Summary: High-quality CPR with fewer interruptions is the goal of this update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care. Focusing on the value of quality CPR in saving lives when hearts are stopped, a consortium of experts recommended simplifying and streamlining the guidelines for CPR. The biggest change is increasing to 30 the number of chest compressions given for every two rescue breaths for cardiac arrest victims.

Why it’s important: Experts in resuscitation are concerned that the overall cardiac arrest survival rate has not changed significantly in the past decade, said Mary Fran Hazinski RN, MSN, clinical nurse specialist in pediatric emergency and critical care at Vanderbilt University and the AHA Emergency Cardiovascular Care Senior Science Editor. However, immediate bystander CPR can double or triple a cardiac arrest victim’s chances of survival. Michael Sayre, MD, associate professor of emergency medicine at Ohio State University School of Medicine in Columbus and a member of the AHA’s Emergency Cardiovascular Care committee said, “The most common reason that many people die is because none of the people nearby knew CPR, and if they knew it, they didn’t do it. One of the reasons is that the skill has been too complicated. These guidelines simplify the instructions and make them easier to remember.”

What’s already known: Survival from out-of-hospital cardiac arrest (i.e., the heart suddenly stops pumping blood) remains unacceptably low worldwide, averaging about 6 percent overall in the United States. Yet, survival rates can be more than 50 percent for victims when immediate and effective CPR is combined with prompt use of an automated external defibrillator. The highest survival rates are typically achieved by response programs that include effective training and regular practice.

Pushing hard and fast on the middle of the chest of a person whose heart has stopped and allowing the chest to recoil completely is the best way to perform CPR. “The more time someone spends pushing on the chest, the better off the patient is,” said Dr Sayre. “There is more blood flow to the heart, brain and vital organs. We know that stopping means that blood flow stops, and it takes a few pushes to get the blood flow going again.”

Some experts have recommended using only chest compressions but, since many cardiac arrest victims will benefit from rescue breaths as well, the new guidelines still recommend including that part of CPR for all victims. People who have drowned or whose hearts have stopped for reasons related to breathing problems are examples of those who need rescue breaths, as well as chest compressions. “Traditional CPR including rescue breathing is especially important for infants and children because their cardiac arrests most often began as a breathing problem, such as drowning,” said Dr Sayre.

How this study was done: The changes in the guidelines were based on a thorough review of the most current scientific evidence through collaboration with hundreds of international experts over three years. The AHA committee that made the final recommendations included individuals from all parts of the healthcare community — physicians, nurses, scientists, researchers, emergency medical services personnel and others — who were appointed by their peers. A rigorous conflict of interest process was used to ensure full disclosure and comprehensive management of potential conflicts.

What was found: Streamlining CPR for the lay person who witnesses someone suffering a cardiac arrest promises to save lives. “We eliminated some steps,” said Dr Sayre. “One is that if someone encounters a person who cannot be awakened and is not breathing, he or she should assume that the person is in cardiac arrest. They should give two breaths and move right into giving chest compressions without wasting any more time evaluating the victim. We hope that this change will help make it easier for rescuers to remember and act on the steps of CPR.”

The other major change for bystanders is to increase to 30 the number of chest compressions given before pausing to give two rescue breaths. This change applies to victims of all ages (except newborn infants) and is even recommended for healthcare professionals who might be working on their own before additional help arrives.

The emphasis on providing high quality CPR with fewer interruptions is also reflected in the changes to the new guidelines for using a defibrillator. For example, rescuers are advised to use only one shock before resuming CPR, rather than three, as previously recommended. Robert O’Connor, MD, director of education and research at Christiana Care Health System in Newark, Delaware, and vice chair of the AHA Emergency Cardiovascular Care Committee, said the change was made because the benefit of the additional shocks was questionable. “Most patients who are successfully converted (their hearts resume a normal rhythm) by today’s defibrillators are converted after only one shock. Those who do not convert with the first shock will have a better chance of responding to another shock if they first receive some CPR. This also reduces the length of time that the victim is left with no blood flow to the heart, brain and other vital organs.”

“Advanced cardiac life support providers will need to be attentive to providing CPR during defibrillation, intubation and delivery of medications,” said. Dr O’Connor. “There will have to be careful choreography by the advanced care providers to ensure minimal interruption of CPR during advanced care procedures. But my overarching interpretation of the new guidelines is that they strengthen the chain of survival by giving patients a higher likelihood of receiving earlier CPR, earlier defibrillation and more effective advanced care.”

The bottom line: Simplifying CPR increases the likelihood that bystanders will provide high quality CPR to people whose hearts have stopped beating. That in turn increases the chance that a victim will survive and leave the hospital to continue productive living.

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