Put away your ABCs, and start learning your CAB – compressions, airway, and breathing. That’s the message from the American Heart Association for both adult and pediatric cardiopulmonary resuscitation in the “2020 American Heart Association Guidelines for CPR and ECC.”

The AHA now says both lay people and healthcare professionals should start CPR by compressing the chest at least 100 times a minute. “Look, listen and feel” is out of the basic life support algorithm for laypeople.

“Opening the airway and delivering breaths is the most challenging skill for CPR and requires some sort of equipment such as a pocket mask or bag/valve mask,” said Mary Fran Hazinski, RN, MSN, FAAN, co-chair of the 2016 International Liaison Committee on Resuscitation and co-lead author of the executive summary of its recommendations. “It can stall the whole resuscitation effort.”

Focusing on this basic skill will encourage bystanders to act. “Some compressions are better than no compressions,” according to Hazinski, who is a professor at Vanderbilt University School of Nursing.

Healthcare professionals should still assess for breathing simultaneously with assessing unresponsiveness. After alerting the EMS and sending someone for an automated external defibrillator if one is available, do a quick pulse check. “Even healthcare professionals can have trouble finding a pulse, so don’t spend more than 10 seconds checking,” said Beth Mancini, RN, PhD, NE-BC, FAHA, FAAN, professor and associate dean at the University of Texas at Arlington College of Nursing and co-chair of ILCOR’s Education, Implementation and Teams Task Force. “If there is no pulse, begin CPR, starting with compressions.

Although those with years of experience with “airway first” might balk, Mancini said, “An adult arrest is typically a cardiac event, and the individual needs compressions to circulate the blood. Research shows there is usually enough oxygen in the blood in the heart and the rest of the body, you just need to keep it circulating to the heart and brain with high-quality compressions. That can continue until advanced life support arrives.” Making the airway top priority can delay compressions by 30 seconds or more.

Hazinski said starting with compressions shouldn’t significantly delay airway management for healthcare professionals since they are working in a team. “Teams perform action and skills simultaneously so they are already performing simultaneous activities.”

Quality CPR and Defibrillation

Research has shown that quality CPR boosts the chance of successful resuscitation. “You need to push hard and push fast to keep the oxygenated blood circulating, and let the chest completely recoil between compressions,” said Diana Cave, RN, MSN, writing-group chair for the 2020 AHA Guidelines chapter on CPR techniques and devices and immediate past chair of the AHA BLS subcommittee. She said that nurses can make sure compressions are done correctly: “The nurse is the one who says, ‘You’re doing a great job, you’re generating a blood pressure,’ or, ‘The CPR isn’t effective, we need someone else to take over compressions.'”

Nurses also need to monitor the time “off the chest,” keeping interruption of chest compressions to a minimum. “We should not be interrupting compressions to intubate,” said Mary Cotogno, RNC, director of the New Jersey affiliate for Training for Life Inc., an international, nonprofit CPR training center. “It takes 18 seconds from the time you start compressions to when you perfuse the brain, so every second counts.”

A shock should be delivered as soon as possible, followed immediately by more compressions, said Cotogno, adding that when a patient is defibrillated with an AED within 3 to 6 minutes, there is a 90% success rate for return of spontaneous circulation. “Everything is about pushing and shocking. That is what is going to perfuse the brain.”