR with 30 compressions
requires an emphasis not only on an adequate compression rate
rather than 2 ventilations leads to improved outcome, chest
but also on minimizing interruptions to this critical component of
compressions provide the blood flow, and studies of out-of-
CPR. An inadequate compression rate or frequent interruptions
hospital adult cardiac arrest showed that survival was higher
(or both) wil reduce the total number of compressions delivered
when bystanders provided chest compressions rather than no
per minute. For further information, see Box 2 on page 4.
chest compressions. Animal data demonstrate that delays or
Chest Compression Depth*
interruptions in chest compressions reduce survival, so such
delays and interruptions should be minimized throughout the
entire resuscitation. Chest compressions can be started almost
2010 (New): The adult sternum should be depressed at least 2
immediately, whereas positioning the head and achieving a
inches (5 cm).
seal for mouth-to-mouth or bag-mask rescue breathing al take
2005 (Old): The adult sternum should be depressed 1½ to 2
time. The delay in initiation of compressions can be reduced if 2
inches (approximately 4 to 5 cm).
rescuers are present: the first rescuer begins chest compressions,
and the second rescuer opens the airway and is prepared to
Why: Compressions create blood flow primarily by increasing
deliver breaths as soon as the first rescuer has completed the
intrathoracic pressure and directly compressing the heart.
first set of 30 chest compressions. Whether 1 or more rescuers
Compressions generate critical blood flow and oxygen and
are present, initiation of CPR with chest compressions ensures
energy delivery to the heart and brain. Confusion may result
that the victim receives this critical intervention early.
when a range of depth is recommended, so 1 compression
depth is now recommended. Rescuers often do not adequately
Elimination of “Look, Listen, and Feel
compress the chest despite recommendations to “push hard.”
for Breathing”*
In addition, the available science suggests that compressions
of at least 2 inches are more effective than compressions
2010 (New): “Look, listen, and feel for breathing” was
of 1½ inches. For this reason the 2010 AHA Guidelines for CPR
removed from the sequence for assessment of breathing after
and ECC recommend a single minimum depth for compression
opening the airway. The healthcare provider briefly checks
of the adult chest, and that compression depth is deeper than
for breathing when checking responsiveness to detect signs
in the old recommendation.
A m e r i c a n H e a r t A s s o c i a t i o n
Highlights of the 2010 AHA Guidelines for CPR and ECC
7

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H E A LT H C A R E P R O V I D E R B L S
Table 1
Summary of Key BLS Components for Adults, Children, and Infants*
Recommendations
Component
Adults
Children
Infants
Unresponsive (for all ages)
Recognition
No breathing or no normal
breathing (ie, only gasping)
No breathing or only gasping
No pulse palpated within 10 seconds for all ages (HCP only)
CPR sequence
C-A-B
Compression rate
At least 100/min
Compression depth
At least 2 inches (5 cm)
At least ¹⁄³ AP diameter
At least ¹⁄³ AP diameter
About 2 inches (5 cm)
About 1½ inches (4 cm)
Allow complete recoil between compressions
Chest wall recoil
HCPs rotate compressors every 2 minutes
Minimize interruptions in chest compressions
Compression interruptions
Attempt to limit interrruptions to <10 seconds
Airway
Head tilt–chin lift (HCP suspected trauma: jaw thrust)
30:2
Compression-to-ventilation
Single rescuer
ratio (until advanced
30:2
1 or 2 rescuers
airway placed)
15:2
2 HCP rescuers
Ventilations: when rescuer
untrained or trained and
Compressions only
not proficient
1 breath every 6-8 seconds (8-10 breaths/min)
Ventilations with advanced
Asynchronous with chest compressions
airway (HCP)
About 1 second per breath
Visible chest rise
Defibrillation
Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock;
resume CPR beginning with compressions immediately after each shock.
Abbreviations: AED, automated external defibrillator; AP, anterior-posterior; CPR, cardiopulmonary resuscitation; HCP, healthcare provider.
*Excluding the newly born, in whom the etiology of an arrest is nearly always asphyxial.
Team Resuscitation
Why: Some resuscitations start with a lone rescuer who
cal s for help, whereas other resuscitations begin with several
2010 (New): The steps in the BLS algorithm have traditional y
wil ing rescuers. Training should focus on building a team
been presented as a sequence to help a single rescuer
as each rescuer arrives, or on designating a team leader if
prioritize actions. There is increased focus on providing
multiple rescuers are present. As additional personnel arrive,
CPR as a team because resuscitations in most EMS and
responsibilities for tasks that would ordinarily be performed
healthcare systems involve teams of rescuers, with rescuers
sequential y by fewer rescuers may now be delegated to a team
performing several actions simultaneously. For example, one
of providers who perform them simultaneously. For this reason,
rescuer activates the emergency response system while a
BLS healthcare provider training should not only teach individual
second begins chest compressions, a third is either providing
skil s but should also teach rescuers to work in effective teams.
ventilations or retrieving the bag-mask for rescue breathing,
Comparison of Key Elements of Adult, Child,
and a fourth is retrieving and setting up a defibril ator.
and Infant BLS
2005 (Old): The steps of BLS consist of a series of sequential
assessments and actions. The intent of the algorithm is to
As in the 2005 AHA Guidelines for CPR and ECC, the 2010 AHA
present the steps in a logical and concise manner that wil be
Guidelines for CPR and ECC contain a comparison table that lists
easy for each rescuer to learn, remember, and perform.
the key elements of adult, child, and infant BLS (excluding CPR for
newly born infants). These key elements are included in Table 1.
8
A m e r i c a n H e a r t A s s o c i a t i o n

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