Summary Document - LifeForceUSA, Inc. · G2015&Guidelines&Summary&©2015Health&&&Safety&Institute&...

Summary DocumentSummary Document

Protecting and Saving Lives Made Easy™

G2015 Guidelines Summary ©2015 Health & Safety Institute

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Table of Contents Introduction ................................................................................................................................................... 2

About Health & Safety Institute (HSI) ........................................................................................................... 2

Integrating 2015 Science, Treatment Recommendations, and Guidelines .................................................. 2

Update Subjects by Brand ............................................................................................................................. 3

American Safety & Health Institute (ASHI) ........................................................................................ 4

MEDIC First Aid .................................................................................................................................. 4

Update Subjects by Area and Training Level

TABLE 1: Education ........................................................................................................................... 5

TABLE 2: Layperson Adult CPR and AED ............................................................................................ 8

TABLE 3: Layperson Pediatric CPR and AED ...................................................................................... 15

TABLE 4: First Aid .............................................................................................................................. 17

TABLE 5: Healthcare Provider Adult BLS ........................................................................................... 33

TABLE 6: Healthcare Provider Pediatric BLS ...................................................................................... 43

HSI Advisory Group ........................................................................................................................................ 45


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Introduction The purpose of the document is to highlight the major changes in science, treatment recommendations, and guidelines. We are hopeful that it and other resources related to the process will provide helpful guidance to both instructors and students during the transition. On October 15, 2015, the International Liaison Committee on Resuscitation, or ILCOR, released the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. On the same day the American Heart Association, Inc. (AHA) released updated treatment guidelines based on the ILCOR Consensus on Science. In addition, the ILCOR First Aid Task Force also released the 2015 International Consensus on First Aid Science With Treatment Recommendations which coincided with the release of the 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. The Consensus on Science process, which spanned a five year period, was designed to identify and review international science and knowledge relevant to cardiopulmonary resuscitation, emergency cardiac care, and first aid treatment. These publications provide updated treatment recommendations for emergency medical care based on the most current scientific evidence and are now being integrated into updated ASHI and MEDIC First Aid training materials. About Health & Safety Institute (HSI) HSI unites the recognition and expertise of the American Safety & Health Institute and MEDIC First Aid to create the largest privately held training organization in the industry. For more than 35 years, and in partnership with thousands of approved training centers and hundreds of thousands of professional emergency care, safety, and health educators, HSI authorized instructors in the U.S. and more than 100 countries throughout the world have certified more than 28 million emergency care providers. HSI representatives for ASHI and MEDIC First Aid were volunteer members of the 2010 and 2015 International First Aid Advisory Board founded by the AHA and ARC, and contributed to the 2010 and 2015 Consensus on First Aid Science With Treatment Recommendations. HSI is an accredited organization of the Continuing Education Board for Emergency Medical Services (CECBEMS), the national accreditation body for Emergency Medical Service Continuing Education programs. CECBEMS is an organization established to standardize the review and approval of EMS continuing education activities. To ensure accepted standards, CECBEMS accreditation requires an evidence-‐based peer-‐review process for continuing education programs comparable to all healthcare accreditors. HSI’s professional-‐level resuscitation programs are CECBEMS-‐approved and meet the requirements of the Joint Commission and the Commission on Accreditation of Medical Transport Systems. HSI’s basic-‐ and professional-‐level programs are nationally approved by the Department of Homeland Security, United States Coast Guard, and are endorsed, accepted, approved, or meet the requirements of more than nearly 4000 state regulatory agencies and occupational licensing boards. HSI is a member of the American National Standards Institute and ASTM International, two of the largest voluntary standards-‐development and conformity-‐assessment organizations in the world. Integrating the 2015 Science, Treatment Recommendations, and Guidelines In order to integrate the 2015 science, treatment recommendations, and guidelines, time is required to make systematic and organized changes to our training products. We are currently revising all of our emergency care training materials and will incorporate the updated information into our basic and advanced training program materials throughout 2016.


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Updated ASHI and MEDIC First Aid training program materials will be based upon these publications:

� 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendationsi

� 2015 International Consensus on First Aid Science With Treatment Recommendationsii � 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency

Cardiovascular Careiii � 2015 American Heart Association and American Red Cross Guidelines Update for First Aidiv

We will be creating interim training materials that allow instructors to immediately incorporate some of the most significant changes in science and treatment recommendations into current (2010) training materials. The interim materials are only intended to be used until the new training programs are made available. The use of these interim materials is an option and not a requirement. Instructors can also continue to use the current (2010) materials as designed. IMPORTANT: THE NEW SCIENCE AND TREATMENT RECOMMENDATIONS DO NOT IMPLY THAT EMERGENCY CARE OR INSTRUCTION INVOLVING THE USE OF EARLIER SCIENCE AND TREATMENT RECOMMENDATIONS IS UNSAFE. YOU MAY CONTINUE TO PURCHASE AND TEACH USING THE CURRENT (2010) TRAINING MATERIALS UNTIL DECEMBER 31, 2016, OR UNTIL THE CURRENT MATERIALS ARE DEPLETED. Update Subjects by Brand Every instructor needs to understand the guideline changes that affect the program(s) he or she is authorized to teach. On the following pages the most significant guideline changes are organized into tables by area and training level. For each identified change, the guideline tables provide the 2010 guideline for reference, the updated 2015 guideline, and the reason for the change. To assist instructors, the program tables immediately below reference the guideline tables an instructor must review in relation to the current programs he or she is authorized to teach. Instructors for the ASHI Advanced Cardiac Life Support (ACLS) and the Pediatric Advanced Life Support (PALS) training programs can find specific guideline tables for those programs in a separate 2015 HSI Updated Training Guidelines Supplement that will be released in the coming weeks.


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American Safety & Health Institute Training Programs

If you teach: Related changes are in:

CPR/AED Tables 1, 2, 3 Basic First Aid Tables 1, 2, 3, 4 Basic Wilderness & Wilderness First Aid Tables 1, 2, 3, 4 Child and Babysitting Safety Tables 1, 2, 3, 4 Emergency Oxygen Administration Tables 1, 2, 3, 4 CPR Pro Tables 1, 5, 6 Emergency Medical Responder Tables 1, 5, 6 Wilderness First Responder Tables 1, 5, 6 Wilderness EMT Upgrade Tables 1, 5, 6

MEDIC First Aid Training Programs

If you teach: Related changes are in:

BasicPlus CPR, AED, and First Aid for Adults Tables 1, 2, 3, 4 Child/Infant CPR and AED Supplement Tables 1, 2, 3 CarePlus CPR and AED Tables 1, 2, 3 PediatricPlus CPR, AED and First Aid for Children, Infants, and Adults Tables 1, 2, 3, 4


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TABLE 1: Education

Topic Type 2010* 2015** Reason for Change Basic Life Support Training

Updated

Because even minimal training in AED use has been shown to improve performance in simulated cardiac arrests, training opportunities should be made available and promoted for lay rescuers. S922

A combination of self-‐instruction and instructor-‐led teaching with hands-‐on training can be considered as an alternative to traditional instructor-‐led courses for lay providers. If instructor-‐led training is not available, self-‐directed training may be considered for lay providers learning AED skills (Class IIb, LOE C-‐EO). S564

Although AEDs are located in public areas and untrained providers are encouraged to use them, even minimal training can improve actual performance. Self-‐directed training can provide more training opportunities for lay rescuers who typically would not attend a traditional training course.

Basic Life Support Training

Updated

Short video instruction combined with synchronous hands-‐on practice is an effective alternative to instructor-‐led BLS courses. S922

CPR self-‐instruction through video-‐ and/or computer-‐based modules paired with hands-‐on practice may be a reasonable alternative to instructor-‐led courses (Class IIb, LOE C-‐LD). S564

Video-‐based, self-‐directed instruction in CPR with hands-‐on practice has been found to be as effective as traditional instructor-‐led courses. Self-‐directed instruction could help to train more people at a lower cost.


Updated

The use of a CPR feedback device can be effective for training. S923

Use of feedback devices can be effective in improving CPR performance during training (Class IIa, LOE A). S564

Today's technology allows us to effectively measure high performance CPR recommendations such as compression rate, depth, and recoil using standalone or manikin-‐integrated feedback devices. The ability to provide that feedback in training allows learners to get a realistic sense of proper skills and the effort it takes to perform them.


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TABLE 1: Education Topic Type 2010* 2015** Reason for Change


Updated

The use of a CPR feedback device can be effective for training. S923

If feedback devices are not available, auditory guidance (eg, metronome, music) may be considered to improve adherence to recommendations for chest compression rate only (Class IIb, LOE B-‐R). S564

If a comprehensive feedback device is not available for training due to cost or logistics, an auditory guidance device such as a metronome can be used to provide some guidance as to compression rate. Many metronome apps are available for no or low cost for mobile devices.


Updated

Skill performance should be assessed during the 2-‐year certification with reinforcement provided as needed. S923

Given the rapidity with which BLS skills decay after training, coupled with the observed improvement in skill and confidence among students who train more frequently, it may be reasonable for BLS retraining to be completed more often by individuals who are likely to encounter cardiac arrest (Class IIb, LOE C-‐LD). S566

A renewal or recertification period of two years has proven for most people to be inadequate for maintaining effective CPR performance. An optimal time for retraining can vary from person to person depending on factors such as the quality of initial training and the frequency in which the skills are used in actual resuscitations. Evidence has shown an improvement in those who train more frequently.


New

Self-‐directed methods can be considered for healthcare professionals learning AED skills (Class IIb, LOE C-‐EO). S564

Similar to the recommendation for lay rescuers, self-‐directed training can provide more frequent training opportunities for healthcare providers.


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TABLE 1: Education Topic Type 2010* 2015** Reason for Change

Special Considerations

New

Communities may consider training bystanders in compression-‐only CPR for adult out-‐of-‐hospital cardiac arrest as an alternative to training in conventional CPR (Class IIb, LOE C-‐LD). S566

While it is important to still cover both breaths and compressions for trained providers because of the chance of a respiratory-‐related arrest, sudden cardiac arrests involving adults are still a major overall issue for the public at large. Compression-‐only CPR by an untrained bystander has shown to be effective as an initial approach to SCA and can be quickly understood via a public service announcement, large group presentation, or by an EMS dispatcher over the phone.

Special Considerations

New

Training primary caregivers and/or family members of high-‐risk patients may be reasonable (Class IIb, LOE C-‐LD), although further work needs to help define which groups to preferentially target. S566

CPR performed by trained family members or caregivers of individuals who have been identified as high-‐risk cardiac patients, has shown to improve outcomes compared to situations in which there was no training.

*American Heart Association. “2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Circulation 122, suppl 3 (2010): S639-‐S946. **American Heart Association. “2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Circulation 132, suppl 2 (2015): S313-‐S589.


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TABLE 2: Layperson Adult CPR and AED

Topic 2010* 2015** Reason for Change Untrained Lay Rescuer

Updated Because it is easier for rescuers receiving telephone CPR instructions to perform Hands-‐Only (compression only) CPR than conventional CPR (compressions plus rescue breathing), dispatchers should instruct untrained lay rescuers to provide Hands-‐Only CPR for adults with SCA (Class I, LOE B). S686

Untrained lay rescuers should provide compression-‐only CPR, with or without dispatcher assistance (Class I, LOE C-‐LD). The rescuer should continue compression-‐only CPR until the arrival of an AED or rescuers with additional training (Class I, LOE C-‐LD). S416

Compression-‐only CPR, provided by a bystander for adult cardiac arrest outside of a hospital, has shown to be as effective as traditional CPR. Due to the simplicity of compression-‐only CPR, untrained bystanders may be able to provide some early treatment for adult sudden cardiac arrest, a major public health crisis. Information on compression-‐only CPR can be distributed in messaging to large numbers of people, such as through public service announcements. It can also be easily promoted through a phone conversation with an EMS dispatcher. It has been shown that compression-‐only CPR initiated through dispatcher instructions has improved survival compared to traditional CPR. It is important to note that the use of compression-‐only CPR is limited to very specific circumstances and does not take the place of formal training in CPR, which includes training in delivering rescue breaths.


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TABLE 2: Layperson Adult CPR and AED Topic 2010* 2015** Reason for Change

Layperson—Compression-‐ Only CPR Versus Conventional CPR

Updated Because rescue breathing is an important component for successful resuscitation from pediatric arrests (other than sudden, witnessed collapse of adolescents), from asphyxial cardiac arrests in both adults and children (eg, drowning, drug overdose) and from prolonged cardiac arrests, conventional CPR with rescue breathing is recommended for all trained rescuers (both in hospital and out of hospital) for those specific situations (Class IIa, LOE C). S 691

All lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest (Class I, LOE C-‐LD). In addition, if the trained lay rescuer is able to perform rescue breaths, he or she should add rescue breaths in a ratio of 30 compressions to 2 breaths.(Class I, LOE C LD).S417

The 2015 evidence evaluation found no overall differences between compression-‐only and conventional CPR (compressions plus breaths). However, much of the research has been done on persons assumed to have suffered sudden cardiac arrest. When considering the importance of rescue breaths in CPR delivery, the underlying cause matters. Compression-‐only CPR can be effective early in a sudden cardiac arrest, where the underlying initial cause is the disruption of the heart's own electrical pathway and resulting ventricular fibrillation. Unfortunately, without a quick AED or EMS response, there is a point at which the absence of rescue breaths may reduce survival because of inadequate oxygen and increased carbon dioxide in the blood. Cardiac arrest can also be the progressive end result of the loss of an airway and/or breathing. In these cases, the inclusion of rescue breaths could actually reverse the progression and restore breathing and circulation. While compression-‐only CPR can quickly be understood without formal training, those who choose to be trained benefit from learning both compressions and rescue breaths. Consequently, if a trained lay rescuer can perform rescue breaths, they should be provided.


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Cardiac or Respiratory Arrest Associated With Opioid Overdose

New and Updated

There are no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose.S840

Empiric administration of IM or IN naloxone to all unresponsive opioid associated life-‐threatening emergency patients may be reasonable as an adjunct to standard first aid and non–healthcare provider BLS protocols (Class IIb, LOE C-‐EO). S505

In high doses, opioids such as morphine, heroin, tramadol, oxycodone, and methadone can cause respiratory depression and death. Opioid overdose is a public health crisis. Naloxone is an antidote to opioid overdose and can completely reverse its effects if administered in time. Naloxone administered by bystanders -‐ particularly by family members and friends of those known to be addicted is a potentially life-‐saving treatment.


New

Unless the patient refuses further care, victims who respond to naloxone administration should access advanced healthcare services (Class I, LOE C-‐EO) S506. Responders should not delay access to more-‐advanced medical services while awaiting the patient’s response to naloxone or other interventions (Class I, LOE C-‐EO). S505

While naloxone administered by bystanders is a potentially life-‐saving treatment, it should not be seen as a replacement for more advanced medical care. The 2015 evidence evaluation determined that naloxone administration improves spontaneous breathing and consciousness in the majority of persons treated, and complication rates are low. However, activation of EMS and CPR should never be delayed for naloxone administration.


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New Victims who respond to naloxone administration should access advanced healthcare services (Class I, LOE C-‐EO). Responders should not delay access to more-‐advanced medical services while awaiting the patient’s response to naloxone or other interventions (Class I, LOE C-‐EO). S505

Providing naloxone to individuals most likely to witness an opioid overdose (bystanders, friends, family) and training them on its use can substantially reduce the deaths resulting from opioid overdose.


New It is reasonable to provide opioid overdose response education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose (Class IIa, LOE C-‐LD). It is reasonable to base this training on first aid and non–healthcare provider BLS recommendations rather than on more advanced practices intended for healthcare providers (Class IIa, LOE C-‐EO). S418, S505

Educating those most at risk, along with others who have close contact with those at risk, can improve the speed at which naloxone can be provided.


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Chest Compression Depth

Updated The adult sternum should be depressed at least 2 inches (5 cm) (Class IIa, LOE B) S690

During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches or 5 cm for an average adult, while avoiding excessive chest compression depths (greater than2.4 inches or 6 cm) (Class I, LOE C-‐LD). S419

Most CPR compressions are too shallow and it is more effective to compress deeper rather than shallower. Defining an upper limit can help rescuers better understand the allowance for a greater depth. The upper limit also helps rescuers understand that, at some point, compressions become less effective and that there is a small risk of injury. The use of feedback devices during resuscitation may also help rescuers to better achieve the recommended depth range.

Chest Compression Rate

Updated It is therefore reasonable for lay rescuers and healthcare providers to perform chest compressions for adults at a rate of at least 100 compressions per minute (Class IIa, LOE B). S690

In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100/min to 120/min (Class IIa, LOE C-‐LD). S419

Defining an upper limit for compression rate, or speed, can help rescuers focus on achieving an optimum approach during CPR. A faster compression rate of more than 100 compressions per minute has shown to be more effective. However, rates above 120 have shown to diminish overall effectiveness, especially in terms of reduced compression depth. Again, feedback devices can help keep compression rates on track.


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Chest Wall Recoil

Updated Allow the chest to completely recoil after each compression (Class IIa, LOE B). S690

It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest (Class IIa, LOE C-‐LD). S420

Better describing chest recoil in terms of how a rescuer most likely causes it to happen, may help to reduce its occurrence. Rescuers can concentrate on allowing full expansion of the chest if they do not feel like they are leaning on the chest at the top of each compression.

Minimizing Interruptions in Chest Compressions

New In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR with the goal of a chest compression fraction as high as possible, with a target of at least 60% (Class IIb, LOE C-‐LD). S420

Research has shown the benefit of minimizing interruptions to chest compressions during CPR. A compression fraction is the percentage of time during overall CPR performance that chest compressions are actually being provided. While there are necessary interruptions such as giving rescue breaths and using an AED, keeping those to the shortest time possible remains a point of emphasis for high quality CPR.


Updated Performing chest compressions while another rescuer retrieves and charges a defibrillator improves the probability of survival. S694

In adult cardiac arrest, total pre-‐shock and post-‐shock pauses in chest compressions should be as short as possible (Class I, LOE C-‐LD). S420

Because shorter pauses were associated with greater shock success, return of spontaneous circulation, and higher survival to hospital discharge in some studies, minimizing interruptions in chest compressions remains a point of emphasis for high quality CPR.


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Updated Deliver each rescue breath over 1 second (Class IIa, LOE C). S688

For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to pause compressions for less than 10 seconds to deliver 2 breaths (Class IIa, LOE C-‐LD). S420

Remembering that avoiding excessive volume on rescue breaths is a goal of high quality CPR, being able to deliver 2 effective rescue breaths as quickly as possible, and under 10 seconds, is recommended.



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TABLE 3: Layperson Pediatric CPR and AED

Topic Type 2010* 2015** Reason for Change Components of High-‐Quality CPR: Chest Compression Rate and Depth

Updated Chest compressions of appropriate rate and depth. “Push fast”: push at a rate of at least 100 compressions per minute. “Push hard”: push with sufficient force to depress at least one third the anterior-‐posterior (AP) diameter of the chest or approximately 1 1⁄2 inches (4 cm) in infants and 2 inches (5 cm) in children (Class I, LOE C). S864

To maximize simplicity in CPR training, in the absence of sufficient pediatric evidence, it is reasonable to use the adult chest compression rate of 100/min to 120/min for infants and children (Class IIa, LOE C-‐EO). S521

There was very little evidence in regard to an ideal compression depth to recommend for a child or infant. To simplify the overall CPR information, the recommendation was to be consistent with the adult recommendation.

Components of High-‐Quality CPR: Chest Compression Rate and Depth


It is reasonable that in pediatric patients (1 month to the onset of puberty) rescuers provide chest compressions that depress the chest at least one third the anterior-‐posterior diameter of the chest. This equates to approximately 1.5 inches (4 cm) in infants to 2 inches (5 cm) in children (Class IIa, LOE C-‐LD). S521

There was very little change in the pediatric compression depth recommendation from the previous recommendation in 2010.


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TABLE 3: Layperson Pediatric CPR and AED Topic Type 2010* 2015** Reason for Change

Components of High-‐Quality CPR: Compression-‐Only CPR

Updated

Optimal CPR in infants and children includes both compressions and ventilations, but compressions alone are preferable to no CPR (Class 1 LOE B). S867

Conventional CPR (rescue breathing and chest compressions) should be provided for pediatric cardiac arrests (Class I, LOE B-‐NR). The asphyxial nature of the majority of pediatric cardiac arrests necessitates ventilation as part of effective CPR. However, because compression-‐only CPR is effective in patients with a primary cardiac event, if rescuers are unwilling or unable to deliver breaths, we recommend rescuers perform compression-‐only CPR for infants and children in cardiac arrest (Class I, LOE B-‐NR). S522

When considering the importance of rescue breaths in CPR, the underlying cause matters. In adults, most cardiac arrests are sudden and caused by abnormal heart rhythms. Compression-‐only CPR is focused on these arrests in an attempt to circulate oxygen still available within the blood. Cardiac arrest in infants and children is rarely sudden. Most occur as a result of a severe oxygen shortage in the body, or asphyxia, when breathing is restricted or stops. Causes include respiratory diseases, suffocation, strangulation, submersion, and choking. Giving rescue breaths to a child is extremely important. Rescue breaths improve oxygenation which may prevent brain damage and restore breathing and circulation. Studies show that the use of compression-‐only CPR on pediatric patients was associated with worse neurologic outcomes when compared with conventional CPR. Thus, rescue breaths remain a critically important component of effective CPR for infants and children in cardiac arrest.



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TABLE 4: First Aid

Topic Type 2010* 2015** Reason for Change Burns

Updated

Cool thermal burns with cold (15° to 25°C) tap water as soon as possible and continue cooling at least until pain is relieved (Class I, LOE B). S937

Cool thermal burns with cool or cold potable water as soon as possible and for at least 10 minutes (Class I, LOE B-‐NR). S580

Early cooling of a burn has been found to minimize the risk and depth of injury. Both cool and cold water can be effective. The use of ice is not recommended and the time to cool a burn has been more clearly defined.

Burns

Updated

Loosely cover burn blisters with a sterile dressing but leave blisters intact because this improves healing and reduces pain (Class IIa, LOE B). S937

After cooling of a burn, it may be reasonable to loosely cover the burn with a sterile, dry dressing (Class IIb, LOE C-‐LD). S580

The use of a dry, sterile dressing on a burn after cooling may be reasonable to help keep the burn clean.

Burns

New

If cool or cold water is not available, a clean cool or cold, but not freezing, compress can be useful as a substitute for cooling thermal burns (Class IIa, LOE B-‐NR). S580

Early cooling of a burn has been found to minimize the risk and depth of injury. Clean, cool, or cold (not frozen) dressings can be used as a substitute when running water is not immediately available.

Burns

New

Care should be taken to monitor for hypothermia when cooling large burns (Class I, LOE C-‐EO). S580

For larger and deeper burns, cooling could have a secondary effect of cooling the body overall and causing hypothermia. This is especially true for children.


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TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change

Burns

New

In general, it may be reasonable to avoid natural remedies, such as honey or potato peel dressings (Class IIb, LOE C-‐LD). However, in remote or wilderness settings where commercially made topical antibiotics are not available, it may be reasonable to consider applying honey topically as an antimicrobial agent (Class IIb, LOE C-‐LD). S580

Honey has shown in some studies to actually decrease the risk of infection and healing time for burns. However, the studies were questioned in regard to the quality of the information. At this time, it is generally recommended to avoid natural remedies for burn dressings. Using honey as a topical agent in a remote or wilderness setting when antibiotic ointments are not available may be a reasonable consideration for reducing the risk of infection.

Burns

New

Burns associated with or involving (1) blistering or broken skin; (2) difficulty breathing; (3) the face, neck, hands, or genitals; (4) a larger surface area, such as trunk or extremities; or (5) other cause for concern should be evaluated by a healthcare provider (Class I, LOE C-‐EO). S580

Burns most likely to have secondary complications such as infection, restrictions on function, or poor healing due to surface contact or repeated movements, should be evaluated by a healthcare provider.

Dental Injury

New

Following dental avulsion, it is essential to seek rapid assistance with reimplantation (Class I, LOE C-‐EO). S580

Immediate reimplantation of an avulsed tooth is felt to provide the best chance of survival for the tooth.


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Dental Injury

Updated

Place the tooth in milk, or clean water if milk is not available. S939

In situations that do not allow for immediate reimplantation, it can be beneficial to temporarily store an avulsed tooth in a variety of solutions shown to prolong viability of dental cells (Class IIa, LOE C-‐LD). If none of these solutions are available, it may be reasonable to store an avulsed tooth in the injured person’s saliva (not in the mouth) pending reimplantation (Class IIb, LOE C-‐LD). S580

When a situation forces a delay in reimplantation, certain solutions have shown to prolong the time period in which successful reimplantation can occur. In order of preference, the solutions are Hank’s Balanced Salt Solution (containing calcium, potassium chloride and phosphate, magnesium chloride and sulfate, sodium chloride, sodium bicarbonate, sodium phosphate dibasic and glucose), propolis, egg white, coconut water, Ricetral, or whole milk. If these solutions are not immediately available for the storage of an avulsed tooth, it may be reasonable to store the tooth in the saliva of the affected person. Due to the risk of additional tooth damage or accidentally swallowing the tooth, it is not recommended to store the tooth in the affected person's mouth.

First Aid Education New

Education and training in first aid can be useful to improve morbidity and mortality from injury and illness (Class IIa, LOE C-‐LD). S575

Studies have shown that education and training in first aid can help to improve the recognition, resolution, and survival of medical emergencies.


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Medical Emergencies: Anaphylaxis

Updated

In unusual circumstances, when advanced medical assistance is not available, a second dose of epinephrine may be given if symptoms of anaphylaxis persist. S936

When a person with anaphylaxis does not respond to the initial dose, and arrival of advanced care will exceed 5 to 10 minutes, a repeat dose may be considered (Class IIb, LOE C-‐LD). S577

Greater clarification of the need and timing for a second dose of epinephrine when the symptoms of anaphylaxis do not respond to the first dose and advanced medical care is still not available.

Medical Emergencies: Asthma

Updated

First aid providers are not expected to make a diagnosis of asthma, but they may assist the victim in using the victim’s prescribed bronchodilator medication (Class IIa, LOE B) under the following conditions: ● The victim states that he or she is having an asthma attack or symptoms associated with a previously diagnosed breathing disorder, and the victim has the prescribed medications or inhaler in his or her possession. ● The victim identifies the medication and is unable to administer it without assistance. S936

It is reasonable for first aid providers to be familiar with the available inhaled bronchodilator devices and to assist as needed with the administration of prescribed bronchodilators when a person with asthma is having difficulty breathing (Class IIa, LOE B-‐R). S576

Inhaled bronchodilators have shown to be an effective treatment for asthma and other breathing disorders related to the narrowing of the small breathing passages in the lungs. The risk of adverse reactions from using these medications is low. Being familiar with the use of these devices and being able to assist someone in using one are reasonable training goals for a first aid provider.


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Medical Emergencies: Chemical Eye Injury

New

First aid providers caring for individuals with chemical eye injury should contact their local poison control center or, if a poison control center is not available, seek help from a medical provider or 9-‐1-‐1 (Class I, LOE C-‐EO). S578

Local poison control centers reached through the Poison Help line (1-‐800-‐222-‐1222), a medical provider, or EMS can help to quickly identify treatment recommendations for specific chemicals that have injured an eye.

Medical Emergencies: Chest Pain

Updated

While waiting for EMS to arrive, the first aid provider may encourage the victim to chew and swallow 1 adult (non–enteric-‐coated) or 2 low-‐dose “baby” aspirins if the patient has no allergy to aspirin or other contraindication to aspirin, such as evidence of a stroke or recent bleeding. S936

Aspirin has been found to significantly decrease mortality due to myocardial infarction in several large studies and is therefore recommended for persons with chest pain due to suspected myocardial infarction (Class I, LOE B-‐R). While waiting for EMS to arrive, the first aid provider may encourage a person with chest pain to take aspirin if the signs and symptoms suggest that the person is having a heart attack and the person has no allergy or contraindication to aspirin, such as recent bleeding (Class IIa, LOE B-‐NR). If a person has chest pain that does not suggest that the cause is cardiac in origin, or if the first aid provider is uncertain or uncomfortable with administration of aspirin, then the first aid provider should not encourage the person to take aspirin (Class III: Harm, LOE C-‐EO). S577

The early administration of aspirin in the first aid setting for chest pain related to myocardial infarction (typically a blood clot blocking an artery responsible for providing oxygen to heart tissue), has shown to be of greater benefit than when given later in the healthcare setting. First aid providers need to be confident in their suspicion of heart-‐related pain and their ability to rule out any allergies or other reasons, such as recent bleeding If the first aid provider is not confident that the chest pain is related to a cardiac problem, then the provider should not encourage the use of aspirin.


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Medical Emergencies: Hypoglycemia

New

If a person with diabetes reports low blood sugar or exhibits signs or symptoms of mild hypoglycemia and is able to follow simple commands and swallow, oral glucose should be given to attempt to resolve the hypoglycemia. Glucose tablets, if available, should be used to reverse hypoglycemia in a person who is able to take these orally (Class I, LOE B-‐R). It is reasonable to use dietary sugars as an alternative to glucose tablets (when not available) for reversal of mild symptomatic hypoglycemia (Class IIa, LOE B-‐R). For diabetics with symptoms of hypoglycemia, symptoms may not resolve until 10 to 15 minutes after ingesting glucose tablets or dietary sugars. First aid providers should therefore wait at least 10 to 15 minutes before calling EMS and re-‐treating a diabetic with mild symptomatic hypoglycemia with additional oral sugars (Class I, LOE B-‐R). If the person’s status deteriorates during that time or does not improve, the first aid provider should call EMS (Class I, LOE C-‐EO). S577-‐S578

If a diabetic person is suspected to have low blood sugar and is able to swallow safely, it is recommended to use oral glucose tablets to reverse early mild symptoms of hypoglycemia. If glucose tablets are not available, specific dietary sugars are recommended for use instead. Because symptoms will diminish gradually, it is recommended that first aid providers wait 10 to 15 minutes before activating EMS and providing additional oral glucose or dietary sugars. If a person's condition deteriorates at any time, it is recommended that EMS be activated immediately.


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Medical Emergencies: Stroke

New The use of a stroke assessment system by first aid providers is recommended (Class I, LOE B-‐NR). S577

Hospital-‐based advanced treatments for strokes are available, but the time to get to them is a big factor in effectiveness and survival. Early use of a stroke assessment by a first aid provider has shown to significantly decrease the time between the onset of the stroke and definitive treatment in a hospital.

Medical Emergencies: Toxic Eye Injury

Updated

Rinse eyes exposed to toxic substances immediately with a copious amount of water (Class I, LOE), unless a specific antidote is available. S940

It can be beneficial to rinse eyes exposed to toxic chemicals immediately and with a copious amount of tap water for at least 15 minutes or until advanced medical care arrives (Class IIa, LOE C-‐LD). If tap water is not available, normal saline or another commercially available eye irrigation solution may be reasonable (Class IIb, LOE C-‐LD). S578

The immediate flushing of eyes that have been exposed to toxic substances with copious, or large, volumes of tap water has been found to be the easiest and best approach. Because some toxic substances take longer to become diluted than others, it is recommended to flush for at least 15 minutes or until advanced help arrives. When tap water is not immediately available, normal saline or another commercially available eye irrigating solution can be used.


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Musculoskeletal Trauma

Updated

Do not move or try to straighten an injured extremity (Class III, LOE C). Expert opinion suggests that splinting may reduce pain and prevent further injury. So, if you are far from definitive health care, stabilize the extremity with a splint in the position found (Class IIa, LOE C). S938

In general, first aid providers should not move or try to straighten an injured extremity (Class III: Harm, LOE C-‐EO). Based on training and circumstance (such as remote distance from EMS or wilderness settings, presence of vascular compromise), some first aid providers may need to move an injured limb or person. In such situations, providers should protect the injured person, including splinting in a way that limits pain, reduces the chance for further injury, and facilitates safe and prompt transport (Class I, LOE C-‐EO). S580

As a general approach, it is best to not move or straighten an injured extremity that is unnaturally bent or angulated. However, there may be additional training necessary on moving and splinting in specific cases, such as in remote settings or if neurological/vascular compromise is suspected. Training in moving and splinting an injured extremity should emphasize the protection of the affected person, limiting pain, reducing the chance for further injury, and facilitating quick and safe transportation to a healthcare facility.

Musculoskeletal Trauma

New

If an injured extremity is blue or extremely pale, activate EMS immediately (Class I, LOE C-‐EO). S580

When the skin color of an injured extremity indicates a lack of oxygen in the blood (blue) or a lack of blood flow (pale), there is a likely possibility that the vascular system has been compromised by the injury. Early recognition and EMS activation by a first aid provider can help to prevent additional injury.


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Oxygen Use in First Aid

Updated

There is no evidence for or against the routine use of oxygen as a first aid measure for victims experiencing shortness of breath or chest pain. Oxygen may be beneficial for first aid in divers with a decompression injury. S935-‐S936

The use of supplementary oxygen by first aid providers with specific training is reasonable for cases of decompression sickness (Class IIa, LOE C-‐LD). For first aid providers with specific training in the use of oxygen, the administration of supplementary oxygen to persons with known advanced cancer with dyspnea and hypoxemia may be reasonable (Class IIb, LOE B-‐R). Although no evidence was identified to support the use of oxygen, it might be reasonable to provide oxygen to spontaneously breathing persons who are exposed to carbon monoxide while waiting for advanced medical care (Class IIb, LOE C-‐EO). S576

Even though supplementary oxygen is used commonly in healthcare environments, there was not much evidence of its beneficial use in the first aid setting. The use of supplementary oxygen in first aid situations is not a standard skill. However, there were a few specific circumstances in which the benefit of supplemental oxygen was shown. In addition, it was felt to be reasonable to provide oxygen, while waiting for advanced medical care, for individuals who had been exposed to carbon monoxide. Specialized training in the use of oxygen delivery systems is required when it is made available.

Position for Shock

Updated

If a victim shows evidence of shock, have the victim lie supine. If there is no evidence of trauma or injury, raise the feet about 6 to 12 inches (about 30° to 45°) (Class IIb, LOE C). Do not raise the feet if the movement or the position causes the victim any pain. S935

If there is no evidence of trauma or injury (eg, simple fainting, shock from nontraumatic bleeding, sepsis, dehydration), raising the feet about 6 to 12 inches (about 30° to 60°) from the supine position is an option that may be considered while awaiting arrival of EMS (Class IIb, LOE C-‐LD). S576

Clarification is provided for the description of non-‐traumatic situations, including nervous system reactions (fainting), non-‐traumatic bleeding, sepsis, and dehydration. The recommendation is simply an option to consider based on the limited, or lack of any, benefit shown by the evidence.


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Positioning the Ill or Injured Person

Updated

If the victim is facedown and is unresponsive, turn the victim face up. If the victim has difficulty breathing because of copious secretions or vomiting, or if you are alone and have to leave an unresponsive victim to get help, place the victim in a modified HAINES recovery position. S935

If a person is unresponsive and breathing normally, it may be reasonable to place him or her in a lateral side-‐lying recovery position (Class IIb, LOE C-‐LD). If a person has been injured and the nature of the injury suggests a neck, back, hip, or pelvic injury, the person should not be rolled onto his or her side and instead should be left in the position in which he or she was found, to avoid potential further injury (Class I, LOE C-‐EO). If leaving the person in the position found is causing the person’s airway to be blocked, or if the area is unsafe, move the person only as needed to open the airway and to reach a safe location (Class I, LOE C-‐EO). S575

When an unresponsive and breathing person is not suspected of being injured, it is reasonable to place them in a lateral side-‐lying recovery position to improve the airway and the ability to breath. This position uses an extended arm to rest the head on and positioning of the legs to stabilize the body. To avoid additional injury, it is best to leave an injured person, who is unresponsive and breathing, in the position he or she was found. If that position is unsafe or results in a compromised airway, it is appropriate to move the person as needed to create a clear airway or be removed from danger.


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Trauma Emergencies: Concussion

New

Any person with a head injury that has resulted in a change in level of consciousness, has progressive development of signs or symptoms as described above, or is otherwise a cause for concern should be evaluated by a healthcare provider or EMS personnel as soon as possible (Class I, LOE C-‐EO). S579

Available two-‐stage assessment processes for identifying concussions are not appropriate for use in first aid settings because they require an assessment prior to injury for comparison. An appropriate single stage assessment for first aid is currently not available. The first aid recommendation is to suspect the possibility of a concussion whenever there is a change in the level of consciousness or if there is a progressive development of signs such as feeling stunned or dazed, experiencing headache, nausea, dizziness or difficulty in balance, or showing visual disturbance, confusion, or loss of memory (from either before or after the injury). If a concussion is suspected, it is appropriate for the affected person to be evaluated by EMS or another healthcare provider as soon as possible.

Trauma Emergencies: Concussion

New

Using any mechanical machinery, driving, cycling, or continuing to participate in sports after a head injury should be deferred by these individuals until they are assessed by a healthcare provider and cleared to participate in those activities (Class I, LOE C-‐EO). S579

Because of the progressive nature of concussion, it is best not to allow an affected person to perform actions that could pose a risk for additional injury, until he or she can adequately be assessed by a healthcare provider.


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Trauma Emergencies: Control of Bleeding

Updated

Bleeding is best controlled by applying pressure until bleeding stops or EMS rescuers arrive (Class I, LOE A). S936

The standard method for first aid providers to control open bleeding is to apply direct pressure to the bleeding site until it stops. Control open bleeding by applying direct pressure to the bleeding site (Class I, LOE B-‐NR). S578

Further clarification of direct pressure as the standard method of bleeding control for open bleeding.


New

Local cold therapy, such as an instant cold pack, can be useful for these types of injuries to the extremity or scalp (Class IIa, LOE C-‐LD). Cold therapy should be used with caution in children because of the risk of hypothermia in this population (Class I, LOE C-‐EO). S578

Although there is limited data on the benefit, local cooling of a closed injury, such as bruising, can be useful when the scalp or an extremity is injured.


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Updated

Because of the potential adverse effects of tourniquets and difficulty in their proper application, use of a tourniquet to control bleeding of the extremities is indicated only if direct pressure is not effective or possible (Class IIb, LOE B). S937

Because the rate of complications is low and the rate of hemostasis is high, first aid providers may consider the use of a tourniquet when standard first aid hemorrhage control does not control severe external limb bleeding. (Class IIb, LOE C-‐LD). A tourniquet may be considered for initial care when a first aid provider is unable to use standard first aid hemorrhage control, such as during a mass casualty incident, with a person who has multisystem trauma, in an unsafe environment, or with a wound that cannot be accessed (Class IIb, LOE C-‐EO). S579

Additional evidence since 2010 indicates a low rate of potential complications and a high rate of success when using a tourniquet for severe bleeding control. For most situations, the guideline remains the same: Begin with direct pressure on a severely bleeding limb wound and use a tourniquet if direct pressure cannot be applied or control the bleeding effectively. However, in certain circumstances, such as a large mass-‐casualty event, a single person with multiple injuries, a dangerous environment, or a wound that cannot be accessed, the use of a tourniquet as the first bleeding control measure can be considered.


New

It is reasonable for first aid providers to be trained in the proper application of tourniquets, both manufactured and improvised (Class IIa, LOE C-‐EO). S579

Commercially manufactured tourniquets have shown to be more effective than improvised ones. If a manufactured tourniquet is not immediately available, it is possible to create an improvised tourniquet using nearby materials.


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Updated

Among the large number of commercially available hemostatic agents, some have been shown to be effective. However, their routine use in first aid cannot be recommended at this time because of significant variation in effectiveness by different agents and their potential for adverse effects, including tissue destruction with induction of a pro embolic state and potential thermal injury (Class IIb, LOE B). S397

Hemostatic dressings may be considered by first aid providers when standard bleeding control (direct pressure with or without gauze or cloth dressing) is not effective for severe or life threatening bleeding (Class IIb, LOE C-‐LD). Proper application of hemostatic dressings requires training (Class I, LOE C-‐EO). S579

Manufactured hemostatic dressings that are impregnated with clot-‐promoting agents have evolved significantly since the 2010 first aid guidelines. The latest generation of these dressings has a much lower risk of complications and is now recommended for use by first aid providers. Hemostatic dressings have shown to be beneficial for body locations (trunk, abdomen, groin) where standard bleeding control recommendations are not effective, or when a tourniquet is not available or cannot control bleeding on its own.


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Trauma Emergencies: Open Chest Wounds

New

We recommend against the application of an occlusive dressing or device by first aid providers for individuals with an open chest wound (Class III: Harm, LOE C-‐EO). In the first aid situation, it is reasonable to leave an open chest wound exposed to ambient air without a dressing or seal (Class IIa, LOE C-‐EO). S579

The generally accepted first aid approach to manage an open wound on the chest wall has been to prevent the "sucking" of air through the wound and into the chest cavity by using an occlusive, or air tight, dressing. This was accompanied by the recommendation of leaving an unsealed corner or side of the dressing to allow pressurized air to escape. This addressed the possibility of a tension pneumothorax which can rapidly cause serious complications. Due to a lack of evidence of the effectiveness of an occlusive dressing and the high risk of an unmanaged tension pneumothorax, the new recommendation is to not use occlusive dressings for open injuries of the chest.


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Trauma Emergencies: Spinal Motion Restriction

Updated

Because of the dire consequences if secondary injury does occur, maintain spinal motion restriction by manually stabilizing the head so that the motion of head, neck, and spine is minimized (Class IIb, LOE C). S938

If a first aid provider suspects a spinal injury, he or she should have the person remain as still as possible and await the arrival of EMS providers (Class I, LOE C-‐EO). For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction (eg, placing 1 hand on either side of the patient’s head to hold it still) rather than immobilization devices, because use of immobilization devices by lay rescuers may be harmful (Class III: Harm, LOE C-‐LD). S580, S421

Further clarification was provided in regard to the technique of spinal motion restriction, including verbal instructions for a victim to remain still and manually stabilizing the head with a hand on either side of the head. Additionally, the use of a head immobilization device by a lay rescuer was not recommended because of the potential difficulty of being able to maintain a clear and open airway with one in place.

Trauma Emergencies: Spinal Motion Restriction

New

With a growing body of evidence showing more actual harm and no good evidence showing clear benefit, we recommend against routine application of cervical collars by first aid providers (Class III: Harm, LOE C-‐LD). S580

The 2015 evaluation of spinal motion restriction was limited to the application of cervical collars by first aid providers. No evidence was shown that the use of the cervical collars decreased the occurrence of neurological injury, but there was evidence of adverse effects, such as increasing pressure within the cranium and airway compromise, in their use by providers with limited training.



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TABLE 5: Healthcare Provider Adult BLS

Topic 2010* 2015** Reason for Change Cardiac Arrest Associated With Pregnancy

New and Updated

To relieve aortocaval compression during chest compressions and optimize the quality of CPR, it is reasonable to perform manual left uterine displacement in the supine position first (Class IIa, LOE C).S834

Priorities for the pregnant woman in cardiac arrest are provision of high-‐quality CPR and relief of aortocaval compression (Class I, LOE C-‐LD). If the fundus height is at or above the level of the umbilicus, manual LUD can be beneficial in relieving aortocaval compression during chest compressions (Class IIa, LOE C-‐LD). S503

At approximately 20 weeks into a pregnancy, a woman's enlarged uterus can compress the inferior vena cava that returns blood to the heart, especially when the woman is in a supine position. If it was necessary to perform CPR, this restriction of blood flow to the heart would reduce the quality of the CPR provided. It is recommended to relieve the compression by manually displacing the uterus to the woman's left side while compressions are performed. This BLS modification for maternal cardiac arrest is now recommended as a priority for all BLS providers. In 2010 it was limited to subsequent but not first responders.


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TABLE 5: Healthcare Provider Adult BLS Topic 2010* 2015** Reason for Change


New

For patients with known or suspected opioid overdose who have a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS care, it is reasonable for appropriately trained BLS healthcare providers to administer IM or IN naloxone (Class IIa, LOE C-‐LD). It may be reasonable to administer IM or IN naloxone based on the possibility that the patient is not in cardiac arrest (Class IIb, LOE C-‐EO). Bag-‐mask ventilation should be maintained until spontaneous breathing returns, and standard ACLS measures should continue if return of spontaneous breathing does not occur (Class I, LOE C-‐LD). S418

Opioid overdose is a significant health problem. Naloxone is a medication that can quickly reverse the depression of the respiratory drive caused by an overdose of opioids. Eliminating the effect of the opioids can remove the underlying cause of respiratory arrest and allow the person to resume breathing on his or her own.


New and Updated

There are no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose. Resuscitation from cardiac arrest should follow standard BLS and ACLS algorithms. S840 Naloxone has no role in the management of cardiac arrest. S841

For patients in cardiac arrest, medication administration is ineffective without concomitant chest compressions for drug delivery to the tissues, so naloxone administration may be considered after initiation of CPR if there is high suspicion for opiate overdose (Class IIb, LOE C-‐EO). Standard resuscitative measures should take priority over naloxone administration (Class I, LOE C-‐EO), with a focus on high-‐quality CPR (compressions plus ventilation). S418

CPR is the priority over any other treatment for cardiac arrest. If the heart is not moving blood forward to distribute the medication to the body tissues where it has its therapeutic effect, there will be little or no benefit.


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Suspected Opioid-‐ Related Life-‐Threatening Emergency

New It is reasonable to provide opioid overdose response education with or without naloxone distribution to persons at risk for opioid overdose in any setting (Class IIa, LOE C-‐LD). S418

Early recognition and treatment for an opioid overdose can have a significant effect on survival. Educating those most at risk, along with others who have close contact with those at risk, can improve the speed at which naloxone can be provided.

Chest Compression Depth

Updated The adult sternum should be depressed at least 2 inches (5 cm). (Class IIa, LOE B). S690

During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches or 5 cm for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches or 6 cm) (Class I, LOE C-‐LD). S419

Most CPR compressions are too shallow and it is more effective to compress deeper rather than shallower. Defining an upper limit can help rescuers better understand the allowance for a greater depth. The upper limit also helps rescuers understand that at some point compressions become less effective and there is a small risk of injury. The use of feedback devices during resuscitation may also help rescuers to better achieve the recommended depth range.


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Chest Compression Rate

Updated It is therefore reasonable for lay rescuers and healthcare providers to perform chest compressions for adults at a rate of at least 100 compressions per minute (Class IIa, LOE B). S690

In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100/min to 120/min (Class IIa, LOE C-‐LD). S419

Defining an upper limit for compression rate, or speed, can help rescuers focus on achieving an optimum approach during CPR. A faster compression rate of more than 100 compressions per minute has shown to be more effective. However, rates above 120 have shown to diminish overall effectiveness, especially in terms of reduced compression depth. Again, feedback devices can help keep compression rates on track.

Chest Wall Recoil

Updated Allow the chest to completely recoil after each compression (Class IIa, LOE B). S690

It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest (Class IIa, LOE C-‐LD). S420

Better describing chest recoil in terms of how a rescuer most likely causes it to happen, may help to reduce its occurrence. Rescuers can concentrate on allowing full expansion of the chest if they do not feel like they are leaning on the chest at the top of each compression.


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Chest Compression Feedback

Updated Nevertheless, real-‐time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa, LOE B). S697

It may be reasonable to use audiovisual feedback devices during CPR for real-‐time optimization of CPR performance (Class IIb, LOE B-‐R). Although the effectiveness of CPR feedback devices was not reviewed by this writing group, the consensus of the group is that the use of feedback devices likely helps the rescuer optimize adequate chest compression rate and depth, and we suggest their use when available (Class IIb, LOE C-‐EO). S423

Real-‐time measurement of the high-‐quality components of CPR, including compression rate, depth, and full-‐recoil allows rescuers to make ongoing adjustments to performance in order to achieve the most effective CPR possible.

Delayed Ventilation

New

For witnessed OHCA with a shockable rhythm, it may be reasonable for EMS systems with priority-‐based, multi-‐tiered response to delay positive-‐pressure ventilation by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts (Class IIb, LOE C-‐LD). S417

A number of EMS systems with a tiered response approach (closest BLS engine or aid car, followed by closest ALS unit) have tested the concept of having initial BLS responders perform uninterrupted chest compressions, along with passive oxygen insufflation for suspected sudden cardiac arrest. This is based on the underlying concept that a limited amount of uncirculated oxygen remains in the circulatory system after arrest and the benefit of uninterrupted chest compressions can be fully utilized to improve defibrillation success. It is important to note that this is a system approach and not an individual recommendation for trained rescuers.


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Devices to Support Circulation: Load-‐ Distributing Band Devices (LDB)

New and Updated

The LDB may be considered for use by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb, LOE B). However, there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest. S723

The evidence does not demonstrate a benefit with the use of LDB-‐CPR for chest compressions versus manual chest compressions in patients with cardiac arrest. Manual chest compressions remain the standard of care for the treatment of cardiac arrest, but LDB-‐CPR may be a reasonable alternative for use by properly trained personnel (Class IIb, LOE B-‐R). The use of LDB-‐CPR may be considered in specific settings where the delivery of high-‐quality manual compressions may be challenging or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR]), provided that rescuers strictly limit interruptions in CPR during deployment and removal of the devices (Class IIb, LOE E). S438-‐S439

The use of a load distributing band device (LDB) to mechanically deliver compressions has not shown to be more beneficial than manual chest compressions. The recommendation defines manual compressions as the continuing standard of care for delivering compressions during CPR. However, the use of an LDB can be used in extended or resource limited situations, provided the interruption caused by setting up or removing an LDB is minimized.


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Devices to Support Circulation: Mechanical Chest Compression Devices: Piston Device

New and Updated

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest. Mechanical piston devices may be considered for use by properly trained personnel in specific settings for the treatment of adult cardiac arrest in circumstances (e.g., during diagnostic and interventional procedures) that make manual resuscitation difficult (Class IIb, LOE C).

The evidence does not demonstrate a benefit with the use of mechanical piston devices for chest compressions versus manual chest compressions in patients with cardiac arrest. Manual chest compressions remain the standard of care for the treatment of cardiac arrest, but mechanical chest compressions using a piston device may be a reasonable alternative for use by properly trained personnel (Class IIb, LOE B-‐R). The use of piston devices for CPR may be considered in specific settings where the delivery of high-‐quality manual compressions may be challenging or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR]), provided that rescuers strictly limit interruptions in CPR during deployment and removal of the device (Class IIb, LOE C-‐EO). S438

The use of a piston device to mechanically deliver compressions has not shown to be more beneficial than manual chest compressions. The recommendation defines manual compressions as the continuing standard of care for delivering compressions during CPR. However, the use of a piston device can be used in extended or resource limited situations, provided the interruption caused by setting up or removing a piston device is minimized.


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New and Updated

High-‐quality CPR is important not only at the onset but throughout the course of resuscitation. Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPR. S686

In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR with the goal of a chest compression fraction as high as possible, with a target of at least 60% (Class IIb, LOE C-‐LD). S420

Research has shown the benefit of minimizing interruptions to chest compressions during CPR. A compression fraction is the percentage of time during overall CPR performance that chest compressions are actually being provided. While there are necessary interruptions such as giving rescue breaths and using an AED, keeping those to the shortest time possible is beneficial for the overall resuscitation attempt.


Updated Shortening the interval between the last compression and the shock by even a few seconds can improve shock success (defibrillation and ROSC).Thus, it is reasonable for healthcare providers to practice efficient coordination between CPR and defibrillation to minimize the hands-‐off interval between stopping compression and administering shock (Class IIa, LOE C). S707

In adult cardiac arrest, total pre-‐shock and post-‐shock pauses in chest compressions should be as short as possible (Class I, LOE C-‐LD). S420

Because shorter pauses were associated with greater shock success, return of spontaneous circulation, and higher survival to hospital discharge in some studies, minimizing interruptions in chest compressions remains a point of emphasis for high-‐quality CPR.


Updated Deliver each rescue breath over 1 second (Class IIa, LOE C). S688

For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to pause compressions for less than 10 seconds to deliver 2 breaths (Class IIa, LOE C-‐LD). S420

Remembering that avoiding excessive volume on rescue breaths is a goal of high-‐quality CPR, being able to deliver 2 effective rescue breaths as quickly as possible, and under 10 seconds, is recommended.


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Passive Oxygen Versus Positive-‐Pressure Oxygen During CPR

New

We do not recommend the routine use of passive ventilation techniques during conventional CPR for adults, because the usefulness/effectiveness of these techniques is unknown (Class IIb, LOE C-‐EO). However, in EMS systems that use bundles of care involving continuous chest compressions, the use of passive ventilation techniques may be considered as part of that bundle (Class IIb, LOE C-‐LD). S422

Passive ventilation is the reliance on the mechanics of CPR compression to drive an exchange of air by a number of means, including positioning the body, inserting an oral airway, and administration of oxygen (with or without a nonrebreather mask). It is not recommended because of a lack of evidence on its benefit. However, in cases where EMS systems are implementing controlled initial compression-‐only protocols, passive ventilation can be considered as a part of the overall approach.


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Ventilation With an Advanced Airway

Updated When the victim has an advanced airway in place during CPR, rescuers no longer deliver cycles of 30 compressions and 2 breaths (ie, they no longer interrupt compressions to deliver 2 breaths). Instead, continuous chest compressions are performed at a rate of at least 100 per minute without pauses for ventilation, and ventilations are delivered at the rate of 1 breath about every 6 to 8 seconds (which will deliver approximately 8 to 10 breaths per minute). S693

When the victim has an advanced airway in place during CPR, rescuers no longer deliver cycles of 30 compressions and 2 breaths (i.e., they no longer interrupt compressions to deliver 2 breaths). Instead, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (Class IIb, LOE C-‐LD). S421

This change represents a simplification from 2010 to a simple rate (1 breath every 6 seconds) from a range (1 breath about every 6 to 8 seconds) to make ventilation with an advanced airway easier to learn, remember, and perform.



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TABLE 6: Healthcare Provider (BLS) Pediatric

Topic Type 2010* 2015** Reason for Change Components of High-‐Quality CPR: Chest Compression Rate and Depth


To maximize simplicity in CPR training, in the absence of sufficient pediatric evidence, it is reasonable to use the adult chest compression rate of 100/min to 120/min for infants and children (Class IIa, LOE C-‐EO). S521

There was very little evidence in regard to an ideal compression depth to recommend for a child or infant. To simplify the overall CPR information, the recommendation was to be consistent with the adult recommendation.

Components of High-‐Quality CPR: Chest Compression Rate and Depth


It is reasonable that in pediatric patients (1 month to the onset of puberty) rescuers provide chest compressions that depress the chest at least one third the anterior-‐posterior diameter of the chest. This equates to approximately 1.5 inches (4 cm) in infants to 2 inches (5 cm) in children (Class IIa, LOE C-‐LD). S521

There was very little change in the pediatric compression depth recommendation from the previous recommendation in 2010.


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TABLE 6: Healthcare Provider (BLS) Pediatric Topic Type 2010* 2015** Reason for Change

Components of High-‐Quality CPR: Compression-‐Only CPR

Updated

Optimal CPR in infants and children includes both compressions and ventilations, but compressions alone are preferable to no CPR (Class 1 LOE B). S867

Conventional CPR (rescue breathing and chest compressions) should be provided for pediatric cardiac arrests (Class I, LOE B-‐NR). The asphyxial nature of the majority of pediatric cardiac arrests necessitates ventilation as part of effective CPR. However, because compression-‐only CPR is effective in patients with a primary cardiac event, if rescuers are unwilling or unable to deliver breaths, we recommend rescuers perform compression-‐only CPR for infants and children in cardiac arrest (Class I, LOE B-‐NR). S522

When considering the importance of rescue breaths in CPR delivery, the underlying cause matters. Compression-‐only CPR is focused on sudden cardiac arrest, where the underlying initial cause is the disruption of the heart's electrical pathway and the resulting ventricular fibrillation. Cardiac arrest is also the progressive end result of situations in which the loss of an airway and/or breathing is the initiating factor. This is the most likely situation in a child or infant. The inclusion of rescue breaths can potentially reverse the progression and restore breathing and circulation. While compression-‐only CPR can quickly be understood without formal training, those who choose to be trained benefit from learning both compressions and rescue breaths.



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HSI Advisory Group HSI’s interpretations of the most significant recent changes to emergency care science and instruction included review and input of HSI’s Medical Director, Chief Learning Officer, Program Advisory Groups, and professional staff. HSI Medical Director Gregory R. Ciottone, MD, FACEP HSI Chief Learning Officer Jeffrey T. Lindsey, PhD, PM, CFOD, EFO ASHI and MEDIC First Aid Program Advisory Group Kim Dennison, RN, MPH, BSN, COHN-‐S, COHC Tanya LeDonne, EMT Bradford A. Dykens, EMT-‐P Jason Royce Howard Main, NREMTP, CCEMTP Jill White, Founder, Starfish Aquatics Institute (SAI) John F. Mateus, EMT(i), MSN, RN, NREMT-‐P Pam Isom W. Daniel Rosenthal RN, BS Lake White Tana Sawzak, EMT-‐B Craig Aman, MICP Marcy Thobaben, LPN, EMT-‐B Benjamin Karp, MA, President/Owner of Georgia CPR, LLC Brandon Condon, BA, RN, EMT-‐B (ret) James Clover, MED, ATC, PTA, CES Jeannie Hanson, EMT-‐B Wade Himmerlick Neal Shabashov Kira A. Miller, EMT, CNA (ret) HSI Professional Staff William Clendenen Steve Barnett Donna Medina Ralph Shenefelt William Rowe Corey Abraham Jeff Myers iHazinski MF, Nolan JP, et al., 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132(suppl 1):S2–S268. iiSingletary EM, Zideman DA, et al., Part 9: first aid: 2015 International Consensus on First Aid Science With Treatment Recommendations. Circulation. 2015;132(suppl 1):S269–S311. iiiNeumar RW, Shuster M, et al., 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S315–S573. ivSingletary EM, Charlton NP, et al., Part 15: first aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. Circulation. 2015;132(suppl 2):S574–S589.

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