The ABC of resuscitation and the Dutch (re)treat

Abstract

In 1982 the Netherlands made a unilateral decision to change the established airway–breathing–circulation (ABC) training sequence to a different approach that stressed efficiency in diagnosis and treatment. This Dutch approach became known as the CAB (circulation–airway–breathing) sequence. Twenty years later, being confronted with the new international guidelines (published 2000) that still use the ABC approach, the Netherlands Resuscitation Council (NRR) questioned again the validity of our persistence in using the “Dutch variant” of resuscitation. This resulted in revised national guidelines that conform again with the international guidelines.

This article restates the main rationale and arguments behind the original decision to change to a Dutch (CAB) version of resuscitation over 20 years ago. The national decision to adopt the ABC approach once again was mainly to prevent resuscitation in the Netherlands from being isolated from the rest of the world and was not based on present knowledge of physiology and resuscitation. The authors hope that this article will open the discussion once again.

Introduction

Until the technique of external chest compression was published by Kouwenhoven et al. in 1960 [1], only surgeons and a few specially trained physicians were able to start resuscitation, and this only in-hospital, because a thoracotomy was needed. Even after 1960, the use of external chest compression was reserved initially for physicians only. Since 1962, after training, nurses, respiratory therapists and many other groups including the lay public have also been authorised to apply basic life support (BLS) [2]. The rapid increase in the number of students and courses created the need for standardisation. Safar et al. [3] presented the airway–breathing–circulation (ABC) schedule in 1962. The actual ABC flowchart (Fig. 1) was published in 1974 [4]. Compared with in-hospital resuscitation out-of-hospital resuscitation was still very rare.

In contrast to external chest compressions, authorisation of the practice of mouth-to-mouth ventilation was never in doubt; this technique had been applied for centuries by laymen. The ABC sequence may have been based on this difference in and authorisation between the general public and professionals, and also because professional resuscitation was mainly aimed at the drowning victim and the postoperative patient with depressed respiration where respiratory support was paramount. Coronary care units hardly existed in 1962 and therefore, circulatory collapse was relatively untreated. There was no experimental or clinical evidence to support the ABC sequence and it received criticism both during and after its presentation [3], [5], [6], [7], [8]. Over the years it was modified only slightly (Fig. 2).

In the 1970s the scope of resuscitation changed to include unexpected sudden cardiac death. Criticism of the ABC sequence continued, especially in the Netherlands [8], [9], [10], [11]. It was felt that more attention should be paid to the circulation rather than to airway and breathing. Experimental evidence to support this “reversed” schedule (CAB) was presented [12]. At that time, laymen resuscitation had been started in pilot areas and its value was proven [13]. When Dutch organisations, involved in resuscitation courses for laymen, began training on a large scale, they used the CAB approach in their BLS training [14]. A decade later pilot studies with early defibrillation were started. Since the 1960s the period between the onset of cardiac arrest and start of BLS or advanced life support measures proved over and over again to be the most important factor for a satisfactory outcome. Although other resuscitation concepts and techniques have changed, the ABC schedule has so far survived all developments and counter arguments.

After the publication of the CPR Guidelines in 2000 from the International Liaison Committee on Resuscitation (ILCOR) [15], the Netherlands Resuscitation Council (NRR) had to question again its adherence to the CAB approach after 20 years.

Many believe that the discussion on ABC versus CAB is in fact only a minor detail that distracts attention from the essentials. We disagree with that view. In our experience the CAB approach and the related discussion is easier to use in teaching the pathophysiology of cardiac arrest due to diverse aetiologies. Successful resuscitation is not only a “chain of survival”, but also a chain of knowledge and decisions.

In our opinion we should reconsider the arguments which were once used for the change to the Dutch style of resuscitation.