a b s t r a c t

Objective: The 2010 American Heart Association (AHA) for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science has changed the basic life support (BLS) sequence from “A-B-C” to “C-A-B.” The AHA explained that this change may shorten the initiation time for chest compressions. In this study, the 2010 AHA guidelines for BLS (2010-BLS) were studied through a simulation program and practiced on a manikin. The time saved in initiating initial chest compressions was calculated, and the significance of the new guidelines was evaluated.

Methods: Forty health care providers who had undergone both the BLS guidelines of 2005 (2005-BLS) and the 2010-BLS programs were targeted in this study. The following items were measured: time spent on rescue breathing, including setting up of ventilation equipment; time taken to initiate chest compressions; and time taken to initiate chest compressions without performance of rescue breathing because of the lack of ventilation equipment.

Results: The time taken to initiate chest compressions was 36.0 +- 4.1 seconds when 2005-BLS was followed and 15.4 +- 3.0 seconds when 2010-BLS was followed (P b .001). Furthermore, chest compressions were initiated earlier when 2010-BLS was followed (15.4 +- 3.0 seconds) than when 2005-BLS was followed without the performance of rescue breathing (19.8 +- 2.7 seconds; P b .001). The mean time spent on setting up ventilation equipment and performing rescue breathing was 15.9 +- 3.8 seconds, indicating considerable time variations among individuals.

Conclusion: Chest compressions were initiated earlier by health care providers who were re-educated according to the 2010 AHA guidelines.

(C) 2013

Introduction

In 2010, the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science introduced the concept of look, listen, and feel during basic life support (BLS), while they eliminated the step of opening the airway after checking for breathing and changed the BLS procedure from “A-B-C” (airway, breathing, chest compressions) to “C-A-B” (chest compressions, airway, breathing) [1]. Although this revised procedure gives no evidence indicating an increase in the rates of spontaneous circulation return and rehabilitation in the European Resuscitation Council (ERC) guidelines of 2005, the BLS procedure has

? Conflicts of interest: There are no financial and/or personal relationships of any of the authors with people or organizations that inappropriately influenced this study.

* Corresponding author. Department of Emergency Medicine, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa 903-0215, Japan. Tel.: +80 98 895 3331.

E-mail address: qqp54x429@gaea.ocn.ne.jp (H. Sekiguchi).

already been changed. The revised procedure in the ERC guidelines of 2005-BLS can reportedly shorten the time taken to initiate chest compressions [2,3]. However, the 2010 ERC guidelines and the 2010 AHA guidelines for BLS are different in terms of procedures for checking the victim for a response and the time taken to activate the emergency response system and initiate chest compressions. The reason why the BLS procedure was changed is because the AHA emphasizes that the critical component of immediate BLS is based on chest compressions and rapid defibrillation, whereas in the “A-B-C” sequence, chest compressions were often delayed while the rescuer opened the airway, obtained a barrier device, and set up the ventilation equipment. Chest compressions are initiated as quickly as possible by changing the sequence to “C-A-B” [4]. Furthermore, AHA indicates that all health care providers, including those who have been trained in concert with the 2005 AHA guidelines for BLS (2005- BLS), are required to be re-educated according to the change in guidelines [1]. In this study, we determined how much time was saved in initiating chest compressions using the “C-A-B” sequence recommended in the AHA 2010-BLS on a manikin with simulated

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H. Sekiguchi et al. / American Journal of Emergency Medicine 31 (2013) 1248–1250 1249

adult cardiopulmonary arrest. In addition, we determined how much time was spent on setting up of ventilation equipment and performance of rescue breathing, which are factors that delay the onset of chest compressions. We also review the significance of this change in AHA guidelines and the importance of re-education according to the new guidelines. However, this study is based on a simulation program wherein the participants performed chest compressions on a manikin. Therefore, it is still speculative whether the time taken to initiate chest compressions can be decreased in cases of cardiopulmonary arrest in actual medical settings. Further investigation of actual cases of cardiopulmonary arrest and the rates of spontaneous circulation return and rehabilitation in our hos- pital is necessary.

Methods

Study setting and population

Forty health care providers, including 32 registered nurses and 8 physical therapists, were selected as subjects for this study. They all had completed both the 2005-BLS and 2010-BLS programs that complied with the AHA guidelines and were conducted at our hospital. All subjects provided informed consent to participate in this study, which was approved by the Human Ethics Committee of Tomishiro Central Hospital.

Study protocol

The subjects were categorized by age, sex, and occupation (Table 1). Each subject practiced BLS according to both 2005-BLS and 2010-BLS using a Resusci Anne manikin (Laerdal, Tokyo, Japan). A stopwatch was used to measure the amount of time elapsed before the initiation of chest compressions. The stopwatch was started when the subject contacted the manikin to check for consciousness and a response. The end point of measurement was that when chest compressions began. A pocket mask was used as ventilation equipment when rescue breathing was conducted. The pocket mask was kept in a hard case. The subjects reviewed the BLS procedure according to each guideline once before measurement. The following parameters were measured: (1) time taken to initiate chest compressions according to 2005-BLS, (2) time taken to initiate chest compressions according to 2005-BLS without the performance of rescue breathing because ven- tilation equipment was not carried, (3) time taken to initiate chest compressions according to 2010-BLS, (4) time taken to assemble ven- tilation equipment, (5) time taken to perform rescue breathing, and (6) time taken to perform rescue breathing and assemble the ventilation equipment. These items were measured randomly.

Statistical analysis

The results are expressed as mean +- SD (seconds). The Student t test was used to compare the time taken to initiate chest compressions when 2005-BLS was followed with that when 2010- BLS was followed. P b .01 was considered statistically significant.

Results

The time taken to initiate chest compressions when the “A-B-C” sequence recommended in 2005-BLS was followed and a pocket mask was used as ventilation equipment was 36.0 +- 4.1 seconds. In contrast, the time taken to initiate chest compressions according to the “C-A-B” sequence recommended in 2010-BLS was 15.4 +- 3.0 seconds, and all subjects completed the task (P b .001, Student t test). Furthermore, the time taken to initiate chest compressions when 2005-BLS was followed without the performance of rescue breathing was significantly longer (19.8 +- 2.7 seconds) than that (15.4 +- 3.0 seconds) when 2010-BLS was followed (P b .001, Student t test; Fig. 1). The time taken to assemble ventilation equipment was 10.1 +-

2.7 seconds, whereas that for performing 2 rescue breaths using a pocket mask was 7.7 +- 2.8 seconds. Moreover, the time taken to complete 2 rescue breaths and assemble ventilation equipment was

7.7 +- 2.8 seconds (Table 2).

Discussion

The 2010 AHA Guidelines for CPR and ECC introduced the concept of look, listen, and feel during BLS, while they eliminated the step of opening the airway following the breathing check to conduct immediate CPR before chest compression. Therefore, the BLS proce- dure was changed from “A-B-C” (airway, breathing, chest compres- sions) to “C-A-B” (chest compressions, airway, breathing). We determined that the time taken to initiate chest compressions on a manikin with simulated cardiopulmonary arrest was actually shorter when the new guidelines were followed. Although there is no evidence indicating an increase in the rates of spontaneous circulation return and rehabilitation in the ERC guidelines of 2005 and 2010, the BLS procedure that complied with the ERC guidelines has been changed. Furthermore, it has been reported by Roessler et al [2], Kobayashi et al [3], and Lubrano et al [5] that the time taken to initiate chest compressions can be shortened when the new guidelines were followed. Although the 2010 ERC guidelines and the 2010 AHA guidelines for BLS are different in terms of procedures for checking the victim for a response and the time taken to activate the emergency response system and initiate chest compressions, we showed that all subjects achieved a shorter chest compression initiation time after

70

A

B

P < .001

P < .001

60

50

40

30

20

10

0

Table 1

SubjeCT characteristics

G2005 G2010 G2005 without Rescue Breathe

G2010 (Second)

Fig. 1. A, Comparison of time taken to initiate chest compressions between the 2005

Characteristics Total (n = 40)

Age, mean (SD), y	30.7 (5.2)
Male, n (%)	18 (45%)
Occupation, n (%)
Nurse	32 (80%)
Physical therapist	8 (20%)

and 2010 guidelines of the AHA for BLS (2005-BLS and 2010-BLS, respectively). Time from contacting the manikin to initiating chest compressions was 36.0 +- 4.1 seconds when 2005-BLS was followed and 15.4 +- 3.0 seconds when the 2010-BLS was followed (P b .001). B, The time taken to initiate chest compressions was 19.8 +- 2.7 seconds when 2005-BLS was followed without the performance of rescue breathing due to a lack of ventilation equipment and 15.4 +- 3.0 seconds when 2010-BLS was followed (P b .001).

1250 H. Sekiguchi et al. / American Journal of Emergency Medicine 31 (2013) 1248–1250

Table 2

Measurement outcomes

Measurement items Mean

(SD), s

Time taken to initiate chest compressions according to 2005-BLS 36.0 (4.1)

Time taken to initiate chest compressions according to 2005-BLS 19.8 (2.7) without rescue breathing

Time taken to initiate chest compressions according to 2010-BLS 15.4 (3.0)

Time taken to assemble ventilation equipment 10.1 (2.7)

Time taken to perform rescue breathing 7.7 (2.8)

Time taken to perform rescue breathing and assemble the 15.9 (3.8) ventilation equipment

completing their re-education according to the new AHA guidelines [6-14]. At the time when 2005-BLS was developed, health care providers were considered not to have ventilation equipment for cardiopulmonary arrest, indicating that BLS may have actually been performed without rescue breathing. Based on a comparison between time taken to initiate chest compressions according to 2005-BLS without rescue breathing and that according to 2010-BLS, we showed that chest compressions were initiated faster when 2010-BLS was followed and conclude that the new AHA guidelines were better as they allowed for immediate chest compressions. From this result, it is reasonable to conclude that the time taken to initiate chest com- pressions can be saved in Medical care facilities that follow 2010-BLS. In this study, rescue breathing took approximately 15.9 +- 3.8 seconds (range, 9-27 seconds) to complete the sequence from assembling the ventilation equipment to performing 2 rescue breaths. This time may depend on the rescuer’s level of proficiency. According to the new AHA guidelines, rescue breathing should be performed twice after 30 chest compressions, and we showed that time to assemble the ventilation equipment was 10.1 +- 2.7 seconds. Therefore, it is necessary that health care providers re-educate themselves about the rescue breathing procedure that includes assembly of the ventilation equipment to provide high-quality CPR with a combination of chest compressions and rescue breathing. However, this study is based on a simulation program wherein the participants performed chest compressions on a manikin. Certainly, the final goal is to improve the clinical outcomes, recovery, and survival with improved long- term quality of life. However, it is still unclear whether the time taken to initiate chest compressions can be decreased in cases of cardio- pulmonary arrest in actual medical settings. Therefore, it is necessary to evaluate actual cases of cardiopulmonary arrest in our hospital. The results of this study may lead to better resuscitation outcomes in actual medical settings. However, further studies are required to define how the decreased time taken to initiate chest compressions

increases the rates of return of spontaneous circulation and reha- bilitation and decreases neurologic sequelae.

Conclusion

We conclude that the time taken to initiate chest compressions could be shortened on the BLS of the new AHA guidelines using a manikin with simulated cardiopulmonary arrest. Further studies are required to reveal whether this shortened time practically leads to increased rates of spontaneous circulation return and rehabilitation and decreases neurologic sequelae.

Acknowledgments

We express gratitude to Aritoshi Nakaz, Department of Infertility and Endocrinology, ALBA OKINAWA CLINIC, Okinawa, Japan.

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