ACLS 2015

HIGHLIGHTSof the 2015 American Heart Association Guidelines Update for CPR and ECC Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Ethical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Systems of Care and Continuous Quality Improvement . . . . . . . . . . . . 3 Adult Basic Life Support and CPR Quality: Lay Rescuer CPR . . . . . . . 5 Adult Basic Life Support and CPR Quality: HCP BLS. . . . . . . . . . . . . . 8 Alternative Techniques and Ancillary Devices for CPR. . . . . . . . . . . . 11 Adult Advanced Cardiovascular Life Support. . . . . . . . . . . . . . . . . . . 13 Post–Cardiac Arrest Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Acute Coronary Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Special Circumstances of Resuscitation. . . . . . . . . . . . . . . . . . . . . . . 18 Pediatric Basic Life Support and CPR Quality . . . . . . . . . . . . . . . . . . 20 Pediatric Advanced Life Support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Neonatal Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Acknowledgments The American Heart Association thanks the following people for their contributions to the development of this publication: Mary Fran Hazinski, RN, MSN; Michael Shuster, MD; Michael W. Donnino, MD; Andrew H. Travers, MD, MSc; Ricardo A. Samson, MD; Steven M. Schexnayder, MD; Elizabeth H. Sinz, MD; Jeff A. Woodin, NREMT-P; Dianne L. Atkins, MD; Farhan Bhanji, MD; Steven C. Brooks, MHSc, MD; Clifton W. Callaway, MD, PhD; Allan R. de Caen, MD; Monica E. Kleinman, MD; Steven L. Kronick, MD, MS; Eric J. Lavonas, MD; Mark S. Link, MD; Mary E. Mancini, RN, PhD; Laurie J. Morrison, MD, MSc; Robert W. Neumar, MD, PhD; Robert E. O’Connor, MD, MPH; Eunice M. Singletary, MD; Myra H. Wyckoff, MD; and the AHA Guidelines Highlights Project Team. © 2015 American Heart Association For more detailed information and references, readers are Introduction encouraged to read the 2015 AHA Guidelines Update for CPR and ECC, including the Executive Summary,1 published This “Guidelines Highlights” publication summarizes the in Circulation in October 2015, and to consult the detailed key issues and changes in the 2015 American Heart summary of resuscitation science in the 2015 International Association (AHA) Guidelines Update for Cardiopulmonary Consensus on CPR and ECC Science With Treatment Resuscitation (CPR) and Emergency Cardiovascular Care Recommendations, published simultaneously in Circulation2 (ECC). It has been developed for resuscitation providers and and Resuscitation.3 for AHA instructors to focus on the resuscitation science and guidelines recommendations that are most significant The 2015 AHA Guidelines Update for CPR and ECC is or controversial or those that will result in changes in based on an international evidence evaluation process that resuscitation practice or resuscitation training. In addition, it involved 250 evidence reviewers from 39 countries. The provides the rationale for the recommendations. process for the 2015 International Liaison Committee on Resuscitation (ILCOR) systematic review was quite different Because this publication is designed as a summary, it does when compared with the process used in 2010. For the not reference the supporting published studies and does 2015 systematic review process, the ILCOR task forces not list Classes of Recommendation or Levels of Evidence. prioritized topics for review, selecting those where there was Figure 1 New AHA Classification System for Classes of Recommendation and Levels of Evidence* CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE‡ CLASS I (STRONG) Benefit >>> Risk LEVEL A Suggested phrases for writing recommendations: ■ High-quality evidence‡ from more than 1 RCTs ■ Is recommended ■ Meta-analyses of high-quality RCTs ■ Is indicated/useful/effective/beneficial ■ One or more RCTs corroborated by high-quality registry studies ■ Should be performed/administered/other ■ Comparative-Effectiveness Phrases†: LEVEL B-R (Randomized) º Treatment/strategy A is recommended/indicated in preference to treatment B ■ Moderate-quality evidence‡ from 1 or more RCTs º Treatment A should be chosen over treatment B ■ Meta-analyses of moderate-quality RCTs CLASS IIa (MODERATE) Benefit >> Risk LEVEL B-NR (Nonrandomized) Suggested phrases for writing recommendations: ■ Is reasonable ■ Moderate-quality evidence‡ from 1 or more well-designed, ■ Can be useful/effective/beneficial well-executed nonrandomized studies, observational ■ Comparative-Effectiveness Phrases†: studies, or registry studies ■ Meta-analyses of such studies º Treatment/strategy A is probably recommended/indicated in preference to treatment B LEVEL C-LD (Limited Data) º It is reasonable to choose treatment A over treatment B ■ Randomized or nonrandomized observational or registry studies with limitations of design or execution CLASS IIb (WEAK) Benefit ≥ Risk ■ Meta-analyses of such studies Suggested phrases for writing recommendations: ■ Physiological or mechanistic studies in human subjects ■ May/might be reasonable ■ May/might be considered LEVEL C-EO (Expert Opinion) ■ Usefulness/effectiveness is unknown/unclear/uncertain or not well established Consensus of expert opinion based on clinical experience CLASS III: No Benefit (MODERATE) Benefit = Risk COR and LOE are determined independently (any COR may be paired with any LOE). (Generally, LOE A or B use only) A recommendation with LOE C does not imply that the recommendation is weak. Many Suggested phrases for writing recommendations: important clinical questions addressed in guidelines do not lend themselves to clinical ■ Is not recommended trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. ■ Is not indicated/useful/effective/beneficial * The outcome or result of the intervention should be specified (an improved clinical ■ Should not be performed/administered/other outcome or increased diagnostic accuracy or incremental prognostic information). † For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), CLASS III: Harm (STRONG) Risk > Benefit studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. Suggested phrases for writing recommendations: ‡ The method of assessing quality is evolving, including the application of standardized, ■ Potentially harmful widely used, and preferably validated evidence grading tools; and for systematic reviews, ■ Causes harm the incorporation of an Evidence Review Committee. ■ Associated with excess morbidity/mortality COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level ■ Should not be performed/administered/other of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 1 When sufficient cancer and stroke research over the past 2 decades. topics reviewed in 2015 will be updated as needed and new topics will be added.heart. and Evaluation (GRADE.org/seers. to be used infrequently when evidence recommendation). recommendations are supported by the lowest Levels of quality study (Level of Evidence [LOE] A or B. 1% addressing only those topics addressed by the 2015 ILCOR evidence review or those requested by the training network. To learn more about SEERS and to see a comprehensive list of all systematic reviews conducted by ILCOR. The evidence emerges that indicates the need to change the AHA gaps in the science are clear when the recommendations Guidelines for CPR and ECC. The 2015 AHA Guidelines Update for CPR and ECC is very different from previous editions of the AHA Levels of Evidence Guidelines for CPR and ECC. 45%) to be no better than the control. there were fewer reviews completed in 2015 (166) than in 2010 (274).org. and all Guidelines writing group chairs and and the AHA ECC consensus response to this report. to improve the 2015 Classes of Recommendation consistency and quality of the 2015 systematic reviews. Most (69%) of the 2015 Guidelines Update suggests a strategy is demonstrated by a high. Readers will want to monitor the SEERS resuscitation. Class III: Harm Class III: No Benefit Second. Distribution of Classes of Once the topics were selected. visit www. This SEERS site was used to provide public disclosure of drafts of the ILCOR 2015 International Consensus on CPR Class IIb 45% and ECC Science With Treatment Recommendations and to Class IIa 23% receive public comment. Readers will note that the highest Level of Evidence (LOE A) and only 25% of the this version contains a modified Class III recommendation. recommendations (78 of 315) designated as Class I (strong Class III: No Benefit. and C-EO (expert opinion).org). As a result. the Levels of Evidence and the Classes The 2015 Guidelines Update used the most recent version of Recommendation in resuscitation are low. reviewers from around the world were able to work 2% 5% together virtually to complete the systematic reviews through the use of a purpose-built AHA Web-based platform. and nearly half (144 of 315. respectively) Evidence (LOE C-LD or C-EO). The ECC Committee LOE A determined that this 2015 version would be an update. The Percent of 315 recommendations. Collectively.5 more at least 50% of Guidelines writing group members were needs to be done to advance the science and practice of required to be free of relevant conflicts of interest. (Figure 2). such changes will be made and contained within the 2015 Guidelines Update are scrutinized communicated to clinicians and to the training network. There must be a concerted effort to fund site to keep up-to-date on the newest resuscitation science cardiac arrest resuscitation research similar to what has driven and the ILCOR evaluation of that science. The AHA staff processed more than 1000 conflict of interest As outlined in the recently published Institute of Medicine report4 disclosures. participants adhered studies). As a result of this prioritization. LOE B is now divided into LOE Throughout the ILCOR evidence evaluation process and the B-R (randomized studies) and LOE B-NR (nonrandomized 2015 Guidelines Update development. 2 American Heart Association . and that is the process created by LOE B-NR ILCOR. The Levels of Evidence are categorized as Class IIb (weak recommendation). Development. Evidence as Percent of 315 Total reviewers used Grading of Recommendations Recommendations in Assessment. the 2015 AHA Guidelines Update for CPR 15% and ECC is not a comprehensive revision of the 2010 AHA Guidelines for CPR and ECC. 2015 AHA Guidelines Update www. the Systematic Evidence Evaluation and Review System (SEERS). have also been modified.gradeworkinggroup. a highly structured and reproducible evidence review system.or moderate. 46% The publication of the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations begins a process of ongoing review of resuscitation science. LOE B-R This decision ensures that we have only one standard for LOE C-EO 15% 23% evidence evaluation. there were 2 important Recommendation and Levels of additions to the 2015 process of review itself. with only 1% of the AHA definitions for the Classes of Recommendation of the total recommendations in 2015 (3 of 315) based on and Levels of Evidence (Figure 1). Class I 25% designed to support the many steps of the evaluation process. First. LOE C is now divided into LOE C-LD (limited data) strictly to the AHA conflict of interest disclosure requirements. Such an integrated version is LOE C-LD available online at ECCguidelines.ilcor. sufficient new science or controversy to prompt a systematic Figure 2 review. In addition. and there is increasing availability of the Ethical issues surrounding whether to start or when to Physician Orders for Life-Sustaining Treatment (POLST) terminate CPR are complex and may vary across settings form. ethical considerations There is greater awareness that although children and must also evolve. of the 2015 Guidelines Update. The increased use of Patient Structure Process System Outcome targeted temperature management (TTM) has led to Quality Safety new challenges for predicting neurologic outcomes in comatose post–cardiac arrest Continuous Quality Improvement patients. Benchmarking. providers (basic or advanced). and the latest data about the Integration. children. differentiating in- • Review of evidence about prognostic scores for preterm infants hospital cardiac arrests (IHCAs) from out-of-hospital cardiac arrests (OHCAs). and likely benefits related to such new treatments will have an impact on Figure 3 decision making. both in patient population (neonatal. associated with resuscitation is challenging from many information should be shared with them to the extent perspectives. a new method of legally identifying people with (in. Understanding the elevation myocardial infarction (STEMI). Measurement. the data that inform many ethical donors is unrelated to whether the donor receives CPR. and specific limits on interventions at the end of life. The 2015 ILCOR evidence review process and Viewpoints on several important ethical concerns that are resultant AHA Guidelines Update include several science the topics of ongoing debate around organ donation in an updates that have implications for ethical decision making for emergency setting are summarized in “Part 3: Ethical Issues” periarrest. pediatrics. using appropriate language and information (HCPs) are dealing with the ethics surrounding decisions to for each patient’s level of development. implications. the provide or withhold emergency cardiovascular interventions. There is new information Taxonomy of Systems of Care: SPSO about prognostication for neonates. adult). arrest. phrase limitations of care has been changed to limitations of interventions. Pediatric Education Policies Organization Advanced Life Equipment Procedures Culture Support. Although and out of healthcare facilities. Significant New and Updated Recommendations That May Inform Systems of Care and Continuous Ethical Decisions Quality Improvement • The use of extracorporeal CPR (ECPR) for cardiac arrest The 2015 Guidelines Update provides stakeholders with • Intra-arrest prognostic factors a new perspective on systems of care. ST-segment Support section in this publication). and postarrest patients. Managing the multiple decisions adolescents cannot make legally binding decisions. usefulness of particular tests and studies should inform Ethical Issues decisions about goals of care and limiting interventions. no more so than when healthcare providers possible. Even with new information ethical principles have not changed since the 2010 that the success of kidney and liver transplants from adult Guidelines were published. As resuscitation practice evolves. Collaboration. Major highlights include • Prognostication for children and adults after cardiac arrest • A universal taxonomy of systems of care • Function of transplanted organs recovered after cardiac arrest • Separation of the AHA adult Chain of Survival into 2 chains: one for New resuscitation strategies such as ECPR have made in-hospital and one for out-of-hospital systems of care decisions to discontinue resuscitation measures more • Review of best evidence on how these cardiac arrest systems of complicated (see the Adult Advanced Cardiovascular Life care are reviewed. Feedback Highlights of the 2015 AHA Guidelines Update for CPR and ECC 3 . and stroke appropriate use. process. and Post– Cardiac Arrest Care). with a focus on cardiac arrest. the discussions have been updated through the evidence review donation of organs after resuscitation remains controversial. and adults in cardiac Structure Process System Outcome arrest and after cardiac arrest (see Neonatal People Protocols Programs Satisfaction Resuscitation.or out-of-hospital). If cardiac arrest occurs. The patient is ultimately transferred to programs. produce a system (eg. who have an IHCA depend on a system of appropriate An effective system of care comprises all of these elements— surveillance (eg. patients outcomes (eg. nurses. In contrast. depend on the smooth interaction of the institution’s various departments and services and on a multidisciplinary team Chains of Survival of professional providers. education) and process (eg. protocols. call for help. (EMS) providers assumes responsibility and then transports equipment. The elements of structure and process Why: There is limited evidence to support the use of social media by dispatchers to notify potential rescuers of a possible Figure 4 IHCA and OHCA Chains of Survival IHCA Surveillance Recognition and Immediate Rapid Advanced life and prevention activation of the high-quality CPR defibrillation support and emergency postarrest care response system Primary providers Code team Cath ICU lab OHCA Recognition and Immediate Rapid Basic and advanced Advanced life activation of the high-quality CPR defibrillation emergency support and emergency medical services postarrest care response system Lay rescuers EMS ED Cath ICU lab 4 American Heart Association . regardless who are in close proximity to a victim of suspected OHCA of where their arrests occur. when integrated. Components of a System of Care that are required before that convergence are very different for the 2 settings. including physicians. policies. and initiate CPR and provide common framework with which to assemble an integrated defibrillation (ie. team of professionally trained emergency medical service Why: Healthcare delivery requires structure (eg. Patients who have an OHCA depend on 2015 (New): Universal elements of a system of care their community for support. quality. catheterization lab. patient survival and safety. generally in an intensive care unit where post–cardiac arrest care is provided. organizations. process. rapid response or early warning system) structure. patients framework of continuous quality improvement. the patient to an emergency department and/or cardiac procedures) that. respiratory therapists. and patient outcomes—in a to prevent cardiac arrest. Lay rescuers must recognize have been identified to provide stakeholders with a the arrest. satisfaction). public-access defibrillation [PAD]) until a resuscitation system (Figure 3). people. and others. converges in the hospital. 2015 (New): It may be reasonable for communities to incorporate social media technologies that summon rescuers Why: The care for all post–cardiac arrest patients. cultures) that leads to optimal a critical care unit for continued care. 2015 (New): Separate Chains of Survival (Figure 4) have been recommended that identify the different pathways Use of Social Media to Summon Rescuers of care for patients who experience cardiac arrest in the hospital as distinct from out-of-hospital settings. system. and are willing and able to perform CPR. There are likely to be opportunities to improve CPR: compressing the chest at an adequate rate and depth.and hospital-based resuscitation programs • T he recommended chest compression rate is 100 to 120/min should systematically monitor cardiac arrests. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 5 . rapid response team improved survival rates that followed establishment of other (RRT) or medical emergency team (MET) systems can systems of care. and activation of social media has not Regionalization of Care been shown to improve survival from OHCA. with universal Adult Basic Life Support (BLS) Algorithm. bedside when acute deterioration is identified by hospital • It is recommended that communities with people at risk for cardiac staff. Although the evidence is still evolving. Resuscitation Programs • E mphasis has been increased about the rapid identification of 2015 (Reaffirmation of 2010): Resuscitation systems should potential cardiac arrest by dispatchers. resuscitation equipment and drugs. and avoiding excessive ventilation. the goal of preventing IHCA. there is face validity in the concept of having • R  ecommendations have been strengthened to encourage teams trained in the complex choreography of resuscitation. expert Summary of Key Issues and Major Changes consensus recommended the systematic identification of Key issues and major changes in the 2015 Guidelines patients at risk of cardiac arrest. and respiratory rescuers can activate an emergency response (ie. be effective in reducing the incidence of cardiac arrest. survival rates in many communities. and analysis. immediate recognition of unresponsiveness. and Medical performance improvement that includes measurement. through use of a therapists. the level of (updated from at least 100/min). 7-day percutaneous coronary intervention (PCI) capability. municipalities could consider incorporating these provides evidence-based care in resuscitation and post– technologies into their OHCA systems of care. These teams are usually summoned to a patient mobile telephone) without leaving the victim’s side. and outcome. an organized response Update recommendations for adult CPR by lay rescuers to such patients.6 Given the low harm and the resuscitation centers may be considered. Continuous quality improvement includes systematic evaluation and • T he clarified recommendation for chest compression depth for adults feedback. and commitment to ongoing Systems. need for communities and systems to accurately identify each occurrence of treated cardiac arrest and to record • T here is continued emphasis on the characteristics of high-quality outcomes. It is hoped that resuscitation systems of care will achieve the 2015 (Updated): For adult patients. gasping). The team typically brings emergency monitoring and arrest implement PAD programs. and both feedback and process change. with immediate provision of establish ongoing assessment and improvement of systems CPR instructions to the caller (ie. The use of early warning sign systems may be considered Quality: Lay Rescuer CPR for adults and children. Pediatric MET/RRT systems may be considered in facilities where children with Adult Basic Life Support and CPR high-risk illnesses are cared for in general in-patient units. Rapid Response Teams. including 24-hour. • T he crucial links in the out-of-hospital adult Chain of Survival are Why: RRTs or METs were established to provide early unchanged from 2010. • T he recommended sequence for a single rescuer has been Why: There is evidence of considerable regional variation confirmed: the single rescuer is to initiate chest compressions in the reported incidence and outcome of cardiac arrest before giving rescue breaths (C-A-B rather than A-B-C) to reduce in the United States. Teams can be composed of • T he Adult BLS Algorithm has been modified to reflect the fact that varying combinations of physicians. is at least 2 inches (5 cm) but not greater than 2. such as trauma.4 inches (6 cm). cardiac arrest care. as well as the ubiquitous presence of digital Why: A cardiac resuscitation center is a hospital that devices. Community. Emergency Team Systems benchmarking. in a recent study in Sweden. with continued emphasis on the simplified intervention for patients with clinical deterioration. there was a significant increase in 2015 (Reaffirmation of 2010): A regionalized approach the rate of bystander-initiated CPR when a mobile-phone to OHCA resuscitation that includes the use of cardiac dispatch system was used. This variation underscores the delay to first compression. of care. nurses. performance can be narrowed. 2010 (Old): Although conflicting evidence exists. Continuous efforts are needed to optimize resuscitation • B  ystander-administered naloxone may be considered for suspected care so that the gaps between ideal and actual resuscitation life-threatening opioid-associated emergencies. The single rescuer should begin CPR with 30 chest compressions followed by 2 breaths. minimizing interruptions in compressions. TTM with an adequate Team Resuscitation: Early Warning Sign annual volume of cases. allowing complete chest recoil after each compression. dispatch-guided CPR). and an evaluation of outcomes to foster include the following: continuous quality improvement. potential benefit. However. and initiation of CPR if the lay rescuer finds an unresponsive victim is not breathing or not breathing Continuous Quality Improvement for normally (eg. resuscitation care provided. particularly in the general care wards. measurement or benchmarking.cardiac arrest nearby. activation of the emergency response system. immediate access to role that emergency dispatchers can play in helping the lay a defibrillator is a primary component of the system of care. The 2010 Guidelines recommended arrest. an asterisk (*). Thus. prearrival dispatch protocols. activity or agonal gasps that can confuse potential rescuers. airports. ask straightforward questions about whether the patient is (3) an integrated link with the local EMS system. to identify patients with possible cardiac arrest and enable A system-of-care approach for OHCA might include public dispatcher-guided CPR. sports facilities). This information is expanded in “Part breaths. Dispatchers should be arrest (eg. The implementation of a PAD program requires 4 essential Dispatchers should be specifically educated to help components: (1) a planned and practiced response. oversight by an HCP. In addition. or follow cardiac arrest in public settings. For the 20% of OHCAs that occur in public for victims of cardiac arrest. the term public Emphasis on Chest Compressions* service access point has replaced the less-precise EMS 2015 (Updated): Untrained lay rescuers should provide dispatch center). More Cardiac arrest victims sometimes present with seizure-like information about these changes appears below. policy that encourages reporting of public AED locations to public service access points (PSAPs. these community programs represent an important rescuer is able to perform rescue breaths. the rescuer and the dispatcher should assume where there is a relatively high likelihood of witnessed cardiac that the victim is in cardiac arrest. can improve outcomes. if the trained lay areas. the the deployment of AEDs in homes. airports. along with effective. If the victim is unresponsive with absent or abnormal for patients with OHCA be implemented in public locations breathing. and (4) a unresponsive and if breathing is normal or abnormal in order program of ongoing quality improvement. Victims of OHCAs that bystander should provide compression-only CPR for
the occur in private residences are much less likely to receive adult victim who suddenly collapses. for adult victims of cardiac arrest. There is insufficient evidence to recommend for or against 2010 (Old): If a bystander is not trained in CPR. casinos. with or without bystanders to retrieve nearby AEDs and assist in their use dispatcher guidance. dispatchers should inquire about a victim’s absence of Community Lay Rescuer AED Programs responsiveness and quality of breathing (normal versus not 2015 (Updated): It is recommended that PAD programs normal). Such a policy would enable PSAPs to direct compression-only (Hands-Only) CPR. the victim. Robust community CPR and is ready for use or EMS providers take over care of training programs for cardiac arrest. if the victim is breathing. defibrillators (AEDs) by public safety first responders were recommended to increase survival rates for out-of-hospital 2010 (Old): To help bystanders recognize cardiac sudden cardiac arrest. changes or points of emphasis presentations
of cardiac arrest to enable prompt recognition that are similar for lay rescuers and HCPs are noted with and immediate dispatcher-guided CPR. Why: There is clear and consistent evidence of improved survival from cardiac arrest when a bystander performs Why: This change from the 2010 Guidelines emphasizes the CPR and rapidly uses an AED. and. which bystanders recognize that agonal gasps are a sign of ideally includes identification of locations and neighborhoods cardiac arrest. casinos. The rescuer should provided by emergency dispatchers may help potential continue compression-only CPR until an AED arrives in-home rescuers to initiate action. The rescuer should continue CPR until an AED 4: Systems of Care and Continuous Quality Improvement” in arrives and is ready for use. and if the breathing there is a relatively high likelihood of witnessed cardiac arrest is normal. (2) professional emergency responders. In summary. the victim. gasps (ie. EMS providers take over care of the 2015 Guidelines Update. educated to identify unresponsiveness with abnormal and agonal gasps across a range of clinical presentations and 2010 (Old): CPR
and the use of automated external descriptions. dispatchers should ask about an adult victim’s the establishment of AED programs
in public locations where responsiveness. in addition to activating location of the AEDs. 6 American Heart Association . placement of AEDs brief generalized seizures may be the first manifestation in those areas and ensuring that bystanders are aware of the of cardiac arrest. The when OHCA occurs. All lay in municipal buildings. the dispatcher should training of anticipated rescuers in CPR and use of the AED. provide chest compressions and schools. All trained lay rescuers should. typically. large public venues. in those who need CPR) from victims who are breathing normally and do not need CPR. with an emphasis to chest compressions than are patients who experience “push hard and fast” on the center of the chest. 
 2015 (Updated): To help bystanders recognize cardiac arrest. airports. he or she should link in the Chain of Survival between recognition and add rescue breaths in a ratio of 30 compressions to 2 activation of the PSAPs. Many municipalities as well as the US rescuer should continue compression-only CPR until the federal government have enacted legislation to place AEDs arrival of an AED or rescuers with additional training. casinos. rescuers should. or the victim starts to move. in an attempt to distinguish victims with agonal (eg. at a minimum. Dispatchers should be specifically trained to identify these In the following topics. These changes are designed to simplify lay rescuer Dispatcher Identification of Agonal Gasps training
and to emphasize the need for early chest compressions for victims of sudden cardiac arrest. Dispatchers should also be aware that where there is high risk of cardiac arrest. at a minimum. sports facilities). Real-time instructions the directions of the EMS dispatcher. rescuer recognize absent or abnormal breathing. The rescuer should are associated with lower survival rates. rescuers should deliver effective compressions at an providing standard BLS care. trained lay rescuers and BLS providers. addition. Provision of adequate continue CPR until an AED arrives and is ready for use or chest compressions requires an emphasis not only on an EMS providers take over care of the victim. which in turn results in critical blood flow and oxygen delivery Box 1 to the heart and brain. it is effect of compression rate and interruptions on total number of reasonable for rescuers to perform chest compressions at a compressions delivered during resuscitation. When traveling in an automobile. and important determinant of survival from cardiac arrest. spontaneous circulation (ROSC) and survival with good 2010 (Old): The adult sternum should be depressed at least neurologic function. Increases in compression rate and fraction between excessive compression depth and injuries that increase the total number of compressions delivered. Opioid overdose response and duration of interruptions in chest compressions. the 2015 Guidelines Update incorporates new evidence about the potential for an upper threshold of Rate and by Interruptions compression depth (greater than 2. The actual number of chest compressions 2 inches (5 cm). Moreover. perform chest compressions to a depth of at least 2 inches Why: The number of chest compressions delivered per (5 cm) for an average adult. New to the over the telephone. rate of 100 to 120/min. Compression depth may The total number of compressions delivered during resuscitation is an be difficult to judge without use of feedback devices. to administer intramuscular appropriate rate (100 to 120/min) and depth while minimizing the number (IM) or intranasal (IN) naloxone.4 inches [6 cm]). in addition to • D  uring CPR. rescuers should perform chest compressions at a rate of at least 100/min. beyond which complications may occur. while avoiding excessive chest minute during CPR is an important determinant of return
of compression depths (greater than 2. An inadequate compression Why: Compression-only CPR is easy for an untrained rescuer rate or frequent interruptions (or both) will reduce the total to perform and can be more effectively guided by dispatchers number of compressions delivered per minute. In compressions (eg. the recommendation remains for the upper limit of compression rate is based on 1 large registry rescuer to perform both compressions and breaths. more compressions are breaths.provide chest compressions for victims of cardiac arrest. for the trained and depth adversely affect outcomes. The more frequent and the more prolonged the stops. delivered per minute is determined by the rate of chest compressions and the number and duration of interruptions in Why: Compressions create blood flow primarily by increasing intrathoracic pressure and directly compressing the heart. breathing but a pulse. Chest Compression Depth* 2010 (Old): It is reasonable for lay rescuers and HCPs to 2015 (Updated): During manual CPR. study analysis associating extremely rapid compression rates (greater than 140/min) with inadequate compression depth. if
the trained lay rescuer is able to perform rescue allow AED analysis). based on only CPR or CPR with both compressions and rescue breaths preliminary data suggesting that excessive compression rate when provided before EMS arrival. shallow than they are too deep. • A n analogy can be found in automobile travel. Compression were not life-threatening. to open the airway. Traveling 60 mph without interruptions Threatening Emergencies* translates to an actual travel distance of 60 miles in an hour. it is reasonable for appropriately the lower the actual miles traveled. compressions and breaths should be provided in a associated with higher survival rates. and fewer compressions ratio of
30 compressions to 2 breaths.4 inches [6 cm]). Chest Compression Rate* Box 1 uses the analogy of automobile travel to explain the 2015 (Updated): In adult victims of cardiac arrest. Additional education with or without naloxone distribution to persons components of high-quality CPR include allowing complete chest recoil at risk for opioid overdose in any setting may be considered. deliver rescue breaths. identification of upper limits of compression depth may be • T he number of compressions delivered is affected by the compression challenging. This topic is also addressed in the Special Circumstances of Resuscitation section. The addition of an lay rescuer who is able. after each compression and avoiding excessive ventilation. survival rates from adult cardiac 2015 Guidelines Update are upper limits of recommended arrests of cardiac etiology are similar with either compression- compression rate and compression depth. adequate compression rate but also on minimizing interruptions to this critical component of CPR. Most monitoring via CPR feedback fraction is improved by reducing the number and duration of any devices suggests that compressions are more often too interruptions in compressions. Rescuers often do not compress the chest deeply enough despite the recommendation to “push Number of Compressions Delivered hard. the number of miles traveled in a day is affected not only by Bystander Naloxone in Opioid-Associated Life- the speed (rate of travel) but also by the number and duration of any stops (interruptions in travel). In most studies.” While a compression depth of at least 2 inches (5 cm) Affected by Compression is recommended. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 7 . Traveling 60 2015 (New): For patients with known or suspected mph except for a 10-minute stop translates to an actual travel of 50 opioid addiction who are unresponsive with no normal miles in that hour. It is important for rescuers to know that the rate (the frequency of chest compressions per minute) and by the recommendation about the upper limit of compression depth compression fraction (the portion of total CPR time during which is based on 1 very small study that reported an association compressions are performed). However. the large burden of disease from lethal opioid overdoses. efficient simultaneous • Increased emphasis has been placed on high-quality CPR using assessment and response. Emphasis on Chest Compressions* See Table 1. and avoiding excessive ventilation).4 inches (6 cm) Allow full recoil after each compression Lean on the chest between compressions Minimize pauses in compressions Interrupt compressions for greater than 10 seconds Ventilate adequately (2 breaths after 30 compressions. chest compressions and ventilation for all adult patients in  ompression depth for adults is modified to at least 2 inches (5 •C cardiac arrest. • T o allow full chest wall recoil after each compression. recommendation incorporates the newly approved treatment. approach that accomplishes multiple steps and assessments 2010 (Old): The HCP should check for response while simultaneously rather than the sequential manner used by individual looking at the patient to determine if breathing is absent or rescuers (eg.7 The resuscitation training network has • F or patients with ongoing CPR and an advanced airway in place. This per minute) is recommended. too many breaths or breaths with excessive force) 8 American Heart Association . methodical. Table 1 BLS Dos and Don’ts of Adult High-Quality CPR Rescuers Should Rescuers Should Not Perform chest compressions at a rate of 100-120/min Compress at a rate slower than 100/min or faster than 120/min Compress to a depth of at least 2 inches (5 cm) Compress to a depth of less than 2 inches (5 cm) or greater than 2. and a Why: The intent of the recommendation change is to fourth retrieves and sets up a defibrillator). step-by-step approach. each breath Provide excessive ventilation delivered over 1 second. each causing chest rise) (ie. but it would be practical for an HCP steps (ie. CPR Quality: HCP BLS In the following topics for HCPs. checking for breathing and pulse at the same time). one rescuer activates the emergency response system not normal. while another begins chest compressions. More information about these changes follows.4 inches (6 cm). 2010 (Old): It is reasonable for both EMS and in-hospital  riteria for minimizing interruptions is clarified with a goal of •C professional rescuers to provide chest compressions and rescue breaths for cardiac arrest victims. rescuers and HCPs. a requested information about the best way to incorporate simplified ventilation rate of 1 breath every 6 seconds (10 breaths such a device into the adult BLS guidelines and training. in an to continue to assess the breathing and pulse simultaneously effort to reduce the time to first chest compression. a third either provides ventilation or retrieves the bag-mask device for rescue breaths. rescuers must avoid leaning on the chest between compressions. performance targets (compressions of adequate rate and depth. rather than a slow. the use of passive ventilation at risk. Why: There is substantial epidemiologic data demonstrating chest compression fraction as high as possible. 2015 (Updated): It is reasonable for HCPs to provide • Compression rate is modified to a range of 100 to 120/min. In 2014. 
 Key issues and major changes in the 2015 Guidelines Update recommendations for HCPs include the following: Immediate Recognition and Activation of • T hese recommendations allow flexibility for activation of the Emergency Response System emergency response system to better match the HCP’s clinical setting. an asterisk (*) marks Summary of Key Issues and Major Changes those that are similar for HCPs and lay rescuers. before fully activating the emergency response system (or • Integrated teams of highly trained rescuers may use a choreographed calling for backup). allowing complete chest recoil between compressions. as well as some documented success in targeted national • W  here EMS systems have adopted bundles of care involving strategies for bystander-administered naloxone for people continuous chest compressions. 2015 (Updated): HCPs must call for nearby help upon finding • T rained rescuers are encouraged to simultaneously perform some the victim unresponsive. with a target of at least 60%. the naloxone autoinjector was approved techniques may be considered as part of that bundle for victims by the US Food and Drug Administration for use by lay of OHCA. it is realistic for HCPs to tailor the sequence of rescue actions to the most likely cause of arrest. Moreover. These changes are designed to simplify training for HCPs and to continue to emphasize the need to provide early Adult Basic Life Support and and high-quality CPR for victims of cardiac arrest. minimize delay and to encourage fast. minimizing interruptions in compressions. cm) but should not exceed 2. whether from a cardiac or noncardiac cause. rhythm with the AED or on the electrocardiogram (ECG) and preparing for defibrillation. especially if acting alone. Why: Compression-only CPR is recommended for untrained Why: The minimum recommended compression rate rescuers because it is relatively easy for dispatchers to remains 100/min. Chest Compression Rate: 100 to 120/min* Minimizing Interruptions in Chest 2015 (Updated): In adult victims of cardiac arrest. In such instances. if indicated. Why: Full chest wall recoil occurs when the sternum returns Why: While numerous studies have addressed the question to its natural or neutral position during the decompression of whether a benefit is conferred by providing a specified phase of CPR. completely before the next compression. rescuers should defibrillator be used as soon as possible. While there is less should start CPR with chest compressions and use the AED evidence about whether there is an upper threshold beyond as soon as possible. the time from ventricular chest after each compression. Why: A compression depth of approximately 5 cm is 2010 (Old): When any rescuer witnesses an out-of-hospital associated with greater likelihood of favorable outcomes arrest and an AED is immediately available on-site. as compared with delivering a cardiopulmonary blood flow. it is Compressions* reasonable for rescuers to perform chest compressions at a 2015 (Reaffirmation of 2010): Rescuers should attempt to rate of 100 to 120/min. blood flow and can influence resuscitation outcomes. CPR should be 2015 (Updated): It is reasonable for rescuers to avoid leaning provided while the defibrillator is retrieved. on the chest between compressions. Leaning on the chest wall shock as soon as the AED can be readied.4 inches soon as it is available. It is expected that added because 1 large registry series suggested that as the HCPs are trained in CPR and can effectively perform both compression rate increases to more than 120/min. the rescuer compared with shallower compressions. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 9 . For adults with perform chest compressions to a depth of at least 2 inches unmonitored cardiac arrest or for whom an AED is not (5 cm) for an average adult while avoiding excessive chest immediately available. However. coronary perfusion pressure. Chest wall recoil creates a relative negative period (typically 1½ to 3 minutes) of chest compressions intrathoracic pressure that promotes venous return and before shock delivery. For example. while the defibrillator equipment is being retrieved and 2010 (Old): The adult sternum should be depressed at least applied and that defibrillation. inadequate depth in 70% of compressions when compression rate was more than 140/min. it is reasonable that CPR be initiated compression depths (greater than 2. there is insufficient recoil for adults in cardiac arrest. no difference in between compressions precludes full chest wall recoil. evidence to support or refute CPR before defibrillation. the priority for the depth decreases in a dose-dependent manner. to allow the heart to fill fibrillation (VF) to shock delivery should be under 3 minutes. 
 and CPR should be performed while the defibrillator is readied. minimize the frequency and duration of interruptions in 2010 (Old): It is reasonable for lay rescuers and HCPs to compressions to maximize the number of compressions perform chest compressions at a rate of at least 100/min. such as the availability of an AED that when the compression rate was 120 to 139/min and to the provider can quickly retrieve and use. EMS may initiate CPR while checking the often too shallow than too deep. Shock First vs CPR First 2015 (Updated): For witnessed adult cardiac arrest when Chest Compression Depth* an AED is immediately available. a recent very small and other facilities with on-site AEDs or defibrillators should study suggests potential injuries (none life-threatening) from provide immediate CPR and should use the AED/defibrillator as excessive chest compression depth (greater than 2. There may be circumstances that warrant a but increased to inadequate depth in 50% of compressions change of sequence. it is reasonable that the 2015 (Updated): During manual CPR. in monitored patients. outcome has been shown. The upper limit rate of 120/min has been guide with telephone instructions. CPR should be provided while Incomplete recoil raises intrathoracic pressure and reduces the AED pads are applied and until the AED is ready to venous return. Compression depth may be difficult to judge without to support early CPR and early defibrillation. provider. When an OHCA is not witnessed for rescuers to know that chest compression depth is more by EMS personnel. It is important of sudden cardiac arrest. and identification of upper limits an AED or defibrillator is available within moments of the onset of compression depth may be challenging. be attempted as 2 inches (5 cm). to allow full chest wall With in-hospital sudden cardiac arrest. should still be to activate the proportion of compressions of inadequate depth was the emergency response system and to provide chest about 35% for a compression rate of 100 to 119/min compressions. particularly when use of feedback devices. HCPs who treat cardiac arrest in hospitals which compressions may be too deep. delivered per minute. Chest Recoil* Whenever 2 or more rescuers are present.4 inches [6 cm]). and myocardial analyze the rhythm. 2010 (Old): Rescuers should allow complete recoil of the However. compression compressions and ventilation. These recommendations are designed [6 cm]). soon as the device is ready for use. 1½ to 3 minutes of CPR may be considered before attempted defibrillation. Return to the child or infant and resume CPR. automated external defibrillator. do not lean on the chest after each compression Minimizing Limit interruptions in chest compressions to less than 10 seconds interruptions *Compression depth should be no more than 2. breastbone (sternum) just below the nipple line 2 or more rescuers 2 thumb–encircling hands in the center of the chest. 10 American Heart Association . anteroposterior. send someone and Leave the victim to activate the emergency response system and get the AED begin CPR immediately. Abbreviations: AED. leave the victim to activate the Follow steps for adults and adolescents on the left response system emergency response system and get Unwitnessed collapse the AED before beginning CPR Give 2 minutes of CPR Otherwise. cardiopulmonary resuscitation. use the AED as soon as it is available use the AED as soon as it is available Compression. AP. 1 or 2 rescuers 1 rescuer ventilation 30:2 30:2 ratio without advanced airway 2 or more rescuers 15:2 Compression. CPR. Adolescents (Age 1 Year to Puberty) Excluding Newborns) Scene safety Make sure the environment is safe for rescuers and victim Recognition of Check for responsiveness cardiac arrest No breathing or only gasping (ie. Continuous compressions at a rate of 100-120/min ventilation Give 1 breath every 6 seconds (10 breaths/min) ratio with advanced airway Compression rate 100-120/min Compression At least 2 inches (5 cm)* At least one third AP diameter of chest At least one third AP diameter of chest depth About 2 inches (5 cm) About 1½ inches (4 cm) Hand placement 2 hands on the lower half of the 2 hands or 1 hand (optional for very 1 rescuer breastbone (sternum) small child) on the lower half of the 2 fingers in the center of the chest. Table 2 Summary of High-Quality CPR Components for BLS Providers Infants Adults and Children Component (Age Less Than 1 Year. no normal breathing) No definite pulse felt within 10 seconds (Breathing and pulse check can be performed simultaneously in less than 10 seconds) Activation of If you are alone with no mobile Witnessed collapse emergency phone.4 inches (6 cm). just below the nipple line Chest recoil Allow full recoil of chest after each compression. whether the characteristics of compression rate and depth and chest trained providers are nearby. possible. There is some evidence may require modifications in the BLS sequence. recording. location. Why: This simple single rate for adults. type of arrest. respect to generating significant cardiac output. studies to date have not demonstrated a significant improvement Alternative Techniques and in favorable neurologic outcome or survival to hospital Ancillary Devices for CPR discharge with the use of CPR feedback devices during actual cardiac arrest events. the 2015 Guidelines Update allows focus on demonstrating mastery. give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions 2015 (Updated): It may be reasonable to use audiovisual (this will result in delivery of 8 to 10 breaths per minute). Advanced Airway 2015 (Updated): It may be reasonable for the provider to Comparison of Key Elements of Adult. or laryngeal mask airway) is in place during Chest Compression Feedback 2-person CPR. increase in chest compression fraction can be achieved by showed improved survival with favorable neurologic status minimizing pauses in chest compressions. multitiered response in as part of required care (ie. been presented as a sequence in order to help a single for debriefing after resuscitation. 2010 (Old): When an advanced airway (ie. In all of these EMS systems. Since the 2010 and airway adjuncts. whether the rescuer must leave recoil while minimizing interruptions is a complex challenge a victim to activate the emergency response system) that even for highly trained professionals. Combitube. children. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 11 . separate evidence that CPR feedback decreases the leaning force during chest compressions. with a target of at least 60%. A variety based. and infant BLS (excluding CPR for newly born infants). during CPR with an advanced airway). Table 2 lists the 2015 key elements of adult. for chest compression fraction has not been defined. and 200 resuscitation time that compressions are performed. rescuer distraction). and there is flexibility in sequence is appropriate. including both physiologic patient parameters and rescuer performance metrics. Maintaining focus during CPR on in any resuscitation (eg. interspersed with rescue breaths is inherently inefficient with it may be reasonable for EMS systems with priority. The updated that the use of CPR feedback may be effective in modifying BLS HCP algorithms aim to communicate when and where chest compression rates that are too fast. feedback devices during CPR for real-time optimization of CPR performance. rhythm analysis and ventilation) both urban and rural communities. multitiered response to delay positive-pressure of alternatives and adjuncts to conventional CPR have ventilation (PPV) by using a strategy of up to 3 cycles of 200 been developed with the aim of enhancing cardiac output continuous compressions with passive oxygen insufflation during resuscitation from cardiac arrest. and Infant BLS while continuous chest compressions are being performed (ie. it may be reasonable to perform providing initial continuous chest compressions with delayed CPR with the goal of a chest compression fraction as high as PPV for adult victims of OHCA. Summary of Key Issues and Major Changes Delayed Ventilation Conventional CPR consisting of manual chest compressions 2015 (New): For witnessed OHCA with a shockable rhythm. the providers received additional training with emphasis on provision of high-quality chest compressions. there are several factors improvement programs. However. flexibility for activation of the emergency response and subsequent management in order to better match the Why: Technology allows for real-time monitoring. Chest compression package of care that includes up to 3 cycles of passive fraction is a measurement of the proportion of total oxygen insufflation. Three studies Why: Interruptions in chest compressions can be intended in systems that use priority-based. and infants—rather than a range of breaths per minute—should 2010 (Old): New CPR prompt and feedback devices be easier to learn. and provide a bundled or unintended (ie. deliver 1 breath every 6 seconds (10 breaths per minute) Child. endotracheal tube. and for system-wide quality rescuer prioritize actions. remember. Guidelines were published. and feedback about CPR quality. Training for the complex combination of skills required to perform adequate chest compressions should 2015 (New): For HCPs. The optimal goal for victims with witnessed arrest or shockable rhythm. An continuous chest compressions with interposed shocks. These Why: The steps in the BLS algorithms have traditionally important data can be used in real time during resuscitation. may be useful for training rescuers and as part of an overall strategy
to improve the quality of CPR in actual Team Resuscitation: Basic Principles resuscitations. child. and perform. 2015 (New): For adults in cardiac arrest who receive CPR Why: Several EMS systems have tested a strategy of without an advanced airway. provider’s clinical setting (Figure 5). The addition of a target compression fraction is intended to limit interruptions in compressions and to maximize coronary Ventilation During CPR With an perfusion and blood flow during CPR. a number of clinical trials have provided new data on the effectiveness of these alternatives. airway adjunct insertion. However. rhythm check). emergency pulse (simultaneously). Shout for nearby help. AED arrives. • Continue rescue breathing. begin CPR (go to “CPR” box). Activate emergency response system via mobile device (if appropriate). Continue until ALS providers take Continue until ALS providers take over or victim starts to move. emergency response system or backup is activated. system (if not already done) Monitor until has pulse or only gasping and check has pulse after 2 minutes. shockable nonshockable Give 1 shock. • If possible opioid overdose. no pulse By this time in all scenarios. and AED and emergency equipment are retrieved or someone is retrieving them. Check rhythm. Provide rescue breathing: 1 breath every 5-6 seconds. Resume CPR Resume CPR immediately for immediately for about 2 minutes about 2 minutes (until prompted (until prompted by AED to allow by AED to allow rhythm check). Victim is unresponsive. Normal No normal • Activate emergency response breathing. No. Look for no breathing breathing. Get AED and emergency equipment (or send someone to do so). 12 American Heart Association . available per protocol. or about 10-12 breaths/min. Is pulse definitely felt check pulse about every within 10 seconds? 2 minutes. No breathing administer naloxone if or only gasping. over or victim starts to move. responders arrive. Use AED as soon as it is available. Figure 5 BLS Healthcare Provider Adult Cardiac Arrest Algorithm—2015 Update BLS Healthcare Provider Adult Cardiac Arrest Algorithm—2015 Update Verify scene safety. Shockable rhythm? Yes. CPR Begin cycles of 30 compressions and 2 breaths. If no pulse. with improved neurologically intact survival for patients with OHCA. devices have been tested only in highly selected subgroups Why: Three large randomized controlled trials comparing of cardiac arrest patients. vasopressin for use by properly trained personnel in specific settings for has been removed from the Adult Cardiac Arrest Algorithm– the treatment of adult cardiac arrest in circumstances (eg. with arrest of cardiac origin. adjunct during conventional CPR is not recommended. acute myocardial infarction). after control arm did not have the use of such feedback devices). personnel as a CPR adjunct in adult cardiac arrest. However. to simplify the algorithm. Manual chest compressions remain the standard of care for the treatment of cardiac arrest. Impedance Threshold Devices 2010 (Old): There was insufficient evidence to recommend 2015 (Updated): The routine use of the ITD as an the routine use of ECPR for patients in cardiac arrest. it must be noted that some techniques and specific settings for the treatment of cardiac arrest. Also. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 13 . 2015 (Updated): ECPR may be considered an alternative • The use of ECPR may be considered for selected patients in to conventional CPR for select patients who have a cardiac settings where a reversible cause of cardiac arrest is suspected. Although these inclusion criteria are highly compression-decompression CPR plus the ITD also had variable. However. 2015 (Updated): The evidence does not demonstrate a benefit with the use of mechanical piston devices for chest Adult Advanced Cardiovascular compressions versus manual chest compressions in patients Life Support with cardiac arrest. Therefore. many of these techniques during diagnostic and interventional procedures) that make and devices require specialized equipment and training. while the with limited comorbidities. ECPR is a complex process that requires a highly active compression-decompression CPR plus an ITD when trained team. but special settings where this technology may be Perfusion Devices useful are identified. • The routine use of mechanical chest compression devices is not Extracorporeal Techniques and Invasive recommended. arrest and for whom the suspected etiology of the cardiac arrest is potentially reversible. specialized equipment. support within the local healthcare system. it may The combination of ITD with active compression. The load-distributing band When rescuers or healthcare systems are considering may be considered for use by properly trained personnel in implementation. such a device may be a reasonable alternative to Summary of Key Issues and Major Changes conventional CPR in specific settings where the delivery of Key issues and major changes in the 2015 Guidelines high-quality manual compressions may be challenging or Update recommendations for advanced cardiac life support dangerous for the provider (eg. CPR during hypothermic cardiac arrest. advantage to using standard-dose epinephrine in cardiac arrest.Compared with conventional CPR. drug intoxication) or amenable to properly trained personnel. conventional CPR for more than 10 minutes without ROSC. CPR in a moving ambulance. most included only patients aged 18 to 75 years CPR delivered using CPR quality feedback devices. For this • A recent randomized controlled trial suggests that the use of the reason. include the following: prolonged CPR. 2015 Update. mechanical chest compression devices have not • The routine use of the impedance threshold device (ITD) as an demonstrated improved outcomes for patients with OHCA adjunct to conventional CPR is not recommended. The goal of ECPR is to support patients with a sham device) as an adjunct to conventional CPR. heart transplantation (eg. be considered when the time without blood flow is brief and decompression CPR may be a reasonable alternative to the condition leading to the cardiac arrest is reversible (eg. CPR in the angiography suite. manual chest compressions remain the standard ITD plus active compression-decompression CPR is associated of care. and available published series have estimate were very broad. There are no confidence intervals around the primary outcome point clinical trials on ECPR. manual resuscitation difficult. However. in cardiac arrest while potentially reversible conditions are Another clinical trial demonstrated a benefit with the use of treated. ECPR involves multicenter randomized clinical trial failed to demonstrate any the emergency cannulation of a large vein and artery (eg. and there is a high risk of bias used rigorous inclusion and exclusion criteria to select on the basis of co-intervention (the group receiving active patients for ECPR. One large the resuscitation of a patient in cardiac arrest. improvement associated with the use of an ITD (compared femoral vessels). when compared with manual chest compressions. • The combined use of vasopressin and epinephrine offers no CPR during preparation for ECPR). vasopressin does not offer an advantage over the use of 2010 (Old): Mechanical piston devices may be considered epinephrine alone. myocarditis) or revascularization 2010 (Old): The use of the ITD may be considered by trained (eg. These inclusion criteria should be considered in a provider’s Mechanical Chest Compression Devices selection of potential candidates for ECPR. in settings where ECPR is readily available. Why: The term extracorporeal CPR is used to describe the Why: Two large randomized controlled trials have provided initiation of extracorporeal circulation and oxygenation during new information about the use of the ITD in OHCA. and multidisciplinary compared with conventional CPR and no ITD. limited rescuers available. conventional CPR in settings with available equipment and accidental hypothermia. so it is inadvisable to rely solely on conventional CPR. a number of lower-quality • One observational study suggests that ß-blocker use after cardiac arrest may be associated with better outcomes than when studies suggest improved survival with good neurologic ß-blockers are not used. However. • In cardiac arrest patients with nonshockable rhythm and who are otherwise receiving epinephrine. However. Because ECPR is strong-enough evidence to recommend routine use. a recent study of lidocaine in cardiac arrest Why: Both epinephrine and vasopressin administration survivors showed a decrease in the incidence of recurrent during cardiac arrest have been shown to improve ROSC. ß-blocker administration initial nonshockable rhythm. the Cardiac Arrest Algorithm. failure to achieve an for decision making. Vasopressors for Resuscitation: Vasopressin Post–Cardiac Arrest Drug Therapy: Lidocaine 2015 (Updated): Vasopressin in combination with epinephrine 2015 (New): There is inadequate evidence to support the offers no advantage as a substitute for standard-dose routine use of lidocaine after cardiac arrest. been associated with an extremely poor chance of ROSC • When rapidly implemented. vasopressin has been removed from the Adult routine use of a ß-blocker after cardiac arrest. the epinephrine in cardiac arrest. was associated with higher survival rates. component of a multimodal approach to decide when to end • Steroids may provide some benefit when bundled with vasopressin resuscitative efforts but should not be used in isolation. However. survival to hospital discharge. the early provision of epinephrine Extracorporeal CPR is suggested. initiation or continuation of an oral or IV ß-blocker may be considered early after hospitalization from cardiac arrest due Vasopressors for Resuscitation: Epinephrine to VF/pVT. 2015 (New): ECPR may be considered among select cardiac • Studies about the use of lidocaine after ROSC are conflicting. initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT. the studies to date are limited in that provide time to treat potentially reversible conditions or arrange for they have potential confounders and have included relatively cardiac transplantation for patients who are not resuscitated by small numbers of patients. or to support a patient while waiting for a cardiac transplant. and epinephrine in treating IHCA. Review of the available evidence shows that efficacy of the 2 drugs is similar and that there is no demonstrable benefit Post–Cardiac Arrest Drug Therapy: ß-Blockers from administering both epinephrine and vasopressin as compared with epinephrine alone. ECPR can prolong viability. and the Why: A very large observational study of cardiac arrest with routine use of ß-blockers after cardiac arrest is potentially nonshockable rhythm compared epinephrine given at 1 to hazardous because ß-blockers can cause or worsen 3 minutes with epinephrine given at 3 later time intervals (4 hemodynamic instability. the initiation resource intensive and costly. this finding is only an associative relationship. VF/pVT but did not show either long-term benefit or harm. While routine use is not Why: Failure to achieve an ETCO2 of 10 mm Hg by recommended pending follow-up studies. as it may and survival. and arrest patients who have not responded to initial conventional routine lidocaine use is not recommended. 2010 (Old): One dose of vasopressin 40 units IV/ intraosseously may replace either the first or second dose of Why: While earlier studies showed an association between epinephrine in the treatment of cardiac arrest. giving lidocaine after myocardial infarction and increased mortality. The study found bradyarrhythmias. However. and neurologically intact survival. it should be considered only or continuation of an oral or intravenous (IV) ß-blocker may be when the patient has a reasonably high likelihood of benefit— considered early after hospitalization from cardiac arrest due to in cases where the patient has a potentially reversible illness VF/pVT. Therefore. In the interest of 2015 (New): There is inadequate evidence to support the simplicity. continuation of lidocaine may be considered immediately after ROSC from VF/pulseless ventricular tachycardia (pVT) cardiac arrest. 2015 (New): It may be reasonable to administer epinephrine Why: In an observational study of patients who had ROSC as soon as feasible after the onset of cardiac arrest due to an after VF/pVT cardiac arrest. and cause to 6. Although this observational study is not outcome for select patient populations. it would be reasonable waveform capnography after 20 minutes of resuscitation has for a provider to administer the bundle for IHCA. in settings where it can be rapidly implemented. and greater than 9 minutes). 14 American Heart Association . However. • Low end-tidal carbon dioxide (ETCO2) in intubated patients after ETCO2 for Prediction of Failed Resuscitation 20 minutes of CPR is associated with a very low likelihood of resuscitation. providers may consider low ETCO2 after 20 ETCO2 of greater than 10 mm Hg by waveform capnography minutes of CPR in combination with other factors to help determine after 20 minutes of CPR may be considered as one when to terminate resuscitation. ETCO2 in determining when to terminate resuscitation. the initiation or CPR. providers should evaluate an association between early administration of epinephrine patients individually for their suitability for ß-blockers. 7 to 9. Why: Although no high-quality studies have compared ECPR to conventional CPR. While this parameter should not be used in isolation 2015 (New): In intubated patients. exacerbate heart failure. and increased ROSC. regardless of whether the patient is comatose or awake. lacking meaningful response to verbal commands) adult patients with ROSC Summary of Key Issues and Major Changes after cardiac arrest should have TTM. Coronary Angiography Continuing Temperature Management Beyond 24 Hours 2015 (Updated): Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) 2015 (New): Actively preventing fever in comatose patients for OHCA patients with suspected cardiac etiology of arrest after TTM is reasonable. be similar for both. initial cardiac arrest should be considered potential organ donors. reasonable to pursue. fever may develop. Because the outcome of coma Hemodynamic Goals After Resuscitation may be improved by correction of cardiac instability. Because preventing fever of suspected cardiac origin but without ST elevation on after TTM is relatively benign and fever may be associated ECG. It had been assumed that earlier initiation of cooling might provide added benefits Why: Multiple observational studies found positive and also that prehospital initiation might facilitate and associations between emergency coronary revascularization encourage continued in-hospital cooling. considered for comatose adult patients with ROSC after • T TM recommendations have been updated with new evidence IHCA of any initial rhythm or after OHCA with an initial rhythm suggesting that a range of temperatures may be acceptable to of pulseless electrical activity or asystole. cooling patients in the prehospital setting regardless of coma. so the recommendation remains after the completion of TTM. A recent high-quality study compared temperature • Identification and correction of hypotension is recommended in the management at 36°C and at 33°C and found outcomes to immediate post–cardiac arrest period. Update recommendations for post–cardiac arrest care then maintained constantly for at least 24 hours. the initial studies suggest • Prognostication is now recommended no sooner than 72 hours that TTM is beneficial. emergency treatment of post– correct hypotension (systolic blood pressure less than 90 cardiac arrest patients should follow identical guidelines. electrically or hemodynamically from TTM is associated with worsened neurologic injury. Why: Initial studies of TTM examined cooling to • After TTM is complete. The selected temperature may be determined by clinician preference or • All patients who progress to brain death or circulatory death after clinical factors. While there are temperatures between 32°C and 34°C compared with no conflicting observational data about the harm of fever after TTM. Emergency coronary angiography Why: In some observational studies. with a target Key issues and major changes in the 2015 Guidelines temperature between 32°C and 36°C selected and achieved. clinicians can select after ROSC. unstable) adult patients who are comatose after OHCA although studies are conflicting. fever after rewarming is reasonable for select (eg. should be initiated Why: Before 2010. target in the post–cardiac arrest period. guidelines already recommend cooling and also identified potential complications when emergency treatment of STEMI and emergency treatment using cold IV fluids for prehospital cooling. Appropriate treatment of acute coronary syndromes (ACS) or STEMI. Taken together. preventing fever is suggested. even in the absence of a clearly defined STEMI. In the high-quality studies demonstrated no benefit to prehospital absence of cardiac arrest. of non–ST-segment elevation ACS with electrical or hemodynamic instability. lacking of meaningful response • Emergency coronary angiography is recommended for all to verbal commands) adult patients with ROSC after out- patients with ST elevation and for hemodynamically or electrically of-hospital VF cardiac arrest should be cooled to 32°C to unstable patients without ST elevation for whom a cardiovascular 34°C for 12 to 24 hours. mean arterial pressure less than 65 mm Hg) during post–cardiac arrest care. including PCI or fibrinolysis. from a wider range of target temperatures. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 15 . Induced hypothermia also may be lesion is suspected. and the prognosis of coma cannot be reliably determined in the first 2015 (New): It may be reasonable to avoid and immediately few hours after cardiac arrest. mm Hg. arrest patients for whom coronary angiography is indicated. recommended. and ST elevation on ECG. include the following: 2010 (Old): Comatose (ie. Recently published and both survival and favorable functional outcome. for those who do not have TTM. prognostication is not recommended any sooner than 72 hours Given that 33°C is no better than 36°C. Out-of-Hospital Cooling 2010 (Old): Primary PCI (PPCI) after ROSC in subjects 2015 (New): The routine prehospital cooling of patients with arrest of presumed ischemic cardiac etiology may be with rapid infusion of cold IV fluids after ROSC is not reasonable. to select a single target temperature and perform TTM. well-defined TTM and found improvement in neurologic the prevention of fever is considered benign and therefore is outcome for those in whom hypothermia was induced. Coronary angiography is reasonable in post–cardiac with harm. had not been extensively evaluated. Targeted Temperature Management Post–Cardiac Arrest Care 2015 (Updated): All comatose (ie. different provide accurate prediction of outcome (Box 2). metabolic derangement. and other clinical factors should be considered carefully because they may affect results or interpretation of some tests. Starting with this update. including hemodynamic control. EEG. because medications have been allowed to resolve. Why: There has been no difference reported in immediate or long-term function of organs from donors who reach brain 2010 (Old): While times for usefulness of specific tests were death after cardiac arrest when compared with donors who identified. and medications may mortality and diminished functional recovery. computed tomography. no specific overall recommendation was made reach brain death from other causes. electrophysiologic modalities. early for patients with possible ACS. electroencephalogram. 2010 (Old): Adult patients who progress to brain death after 2015 (Updated): In patients treated with TTM. hospital arrival *Shock. and marker is affected differently by sedation and systolic blood pressure less than 90 mm Hg or a mean arterial neuromuscular blockade. imaging recovered from similar donors with other conditions. patients may have different requirements to maintain optimal organ perfusion. Acute Coronary Syndromes Box 2 The 2015 Guidelines Update marks a change in the scope of the AHA guidelines for the evaluation and management Useful Clinical Findings of ACS. reasonable to wait until 72 hours after return to normothermia before predicting outcome. Organ Donation Prognostication After Cardiac Arrest 2015 (Updated): All patients who are resuscitated from cardiac arrest but who subsequently progress to death 2015 (New): The earliest time to prognosticate a poor or brain death should be evaluated as potential organ neurologic outcome using clinical examination in patients donors. recommendations will That Are Associated With be limited to the prehospital and emergency department phases of care. Patients who do not achieve ROSC and who would not treated with TTM is 72 hours after cardiac arrest. • Presence of status myoclonus (different from isolated myoclonic jerks) during the first 72 hours after cardiac arrest Summary of Key Issues and Major Changes • Absence of the N20 somatosensory evoked potential cortical wave 24 to 72 hours after cardiac arrest or after rewarming Key issues with major changes in the 2015 Guidelines • Presence of a marked reduction of the gray-white ratio on brain CT Update recommendations for ACS include the following: obtained within 2 hours after cardiac arrest • Prehospital ECG acquisition and interpretation • Extensive restriction of diffusion on brain MRI at 2 to 6 days after • Choosing a reperfusion strategy when prehospital fibrinolysis is cardiac arrest available • Persistent absence of EEG reactivity to external stimuli at 72 hours after cardiac arrest • Choosing a reperfusion strategy at a non–PCI-capable hospital • Persistent burst suppression or intractable status epilepticus on EEG • Troponin to identify patients who can be safely discharged from the after rewarming emergency department Absent motor movements. Multiple specific systolic or mean arterial pressure targets could not modalities of testing and examination used together to be identified. arterial pressures of greater than 100 mm Hg are associated No single physical finding or test can predict neurologic with better recovery. prior sedatives or neuromuscular blockers. temperature. because trials typically studied a bundle of many predict outcome after the effects of hypothermia and interventions. from these donors have success rates comparable to organs Why: Clinical findings. but this otherwise have resuscitation terminated may be considered time can be even longer after cardiac arrest if the residual as potential kidney or liver donors in settings where rapid effect of sedation or paralysis is suspected to confound the organ recovery programs exist. Prehospital ECG Acquisition and Interpretation Abbreviations: CT. the comatose brain pressure of less than 65 mm Hg is associated with higher may be more sensitive to medications. In addition. or myoclonus should not be • Interventions that may or may not be of benefit if given before used alone for predicting outcome. where sedation resuscitation from cardiac arrest should be considered for or paralysis could confound clinical examination. recovery after cardiac arrest with 100% certainty. Why: Studies of patients after cardiac arrest have found that a test. 16 American Heart Association . while systolic take longer to metabolize after cardiac arrest. extensor posturing. it is organ donation. clinical examination. Also. and blood markers are all useful for predicting neurologic outcome in comatose patients. While higher pressures appear superior. In-hospital care is addressed by Poor Neurologic Outcome* guidelines for the management of myocardial infarction published jointly by the AHA and the American College of • Absence of pupillary reflex to light at 72 hours or more after cardiac arrest Cardiology Foundation. are most likely to baseline blood pressure varies from patient to patient. modalities. magnetic resonance imaging. but each finding. Organs transplanted about time to prognostication. 2015 (New): Prehospital 12-lead ECG should be acquired MRI. immediate fibrinolysis may overcome any identified on prehospital ECG. predictions based on negative troponin test results. low risk score per of the STEMI system of care and direct transport to a PCI center Vancouver rule. at the initial hospital with transfer only for ischemia-driven PCI. field transmission of the ECG or a computer report to produce any difference in mortality. In the past 15 years. measured at 0 and 2 ECG interpretation. 2015 (New): Trained nonphysicians may perform ECG 2010 (Old): Transfer of high-risk patients who have received interpretation to determine whether or not the tracing shows primary reperfusion with fibrinolytic therapy is reasonable. Reperfusion Also. early hospital notification of the impending arrival of 2015 (New): High-sensitivity troponin T and troponin I alone a patient with ST elevation or prehospital activation of the measured at 0 and 2 hours (without performing clinical risk catheterization laboratory reduces time to reperfusion and stratification) should not be used to exclude the diagnosis reduces morbidity and mortality. Why: Fibrinolysis has been the standard of care for 2015 (Updated): Computer-assisted ECG interpretation may STEMI for more than 30 years. it may be When a medication reduces morbidity or mortality. A fresh look at the evidence receiving hospital for patients identified as having STEMI. but high-sensitivity troponin I measurements that for the inexperienced provider to develop skill with 12-lead are less than the 99th percentile. There is. hospital and/or prehospital activation of the catheterization However. reasonable to transport all postfibrinolysis patients for early prehospital compared with hospital administration of that routine angiography in the first 3 to 6 hours and up to 24 medication allows the drug to begin its work sooner and hours rather than transport postfibrinolysis patients only may further decrease morbidity or mortality. when PPCI can be provided in a timely manner by experienced practitioners. either initial facility to a PCI center. when urban EMS response and transport times are short. in a delay to treatment. 2015 (New): When STEMI patients cannot be transferred to However. which could result fibrinolysis does reduce the incidence of reinfarction. results in an unacceptably high rate of MACE at 30 days. negative troponin I or troponin T measurements at 0 and between 3 and 6 hours may be used together with very 2015 (New): Where prehospital fibrinolysis is available as part low-risk stratification (TIMI score of 0. decrease in the incidence of intracranial hemorrhage. fibrinolytic therapy combined with structured risk assessment. but transfer for PPCI the receiving hospital was recommended. or low-risk HEART score) to predict a center may be preferred because it results in a small relative less than 1% chance of 30-day MACE. has inhibited expansion of ECG programs to EMS systems. when there is a delay to PPCI. computer interpretation can be expected hours. for clinicians at non–PCI-capable hospitals. alternately. North America and has been shown to modestly improve 2015 (Updated): Prehospital notification of the receiving outcomes. it was recommended that biomarkers 2015 (New): In adult patients presenting with STEMI in the should be remeasured between 6 to 12 hours after emergency department of a non–PCI-capable hospital. depending on the laboratory should occur for all patients with a STEMI length of that delay. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 17 . acceptable alternative to immediate transfer to primary PCI. Similar concerns existed with Troponin to Identify Patients Who Can Be Safely computer interpretation of ECGs. prehospital triage and transport directly to a PCI age less than 50 years. underdiagnosis. we symptom onset. carry a risk of with routine transfer for angiography (see below) may be an less than 1% of MACE at 30 days. Direct transfer to a PCI-capable 2010 (Old): If providers are not trained to interpret the 12-lead hospital compared with prehospital fibrinolysis does not ECG. has allowed stratification of treatment recommendations according to time from symptom onset and anticipated delay Why: A 12-lead ECG is inexpensive. no evidence of mortality benefit of one therapy over 2010 (Old): If biomarkers are initially negative within 6 hours the other. North American Chest Pain score of 0 and is available. evidence of STEMI. or low risk per Vancouver rule) to predict a less than 1% chance of 30-day major adverse cardiac event (MACE). compared with fibrinolysis. be used in conjunction with interpretation by a physician or PPCI has become more readily available in most parts of trained provider to recognize STEMI. additional benefits of PCI. Other Interventions 2015 (New): When fibrinolytic therapy is administered to a STEMI patient in a non–PCI-capable hospital. 1. when they require ischemia-guided angiography. Immediate PCI Concern that nonphysician interpretation of ECGs could after treating with fibrinolysis provides no added benefit. and has enabled recommendations specifically and can rapidly provide evidence of acute ST elevation. however. may be used together with low-risk stratification to increase the accuracy of interpretation when used in (Thrombolysis in Myocardial Infarction [TIMI] score of 0 or conjunction with trained nonphysician interpretation. of symptom onset. does result in a small relative decrease in the incidence 2010 (Old): Advance notification should be provided to the of intracranial hemorrhage. lead to either overdiagnosis with a resulting overuse of but routine angiography within the first 24 hours after giving resources or. instead of immediate fibrinolysis alone or in combination with unstructured risk assessment. Because it may take time of ACS. a PCI-capable hospital in a timely manner. A review of the literature Discharged From the Emergency Department shows that when fibrinolysis is not given in the prehospital setting. recommend immediate transfer without fibrinolysis from the Why: Relying on a negative troponin test result. is easy to perform. However. to PPCI. supported by a multicenter randomized controlled should not delay access to more advanced medical trial published since the 2015 systematic review. procedures. In addition. In systems where prehospital administration of UFH already occurs. weak evidence with known or suspected opioid overdose who have a of no benefit and possible harm prompted a recommendation definite pulse but no normal breathing or only gasping that supplementary oxygen was not needed for patients with (ie. naloxone administration devices local anesthetic systemic toxicity. it is 2015 (New): Empiric administration of IM or IN naloxone to just as reasonable to wait to give UFH until hospital arrival. should not be enoxaparin is a reasonable alternative to UFH. either alone or coupled with naloxone Administration of an adenosine diphosphate inhibitor in the distribution and training. For patients oxygen saturation or respiratory condition. supporting a possible role for Why: Naloxone administration has not previously been ILE in patients who have cardiac arrest and are failing standard recommended for first aid providers. the opportunity for beneficial drug effect may not be great. including EMS activation. For this reason. Responders should not delay access to more-advanced medical services while awaiting the • Intravenous lipid emulsion (ILE) may be considered for treatment of local anesthetic systemic toxicity. intended for use by lay rescuers are now approved and • The importance of high-quality CPR during any cardiac arrest has available for use in the United States. This been highlighted by the Centers for Disease Control. It may rescuers and HCPs is now recommended. and the successful led to a reassessment of the recommendations about relief of implementation of lay rescuer naloxone programs has aortocaval compression during cardiac arrest in pregnancy.9 While reassessment has resulted in refined recommendations about it is not expected that naloxone is beneficial in cardiac strategies for uterine displacement. a patient’s response to naloxone or other interventions. Standard resuscitative measures should administered with apparent safety and effectiveness in the first aid take priority over naloxone administration. or BLS resuscitative measures as the result of drug toxicity other than providers. and simplified training be reasonable to administer IM or IN naloxone based on is being offered. response education. care. non-HCPs. Responders may be harmful. such persons). Where it is not already used in the prehospital setting. oxygen was routinely threatening emergency may be reasonable as an adjunct to administered to all patients with suspected ACS regardless of standard first aid and non-HCP BLS protocols. who are without hypoxemia). In 2010. adding medications increases the complexity of Training and Distribution prehospital care. possible ACS who have a normal oxygen saturation (ie. However. Special Circumstances Cardiac Arrest in Patients With Known or of Resuscitation Suspected Opioid Overdose 2015 (New): Patients with no definite pulse may be in Summary of Key Issues and Major Changes cardiac arrest or may have an undetected weak or slow • Experience with treatment of patients with known or suspected pulse. patients may be reasonable as an adjunct to standard first aid and non-HCP BLS protocols. new recommendation is provided. • Adenosine diphosphate inhibition for hospital patients with 2015 (New): It is reasonable to provide opioid overdose suspected STEMI has been recommended for many years. These patients should be managed as cardiac opioid overdose has demonstrated that naloxone can be arrest patients. which may in turn produce negative effects. in addition to providing standard ACS who had an oxyhemoglobin saturation of 94% or greater (ie. it is recognized that it may be difficult to distinguish cardiac arrest from severe respiratory depression in victims of opioid overdose. While there is no evidence that administration of naloxone will help a patient in cardiac 18 American Heart Association . a new algorithm for management of the possibility that the patient is in respiratory arrest. whether or not the cause is opioid overdose. prehospital administration of UFH or bivalirudin unresponsive opioid-associated resuscitative emergency is reasonable. in the prehospital setting has not been shown to provide additional benefits to giving it in the hospital. a respiratory arrest). arrest. delayed for naloxone administration. in cardiac arrest. Standard resuscitation • For suspected STEMI patients who are being transferred for PPCI. naloxone administration by lay high-quality CPR (compressions plus ventilation). Empiric administration of IM or IN naloxone to all • For STEMI patients. Opioid Overdose Education and Naloxone Moreover. It is reasonable to base this training on first aid and non-HCP BLS recommendations rather than on • Unfractionated heparin (UFH) administered to patients with STEMI more advanced practices intended for HCPs. Further administer IM or IN naloxone to patients with an opioid- evidence that the routine administration of supplementary oxygen associated respiratory emergency (Figure 6). to persons at risk for opioid prehospital setting provides neither additional benefit nor harm overdose (or those living with or in frequent contact with compared with waiting to administer it in the hospital. not unresponsive victims with suspected opioid overdose is provided. all unresponsive victims of possible opioid-associated life- • Before the 2010 recommendations. In addition. with a focus on and BLS settings. it is reasonable to continue Opioid Overdose Treatment to use it. it is reasonable for appropriately trained rescuers to no hypoxemia) and no evidence of respiratory distress.8 strengthens services while awaiting the patient’s response to naloxone the recommendation that oxygen be withheld from patients with or other interventions. If victim is unresponsive with no breathing or only gasping. otherwise respond? No Continue CPR and use AED as soon as it is available. Does the Stimulate and reassess. does the person breathing until advanced help arrives. the provision of naloxone may help an unresponsive local anesthetic toxicity. if a pulse is present). case reports have examined the use of ILE for patients concomitant with standard resuscitative care. Observe for breathing vs no breathing or only gasping. *CPR technique based on rescuer’s level of training. Send someone to call 9-1-1 and get AED and naloxone. perform CPR for about 2 minutes before leaving to phone 9-1-1 and get naloxone and AED. regularly. moan. It may be reasonable to administer patient with severe respiratory depression who only ILE to patients with other forms of drug toxicity who are appears to be in cardiac arrest (ie.* If alone. Check for unresponsiveness and call for nearby help. Give naloxone as soon as it is available. to patients with drug toxicity that is not the result of local anesthetic who have premonitory neurotoxicity or cardiac arrest due to infusion. Begin CPR.4 mg intramuscular. 2010 (Old): It may be reasonable to consider ILE for local anesthetic toxicity. begin CPR. or begin CPR and repeat naloxone. © 2015 American Heart Association arrest. breathe If the person stops responding. Although the results of these studies and reports Highlights of the 2015 AHA Guidelines Update for CPR and ECC 19 . Intravenous Lipid Emulsion Why: Since 2010. 2 mg intranasal or 0. published animal studies and human 2015 (Updated): It may be reasonable to administer ILE. Administer naloxone. May repeat after 4 minutes. Continue until the person responds or until advanced help arrives. it is difficult to determine failing standard resuscitative measures. Figure 6 Opioid-Associated Life-Threatening Opioid-Associated Life-Threatening Emergency (Adult) Algorithm—New 2015 Emergency (Adult) Algorithm Assess and activate. person respond? Continue to check responsiveness and Yes At any time. move purposefully. it is • Mirroring the adult BLS recommended chest compression rate of reasonable to perform manual left uterine displacement in 100 to 120/min the supine position first. As the prognosis of patients who are failing Pediatric Basic Life Support standard resuscitative measures is very poor. If the fundus height is at or above pediatric CPR the level of the umbilicus. empiric administration of ILE in this situation may be reasonable and CPR Quality despite the very weak and conflicting evidence. maternal trauma or prolonged maternal pulselessness. PMCD should be considered compressions. etiology of arrest. Chest Compression Depth 2015 (Updated): It is reasonable that rescuers provide chest compressions that depress the chest at least one third the 20 American Heart Association . Maintaining the same maternal ROSC. rescuers through the initial stages of resuscitation in an Why: PMCD provides the opportunity for separate era in which handheld cellular telephones with speakers resuscitation of the potentially viable fetus and the are common. and system resources. there is no reason to delay performing perimortem has not been changed. The clinical decision to perform a PMCD— sequence for adults and children offers consistency in and its timing with respect to maternal cardiac arrest—is teaching. witnessed collapse. and specific strengthening of the recommendation for lateral uterine research is required to examine the best sequence for CPR displacement. the 2010 sequence futile. 2010 (Old): Initiate CPR for infants and children with chest Cardiac Arrest in Pregnancy: Emergency compressions rather than rescue breaths (C-A-B rather than Cesarean Delivery A-B-C). in the case of sudden. and breathing for CPR in victims of at 4 minutes after onset of maternal cardiac arrest or all ages may be easiest for rescuers who treat people of resuscitative efforts (for the unwitnessed arrest) if there is no all ages to remember and perform. it may be reasonable to maintain with high-quality CPR has prompted the elimination of the sequence from the 2010 Guidelines by initiating CPR the recommendation for using the lateral tilt and the with C-A-B over A-B-C. which may to activate an emergency response while beginning CPR. improve maternal resuscitation outcomes. These algorithms continue to emphasize the the ultimate decision around the timing of emergency high priority for high-quality CPR and. Rescuer HCP CPR 2010 (Old): Emergency cesarean delivery may be Algorithms for 1-rescuer and multiple-rescuer HCP pediatric considered at 4 minutes after onset of maternal cardiac CPR have been separated (Figures 7 and 8) to better guide arrest if there is no ROSC. cesarean delivery. 2015 (Updated): Priorities for the pregnant woman in The topics reviewed here include the following: cardiac arrest are provision of high-quality CPR and relief of • Reaffirming the C-A-B sequence as the preferred sequence for aortocaval compression. and an appropriate wedge is readily available. Consistency in the order of cesarean delivery (PMCD). for obtaining an AED quickly because such an event is likely to have a cardiac etiology. in children. in which maternal resuscitative efforts are obviously Why: In the absence of new data. CPR should begin with 30 compressions (by a single rescuer) or 15 compressions (for resuscitation of infants and 2015 (Updated): In situations such as nonsurvivable children by 2 HCPs) rather than with 2 ventilations. New Algorithms for 1-Rescuer and Multiple- gestational age of the fetus). there may be clinical improvement after ILE administration. complex because of the variability in level of practitioner and team training. • Establishing an upper limit of 6 cm for chest compression depth in 2010 (Old): To relieve aortocaval compression during an adolescent chest compressions and optimize the quality of CPR. 2015 (Updated): Although the amount and quality of quality CPR and the incompatibility of the lateral tilt supporting data are limited. patient factors (eg. airway. The clinical the rescuer can continue conversation with a dispatcher scenario and circumstances of the arrest should inform during CPR. Summary of Key Issues and Major Changes Cardiac Arrest in Pregnancy: Provision of CPR The changes for pediatric BLS parallel changes in adult BLS. C-A-B Sequence Why: Recognition of the critical importance of high. using a firm wedge to support the pelvis and thorax. are mixed. These devices can enable a single rescuer ultimate relief of aortocaval compression. then • Strongly reaffirming that compressions and ventilation are needed providers may consider placing the patient in a left lateral for pediatric BLS tilt of 27° to 30°. manual left uterine displacement • New algorithms for 1-rescuer and multiple-rescuer pediatric HCP can be beneficial in relieving aortocaval compression during CPR in the cell phone era chest compressions. If this technique is unsuccessful. Knowledge gaps exist. Shockable rhythm? Yes. Shout for nearby help. AED analyzes rhythm. rhythm check). has pulse or only gasping and check has pulse of poor perfusion. No. • Activate emergency response and monitor until Is pulse definitely felt system (if not already done) emergency within 10 seconds? after 2 minutes.Figure 7 BLS Healthcare Provider Pediatric Cardiac Arrest Algorithm for the Single Rescuer— BLS Healthcare Provider 2015 Update Pediatric Cardiac Arrest Algorithm for the Single Rescuer—2015 Update Verify scene safety. responders arrive. check pulse about every No breathing 2 minutes. Activate emergency Normal No normal • Add compressions if pulse response system breathing. Look for no breathing breathing. (Use 15:2 ratio if second rescuer arrives. begin or only gasping. over or victim starts to move. CPR (go to “CPR” box). activate emergency response system and retrieve AED (if not already done). remains ≤60/min with signs (if not already done). Continue until ALS providers take Continue until ALS providers take over or victim starts to move. or about 12-20 breaths/min. Resume CPR Resume CPR immediately for immediately for about 2 minutes about 2 minutes (until prompted (until prompted by AED to allow by AED to allow rhythm check). • Continue rescue breathing. No CPR 1 rescuer: Begin cycles of 30 compressions and 2 breaths. if still alone. Provide rescue breathing: 1 breath every 3-5 seconds. no pulse Yes Activate emergency response Witnessed sudden system (if not already done). shockable nonshockable Give 1 shock. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 21 . After about 2 minutes. collapse? and retrieve AED/defibrillator. If no pulse. Return to victim pulse (simultaneously).) Use AED as soon as it is available. Activate emergency response system via mobile device (if appropriate). Victim is unresponsive. the pediatric 2010 (Old): To achieve effective chest compressions. Shockable rhythm? Yes.5 inches (about 4 cm) in most infants and puberty). AED analyzes rhythm. Once children have Why: One adult study suggested harm with chest reached puberty (ie. Is pulse definitely felt system (if not already done) within 10 seconds? after 2 minutes. Provide rescue breathing: 1 breath every 3-5 seconds.5 inches (4 cm) about 2 inches (5 cm) in most children. an upper limit for chest compression depth. No. the recommended adult compressions deeper than 2. Look for no breathing breathing. This corresponds to (infants [younger than 1 year] to children up to the onset of approximately 1. begin or only gasping. Use AED as soon as it is available. • Continue rescue breathing. emergency pulse (simultaneously). in infants to 2 inches (5 cm) in children. remains ≤60/min with signs Monitor until has pulse or only gasping and check has pulse of poor perfusion. Continue until ALS providers take Continue until ALS providers take over or victim starts to move. CPR (go to “CPR” box). Resume CPR Resume CPR immediately for immediately for about 2 minutes about 2 minutes (until prompted (until prompted by AED to allow by AED to allow rhythm check).4 inches (6 cm) is used. This equates to approximately 1. Second rescuer activates emergency response system and retrieves AED and emergency equipment. no pulse CPR First rescuer begins CPR with 30:2 ratio (compressions to breaths). check pulse about every No breathing 2 minutes. Shout for nearby help. anteroposterior diameter of the chest in pediatric patients anteroposterior diameter of the chest. Victim is unresponsive. If no pulse. over or victim starts to move. rhythm check). • Activate emergency response responders arrive. shockable nonshockable Give 1 shock. Normal No normal • Add compressions if pulse breathing. First rescuer remains with victim. adolescents). When second rescuer returns. or about 12-20 breaths/min. A pediatric study observed improved Figure 8 BLS BLS Healthcare Healthcare Provider Provider Pediatric Cardiac Arrest Algorithm for 2 or More Rescuers— 2015 Pediatric Cardiac Arrest Algorithm for Update 2 or More Rescuers—2015 Update Verify scene safety. 22 American Heart Association . experts accepted this recommendation for adolescents rescuers should compress at least one third of the beyond puberty.4 inches (6 cm). use 15:2 ratio (compressions to breaths). This resulted compression depth of at least 2 inches (5 cm) but no greater in a change in the adult BLS recommendation to include than 2. A large randomized trial of therapeutic Compression-Only CPR hypothermia for children with OHCA showed no difference in outcomes whether a period of moderate therapeutic hypothermia 2015 (Updated): Conventional CPR (rescue breaths and (with temperature maintained at 32°C to 34°C) or the strict chest compressions) should be provided for infants and maintenance of normothermia (with temperature maintained 36°C children in cardiac arrest. if rescuers are unwilling or unable to deliver breaths. When a presumed cardiac etiology was Recommendations for Fluid Resuscitation present. See the Adult BLS and CPR Quality section ECPR may be considered. • After ROSC. To maximize educational consistency and retention. after cardiac arrests) treated with compression-only CPR. TTM after resuscitation from cardiac arrest Why: This recommendation continues to emphasize the in infants and children. inotropic support). when conventional CPR (compressions plus breaths) to each patient’s condition. were examined for prognostic significance. rapid IV administration of isotonic fluids compression-only CPR was provided. to 120/min for infants and children. are emphasized. the child’s Paco2 should be targeted to a level appropriate studies. outcomes were similar whether conventional or 2015 (New): Early. administration of bolus IV fluids should New information or updates are provided about fluid be undertaken with extreme caution. Also. For children in shock. for Many key issues in the review of the pediatric advanced children with febrile illness in settings with limited access life support literature resulted in refinement of existing to critical care resources (ie. • Amiodarone or lidocaine is an acceptable antiarrhythmic agent for shock-refractory pediatric VF and pVT in children. 2015 (Updated): To maximize simplicity in CPR training. in the is controversial. and the use of a feedback device that to improved survival. but compressions alone • After ROSC. use of amiodarone and lidocaine in shock. However. mechanical ventilation and recommendations rather than in new recommendations. we caretakers should consider multiple factors in trying to predict recommend rescuers perform compression-only CPR for outcomes during cardiac arrest and in the post-ROSC setting. oxygen should be titrated to a (which compose the vast majority of out-of-hospital pediatric value appropriate to the specific patient condition. Exposure to severe hypercapnia or was not given in presumed asphyxial arrest. when treating pediatric patients with febrile than 2 inches (51 mm). Recently. the use of restrictive volumes of isotonic crystalloid leads difficult at the bedside. use the recommended adult chest compression rate of 100 • If invasive arterial blood pressure monitoring is already in place. Therefore. equipment is available. were no different from when victims did not receive any bystander CPR. for adult BLS. No single variable was identified to be sufficiently reliable to predict outcomes. 2010 (Old): “Push fast”: Push at a rate of at least 100 compressions per minute. rates. refractory VF/pVT. pediatric cardiac arrests necessitates ventilation as part of effective CPR. atropine use before tracheal Individualized treatment and frequent clinical reassessment intubation. resuscitation in febrile illness. is widely accepted as a cornerstone of therapy for septic shock. because compression-only CPR • Several intra-arrest and post–cardiac arrest clinical variables can be effective in patients with a primary cardiac arrest. • Fever should be avoided when caring for comatose children with ROSC after OHCA. it may be used to adjust CPR to achieve specific blood pressure targets for children in cardiac arrest.5°C) was provided. pediatric experts adopted • For pediatric patients with cardiac diagnoses and IHCA in settings the same recommendation for compression rate as is made with existing extracorporeal membrane oxygenation protocols. • Routine use of atropine as a premedication for emergency tracheal Chest Compression Rate intubation in non-neonates. as it may be harmful. Summary of Key Issues and Major Changes an initial fluid bolus of 20 mL/kg is reasonable. both compressions and ventilations. it is reasonable to minimum dose required for atropine for this indication. infants and children in cardiac arrest. fluids and vasoactive infusions should be used to 2010 (Old): Optimal CPR in infants and children includes maintain a systolic blood pressure above the fifth percentile for age. normoxemia should be targeted. When the necessary are preferable to no CPR. Hypoxemia outcomes for presumed asphyxial pediatric cardiac arrests should be strictly avoided. of blood pressure. However. in the absence of pediatric data. routine aggressive volume resuscitation is beneficial. there are data to suggest that there is no absence of sufficient pediatric evidence. specifically to prevent arrhythmias. oxygen administration should be weaned Why: Large registry studies have demonstrated worse to target an oxyhemoglobin saturation of 94% to 99%. Likewise. The asphyxial nature of most to 37.24-hour survival when compression depth was greater • In specific settings. outcomes hypocapnia should be avoided. In 2 ROSC. Judgment of compression depth is illnesses. and post–cardiac arrest management administration of IV fluid for children with septic shock. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 23 . Ideally. a large randomized controlled trial of Pediatric Advanced Life Support fluid resuscitation conducted in children with severe febrile illnesses in a resource-limited setting found worse outcomes to be associated with IV fluid boluses. This contrasts with traditional thinking that provides such information may be useful if available. of this publication for more detail. Why: One adult registry study demonstrated inadequate • Epinephrine continues to be recommended as a vasopressor in chest compression depth with extremely rapid compression pediatric cardiac arrest. and after fluid therapy is given. ROSC and 24-hour survival. Additionally. temperature should be monitored continuously and studied in humans. Extracorporeal life support should be considered only for children in cardiac Invasive Hemodynamic Monitoring During CPR arrest refractory to standard resuscitation attempts.5°C) showed 24 American Heart Association . based on frequent clinical assessment before. and 1 randomized.1 mg IV ECPR Compared With Standard Resuscitation was recommended because of reports of paradoxical 2015 (Updated): ECPR may be considered for children with bradycardia occurring in very small infants who received low underlying cardiac conditions who have an IHCA. However. It may be considered in adult study found that epinephrine was associated with situations where there is an increased risk of bradycardia. it may be Why: OHCA in children was not considered. and equipment are available. such as an intensive care unit. multicenter study of pediatric OHCA amiodarone administration was associated with improved victims randomized to receive either therapeutic hypothermia survival to hospital discharge. out-of-hospital in emergency pediatric intubations. One retrospective registry review showed better position and chest compression depth. For children remaining comatose after IHCA. pediatric IHCA. when used as a premedication for emergency intubation. studies did use atropine doses less than 0. Why: Recent evidence is conflicting as to whether atropine 2010 (Old): Consider early activation of extracorporeal prevents bradycardia and other arrhythmias during life support for a cardiac arrest that occurs in a highly emergency intubation in children. Why: The recommendation about epinephrine administration during cardiac arrest was downgraded Atropine for Endotracheal Intubation slightly in Class of Recommendation. Targeted Temperature Management Why: Two randomized controlled trials in animals found improvements in ROSC and survival to completion of the 2015 (Updated): For children who are comatose in the experiment when CPR technique was adjusted on the basis first several days after cardiac arrest (in-hospital or out-of- of invasive hemodynamic monitoring. not available. compared with from cardiac arrest. there was no difference in overall survival 2010 (Old): If the patient has an indwelling arterial catheter.1 mg without an with the clinical protocols in place and the expertise and increase in the likelihood of arrhythmias. equipment available to initiate it rapidly. provided doses of atropine. equipment and expertise might not be present to effectively address them. it emphasizes individualized treatment plans for Vasopressors for Resuscitation each patient. comparing ECPR to CPR without extracorporeal membrane the waveform can be used as feedback to evaluate hand oxygenation. expertise.5°C) or 2 days of initial continuous 2015 (Updated): Amiodarone or lidocaine is equally hypothermia (32°C to 34°C) followed by 3 days of acceptable for the treatment of shock-refractory VF or pVT in normothermia. it is Antiarrhythmic Medications for Shock. cardiac arrest. It is reasonable for adolescents amiodarone. improved ROSC and survival to hospital admission but not to There is no evidence to support a minimum dose of atropine hospital discharge. considered for children who remain comatose after resuscitation patient pediatric cardiac arrest showed that. In certain resource. during. lidocaine was associated with higher rates of resuscitated from witnessed out-of-hospital VF arrest. are insufficient data to recommend hypothermia over refractory VF or pVT. Compressing to a outcome with ECPR for patients with cardiac disease than specific systolic blood pressure target has not been studied for those with noncardiac disease. neither lidocaine nor Why: A prospective. these recent supervised environment. retrospective. fever should be treated aggressively. limited settings. multi-institution registry of in. appropriate protocols. For reasonable to use it to guide CPR quality. There are no high- quality pediatric studies showing the effectiveness of any 2015 (Updated): There is no evidence to support the routine vasopressors in cardiac arrest. there 2010 (Old): Amiodarone was recommended for shock. excessive fluid boluses given to febrile 2010 (Old): Epinephrine should be given for pulseless children may lead to complications where the appropriate cardiac arrest. reasonable for caretakers to maintain either 5 days of Refractory VF or Pulseless VT normothermia (36°C to 37. Two pediatric observational use of atropine as a premedication to prevent bradycardia studies were inconclusive. 2010 (Old): A minimum atropine dose of 0. (32°C to 34°C) or normothermia (36°C to 37. in humans but may improve outcomes in animals. However. and it presumes the 2015 (Updated): It is reasonable to give epinephrine during availability of other critical care therapies. place at the time of a cardiac arrest in a child. with a 2015 (Updated): If invasive hemodynamic monitoring is in potentially reversible cause of arrest. This has yet to be hospital). For comatose children resuscitated from OHCA. 2010 (Old): Therapeutic hypothermia (32°C to 34°C) may be Why: A recent. Lidocaine can be given if amiodarone is normothermia. children. because providers may not assess heart rate accurately by Why: A large observational pediatric study of IHCA and auscultation or palpation. the most important step for estimation of potential for recovery after cardiac arrest. warmed humidified gases. but there is Why: No single intra-arrest or post–cardiac arrest variable has insufficient evidence to recommend an approach to cord clamping been found that reliably predicts favorable or poor outcomes. until 2015 (New): After ROSC. and even placing the infant after drying in a clean When the requisite equipment is available.THAPCA. prevent hypothermia in preterm infants. Recent • A variety of strategies (radiant warmers. fraction of inspired oxygen to maintain an oxyhemoglobin • Assessment of heart rate remains critical during the first minute saturation of 94% or greater. simple measures to prevent for rescuers to titrate oxygen administration to achieve hypothermia in the first hours of life (use of plastic wraps. reevaluating. made about PaCO2. Intra-arterial pressure monitoring a quality indicator. thermal mattress. successful resuscitation of the newly born who has not responded to the initial steps.org). be weaned to target an oxyhemoglobin saturation within the • If an infant is born through meconium-stained amniotic fluid and range of 94% to 99%. patient outcomes associated with hypocapnia. so following pediatric IHCA (see Therapeutic Hypothermia After initiation of ventilation remains the focus of initial resuscitation. Use of the ECG does not replace the need for pulse mm Hg) was associated with improved survival to pediatric oximetry to evaluate the newborn’s oxygenation. fluids and inotropes/vasopressors more is known of benefits and complications. longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth. it may be reasonable • In resource-limited settings. No recommendations were of resuscitation and the use of a 3-lead ECG may be reasonable. The goal should be to strictly avoid presents with poor muscle tone and inadequate breathing efforts. Appropriate intervention to support ventilation and oxygenation should be initiated as indicated for each 2010 (Old): Once circulation is restored. and a suggestion against the routine use of cord milking (outside of a research Post–Cardiac Arrest Fluids and Inotropes setting) for infants born at less than 29 weeks of gestation. for infants who require resuscitation at birth. compared with hyperoxemia • Resuscitation of preterm newborns of less than 35 weeks of (PaO2 greater than 300 mm Hg). 2015 (Updated): After ROSC in children. This may include intubation and suction if the equipment is in place. observational studies found that children who had post. randomized controlled trial of therapeutic hypothermia for patients who are comatose after ROSC Neonatal cardiac arrest is predominantly asphyxial. Multiple steps. and pulse oximetry may underestimate OHCA found that normoxemia (defined as PaO2 60 to 300 heart rate. oxygen should food-grade plastic bag up to the neck) may reduce mortality. Likewise. Results are currently pending from Summary of Key Issues and Major Changes a large. and increased room ROSC hypotension had worse survival to hospital discharge temperature plus cap plus thermal mattress) may be reasonable to and worse neurologic outcome.no difference in functional outcome at 1 year between the 2 groups. This and other observational studies demonstrated Neonatal Resuscitation no additional complications in the group treated with therapeutic hypothermia. the infant should be placed under a radiant warmer and PPV should ROSC ventilation strategies in children should target a PaCO2 be initiated if needed. intensive care unit discharge. post. vasoactive agents in post-ROSC pediatric patients.5°C after birth through Why: No studies were identified that evaluated specific admission and stabilization. The following were the major neonatal topics in 2015: Intra-arrest and Postarrest Prognostic Factors • The order of the 3 assessment questions has changed to (1) Term gestation? (2) Good tone? and (3) Breathing or crying? 2015 (Updated): Multiple factors should be considered • The Golden Minute (60-second) mark for completing the initial when trying to predict outcomes of cardiac arrest. Routine intubation for tracheal suction is that is appropriate for each patient while avoiding extremes no longer suggested because there is insufficient evidence to of hypercapnia or hypocapnia. maintained between 36. should be used to maintain a systolic blood pressure above • Temperature should be recorded as a predictor of outcomes and as the fifth percentile for age. should be used to continuously monitor blood pressure and • Temperature of newly born nonasphyxiated infants should be identify and treat hypotension. plastic wrap with a cap. and beginning ventilation (if required) is factors play a role in the decision to continue or terminate retained to emphasize the importance of avoiding unnecessary resuscitative efforts during cardiac arrest and in the delay in initiation of ventilation. Adult and animal studies gestation should be initiated with low oxygen (21% to 30%) show increased mortality associated with hyperoxemia. to-skin contact.5°C and 37. if appropriate individual infant. continue this recommendation. 2010 (Old): Practitioners should consider multiple variables to prognosticate outcomes and use judgment to titrate • There is a new recommendation that delayed cord clamping for efforts appropriately. and the oxygen titrated to achieve preductal oxygen saturation Likewise. it may be reasonable to wean the airway is obstructed. Hyperthermia (temperature greater than 38°C) should be avoided because it introduces Post–Cardiac Arrest Pao2 and Paco2 potential associated risks. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 25 . adult studies after ROSC demonstrate worse approximating the range achieved in healthy term infants. skin- normoxemia (oxyhemoglobin saturation of 94% or above). multicenter. Pediatric Cardiac Arrest website: www. hypoxemia while maintaining normoxemia. individual infant. • There are insufficient data about the safety and the method enterocolitis. a team that includes someone skilled in intubation of the • Although there are no available clinical studies about oxygen use newborn should still be present in the delivery room. and stimulating • In resource-limited settings. clearing the airway of secretions if needed. but the device takes 1 to 2 cord clamping is associated with less intraventricular minutes to apply and may not function during states of very hemorrhage. because there is insufficient in the 2010 recommendations. but decisions to continue or discontinue resuscitation and oxygenation should be initiated as indicated for each efforts must be individualized. Routine intubation for tracheal suction in compressions and 30 breaths per minute) remain unchanged. the issue of how to assess the heart rate was 2010 (Old): There is increasing evidence of benefit of addressed: Assessment of heart rate should be done by delaying cord clamping for at least 1 minute in term intermittently auscultating the precordial pulse. if poor muscle tone and inadequate breathing effort moderate to severe hypoxic-ischemic encephalopathy. rescuers may consider using higher evidence to continue recommending this practice. than palpation at other sites. maintaining temperature. It is reasonable to wean the oxygen concentration as a change in the current practice of performing endotracheal soon as the heart rate recovers. delays in providing bag-mask ventilation. was not are present. poor cardiac output or perfusion. Experts placed greater value on harm • In general. the initial steps of resuscitation (warming and reviewed in 2015. less need for transfusion after birth. However. There is insufficient evidence oximetry to evaluate the newborn’s oxygenation. so the 2010 Why: Review of the evidence suggests that resuscitation recommendations remain in effect. frequently than the current 2-year interval. meconium-stained fluid as for those with clear fluid. the use of 3-lead ECG for the rapid and 2015 (Updated): Delayed cord clamping after 30 seconds accurate measurement of the newborn’s heart rate may be is suggested for both term and preterm infants who do not useful. An Apgar score of 0 at 10 minutes is a strong of the intervention of routine tracheal intubation and predictor of mortality and morbidity in late preterm and term suctioning. palpation of the umbilical pulse can also insufficient evidence to support or refute a recommendation provide a rapid estimate of the pulse and is more accurate to delay cord clamping in infants requiring resuscitation. that for infants born at more than 36 weeks of gestation with evolving is. A pulse oximeter can provide a continuous assessment of the pulse without interruption Why: In infants who do not require resuscitation. suctioning of nonvigorous infants with meconium-stained amniotic fluid. Assessment of Heart Rate: Use of 3-Lead ECG Umbilical Cord Management: Delayed Cord Clamping 2015 (Updated): During resuscitation of term and preterm newborns. so the 2010 recommendations remain in effect. • Recommendations about use of epinephrine during CPR and volume administration were not reviewed in 2015. 2015 (Updated): If an infant born through meconium- stained amniotic fluid presents with poor muscle tone • Spontaneously breathing preterm infants with respiratory distress and inadequate breathing efforts. higher blood pressure and blood volume. the heart rate is less than 100/min after the initial steps are completed. and less necrotizing 26 American Heart Association . As this setting is not suggested. The use of ECG does not replace the need for pulse require resuscitation at birth. 15:2) if the arrest is believed to be of cardiac origin. drying. The only adverse consequence found was of application of sustained inflation of greater than 5 seconds’ a slightly increased level of bilirubin. associated with more duration for the transitioning newborn. need for phototherapy. ratios (eg. in the 2010 recommendations about withholding or withdrawing potential harm of the procedure) over the unknown benefit resuscitation. during CPR. and a laryngeal Suctioning Nonvigorous Infants Through mask is recommended during resuscitation of newborns 34 weeks Meconium-Stained Amniotic Fluid or more of gestation when tracheal intubation is unsuccessful or not feasible. should follow the same principles for infants with • Induced therapeutic hypothermia in resource-abundant areas. When a and preterm infants not requiring resuscitation. There is pulse is detectable. the Neonatal Guidelines Writing Group continues to endorse the use of 100% oxygen whenever chest compressions 2010 (Old): There was insufficient evidence to recommend are provided. positioning the infant. the initial steps of may be supported with continuous positive airway pressure initially resuscitation should be completed under the radiant rather than with routine intubation for administering PPV. no new data have been published to justify a change avoidance (ie. be considered under clearly defined protocols similar to those used in clinical trials and in facilities with the capabilities for PPV should be initiated if the infant is not breathing or multidisciplinary care and follow-up. 2010 (Old): Although use of ECG was not mentioned in 2010. delayed of other resuscitation measures. • A laryngeal mask may be considered as an alternative to tracheal intubation if face-mask ventilation is unsuccessful. Appropriate intervention to support ventilation infants. This may include intubation and suction if • It is suggested that neonatal resuscitation task training occur more the airway is obstructed. warmer. use of therapeutic hypothermia may the infant) should be completed under an overbed warmer. PPV should be initiated if the infant is not breathing • Recommendations about chest compression technique (2 thumb– or the heart rate is less than 100/min after the initial steps encircling hands) and compression-to-ventilation ratio (3:1 with 90 are completed. to recommend an approach to cord clamping for infants who require resuscitation at birth. inadequate equipment. Supplementary oxygen may be the psychomotor skill of CPR. Most data • The use of high-fidelity manikins is encouraged for programs were from term infants not during resuscitation. following: 2010 (Old): It is reasonable to initiate resuscitation with air • Use of a CPR feedback device is recommended to assist in learning (21% oxygen at sea level). etc) may be considered and hands-on training can be considered as an alternative to traditional offered under clearly defined protocols similar to those used instructor-led courses for lay providers. and/or practice of pertinent 2010 (Old): It is recommended that infants born at 36 technical skills may optimize learning from adult and pediatric weeks or more of gestation with evolving moderate to advanced life support courses. resuscitation education must use sound educational Administration of Oxygen to Preterm Newborns principles supported by empirical educational research 2015 (Updated): Resuscitation of preterm newborns of to translate scientific knowledge into practice. trained personnel. preterm newborns with high oxygen (65% or greater) is not recommended. information. The ECG has been found to display an arrest victims. the use of this modality in settings where resources may limit The 2015 AHA ECC Education Guidelines Writing Group options for some therapies. online/precourse testing. Postresuscitation Therapeutic Hypothermia: • To minimize the time to defibrillation for cardiac arrest victims. prematurity when preterm newborns (less than 35 weeks • Although prior CPR training is not essential for potential rescuers of gestation) were resuscitated with high (65% or greater) to initiate CPR. or retinopathy of traditional instructor-led courses. severe hypoxic-ischemic encephalopathy should be offered • Given the importance of team dynamics in resuscitation. and resources study of preterm infants during resuscitation. Education Underestimation of the heart rate may lead to unnecessary Despite significant scientific advances in the care of cardiac resuscitation. training therapeutic hypothermia. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 27 . More-frequent training ischemic encephalopathy in resource-abundant settings of basic and advanced life support skills may be helpful for remains unchanged. the confidence to provide CPR when encountering a cardiac arrest victim. Pulse oximetry in survival rates that cannot be attributed to patient more often displayed a lower rate in the first 2 minutes of life. Why: Clinical assessment of heart rate in the delivery room has been found to be both unreliable and inaccurate. with approximating the interquartile range measured in healthy term implementation and teams being included in other parts of infants after vaginal birth at sea level. This recommendation reflects a preference for Summary of Key Issues and Major Changes not exposing preterm newborns to additional oxygen without Key recommendations and points of emphasis include the data demonstrating a proven benefit for important outcomes. Standard manikins continue to be an Why: Data are now available from a meta-analysis of 7 appropriate choice for organizations that do not have this capacity. • Two-year retraining cycles are not optimal. Therapeutic hypothermia should with a focus on leadership and teamwork principles should be be administered under clearly defined protocols similar to incorporated into advanced life support courses. Devices that provide corrective administered and titrated to achieve a preductal oxygen feedback on performance are preferred over devices that provide saturation approximating the interquartile range measured in only prompts (such as a metronome). and the oxygen concentration and teams in its recommendations. While the less than 35 weeks of gestation should be initiated with 2010 AHA education guidelines included implementation low oxygen (21% to 30%). intraventricular hemorrhage. To optimize the likelihood that cardiac often at levels that suggest the need for intervention. Why: While the recommendation for therapeutic hypothermia in the treatment of moderate to severe hypoxic. Initiating resuscitation of the 2015 Guidelines Update. those used in published clinical trials and in facilities with the • Communities may consider training bystanders in compression- capabilities for multidisciplinary care and longitudinal follow-up. the Resource-Limited Settings deployment of an AED should not be limited to trained individuals 2015 (Updated): It is suggested that the use of therapeutic (although training is still recommended). with a single that have the infrastructure. a recommendation was added to guide providers who are likely to encounter a cardiac arrest. arrest victims receive the highest-quality evidence-based care. healthy term infants after vaginal birth at sea level. there remains considerable variability accurate heart rate faster than pulse oximetry. prevention of bronchopulmonary (video or computer based) with hands-on practice as through dysplasia. training helps people to learn the skills and develop compared with low (21% to 30%) oxygen concentration. hypothermia in resource-limited settings (ie. the 2015 AHA should be titrated to achieve a preductal oxygen saturation education guidelines now focus strictly on education. characteristics alone. to maintain the program. randomized studies demonstrating no benefit in survival • BLS skills seem to be learned as easily through self-instruction to hospital discharge. only CPR for adult OHCA as an alternative to training in conventional CPR. in published clinical trials and in facilities with the capabilities • Precourse preparation that includes review of appropriate content for multidisciplinary care and longitudinal follow-up. lack of qualified • A combination of self-instruction and instructor-led courses with staff. agreed on several core concepts to guide the development of courses and course materials (Table 3). 2010 (Old): Realistic manikins may be useful for integrating the knowledge. Abbreviations: AHA. with emphasis on creating relevant training scenarios that can be applied practically to the learners’ real-world setting. newly published literature guidance (eg.26-30 Debriefing The provision of feedback and/or debriefing is a critical component of experiential learning. ECC. Table 3 Core AHA ECC Educational Concepts Simplification Course content should be simplified in both the presentation of the content and the breadth of content to facilitate accomplishment of course objectives. cardiopulmonary resuscitation. such as having hospital-based learners practice CPR on a bed instead of the floor. Learning objectives33 must be clear and measurable and serve as the basis of evaluation. with the appraisal of resuscitation courses including learner. CPR. there was insufficient guide resuscitation education. 2015 (New): It may be reasonable to use alternative Use of High-Fidelity Manikins instructional modalities for basic and advanced life support teaching in resource-limited environments. 2015 (Updated): The use of high-fidelity manikins for advanced life support training can be beneficial for improving 2010 (Old): Short video instruction combined with skills performance at course conclusion. of having more realistic manikins as well as the increased 2015 (New): If feedback devices are not available.10. and program performance. There is new evidence evidence to recommend the routine use of more that specific formats. synchronous hands-on practice is an effective alternative to instructor-led BLS courses. music) may be considered supports the use of high-fidelity manikins. auditory costs and resources involved. evaluation individual instructor. skills. and behaviors in advanced life support Why: Learner outcomes are more important than course training. practice-while- watching instruction is the preferred method for basic psychomotor skill training because it reduces instructor variability that deviates from the intended course agenda. metronome. Assessment strategies should evaluate competence and promote learning. particularly given the additional costs and 2015 (Updated): Use of feedback devices can be effective in resources required. ultimately.34 Training organizations should use this information to drive the continuous quality improvement process.32 Assessment Assessment of learning in resuscitation courses serves to both ensure achievement of competence and provide the benchmarks that students will strive toward. formats. course. to promote student development toward mastery. 2010 (Old): The use of a CPR feedback device can be Blended Learning Formats effective for training. emergency cardiovascular care. resources) are already in place. Hands-on practice Substantial hands-on practice is needed to meet psychomotor and nontechnical/leadership skill performance objectives. Knowledge and skill acquisition and retention and. to feedback that is more comprehensive. with a slight advantage given reasonable alternative to instructor-led courses. 2015 (Updated): CPR self-instruction through video and/or Why: New evidence differentiates the benefit of different computer-based modules with hands-on practice may be a types of feedback for training. Course/program This is an integral component of resuscitation education. particularly to improve adherence to recommendations for chest in programs where resources (eg. Video-mediated. American Heart Association.11-14 Contextual Adult learning principles15 should be applied to all ECC courses.12. such as CPR self-instruction using 28 American Heart Association .11. clinical performance and patient outcome should Why: In the 2010 evidence review. CPR Feedback Devices realistic manikins to improve skills performance in actual resuscitations. Assessment also provides the basis for student feedback (assessment for learning). human and financial compression rate.11 Consistency Course content and skill demonstrations should be presented in a consistent manner. Considering both the potential benefit improving CPR performance during training.31 Feedback and debriefing after skills practice and simulations allow learners (and groups of learners) the opportunity to reflect on their performance and to receive structured feedback on how to improve their performance in the future.16-18 Practice to Learners should have opportunities for repetitive performance of key skills coupled with rigorous assessment mastery and informative feedback in a controlled setting.19-22 This deliberate practice should be based on clearly defined objectives23-25 and not time spent. Factors that affect the arrests. Also. available. in any situation. Studies performed after a statewide educational may be cost prohibitive. other forms of Compression-Only CPR sugar found in common dietary products have been found to be acceptable alternatives to glucose tablets for diabetics with mild 2015 (New): Communities may consider training bystanders symptomatic hypoglycemia who are conscious and are able to in compression-only CPR for adult OHCA as an alternative to swallow and to follow commands. and train more frequently. self-directed training may be considered for lay providers learning AED skills. Self-directed training broadens the opportunities for based simulation may provide cost savings by using less total training for both lay providers and healthcare professionals. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 29 . coupled with the observed improvement members of high-risk patients may be reasonable. 2010 (Old): Skill performance should be assessed during the 2-year certification with reinforcement provided as needed. is limited evidence that teamwork and leadership training affects patient outcomes. it 2015 (Updated): A combination of self-instruction and is reasonable that individuals who are likely to encounter a instructor-led teaching with hands-on training can be cardiac arrest victim perform more frequent manikin-based considered as an alternative to traditional instructor-led retraining. Although data are limited. In these cases. Self-instruction courses offer campaign for bystander compression-only CPR showed that the opportunity to train many more individuals to provide the prevalence of both overall CPR and compression-only CPR while reducing the cost and resources required for CPR by bystanders increased. in skill and confidence among students who train more frequently. Teamwork Summary of Key Issues and Major Changes and leadership are important components of effective • The use of stroke assessment systems can assist first aid resuscitation. The ability to effectively learn than conventional CPR (compressions with breaths) use alternative course formats is particularly important in and can even be coached by a dispatcher during an resource-limited environments where instructor-led courses emergency. training opportunities should be made available and optimal retraining interval include the quality of initial training. it may be reasonable for BLS retraining to be Why: Studies consistently show high scores for CPR completed more frequently by individuals who are likely to performance by trained family members and/or caregivers encounter cardiac arrest. Teamwork and Leadership First Aid 2015 (Updated): Given the very small risk for harm and the potential benefit of team and leadership training. and includes self-care. The scope 2010 (Old): Teamwork and leadership skills training should of first aid has been expanded. they may not be readily available. and promoting recovery. the inclusion The 2015 AHA and American Red Cross Guidelines of team and leadership training as part of advanced life Update for First Aid reaffirms the goals of first aid: to reduce support training is reasonable. Why: Resuscitation is a complex process that often involves the cooperation of many individuals. Why: While growing evidence continues to show that recertification in basic and advanced life support every 2 2010 (Old): Because even minimal training in AED use has years is inadequate for most people. frequent retraining sessions coupled with the potential for Expanded Training for AEDs cost savings from reduced training time and removal of staff from clinical environment for standard refresher training. 2015 (New): Given the potential educational benefits of short. improvement in skills and confidence among students who even minimal training improves performance.video or computer-based modules. timeliness. there is an observed be placed on the use of AEDs by the public. Despite the importance of these factors. can provide similar Why: Compression-only CPR is simpler for lay providers to outcomes to instructor-led courses. frequent refreshers with manikin- efficacy. the optimal timing of been shown to improve performance in simulated cardiac retraining has not been determined. the fact that some skills may be more likely to decay than Why: AEDs can be correctly operated without any prior others. there providers with identifying signs and symptoms of stroke. anyone. If instructor-led training is not optimal time interval. • While glucose tablets are preferred for care of mild hypoglycemia. training in conventional CPR. preventing further illness or injury. promoted for lay rescuers. and the frequency with which skills are used in clinical training: There is no need for a requirement for training to practice. BLS Retraining Intervals Targeted Training 2015 (Updated): Given the rapidity with which BLS skills 2015 (New): Training primary caregivers and/or family decay after training. retraining time as compared with standard retraining intervals. morbidity and mortality by alleviating suffering. training—important factors when considering the vast population of potential rescuers that should be trained. First aid can be initiated by be included in advanced life support courses. Nevertheless. of high-risk cardiac patients as compared with those who were untrained. There is insufficient evidence to recommend the courses for lay providers. 2015 (New): Self-directed methods can be considered for healthcare professionals learning AED skills. by first aid providers is recommended. for recognition of stroke. Treatment of Open Chest Wounds and EMS arrival will exceed 5 to 10 minutes. the ideal method for a first aid provider to help prevent of an occlusive dressing or device to a nonocclusive movement of the spine requires further study but may include dressing or device. and can resolve symptoms of injured and ill persons. of anaphylaxis. direct pressure. or courses resulting in certification can increase identification of stroke. If a dressing and direct pressure are needed to control bleeding. When direct pressure is not effective care must be taken to ensure that a blood-saturated for severe or life-threatening bleeding. Why: The improper use of an occlusive dressing or device for open chest wounds may lead to development • Use of cervical collars by first aid providers is not recommended. a first aid provider should not encourage the person to commonly encounter. can decrease severity of injury and time in the hospital. The Face. The modified High Arm in Endangered of lay providers trained in a stroke assessment system were Spine (HAINES) recovery position is no longer recommended. In 1 study. fractures. As a result of the lack of evidence for use of an occlusive • Topics covered in the 2015 Guidelines Update that have no new device. care should be taken to ensure the 2015 (New): The use of a stroke assessment system dressing does not inadvertently convert to an occlusive dressing. When symptoms of anaphylaxis do not resolve with an initial dose of epinephrine. cooling of thermal burns. other specifically evaluated forms of foods has no allergy or contraindication to aspirin. treatment of suspected long bone chest wound is not recommended. the use of a hemostatic dressing does not inadvertently become occlusive. use of tourniquets. • It is acceptable for a first aid provider to leave an open chest Stroke Recognition wound open and uncovered. stroke assessment systems are the simplest of these tools • First aid education delivered through public health campaigns. Speech. with high sensitivity for the focused topics. a second dose of 2015 (New): A first aid provider caring for an individual epinephrine may be considered. is cardiac in origin. placing the person into a lateral. the update of this recommendation notes that and oligosaccharides can be effective alternatives for if a person has chest pain that does not suggest that the cause reversal of mild symptomatic hypoglycemia. if available. for use by first aid providers. burn dressings. Time temporary storage of the tooth in an appropriate solution may (FAST) or Cincinnati Prehospital Stroke Scale (CPSS) help prolong viability of the tooth. may prevent progression to severe hypoglycemia.35. Compared with • There are no single-stage concussion assessment systems to aid stroke assessment systems that do not require glucose first aid providers in the recognition of concussion. and only a single animal study verbal prompts or manual stabilization while awaiting arrival of advanced care providers. survival rates. or if the first aid provider is uncertain about the cause of the chest pain or uncomfortable with administration Why: Hypoglycemia is a condition that first aid providers of aspirin. the use of oral glucose in the form of lung cancer patients with dyspnea coupled with hypoxemia. often as a 2-dose package. and spinal motion restriction. toxic eye injury. Severe hypoglycemia can result in loss of consciousness or • Epinephrine is recommended for the life-threatening condition seizures and typically requires management by EMS. If a • The primary method to control bleeding is through the application dressing and direct pressure are required to stop bleeding. glucose tablets provides more rapid clinical relief compared • The recommendations still state that while awaiting the arrival with other forms of sugar found in common dietary of EMS providers. Early treatment of mild hypoglycemia take the aspirin. with an open chest wound may leave the wound open. However. of firm. more than 94% or pelvis. should be used to with chest pain to chew aspirin if the signs and symptoms resolve hypoglycemia in these individuals. 30 American Heart Association . able to recognize signs and symptoms of a stroke. administration of oxygen can be beneficial for persons with 2015 (New): For diabetics with mild symptomatic decompression injury. and considering the risk of unrecognized tension recommendations since 2010 include the use of bronchodilators pneumothorax. assessment systems that include glucose measurement have similar sensitivity but higher specificity • When reimplantation of an avulsed tooth will be delayed. the first aid provider may encourage a person products. and this ability persisted at 3 months after training. and those at risk typically carry epinephrine auto-injectors. If glucose tablets suggest that the person is having a heart attack and the person are not available. Why: Evidence shows that the early recognition of stroke with the use of a stroke assessment system decreases the • When caring for an unresponsive person who is breathing interval between the time of stroke onset and arrival at a normally. Other situations when administration may be hypoglycemia who are able to follow commands and considered include suspected carbon monoxide poisoning and for swallow safely. side-lying position may improve airway mechanics. Arm.36 • There continues to be no indication for the routine administration of supplementary oxygen by first aid providers. For injured persons who meet high-risk criteria for spinal There are no human studies comparing the application injury. dressing combined with direct pressure may be considered but requires training in proper application and indications for use. and in the absence of major trauma such as to the spine hospital and definitive treatment. Glucose tablets. measurement. fructose. showed benefit to use of a nonocclusive device. such as recent and liquids containing sugars such as sucrose. of an unrecognized life-threatening tension pneumothorax. control of device by first aid providers for individuals with an open bleeding. For those first aid Hypoglycemia providers with specialized training in the use of supplementary oxygen. the application of an occlusive dressing or for asthma with shortness of breath. bleeding. concussion assessment tools used by healthcare professionals that require a 2-stage assessment (before Oxygen Use in First Aid competition and after concussion) are not appropriate as a 2015 (Updated): There is no evidence supporting the single assessment tool for first aid providers. recommended. If the victim has difficulty breathing as possible. the first aid provider may encourage the victim to chew and swallow 1 Positioning an Ill or Injured Person adult (non–enteric-coated) or 2 low-dose “baby” aspirins if the patient has no allergy to aspirin or other contraindication 2015 (Updated): The recommended recovery position to aspirin. or whole milk. and glucose). or fear of causing pain. improve recognition of acute illness. a tooth. 2010 (Old): While waiting for EMS to arrive. the long-term consequences of unrecognized with a supine position has led to a change in the concussion can be significant. Oxygen may be beneficial beneficial to temporarily store an avulsed tooth in a solution for first aid in divers with a decompression injury. then the first aid provider should not encourage the person to take aspirin and the decision to administer aspirin Why: Evidence shows that education in first aid can can be deferred to an EMS provider. The dental community agrees that immediate reimplantation of the avulsed tooth affords the greatest Chest Pain chance of tooth survival. it might be not available. training and skill. If a person has chest pain that does not suggest a 2015 (New): Education and training in first aid can be useful cardiac source. consciousness. Sport evidence to support this position. has changed from supine to a lateral side-lying position Highlights of the 2015 AHA Guidelines Update for CPR and ECC 31 . The HAINES position is no longer help first aid providers with the recognition of concussion. There is little evidence to suggest that any alternative 2015 (New): An HCP should evaluate any person with recovery position is of greater benefit for an individual who is a head injury that has resulted in a change in level of unresponsive and breathing normally. also shows supplementary oxygen to be effective for relief sodium chloride. or other causes for concern to 2010 (Old): If the victim is facedown and is unresponsive. and associated hypoxemia but not for similar patients Ricetral. Solutions with demonstrated efficacy at prolonging Why: Evidence shows a benefit from use of oxygen for dental cell viability from 30 to 120 minutes include Hank’s decompression sickness by first aid providers who have Balanced Salt Solution (containing calcium. Although no evidence was identified to support the use of oxygen. the first aid provider. cause of chest pain or uncomfortable with administration of and we recommend that it be universally available. aspirin. it may be shortness of breath or chest pain. and aid symptom resolution. due to the paucity and very low quality of no such assessment system has been identified. such as evidence of a stroke or recent bleeding. reimplant an avulsed tooth due to lack of protective 2010 (Old): There is no evidence for or against the routine medical gloves.Concussion for patients without suspected spine. single-stage concussion scoring system could possibly hip. sodium phosphate of dyspnea in advanced lung cancer patients with dyspnea dibasic. Supplementary oxygen may be of benefit in only Dental Avulsion a few specific situations such as decompression injury and 2015 (Updated): First aid providers may be unable to when administered by providers with training in its use. because of copious secretions or vomiting. use of oxygen as a first aid measure for victims experiencing When immediate reimplantation is not possible. and if the person has no allergy or other contraindication to First Aid Education aspirin. but it may not be an option. egg white. progressive development of signs or symptoms of concussion. propolis. indices when the victim is in a lateral position compared In addition. potassium taken a diving first aid oxygen course. The myriad of signs and symptoms of Why: Studies showing some improvement to respiratory concussion can make recognition of this injury a challenge. temporary storage of provider may encourage a person with chest pain to chew an avulsed tooth in an appropriate solution may improve 1 adult or 2 low-dose aspirins if the signs and symptoms chances of tooth survival. The evaluation should occur as soon turn the victim faceup. Limited evidence chloride and phosphate. routine administration of supplementary oxygen by first aid providers. increase survival rates. 
 reasonable to provide oxygen while waiting for advanced Why: Dental avulsion can result in permanent loss of medical care. or if you are alone and have to leave an unresponsive victim to get help. Although a simple validated recommendation for patients without suspected spine. without hypoxemia. coconut water. or if the first aid provider is uncertain of the to improve morbidity and mortality from injury and illness. suggest that the person is having a myocardial infarction. Why: First aid providers often encounter individuals with place the victim in a modified HAINES recovery position. In 2015 (Updated): While waiting for EMS to arrive. sodium bicarbonate. magnesium chloride and sulfate. the first aid the event of delayed reimplantation. when patients exposed to 2010 (Old): Place the tooth in milk—or clean water if milk is carbon monoxide are breathing spontaneously. or pelvis injury. or pelvis injury. shown to prolong viability of dental cells (compared with saliva). hip. minor head injury and possible concussion (mild traumatic brain injury). a second dose of adverse effects.132(18)(suppl 2). 2015 (Updated): First aid providers may consider use of 3. whether first aid providers can recognize 2010 (Old): First aid providers should not use immobilization the signs and symptoms of myocardial infarction. decrease in neurologic injury with the use of cervical collars. N Engl J indications and use may consider a hemostatic dressing. Rosenqvist M. Silver Spring. Accessed July 27. the guidelines revision provides clarification as to the 2. The revision of this guideline reflects a change in 2010 (Old): In unusual circumstances. DC: National Academies Press. 4. in the first few hours after onset application of cervical collars by first aid providers is not of symptoms from myocardial infarction) is compared with recommended.gov/NewsEvents/ providing hemostasis in up to 90% of subjects.36 Thus. epinephrine may be given if symptoms of anaphylaxis persist.0000000000000233. 2015].fda. Hazinski MF. Callaway CW. direct pressure to a wound is CIR. 32 American Heart Association . a repeat dose correctly.372(24):2316-2325. Newsroom/PressAnnouncements/ucm391465. 2015. Neumar RW. http://www. Ringh M. Application of cervical collars is not a first aid may be considered. Nolan JP. but there is no evidence to support the use of aspirin for undifferentiated 2015 (Updated): With a growing body of evidence showing chest pain. first aid providers who have specific training in their of laypersons for CPR in out-of-hospital cardiac arrest. when advanced recommendation class to Class III: Harm due to potential for medical assistance is not available. Circulation. Although the dose and form of by manually stabilizing the head so that motion of the head. Part 1: executive summary: hemostatic dressings when standard bleeding control 2015 International Consensus on Cardiopulmonary Resuscitation measures (with direct pressure with or without gauze or and Emergency Cardiovascular Care Science With Treatment cloth dressing) are not effective for severe or life-threatening Recommendations. It remains possible while awaiting arrival of EMS providers. Part 1: executive summary: time frame for considering a second dose of epinephrine. skill. there is no longer the restriction to cervical collars as a component of spinal motion restriction use non–enteric-coated aspirin. Aicken R. Eigel B. bleeding. there was no evidence found to show a chewed before swallowing. Mobile-phone dispatch bleeding. et al. and are effective in Administration. In press. 2015. 2015. Hazinski MF. The American Heart potential for adverse effects. et al. as long as the aspirin is for blunt trauma. Hollenberg J. including tissue destruction with Association response to the 2015 Institute of Medicine report induction of a proembolic state and potential thermal injury. In fact.htm. Neumar RW. unclear. When direct pressure fails to control severe or life-threatening 6.132(16)(suppl 1). Circulation. et al. Med. Proper technique 2015 (Updated): When a person with anaphylaxis does for application of a cervical collar in high-risk individuals not respond to an initial dose of epinephrine. Washington. Shuster M. Part 1: executive epinephrine to persons with symptoms of anaphylaxis. however. A reduction in mortality is also found when “early” harm and no good evidence showing clear benefit. Callaway CW. 2014. the bioavailability of enteric- coated aspirin is similar to non–enteric-coated when chewed Why: In the 2015 ILCOR systematic review of the use of and swallowed. routine administration of aspirin (ie. after hospital arrival) administration of aspirin for injury should have the injured person remain as still as chest pain due to acute myocardial infarction. still considered the primary means for control of bleeding. et al. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Hemostatic Dressings Recommendations. Institute of Medicine. MD: US Food and Drug effects than older hemostatic agents. studies demonstrated actual or potential adverse Anaphylaxis effects such as increased intracranial pressure and airway compromise with use of a cervical collar. aspirin used for chest pain was not specifically reviewed by neck. doi:10. Circulation. 2015. Nolan JP. and spine is minimized. In press. et al. Strategies to Improve Cardiac Arrest Survival: 2010 (Old): Routine use (of hemostatic agents) in first aid A Time to Act. and arrival of requires significant training and practice to be performed advanced care will exceed 5 to 10 minutes. In press. Aicken R.1161/ Why: The application of firm. the ILCOR First Aid Task Force. A first aid provider who suspects a spinal “later” (ie. April 3. and it is devices because their benefit in first aid has not been proven possible that use of aspirin for noncardiac causes of chest and they may be harmful. Why: The administration of aspirin significantly decreases Spinal Motion Restriction mortality due to myocardial infarction. summary: 2015 American Heart Association Guidelines Update Evidence supports the need for a second dose of epinephrine for Cardiopulmonary Resuscitation and Emergency Cardiovascular for acute anaphylaxis in persons not responding to a first Care. cannot be recommended at this time because of significant variation in effectiveness by different agents and their 5. 2015. Newer-generation hemostatic agent-impregnated dressings 7. Resuscitation. FDA approves new hand-held auto-injector to reverse opioid have been shown to cause fewer complications and adverse overdose [news release]. 
 References Why: The 2010 Guidelines recommended that first aid providers assist with or administer (the victim’s own) 1. Maintain spinal motion restriction pain could cause harm. on Strategies to Improve Cardiac Arrest Survival [published online ahead of print June 30. dose. Mancini ME. Lynch B. Learning effect Development of Effective Instruction. 2009. Imanishi K. Cummings P.74(3):476-486. Englehart M.35(10):e1511-e1530. Addressing stroke signs and symptoms through public education: Simulation in healthcare education: a best evidence practical the Stroke Heroes Act FAST campaign. 9. Does simulation-based medical education with deliberate workplace safety training using a self-directed CPR-AED learning practice yield better results than traditional clinical education? program. Holton EF III. Murakami Y. trial. for lay responders: a controlled randomized study. Winston. J Pharma Sci. 21. Taxonomy of ST-segment-elevation myocardial infarction. 1971. 2006. Chung HS. Improving DB. Cheng A. 2004. prevention programs providing naloxone to laypersons—United AZ: Educational Innovators Press. AMEE Guide No. Monsieurs KG. Handbook I: Cognitive Domain. 32. Medical education featuring mastery learning with deliberate Retention of CPR skills learned in a traditional AHA Heartsaver practice can lead to better health for individuals and populations.13(5):589-595. Air versus oxygen in 23. 1998. van der Jagt E. Swanson RA.48(7):657-666. external defibrillators: the American Airlines Study. Rodgers DL. et al.69(3):443-453. study. Knowles MS.62(2):159-165. 2015. Kirkpatrick J. 2008. Wall HK. Bloom BS. Lynch B. Barsuk JH. Hill W. Pepe P. et al. Developing and Writing Behavioral Objectives.64(23): 25. Prev Chronic Dis. 29. O’Neill J. Duval-Arnould JM. 35. et al. Gilbert MK. Stub D. MA: Butterworth-Heinemann. Ericsson K. Kirkpatrick D. Classification of Educational Goals. Educational Objectives: The Classification of Educational Goals. Issenberg SB. Smith K. Bossaert LL. randomized resuscitation (CPR) to self-directed CPR learning in first year trial of the effectiveness and retention of 30-min layperson medical students: the two-person CPR study. 1956. 2004. 33. Acad Med. Cazzell M.90:56-60. Wheeler E. et al. Mager RF. Nichol G. Nichol G. Quan L. domains. Effectiveness of New York. Devine LA. Hunt EA. Implementing the Four Levels: A 19. New York. NY: Longmans. Sullivan JE. Evolution of the Pediatric Advanced Life Support course: enhanced 17.5(2):A49. Cook DA. Issenberg SB. Heymann R. Sherbino J. Einspruch EL. Iwami T. MMWR Morb Mortal Wkly Rep. Hamstra SJ. Zendejas B. Reder S. Woburn. 2009. 28. Eppich W. Wayne 13. Cohen ER. Tesch-Römer C. Handbook II: Affective Domain. CA: Berrett-Koehler. Atlanta. 10. 1964. 22. Einspruch EL. Aufderheide TP. McGaghie WC. Circulation. Vogels C. Eppich W. Roppolo LP. et al. Foell KM. 2007. 2014. Roppolo LP. A randomized controlled 2011. 2005. Krathwohl D. Cook DA.86(6):706-711. guide.8. 2007. Kusaka A. San maintenance of expert performance in medicine and related Francisco. NY: David McKay Co. 82. 11. Grant V. Prospective. Nishiyama C. Highlights of the 2015 AHA Guidelines Update for CPR and ECC 33 . 16. 2011. Resuscitation. 2015. of an automatic external defibrillator to high school students. Bernard S. Beagan BM. NY: Holt Rinehart & controlled trial. 2013. Med Teach. Jones TS. Wayne DB. Resuscitation. 2014. Barsuk JH. quadruple resident resuscitation skills improve after “rapid cycle deliberate crossover single-blind study on immediate action of chewed practice” training. Iwami T. Resuscitation. Cason CL. 15.86(11):e8-e9. Effectiveness of a 30-min CPR self-instruction program practice in the acquisition of expert performance.131(24):2143-2150. 3rd ed. Nelson-McMillan KL. 2015. et al. et al. Mastery Learning.100(3):363-406. Med Teach. New York. Pediatr Crit Care Med. simplified 15-min refresher BLS training program: a randomized 26. 27. Preparing Instructional Objectives: A Critical Tool in the 18. Effectiveness of learning with a new debriefing tool and Web-based module for simplified chest compression-only CPR training program with or Pediatric Advanced Life Support instructors. Psychol Rev. Resuscitation. training for cardiopulmonary resuscitation and automated 2011. for Effective Performance. McGaghie WC. Krathwohl DR. Nishiyama C. Bloom B. Resuscitation. Campbell L. Davidson PJ. Krampe RT. Kardong-Edgren S. Becker L. Taxonomy of Educational Objectives: The 631-635. Resuscitation. Pepe PE. Issenberg SB. O’Donnell J. Kawamura T. GA: Center of a novel interactive basic life support CD: the JUST system. Resuscitation. et al. Ericsson KA. Motola I. 20. Cheng A. Cohen ER.80(10):1164-1168. trial comparing traditional training in cardiopulmonary 30. Bloom BS. Opioid overdose 24. 2011. and unchewed low-dose acetylsalicylic acid tablets in healthy volunteers. A randomized. Tuscon.79(10)(suppl):S70-S81. Resuscitation. The Adult Learner.85(7):945-951. AAOHN J. 34. 1993. without preparatory self-learning video: a randomized controlled 2012. Dave RH. 2014.100(9):3884-3891. Deliberate practice and the acquisition and Practical Guide for the Evaluation of Training Programs. Aufderheide TP.74(2):276-285. 31. Brydges R.82(3):319-325. 1997. Boddie-Willis CL. Acad Med. 2007. Resuscitation. Pediatric 36. course versus 30-min video self-training: a controlled randomized Acad Med. Med Educ. 14.35(1):e867-e898. 2013. 12. et al. The role of deliberate Idris A. A meta-analytic comparative review of the evidence. Furst E. 1970.67(1):31-43. States. Becker LB.57(4):159-167. Comparative effectiveness of instructional design features in simulation-based education: systematic review and meta-analysis. Sai Y. Comparison of three instructional Debriefing for technology-enhanced simulation: a systematic methods for teaching cardiopulmonary resuscitation and use review and meta-analysis. heart. USA www. Texas 75231-4596. 7272 Greenville Avenue Dallas.heart.org For more information on other American Heart Association programs contact us: 877-AHA-4CPR or www. LOT 5340728   15-1002  10/15 .org/cpr The paper used for this product comes from certified forests that are managed in a sustainable way to meet environmental needs of present and future generations. Printed on 10% PC fiber.