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Compressions Now Come First in CPR

December 01, 2010

You’re on a plane and the child two seats over turns blue and passes out. The child’s mother screams and a flight attendant shouts, “Is there a doctor on the plane?” 

Well, you’re a pediatrician, so now what do you do? 

For many physicians, pediatric resident Julia Noether, M.D., noted at a recent Hopkins Children’s Grand Rounds, such circumstances can be daunting. 

“As part of our medical school training we all learn basic life support and cardiopulmonary resuscitation (CPR) and what to do until a more advanced level of care arrives,” said Noether. “But we all fear being out in the public when someone needs medical attention, when we’re by ourselves and not in an office or hospital with all the usual supports around us. That’s why it’s important to know the guidelines.” 

So, what are the guidelines? What do you do? 

If you’re thinking the ABCs of basic life support – airway, breathing and compression –  recommended by the American Heart Association (AHA) in 2005, re-think it, said Noether. The AHA in October 2010 came out with a new algorithm called CAB – compressions, airway and breathing – with a strong emphasis on compressions. Rather than open the airway, check breathing, give two breaths and check the patient’s pulse, AHA guidelines now call for 30 chest compressions and two breaths right away to minimize the so-called “no-flow time” – the amount of time in which blood is not being sent out to the body. 

“There’s a decreased emphasis on checking the pulse, which takes time and can be hard to feel in someone who is nonresponsive,” Noether said. “’Look, listen and feel’ for breathing was removed from the algorithm.” 

Why the change? 

Noether noted that accumulating evidence points to improved outcomes for adults with ventricular fibrillation (VF) cardiac arrest if compressions are started as early as possible without delays, which can come with trying to position the head and attain a seal for  mouth-to-mouth resuscitation (Pediatrics, November 2010:126;5;e1345-e1360). While asphyxial cardiac arrest is more common than VF cardiac arrest in infants and children, making ventilation extremely important, a recent large pediatric study shows that resuscitation results for asphyxial arrest are better with a combination of ventilations and compressions. Also, it’s not known whether breathing first or compressions first make a difference in pediatric outcomes, but it’s better to do compressions alone rather than do nothing (Lancet 2010:375;1347-1354). 

“Does it make a difference if you do ABC or CAB with children?” Noether asked. “This will be an interesting area of research in pediatrics.” 

She added that the new AHA recommendation simplifies training, which may encourage more CPR by bystanders. Out-of-hospital survival rates and neurologic outcomes can be improved with prompt CPR, but only about one-third to one-half of infants and children who suffer cardiac arrest receive bystander CPR. 

“Some people have concerns about infection or injuring the spinal cord if they move the person’s neck to give rescue breath,” Noether said. “People might be more willing to do CPR on someone they don’t know if they knew they could start with compressions. The new guidelines might empower people to feel like they can make a difference.” 

For more information, see the special report “Pediatric Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” ##