Chain of Survival

AHA Pediatric Chain of Survival
More children and infants survive cardiac arrest when a certain sequence of events happens as quickly as possible. This series of steps is called the Pediatric Chain of Survival. The Chain of Survival is a series of links in a chain to describe actions to save a child or infant victim of cardiac arrest:

  • Injury prevention and safety
  • Early CPR with an emphasis on chest compressions
  • Early access to emergency care. In most communities, phone 911 accesses the EMS system.
  • Early pediatric advanced life support.
  • Comprehensive post-arrest care. This is a new addition chain as compared to the four-chain concept in 2005 guidelines.


Pediatric Chain of Survival | Child CPR | CPR for Children

AHA ECC Adult Chain of Survival
The links in the new AHA ECC Adult Chain of Survival are as follows:

  • Immediate recognition of cardiac arrest and activation of the emergency response system
  • Early CPR with an emphasis on chest compressions
  • Rapid defibrillation
  • Effective advanced life support
  • Integrated post-cardiac arrest care


Adult Chain of Survival | Adult CPR | CPR Techniques


There has been no change in the recommendation for a compression-to-ventilation ratio of 30:2 for single rescuers of adults, children, and infants (excluding newly born infants). The 2010 AHA Guidelines for CPR and ECC continue to recommend that rescue breaths be given in approximately 1 second. Once an advanced airway is in place, chest compressions can be continuous (at a rate of at least 100/min) and no longer cycled with ventilations. Rescue breaths can then be provided at about 1 breath every 6 to 8 seconds (about 8 to 10 breaths per minute). Excessive ventilation should be avoided.

  • Allowing for complete chest recoil after each compression
  • Minimizing interruptions in chest compressions
  • Avoiding excessive ventilation

A Change From A-B-C to C-A-B

The 2010 AHA Guidelines for CPR and ECC recommend a change in the BLS sequence of steps from A-B-C (Airway, Breathing, Chest compressions) to C-A-B (Chest compressions, Airway, Breathing) for adults, children, and infants (excluding the newly born; see Neonatal Resuscitation section). This fundamental change in CPR sequence will require reeducation of everyone who has ever learned CPR, but the consensus of the authors and experts involved in the creation of the 2010 AHA Guidelines for CPR and ECC is that the benefit will justify the effort.

Why: The vast majority of cardiac arrests occur in adults, and the highest survival rates from cardiac arrest are reported among patients of all ages who have a witnessed arrest and an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). In these patients, the critical initial elements of BLS are chest compressions and early defibrillation. In the A-B-C sequence, chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths, retrieves a barrier device, or gathers and assembles ventilation equipment. By changing the sequence to C-A-B, chest compressions will be initiated sooner and the delay in ventilation should be minimal (ie, only the time required to deliver the first cycle of 30 chest compressions, or approximately 18 seconds; when 2 rescuers are present for resuscitation of the infant or child, the delay will be even shorter).

Most victims of out-of-hospital cardiac arrest do not receive any bystander CPR. There are probably many reasons for this, but one impediment may be the A-B-C sequence, which starts with the procedures that rescuers find most difficult, namely, opening the airway and delivering breaths. Starting with chest compressions might encourage more rescuers to begin CPR.

Basic life support is usually described as a sequence of actions, and this continues to be true for the lone rescuer. Most healthcare providers, however, work in teams, and team members typically perform BLS actions simultaneously. For example, one rescuer immediately initiates chest compressions while another rescuer gets an automated external defibrillator (AED) and calls for help, and a third rescuer opens the airway and provides ventilations.

Healthcare providers are again encouraged to tailor rescue actions to the most likely cause of arrest. For example, if a lone healthcare provider witnesses a victim suddenly collapse, the provider may assume that the victim has had a primary cardiac arrest with a shockable rhythm and should immediately activate the emergency response system, retrieve an AED, and return to the victim to provide CPR and use the AED. But for a presumed victim of asphyxial arrest such as drowning, the priority would be to provide chest compressions with rescue breathing for about 5 cycles (approximately 2 minutes) before activating the emergency response system.


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