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Sequence of Chest Compressions and Ventilations:

Question Type:
Full Question:
Among infants and children who are in cardiac arrest in any setting (P), does does the use of a circulation-airway-breathing approach to initial management (I), compared with compared with the use of an airway-breathing-circulation approach to initial management (C), change ROSC, survival to hospital discharge, survival to 180 days with good neurological outcome, time to first compressions (O)?
Consensus on Science:
For the important outcome of time to first chest compression (TFCC), we identified very-low-quality evidence from 3 simulation-based RCTs (all downgraded for imprecision and very serious indirectness), including 2 adult manikin studies(Marsch 2013, w13856; Sekiguchi 2013, 1248-1250) and 1 pediatric manikin study(Lubrano 2012, 1473-1477) showing a reduced time to first chest compression with the use of a C-A-B approach as opposed to A-B-C. Data from 3 simulation-based RCTs showed that TFCC was 18.0 to 24.3 seconds shorter when using a C-A-B sequence (15.4–25.0 seconds) as compared with A-B-C (36.0–43.4 seconds). Furthermore, data from 2 manikin studies(Lubrano 2012, 1473-1477; Marsch 2013, w13856) showed that time to first ventilation is delayed by only 5.7 to 6.0 seconds when using a C-A-B sequence (28.4–43.0 seconds) as compared with A-B-C (22.7–37.0 seconds). There were no clinical (human) studies comparing C-A-B versus A-B-C approaches for the initial management of cardiac arrest that addressed the outcomes of ROSC, survival to hospital admission, or survival to 180 days with good neurologic outcome.
Treatment Recommendation:
The confidence in effect estimates is so low that the panel decided a recommendation was too speculative. Values, Preferences, and Task Force Insights In considering making a recommendation, the task force placed a higher value on the importance of timely rescue breathing as part of CPR over a strategy that significantly delays ventilation when pediatric cardiac arrest is so commonly asphyxial in nature. Both C-A-B and A-B-C approaches for pediatric resuscitation have supportive arguments. The use of a C-A-B approach will lead to simplification of teaching because adult BLS providers use this strategy. The use of an A-B-C approach recognizes the preponderance of asphyxial etiologies in pediatric cardiac arrest and the importance of early ventilation for infants and children. With the availability of only manikin data on this topic, and with the disparate recommendations previously made by various resuscitation councils, the task force concluded that the recommendation would acknowledge that equipoise exists in councils making different guidelines that stem from either argument.
CoSTR Attachments:
ILCOR C2015_Evidence table_CAB vs ABC_CEich_NShimizu_01-02-2015.docx    

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