The main changes in the

Resuscitation Guidelines
AHA/ERC Guidelines 2010

Dr. Az Rifki, SpAn.KIC.KMN

Emphasis on High-Quality CPR

2005 Guidelines
“… blood flow is optimized by using the recommended chest compression
force and duration and maintaining a chest compression rate of
approximately 100 compressions per minute. These guidelines
recommend that all rescuers minimize interruption of chest compressions
… CPR instruction should emphasize the importance of allowing complete
chest recoil between compressions.”

(Circulation. 2005; 112: IV19-IV34)

Emphasis on High-Quality CPR

2010 Guidelines
“To provide effective chest compressions, push
hard and push fast. … compress the adult chest
at a rate of at least 100 compressions per
minute with a compression depth of at least 2
inches/5 cm. … allow complete recoil of the
chest after each compression, to allow the heart
to fill completely before the next compression.
… minimize the frequency and duration of
interruptions in compressions to maximize the
number of compressions delivered per minute.

(Berg, et al. Circulation. 2010;122;S685-S705)

 Highlights
• This is a re-emphasis from 2005.
• For effective compressions:
– Push fast
– Push hard
– Allow chest to fully recoil
– Minimize any interruptions
• Applies to both lay and healthcare providers.
 Rationale For Change
• High-quality chest compressions within CPR
continues to be a critical focal point.
• Well-performed compressions increase the
likelihood of survival.
 Compression Hand Position
2005 Guidelines
“The rescuer should compress the lower half of the victim’s sternum in
the center (middle) of the chest, between the nipples. The rescuer should
place the heel of the hand on the sternum in the center (middle) of the
chest between the nipples and then place the heel of the second hand on
top of the first so that the hands are overlapped and parallel.”

(Circulation. 2005; 112: IV19-IV34)

Compression Hand Position
2010 Guidelines
“The rescuer should place the heel of one hand
on the center (middle) of the victim’s chest
(which is the lower half of the sternum) and the
heel of the other hand on top of the first so that
the hands are overlapped and parallel.”

(Berg, et al. Circulation. 2010;122;S685-S705)

 Highlights
• Hands in center of the chest.
• Lower half of breastbone
• Second hand on top of the first.
• Not on lowest part of breastbone.
• Applies to both lay and healthcare providers.
 Rationale For Change
• Use of the nipple line as a landmark for
hand placement was found to be unreliable.
 Compression Rate
2005 Guidelines
“There is insufficient evidence from human studies to identify a single
optimal chest compression rate. Animal and human studies support a
chest compression rate of >80 compressions per minute to achieve
optimal forward blood flow during CPR. We recommend a compression
rate of about 100 compressions per minute.”

(Circulation. 2005; 112: IV19-IV34)

Compression Rate
2010 Guidelines
“It is reasonable for laypersons and healthcare
providers to compress the adult chest at a
rate of at least 100 compressions per minute
with a compression depth of at least 2 inches
(5 cm.)”

(Berg, et al. Circulation. 2010;122;S685-S705)

 Highlights
• “At least” 100 times per minute.
• It is okay to be a little faster.
• Applies to both lay and healthcare providers.
 Rationale For Change
• It has been found that higher survival rates are
associated with an increase in the number of
compressions provided per minute.
Child/Infant Compression Rate
2005 Guidelines
“Push fast; push at a rate of approximately 100 compressions per
minute.”

(Circulation. 2005; 112: IV156-IV166)

Child/Infant Compression Rate
2010 Guidelines
“Push fast; push at a rate of at least 100
compressions per minute.”

(Berg, et al. Circulation. 2010;122;S862-S875)

 Highlights
• Rescuers tend to compress slower.
• “At least” 100 compressions per minute.
• It is okay to be a little faster.
• Applies to both lay and healthcare providers.
 Rationale For Change
• It has been found that higher survival rates are
associated with an increase in the number of
compressions provided per minute.
 Compression Depth
2005 Guidelines
“Depress the sternum approximately 1 ½ to 2 inches (approximately 4 to
5 cm) and then allow the chest to return to its normal position.”

(Circulation. 2005; 112: IV19-IV34)

Compression Depth
2010 Guidelines
“It is reasonable for laypersons and healthcare
providers to compress the adult chest at a rate of
at least 100 compressions per minute with a
compression depth of at least 2 inches/5 cm.”

(Berg, et al. Circulation. 2010;122;S685-S705)

 Highlights
• “At least” 2 inches on an adult.
• It is okay to compress a little deeper.
• Not enough information to define upper limit.
• Applies to both lay and healthcare providers.
 Rationale For Change
• Research indicates the tendency for CPR
providers to not compress deep enough, even
with the emphasis to "push hard."
Child/Infant Compression Depth
2005 Guidelines
“‘Push hard’: push with sufficient force to depress the chest
approximately one third to one half the anterior-posterior diameter of the
chest.”

(Circulation. 2005; 112: IV156-IV166)

Child/Infant Compression Depth
2010 Guidelines
“Chest compressions of appropriate rate and
depth. ‘Push fast’: push at a rate of at least
100 compressions per minute. ‘Push hard’:
push with sufficient force to depress at least
one third the anterior-posterior (AP)
diameter of the chest or approximately 1 ½
inches (4 cm) in infants and 2 inches (5 cm)
in children.”

(Berg, et al. Circulation. 2010;122;S862-S875)

 Highlights
• “At least” 1/3 of the anterior/posterior diameter
of chest.
• About 2 inches for children and about 1 ½
inches for infants.
• It is okay to compress a little deeper
• Applies to both lay and healthcare providers.
 Rationale For Change
• Research indicates the tendency for CPR
providers to not compress deep enough, even
with the emphasis to "push hard."
 Breathing Assessment
2005 Guidelines
“While maintaining an open airway, look, listen, and feel for breathing.”

(Circulation. 2005; 112: IV19-IV34)

 Breathing Assessment
2010 Guidelines
“After activation of the emergency response system, all rescuers should
immediately begin CPR for adult victims who are unresponsive with no
breathing or no normal breathing (only gasping).”

(Berg, et al. Circulation. 2010;122;S685-S705)

 Highlights
• No more look, listen, and feel.
• Quick “look” for no breathing or no normal
breathing.
• Agonal breaths remain a concern.
• Applies to both lay and healthcare providers.
 Rationale for Change
• Simplifying the breathing assessment is
intended to help laypersons respond more
quickly with chest compressions and CPR.
• There is a high likelihood of agonal, or irregular,
gasping breaths to occur early in cardiac arrest
and confuse rescuers.
 CPR Sequence - Lay
2005 Guidelines
For an unresponsive person who is not breathing or not breathing
normally, begin CPR by opening the airway and giving 2 rescue breaths
followed with 30 chest compressions. Repeat cycles of 30:2 (ABC
method).

(Summary from Circulation. 2005; 112: IV19-IV34)

CPR Sequence - Lay
2010 Guidelines
For an unresponsive person, activate EMS,
then assess breathing. If the person is not
breathing or not breathing normally, begin CPR
with 30 compressions followed by opening the
airway and giving 2 rescue breaths. Repeat
cycles of 30:2 (CAB method).

(Summary from Berg, et al. Circulation.

2010;122;S685-S705)
 Highlights
• Initial assessment steps:
– Assess responsiveness
– Activate EMS
– Assess breathing
– Perform CPR
• CAB – begin CPR cycles with compressions,
followed by airway and breathing.
• Guideline applies to adults, children, and infants.
 Rationale For Change
• The science indicates the importance of not
delaying chest compressions to perform rescue
breaths.
• Early chest compression can immediately
circulate oxygen that is still in the bloodstream.
 CPR Sequence - HCP

2005 Guidelines
For an unresponsive person who is not
breathing or not breathing normally, begin CPR
by opening the airway and giving 2 rescue
breaths followed with 30 chest compressions.
Repeat cycles of 30:2 (ABC method).

(Summary from Circulation. 2005; 112: IV19-

IV34)
CPR Sequence - HCP

2010 Guidelines
For an unresponsive person who is not
breathing or not breathing normally, and has no
obvious pulse, activate EMS and begin CPR
with 30 compressions followed by opening the
airway and giving 2 rescue breaths. Repeat
cycles of 30:2 (CAB method).

(Summary from Berg, et al. Circulation.

2010;122;S685-S705)
 Highlights
• Initial assessment approach:
– Assess responsiveness and breathing
– Activate EMS
– Assess pulse
– Perform CPR
• CAB – begin CPR cycles with compressions,
followed by airway and breathing.
 Rationale For Change
• The science indicates the importance of not
delaying chest compressions to perform rescue
breaths.
• Early chest compression can immediately
circulate oxygen that is still in the bloodstream.
 Use of an AED on an Infant
2005 Guidelines
“There is insufficient data to make a
recommendation for or against the use of AEDs
for infants 1 year of age.”

(Circulation. 2005; 112: IV156-IV166)

Use of an AED on an Infant
2010 Guidelines
“Many AEDs have high specificity in
recognizing pediatric shockable rhythms, and
some are equipped to decrease (or attenuate)
the delivered energy to make them suitable for
infants and children < 8 years of age. For
infants … an AED equipped with a pediatric
attenuator is preferred for infants. If neither is
available, an AED without a dose attenuator
may be used.”

(Link, et al. Circulation. 2010;122;S706-S719)

 Highlights
• Success at defibrillating infants.
• Use attenuator to reduce shock.
• Okay to use AED set for adult.
• Applies to both lay and healthcare providers.
 Rationale For Change
• AEDs designed to be used on adults have been
successful when used on infants with out-of-
hospital cardiac arrest.
• Minimal heart muscle damage and good
neurological outcomes were reported.
 Chain of Survival
2005 Guidelines
•“Early recognition of the emergency and
activation of the emergency medical services
(EMS) or local emergency response system
•Early bystander CPR
•Early delivery of a shock with a defibrillator
•Early advanced life support followed by post
resuscitation care delivered by healthcare
providers”

(Circulation. 2005; 112: IV12-IV18)

Chain of Survival
2010 Guidelines
“These actions are termed the links in the ‘Chain
of Survival.’ For adults they include:
 Immediate recognition of cardiac arrest and
activation of the emergency response system
 Early CPR that emphasizes chest
compressions
 Rapid defibrillation if indicated
 Effective advanced life support
 Integrated post– cardiac arrest care.”

(Travers, et al. Circulation. 2010;122;S676-S684)

 Highlights
• Addition of fifth link in chain.
– Integrated post-cardiac arrest care.
• Applies to both lay and healthcare providers.
 Rationale For Change
• Links in the “Chain of Survival” indicate the
individual actions that must be strong in
order for a person to survive a sudden
cardiac arrest.
• The addition of the fifth link, integrated post-
cardiac arrest care, further emphasizes the
additional dependence on longer-term care
for long-term survival.
Provider Course CPR/AED

Cardiopulmonary
Resuscitation with
Automated
External
Defibrillator
 Objectives

At the end of this course participants should be

able to demonstrate:
– How to assess the collapsed victim
– How to perform chest compression and rescue breathing
(CPR)
– How to operate an automated external defibrillator safely
– How to place an unconscious breathing victim in the
recovery position
 Background

In Europe every 45 seconds a cardiac arrest

takes place

Bystander CPR is a vital intervention before

arrival of emergency services

Early resuscitation and prompt defibrillation

(within 1-2 minutes) can result in >60% survival
Chain of survival
 Approach safely

Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
Approach safely
Approach safely

Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
Check response
Approach
Approach safely
safely
Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
Check response

Shake shoulders gently

Ask “Are you all right?”
If he responds
• Leave as you find him.
• Find out what is wrong.
• Reassess regularly.
Shout for help
Approach
Approach safely
safely
Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
Open airway
Approach
Approach safely
safely
Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
Check breathing
Approach
Approach safely
safely
Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
 Check breathing

Look, listen and feel for NORMAL breathing

 Abnormal breathing

Occurs shortly after the heart stops

in up to 40% of cardiac arrests

Described as barely, heavy, noisy or gasping

breathing

Recognise as a sign of cardiac arrest

Call 112
Approach
Approach safely
safely
Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
30 Chest compressions
Approach
Approach safely
safely
Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
Chest compressions
• Place the heel of one hand in the
centre of the chest
• Place other hand on top
• Interlock fingers or avoid putting
pressure on the side of the chest
• Compress the chest
– Rate 100 – 120 min-1
– Depth 5 – 6 cm
– Equal compression : relaxation
• When possible change CPR
operator every 2 min
2 Rescue breaths
Approach
Approach safely
safely
Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
 Rescue breaths

Pinch the nose

Take a normal breath
Place lips over mouth
Blow until the chest rises
Take about 1 second
Allow chest to fall
Repeat
Continue CPR

30 2
 Approach safely

Check response

Shout for help

Open airway

Check breathing
Call 112
30 chest compressions

2 rescue breaths
Defibrillation
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
Attach AED
Follow voice
prompts
 Switch on AED

Some AEDs will automatically switch

themselves on when the lid is opened
Attach pads to victims bare chest
Analysing Rhythm: Do not touch victim
 Shock indicated

Stand clear
Deliver shock
Shock delivered: Follow AED instructions

30 2
No shock advised: Follow AED instructions

30 2
If victim starts to breathe normally place in
recovery position
 CPR in children

Adult CPR techniques can be used on children

Compressions at least 1/3 of the depth of the

chest
 AED in children
• Age > 8 years
• use adult AED

• Age 1-8 years

• use paediatric pads /
settings if available
(otherwise use adult
mode)

• Age < 1 year

• use only if manufacturer
instructions indicate it is
safe
Any questions?
Approach safely Approach safely
Check response Check response
Shout for help Shout for help
Open airway Open airway
Check breathing Check breathing
Call 112 Call 112
30 chest Attach AED
compressions
2 rescue breaths Follow voice