2015 Interim Resources for BLS

2015 Interim Resources for BLS Original Release: November 25, 2015 Starting in 2016, new versions of American Heart Association online courses will be released to reflect the changes published in the 2015 AHA Guidelines Update for CPR and ECC. All current AHA courses remain valid and should continue to be used for training until the new versions are released. The release of new Guidelines does not mean that the use of earlier Guidelines is unsafe or ineffective. To ensure that students in current courses are aware of the changes in science, the following interim resources are available free of charge for BLS students: Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC (available at 2015ECCguidelines.heart.org): In-depth summary by topic of the changes to science and treatment recommendations published in the 2015 AHA Guidelines Update for CPR and ECC BLS for Healthcare Providers Student Manual Comparison Chart (attached): Chart showing how science changes in the 2015 AHA Guidelines Update for CPR and ECC differ from current BLS course content Interim BLS Course 1- and 2-Rescuer Adult BLS With AED Skills Testing Sheet (attached): Checklist of critical performance steps updated with 2015 science changes Interim BLS Course 1- and 2-Rescuer Infant BLS Skills Testing Sheet (attached): Checklist of critical performance steps updated with 2015 science changes

2015 Interim Training Materials BLS for Healthcare Providers Student Manual Comparison Chart Part 2: BLS/CPR for Adults Immediate recognition and activation of emergency response system New Old Rationale Check for responsiveness. Check for no breathing or no normal breathing. Call for help. Check for pulse for no longer than 10 seconds. Call for nearby help upon finding the victim unresponsive. Continue to assess the breathing and pulse simultaneously. Activate the emergency response system or call for backup. The intent of the recommendation change is to minimize delay and to encourage fast, efficient, simultaneous assessment and response, rather than a slow, methodical, step-by-step approach. BLS for Healthcare Providers Student Manual Comparison Chart 1

Shock first vs CPR first For witnessed adult cardiac arrest, chest compressions should be started immediately. Use a defibrillator as soon as possible. CPR should be provided while the AED pads are applied and until the AED is ready to analyze the rhythm. When any rescuer witnesses an out-ofhospital arrest and an AED is immediately available on-site, the rescuer should start CPR with chest compressions and use the AED as soon as possible. HCPs who treat cardiac arrest in hospitals and other facilities with on-site AEDs or defibrillators should provide immediate CPR and should use the AED/defibrillator as soon as it is available. These recommendations are designed to support early CPR and early defibrillation, particularly when an AED or defibrillator is available within moments of the onset of sudden cardiac arrest. When an OHCA is not witnessed by EMS personnel, EMS may initiate CPR while checking the rhythm with the AED or on the electrocardiogram (ECG) and preparing for defibrillation. In such instances, 1½ to 3 minutes of CPR may be considered before attempted defibrillation. Whenever 2 or more rescuers are present, CPR should be provided while the defibrillator is retrieved. With in-hospital sudden cardiac arrest, there is insufficient evidence to support or refute CPR before defibrillation. However, in monitored patients, the time from ventricular fibrillation (VF) to shock delivery should be under 3 minutes, While numerous studies have addressed the question of whether a benefit is conferred by providing a specified period (typically 1.5 to 3 minutes) of chest compressions before shock delivery, as compared with delivering a shock as soon as the AED can be readied, no difference in outcome has been shown. BLS for Healthcare Providers Student Manual Comparison Chart 2

Chest compression rate Chest compression depth New Old Rationale and CPR should be performed while the In adult victims of cardiac arrest, perform chest compressions at a rate of 100 to 120/min. Perform chest compressions to a depth of at least 2 inches/5 cm for an average adult. Avoid excessive chest compression depths of more than 2.4 inches/6 cm when a feedback device is available. defibrillator is readied. Lay rescuers and healthcare providers perform chest compressions at a rate of at least 100/min. The adult sternum should be depressed at least 2 inches (5 cm). A single large registry series suggested that as the compression rate increases to more than 120/min, compression depth decreases in a dose-dependent manner. For example, the proportion of compressions of inadequate depth was about 35% for a compression rate of 100 to 119/min but increased to inadequate depth in 50% of compressions when the compression rate was 120 to 139/min and to inadequate depth in 70% of compressions when the compression rate was more than 140/min. A compression depth of approximately 5 cm is associated with greater likelihood of favorable outcomes compared with shallower compressions. While there is less evidence about whether there is an upper threshold beyond which compressions may be too deep, a recent very small study suggests potential injuries (none life-threatening) from excessive chest compression depth (greater than 2.4 inches/6 cm). Compression depth may be difficult to judge without use of feedback devices, and identification of upper limits of compression depth may be challenging. It is important for rescuers to know that chest compression depth is more often too shallow than too deep. BLS for Healthcare Providers Student Manual Comparison Chart 3

Chest recoil Minimizing interruptions in chest compressions New Old Rationale Allow complete recoil of the chest after each compression, to allow the heart to fill completely before the next compression. Avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest. Minimize the frequency and duration of interruptions in compressions to maximize the number of compressions delivered per minute. For adults in cardiac arrest who receive CPR without an advanced airway, perform CPR with the goal of a chest compression fraction as high as possible, with a target of at least 60%. Full chest wall recoil occurs when the sternum returns to its natural or neutral position during the decompression phase of CPR. Chest wall recoil creates a relative negative intrathoracic pressure that promotes venous return and cardiopulmonary blood flow. Leaning on the chest wall between compressions precludes full chest wall recoil. Incomplete recoil raises intrathoracic pressure and reduces venous return, coronary perfusion pressure, and myocardial blood flow and can influence resuscitation outcomes. Interruptions in chest compressions can be intended as part of required care (ie, rhythm analysis and ventilation) or unintended (ie, rescuer distraction). Chest compression fraction is a measurement of the proportion of total resuscitation time that compressions are performed. An increase in chest compression fraction can be achieved by minimizing pauses in chest compressions. The optimal goal for chest compression fraction has not been defined. The addition of a target compression fraction is intended to limit interruptions in compressions and to maximize coronary perfusion and blood flow during CPR. BLS for Healthcare Providers Student Manual Comparison Chart 4

Part 4: BLS/CPR for Children; Part 5: BLS/CPR for Infants C-A-B sequence Chest compression depth Chest compression rate New Old Rationale Initiate CPR for infants and children with chest compressions rather than rescue breaths (C-A-B rather than A-B-C). CPR should begin with 30 compressions (by a single rescuer) or 15 compressions (for resuscitation of infants and children by 2 healthcare providers) rather than with 2 ventilations. consistency in teaching. Although the amount and quality of supporting data are limited, providers should maintain the sequence from the 2010 Guidelines by initiating CPR with C-A-B over A-B-C. Rescuers should provide chest compressions that depress the chest at least one third the anteroposterior diameter of the chest in pediatric patients (infants [younger than 1 year] to children up to the onset of puberty). This equates to approximately 1.5 inches (4 cm) in infants to 2 inches (5 cm) in children. Once children have reached puberty (ie, adolescents), the recommended adult compression depth of at least 2 inches (5 cm) but no greater than 2.4 inches (6 cm) is used. To maximize simplicity in CPR training, the adult chest compression rate of 100 to 120/min is used for infants and children. To achieve effective chest compressions, rescuers should compress at least one third of the anteroposterior diameter of the chest. This corresponds to approximately 1.5 inches (about 4 cm) in most infants and about 2 inches (5 cm) in most children. Push at a rate of at least 100 compressions per minute. In the absence of new data, the sequence has not been changed. Consistency in the order of compressions, airway, and breathing for CPR in victims of all ages may be easiest for rescuers who treat people of all ages to remember and perform. Maintaining the same sequence for adults and children offers One adult study suggested harm with chest compressions greater than 6 cm, resulting in a change in the adult BLS recommendation to include an upper limit for chest compression depth; the pediatric experts accepted this recommendation for adolescents beyond puberty. A pediatric study observed improved 24-hour survival when compression depth was greater than 51 mm (2 inches). Judgment of compression depth is difficult at the bedside, and the use of a feedback device that provides such information may be useful if available. One adult registry study demonstrated inadequate chest compression depth with extremely rapid compression rates. To maximize educational consistency and retention, in the absence of pediatric data, pediatric experts adopted the same recommendation for compression rate as is made for adult BLS. BLS for Healthcare Providers Student Manual Comparison Chart 5

Compressiononly CPR Part 7: CPR With an Advanced Airway Ventilation during CPR with an advanced airway New Old Rationale Optimal CPR in infants and children includes both compressions and ventilations, but compressions alone are preferable to no CPR. Conventional CPR (rescue breaths and chest compressions) should be provided for infants and children in cardiac arrest. The asphyxial nature of most pediatric cardiac arrests necessitates ventilation as part of effective CPR. However, because compression-only CPR can be effective in patients with a primary cardiac arrest, if rescuers are unwilling or unable to deliver breaths, we recommend rescuers perform compression-only CPR for infants and children in cardiac arrest. With an advanced airway in place, deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed. When an advanced airway (ie, endotracheal tube, Combitube, or laryngeal mask airway) is in place during 2-person CPR, give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions (this will result in delivery of 8 to 10 breaths per minute). Large registry studies have demonstrated worse outcomes for presumed asphyxial pediatric cardiac arrest, which comprise the vast majority of out-of-hospital pediatric cardiac arrest, treated with compression-only CPR. In 2 studies, when conventional CPR (compressions plus breaths) was not given in presumed asphyxial arrest, outcomes were no different from when victims did not receive any bystander CPR. When a presumed cardiac etiology was present, outcomes were similar whether conventional or compressiononly CPR was provided. This simple single rate for adults, children, and infants rather than a range of breaths per minute should be easier to learn, remember, and perform. BLS for Healthcare Providers Student Manual Comparison Chart 6

BLS Dos and Don ts of Adult High-Quality CPR Rescuers Should Rescuers Should Not Perform chest compressions at a rate of 100 Compress at a rate slower than 100/min or to 120/min faster than 120/min Compress to a depth of at least 2 inches (5 Compress to a depth of less than 2 inches cm) (5 cm) or greater than 2.4 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 Provide excessive ventilation (ie, too many compressions, each breath delivered over 1 breaths or breaths with excessive force) second, each causing chest rise) BLS for Healthcare Providers Student Manual Comparison Chart 7

BLS Course 2015 Interim Tool 1- and 2-Rescuer Adult BLS With AED Skills Testing Sheet Student Name: Test Date: Skill Step CPR Skills (circle one): Pass Needs Remediation AED Skills (circle one): Pass Needs Remediation Critical Performance Criteria 1-Rescuer Adult BLS Skills Evaluation During this first phase, evaluate the first rescuer s ability to initiate BLS and deliver high-quality CPR for 5 cycles. 1 Checks responsiveness 2 Yells for help, activates the emergency response system, and sends for an AED 3 Checks breathing and pulse (breathing and pulse check can be performed simultaneously) for at least 5 seconds and no more than 10 seconds 4 GIVES HIGH-QUALITY CPR: if done correctly Correct compression HAND PLACEMENT Cycle 1: ADEQUATE RATE: 100 to 120/min (ie, delivers each set of 30 chest compressions in no less than 15 seconds and no more than 18 seconds) Cycle 2: ADEQUATE DEPTH: Delivers compressions at least 2 inches in depth (at least 23 out of 30) Cycle 3: Time: ALLOWS COMPLETE CHEST RECOIL (at least 23 out of 30) Cycle 4: MINIMIZES INTERRUPTIONS: Gives 2 breaths with pocket mask in less than 10 seconds Cycle 5: Second Rescuer AED Skills Evaluation and SWITCH During this next phase, evaluate the second rescuer s ability to use the AED and both rescuers abilities to switch roles. 5 DURING FIFTH SET OF COMPRESSIONS: Second rescuer arrives with AED and bag-mask device, turns on AED, and applies pads 6 First rescuer continues compressions while second rescuer turns on AED and applies pads 7 Second rescuer clears victim, allowing AED to analyze RESCUERS SWITCH 8 If AED indicates a shockable rhythm, second rescuer clears victim again and delivers shock First Rescuer Bag-Mask Ventilation During this next phase, evaluate the first rescuer s ability to give breaths with a bag-mask. 9 Both rescuers RESUME HIGH-QUALITY CPR immediately after shock delivery: Cycle 1 Cycle 2 SECOND RESCUER gives 30 compressions immediately after shock delivery (for 2 cycles) FIRST RESCUER successfully delivers 2 breaths with bag-mask (for 2 cycles) AFTER 2 CYCLES, STOP THE EVALUATION If the student completes all steps successfully (a in each box to the right of Critical Performance Criteria), the student passed this scenario. If the student does not complete all steps successfully (as indicated by a blank box to the right of any of the Critical Performance Criteria), give the form to the student for review as part of the student s remediation. After reviewing the form, the student will give the form to the instructor who is reevaluating the student. The student will reperform the entire scenario, and the instructor will notate the reevaluation on this same form. If the reevaluation is to be done at a different time, the instructor should collect this sheet before the student leaves the classroom. Remediation (if needed): Instructor Signature: Print Instructor Name: Date: Instructor Signature: Print Instructor Name: Date:

BLS Course 2015 Interim Tool 1- and 2-Rescuer Infant BLS Skills Testing Sheet Student Name: Test Date: 1-Rescuer BLS and CPR Skills (circle one): Pass Needs Remediation 2-Rescuer CPR Skills Bag-Mask (circle one): Pass Needs Remediation 2 Thumb Encircling Hands (circle one): Pass Needs Remediation Skill Critical Performance Criteria Step 1-Rescuer Infant BLS Skills Evaluation During this first phase, evaluate the first rescuer s ability to initiate BLS and deliver high-quality CPR for 5 cycles. 1 Checks responsiveness 2 Yells for help, activates the emergency response system, and sends for an AED 3 Checks breathing and pulse (breathing and pulse check can be performed simultaneously) for at least 5 seconds and no more than 10 seconds 4 GIVES HIGH-QUALITY CPR: Correct compression FINGER PLACEMENT Cycle 1: if done correctly ADEQUATE RATE: 100 to 120/min (ie, delivers each set of 30 chest compressions in no Cycle 2: Time: less than 15 seconds and no more than 18 seconds) ADEQUATE DEPTH: Delivers compressions at least one third the depth of the chest Cycle 3: (approximately 1½ inches [4 cm]) (at least 23 out of 30) ALLOWS COMPLETE CHEST RECOIL (at least 23 out of 30) Cycle 4: MINIMIZES INTERRUPTIONS: Gives 2 breaths with pocket mask in less than 10 seconds Cycle 5: 2-Rescuer CPR and SWITCH During this next phase, evaluate the FIRST RESCUER S ability to give breaths with a bag-mask and give compressions by using the 2 thumb encircling hands technique. Also evaluate both rescuers abilities to switch roles. 5 DURING FIFTH SET OF COMPRESSIONS: Second rescuer arrives with bag-mask device. RESCUERS SWITCH ROLES. 6 Both rescuers RESUME HIGH-QUALITY CPR: Cycle 1 Cycle 2 SECOND RESCUER gives 15 compressions in no less than 7 seconds and no more than 9 seconds by using 2 thumb encircling hands technique (for 2 cycles) X X FIRST RESCUER successfully delivers 2 breaths with bag-mask (for 2 cycles) AFTER 2 CYCLES, PROMPT RESCUERS TO SWITCH ROLES 7 Both rescuers RESUME HIGH-QUALITY CPR: Cycle 1 Cycle 2 FIRST RESCUER gives 15 compressions in no less than 7 seconds and no more than 9 seconds by using 2 thumb encircling hands technique (for 2 cycles) SECOND RESCUER successfully delivers 2 breaths with bag-mask (for 2 cycles) X X AFTER 2 CYCLES, STOP THE EVALUATION If the student completes all steps successfully (a in each box to the right of Critical Performance Criteria), the student passed this scenario. If the student does not complete all steps successfully (as indicated by a blank box to the right of any of the Critical Performance Criteria), give the form to the student for review as part of the student s remediation. After reviewing the form, the student will give the form to the instructor who is reevaluating the student. The student will reperform the entire scenario, and the instructor will notate the reevaluation on this same form. If the reevaluation is to be done at a different time, the instructor should collect this sheet before the student leaves the classroom. Remediation (if needed): Time: Time: Instructor Signature: Print Instructor Name: Date: Instructor Signature: Print Instructor Name: Date: