Tag Archives: CPR

What’s the Deal with CPR ABCs?

The “ABCs” of CPR have always referred to “airway, breathing, and circulation” or, to be more specific:

  • A: Open the airway and make sure it is clear
  • B: Check for breathing; if necessary, give 2 breaths
  • C: Check for signs of circulation (pulse); make sure there is no severe bleeding; give chest compressions in the absence of a pulse or other signs of life

In 2010, when CPR and first aid guidelines were last reviewed, these ABCs were in certain cases modified in an effort to increase the speed and effectiveness of CPR and related care. Understanding the new ABCs of CPR is key to understanding techniques like compression-only CPR and important priorities that make all the difference when seconds count.


The most significant change by far enacted by the Emergency Cardiac Care (ECC) Committee of the American Heart Association consists of rearranging the ABCs of CPR to CAB for patients of sudden cardiac arrest (SCA). CAB means (upon determining you have an unresponsive patient who suddenly collapsed):

  • C: Determine that there is no severe bleeding and begin 30 chest compressions immediately; if you are reluctant to give ventilations or do not have training in that skill, continue to give compressions to the patient until EMS personnel arrive
  • A: If you decide to give breaths, open the airway and make sure it is clear
  • B: Give 2 breaths followed by 30 more compressions

Why CAB Works

This change is designed to get compressions started as quickly as possible for victims that have oxygenated blood. Think about it. The patient was breathing until the moment of collapse. The heart stopped due to an electrical problem, not a lack of oxygen. Giving compressions immediately starts some oxygen-rich blood moving through the body, delivering oxygen to the brain and other vital organs. Taking time to give breaths delays the care this patient really needs.

According to the Sudden Cardiac Arrest Association, SCA is a leading cause of death in the United States, claiming more than 325,000 lives each year. During a sudden cardiac arrest, heart function ceases – abruptly and without warning. When this occurs, the heart is no longer able to pump blood to the rest of the body, and, in some 95 percent of victims, death occurs.

Why Compression-Only CPR Works

CAB is also explains why compression-only CPR works. Since the patient has oxygen in his/her system, performing compression immediately is a more critical care step. A recent study published in the New England Journal of Medicine showed no significant difference between the survival outcomes of patients given compression-only CPR and standard CPR. Compression-only CPR is easier to teach and to perform, especially by bystanders without protective devices learning CPR over the phone.

(For a hilarious American Heart Association public safety announcement starring Ken Jeong, go here.)

So, What About ABC?

Despite the ease and effectiveness of CAB and compression-only CPR for victims of SCA, the ABCs of CPR should still be followed for patients who are hypoxic (without oxygen). This includes the majority of infants and children and cases of respiratory problems that lead to cardiac arrest due to oxygen depletion.

Take a drowning victim for example. This begins as suffocation in water, but the heart usually keeps beating until the oxygen in the blood is used up. Then cardiac arrest occurs. This patient needs ventilations first and then compressions (standard ABC CPR). Giving compression first, or compressions only, to this patient may not be effective due to lack of oxygen in the bloodstream.

What About the “D”?

The “D” stands for defibrillation, administered using an automated external defibrillator (AED). Both patients may benefit from AED administration, which converts disorganized electrical activity in the heart to a normal rhythm. In other words, you can add a D to either ABC or CAB for a more comprehensive solution.

Come to think about it, “E” is for emergency medical services (EMS), which should already have been called (as soon as you know the patient is unconscious). So, now you have a complete chain of survival in both cases:

  • ABCDE for hypoxic patients and children
  • CABDE for adults who suddenly collapse (SCA) or children with known heart conditions



Ranking Layers of Water Safety Protection

A great way to protect your family around the water is to provide layers of protection that prevent access to water, that alert adult caregivers of unexpected pool access, or that provide supervision and self-reliance around the water. Here is a public safety announcement (PSA) by the National Drowning Prevention Alliance (NDPA) that introduces the Safer 3 principle of layers of protection. Here is another PSA by the NDPA with a clever Mission Impossible theme that emphasizes the importance of multiple layers.

Layers of protection have proven to be an effective means of preventing drowning and water-related injuries. Installing overlapping protective measures means that if one fails, others are still in place to do the job of keeping children safe. Any layer you provide that contributes to water safety is worthwhile.

The Need to Rank Protective Layers

Although many water safety groups talk about providing layers of protection, few discuss the need to rank these layers by their relative importance. One theory may be that as long as several overlapping safety measures are in place, it doesn’t matter which one is most important. I have even seen PSAs that quite rightly state that the most important layer was the one that worked when it needed to. Additionally, there really isn’t a scientific way to rank safety measures against one another; any such rating system would be subjective at best.

Still, it is important to recognize that certain protective layers are more applicable to a particular age group, environment, or activity. In fact, certain protective layers that are effective for one group, location, or activity may not work well for others.

For example, take swimming ability. Being able to swim and to self-rescue is a layer of protection that all individuals should develop as they grow up. It should not be the main layer of protection for children under 4 who may not be able to hold their breath, remain afloat, or even find the exit point of a pool or other body of water. Also, swimming ability for children and adults should never encourage swimming alone, overestimating ability, underestimating the environment, or engaging in risky behavior. These possibilities suggest than other layers of protection are necessary even for the best swimmers.

General Layers of Protection

Before ranking layers of protection, let’s list those that apply to everyone. Again, this is a subjective list and not necessarily a comprehensive one:

  • Adult supervision of children at all times
  • Never swim alone; swim with a buddy in an area supervised by lifeguards/water watchers
  • Place barriers (e.g., fences, covers, etc.) around swimming pools and other containers of water with, as appropriate, locks and self-latching gates; use alarms that sound when gates are opened or the water is disturbed.
  • Be within in arm’s reach of small children while you and they are in the water
  • Learn to swim and learn about water safety
  • Learn first aid and CPR
  • Educate your family about pool rules, safe practices, and safe places to swim
  • Use properly sized US Coast Guard lifejackets around cold water and when boating, hunting, fishing, and participating in fast-moving water sports
  • Have an emergency plan, a phone, and rescue/first aid equipment with you at all times

When applied correctly, these layers of protection can be quite effective in preventing drownings and other injuries in and around the water.

Age-Specific Rankings

In the United States, two groups that have the highest drowning rates are children under 5 and young adults from 15 to 24.

  • For the first group, many of the protections listed above can help, but none are more crucial than adult supervision and barriers/alarms. Even recent studies that point to swimming lessons making young children safer around the water are not nearly as important as simply watching constantly and preventing access. (I believe that the exposure to water safety principles at swimming lessons are more of a reason why families with young children benefit than any swimming readiness the infant/toddler might obtain.)
  • For the 15 to 24 year old, having good swimming skills and following corresponding water safety rules and regulations become more important as individuals grow up and learn to apply sound judgment when deciding how to have fun. Parents should still stress safety awareness, set limits, and know where their children are and what they are doing. At this age, children with the best swimming skills may be tempted to swim where waves or currents are too strong, to exceed their abilities, or to attempt risky behaviors such as diving from a height or ocean swimming at night. Being respectful of rules and safe practices is just as important as being an able swimmer.

All other layers of protection need to be in place as applicable, but parents must teach, enforce, and transfer the responsibility for following safe practices to their children as they grow old enough to understand and appreciate these practices. Children who participate in swimming lessons/competitive swimming, who learn to obey the rules and respect the lifeguard, and have aquatic fun safely may even become the lifeguards and swimming instructors of the future, providing another layer of protection as they help other children to develop this knowledge and these skills.

On Being an Unexpected Layer of Protection

My very last rescue occurred a few years back as a “civilian” at Wood’s Cove in Laguna Beach, California. I had been snorkeling alone (oops!) and was coming in after a brisk hour out around the rocks and kelp beds. I remember I had seen a small octopus that day speeding away from me and giant sea bass hanging out just beyond the rocks, enormous and seemingly unafraid of anything.

As a I got close to shore, I saw a boy get picked up by a wave and carried out a few feet from the steeply angled shore.

As I looked at the boy, he appeared to be running in place, head above water, with eyes wide and white. He was holding his own above water but his eyes told me he was afraid. I swam to him and asked if he needed help. He shook his head to say yes. I looked around and saw that there were two lifeguard stationed talking to one another. There was no parent in sight.

So, with masks and fins handing from one arm by their straps, I picked the boy up by the armpits and placed him on the shore about 2 yards away from where he had been. Again, I looked at the lifeguards and searched the beach for a parent who should now be approaching if he/she saw me picking up his/her child. No one saw what I did. Not the lifeguards and not any one else.

I found out the boy’s name was Jason. I asked Jason where his mother or father was. Jason pointed to a woman seated on a towel, reading a magazine. I told Jason to be more careful, and he said goodbye. As I walked across the beach to the street where I parked my car, I told the mother what had just happened and commented that she should “take her nose out of her magazine and keep a better eye on her child.” She seemed insulted as I walked on. I didn’t bother to say anything else or to speak to the lifeguards still carrying on their conversation.

Jason needs to learn to swim, and he also needs to learn about waves and moving water. Jason’s mother needs to watch her child; she should read her magazine at home or while Jason is taking a rest beside her. The lifeguards were not doing their job at all; neither one was watching the water or they would have seen me picking Jason up and putting him down on the shore. These layers of protection had failed, and this is why drownings occur with parents and lifeguards present.

I guess another way to rank layers of protection for water safety is the layer the does the job—in this case, a bystander with lifeguard experience who just happened to be in the right place at the right time.