Revised Guidelines: Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Guideline Watch |
December 1, 2010

Revised Guidelines: Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

  1. Mark S. Link, MD

The ABCs of CPR have changed.

  1. Mark S. Link, MD

Sponsoring Organization: American Heart Association

Background and Purpose: This update of the 2005 guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, widely used by healthcare providers at all levels, reflects a seismic shift in the philosophy of resuscitation. Gone is the traditional A-B-C (airway, breathing, circulation) sequence, which dates from the development of CPR in sedated surgical patients in the late 1950s. The increasing recognition that witnessed arrests are primarily cardiac in origin has engendered a new emphasis on chest compressions.

Key Points:

1. The major change in CPR is the order of recommended maneuvers, from A-B-C to C-A-B: Chest compressions are now to be administered before airway opening and rescue breathing. Consequently, the directive to “look, listen, and feel” for breathing before beginning chest compressions has been removed from the algorithm.

2. The guidelines now recommend compression-only CPR by individuals who are unable or unwilling to perform rescue breathing. It is hoped that this recommendation, based on a recent surge in supportive data, will increase the number of cardiac-arrest victims who receive CPR.

3. The guidelines focus on minimizing the pauses in chest compression that occur when changing providers or preparing for a shock.

4. Controversy remains about delaying defibrillation to administer CPR. In early studies, survival improved when patients in cardiac arrest longer than 5 minutes received CPR before defibrillation; however, subsequent randomized trials showed no benefit of preshock CPR. In practice, compressions are generally administered before a shock because of the time required to locate, retrieve, and set up an AED.

5. Increased emphasis is placed on integrating automated external defibrillators (AEDs) into systems of emergency care, rather than simply making AEDs pervasive throughout the community.

6. Transcutaneous pacing for bradycardia has not proven to be as beneficial as was hoped, and the new guidelines circumscribe its use. Atropine remains the first-line therapy for bradycardia.

7. Adenosine is now considered reasonable for diagnosis and treatment of wide–complex tachycardias that are regular and monomorphic.

8. Pharmacologic therapy for cardiac arrest has been deemphasized. In retrospective studies and randomized trials, epinephrine, vasopressin, and amiodarone all failed to improve survival to hospital discharge when administered in the field. Rescuers should focus on effective chest compressions and prompt defibrillation.

9. A new link has been added to the traditional “chain of survival”: postarrest care. Recommendations include an expanded role for therapeutic hypothermia, the benefits of which have been borne out in several randomized controlled trials. Hypothermia should now be induced in most patients who are comatose after cardiac arrest.

10. Finally, the visual algorithms have been simplified (e.g., the CPR and advanced cardiac life support algorithms are now circular instead of linear).


A major goal of the new resuscitation guidelines is to increase the rate of bystander resuscitation by endorsing compression-only CPR. The guidelines also emphasize the importance of immediate administration of high-quality CPR rather than reliance on emergency medical systems and AED availability. Simplified advanced life support guidelines and algorithms should not only make guideline adherence easier than ever but also improve the rate of survival after cardiac arrest.


Reader Comments (5)

R Coto

i am renewing my CPR provider certificate, i work in an emergency room, i´ve seen CPR many times in my 20 years as GP, in almost 100% of them, providers usually compress between 150-200 per minute. is it better 90 or 110 per minute¿

Competing interests: None declared



Competing interests: None declared


Blood retains enough oxygen to give some oxygen delivery for good several minutes; many patients would have some ventilation with just chest compressions and recoil; on the other hand, with any interruption in CPR (for breathing, shock ect) once you resume chest compressions it takes 5 or more seconds to achieve good stroke volume - i.e., if you interrupt every 5 seconds, you're not perfusing, if every 10 - at least half of your compressions are useless. The original studies are pretty impressive. In adults, where causes are mostly cardiac, and in relatively recent arrest, survival benefit is huge. As always, it takes years to extablish a new routine

Competing interests: None declared

NA Sadeq

precordial thumb ,with some ribs fracture as early as possible will improve the survive rate of sudden cardiac arrest

Competing interests: None declared

othusitse machola

Am getting confused but i think will get used to it but with Chest compressions first will be circulation deoxgenated blood

Competing interests: None declared

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