CPR NOTES ADULT BASIC AND ADVANCED LIFE

(AHA-American Heart Association) SUPPORT

What are the new AHA Guidelines for CPR?

-The AHA continues to make a strong recommendation

for chest compressions of at least two inches but not
more than 2.4 inches in the adult patient, based on
moderate quality evidence. In contrast, there is a
moderate-strength for compression rates of 100-120
compressions per minute, based on moderate quality
evidence.Nov 2, 2020

AHA Guidelines 2020: An EMS overview

Examining recommendations for EMS

treatment of adult and pediatric cardiac Over the past decade or so, researchers have directed
considerable resources into using research to guide
arrest related to epinephrine, compression
resuscitation education practices as well as driving system
depth and rate, and double sequential of care changes to help optimize survival. (Getty Images)
defibrillation
Chest compression quality
Nov. 3, 2020
-While not altering current recommendations for
compression depth and rate in adult patients, the AHA
The American Heart Association recently released the CPR Guidelines 2020 reaffirm the importance of chest
new American Heart Association Guidelines for compression quality in achieving improved survival
Cardiopulmonary Resuscitation and Emergency measures. The AHA continues to make a strong
Cardiovascular Care 2020. These Guidelines represent the recommendation for chest compressions of at least two
culmination of a rigorous evidence review process inches but not more than 2.4 inches in the adult patient,
spanning multiple years. based on moderate quality evidence. In contrast, there
is a moderate- strength for compression rates of 100-
In total, the AHA made 491 evidence-based 120 compressions per minute, based on moderate
recommendations across six resuscitation quality evidence.
categories. While it might be tempting to believe
strong evidence drives the recommendations,
that is simply not the case. High-quality Double sequential defibrillation
evidence from more than one randomized -Although many EMS agencies around the
controlled trial accounted for only 1% of the country include double sequential defibrillation
recommendations [1]. The expert writing teams in their treatment protocols, previous AHA
based more than half of their recommendations guidelines were silent on the subject [2].
on limited evidence, with expert opinion forming Current published evidence on the usefulness
the basis of an additional 17% of the of this strategy for shock-refractory episodes
recommendations [1]. This article will provide an of ventricular fibrillation or pulseless
overview of the major clinical, educational and ventricular tachycardia remains limited and
system of care recommendations in the AHA weak. Because of this level and quality of
CPR and ECC Guidelines 2020. evidence, the strongest recommendation the
AHA can make in 2020 is that resuscitation
team mays consider the strategy.

Intraosseous access
- Another interesting recommendation involves the
manner in which resuscitation teams gain access to the
 vascular space for medication administration. year, the AHA addressed whether EMS providers
Historically, venous cannulation was the primary should provide bag-mask ventilation with or without
access strategy. Recently however, many EMS agencies an advanced airway [4]. At that time, the AHA stated
began moving away from initial IV attempts during the strength and quality of the evidence prohibited a
resuscitation in favor of intraosseous access. recommendation for or against the use of an
Unfortunately, a rigorous review of the evidence advanced airway during the pediatric resuscitation
questions the efficacy of the IO route when compared attempt. They also could not recommend one type of
to the IV route. Based on moderate quality evidence not advanced airway device as clearly superior to
involving a randomized trial, the AHA believes it is another device. Based on limited data, the AHA CPR
reasonable for resuscitation teams to first attempt IV Guidelines 2020 reviewers conclude that rates of
access. When IV attempts are unsuccessful or access is survival to hospital discharge and survival with good
not feasible, there is a weaker recommendation for the neurologic outcome are similar between pediatric
teams to consider establishing an IO. patients treated with BVM ventilation and those
treated with endotracheal tube ventilation. The AHA
The use of epinephrine in cardiac arrest makes a moderate-strength recommendation for the
- Last year, a focused update on the use of use of bag-mask ventilation over endotracheal tube
epinephrine in cardiac arrest concluded that ventilation.
resuscitation teams should continue to administer
epinephrine for the treatment of cardiac arrest in adult Ventilation rates
patients at 3-5 minute intervals for the duration of the -One of the most interesting recommendations
resuscitation attempt [3]. The AHA CPR Guidelines related to pediatric resuscitation involves updates to
2020 strongly reaffirm that position, based on moderate assisted ventilation rates. For years, the AHA warned
quality evidence. With respect to timing, the AHA about the very real dangers of overventilation during
Guidelines 2015 made a weak recommendation that cardiac arrest. Increasing assisted ventilation rates
resuscitation teams consider giving epinephrine as soon during CPR raises intrathoracic pressure, which
as feasible when the patient presents with a non- reduces venous return to the heart. However, results
shockable rhythm [2]. The AHA CPR Guidelines 2020 from a large multi-center observational trial found
now strengthen that recommendation with moderate in-hospital resuscitation teams often provide
quality evidence based on limited data. The AHA ventilation rates in excess of recommended rates [5].
Guidelines 2015 made no recommendation on when More importantly, researchers found an association
resuscitation teams should administer epinephrine to between faster ventilation rates and improved
patients with shockable rhythms. The 2019 AHA survival to hospital discharge for infants with
focused update recommended epinephrine endotracheal intubation. Thus, based on limited data,
administration for shockable rhythms after initial the AHA CPR Guidelines 2020 make a weak
defibrillation attempts have failed [3]. The AHA CPR recommendation for providing one breath every 2-3
Guidelines 2020 reaffirm that position as a weak seconds (20-30 breaths/min) for infants and children
recommendation based on limited data. Changes to the with an advanced airway.
algorithm now depict epinephrine administration as
appropriate after the second defibrillation attempt for
shock

PEDIATRIC BASIC AND ADVANCED LIFE

SUPPORT The use of epinephrine in cardiac arrest
-No high-quality evidence drives intra- resuscitation
Chest compression rate and depth drug administration recommendations for infants and
-As with the adult patient, the AHA CPR children who suffer cardiac arrest. The basis for all
Guidelines 2020 do not alter previous compression 2020 AHA recommendations is limited data. The AHA
depth and rate recommendations for pediatric CPR Guidelines 2020 reaffirm the previous moderate-
patients. The AHA makes a moderate-strength strength recommendation for the use of epinephrine
recommendation for chest compressions depths of during pediatric resuscitation attempts. The AHA CPR
one-third the anterior-posterior diameter of the chest Guidelines 2020 also make a moderate-strength
for infants and children, based on limited data. recommendation for resuscitation teams to administer
Limited data also supported the AHA CPR the first dose of epinephrine within the five minutes
Guidelines 2020 reaffirmation of the moderate- after beginning chest compressions. This
strength recommendation for compression rates of recommendation should prompt EMS systems to
100-120 compressions per minute. evaluate their current pediatric resuscitation practices
for ways to meet this recommendation. Resuscitation
Advanced airway management teams should continue to administer epinephrine at 3-5
-One recommendation specifically addressed to minute intervals. Finally, the AHA CPR Guidelines
prehospital care involves the decision to use an 2020 reaffirm a previous moderate-strength
advanced airway during pediatric resuscitation. Last recommendation for the use of either amiodarone or
 lidocaine for shock-refractory V-fib/pVT. This article What Are the 7 Steps of CPR In Order?
examines only a glimpse of the recommendations The American Red Cross guidelines for performing CPR
related to major clinical topics associated with are as follows:
resuscitation following cardiac arrest. There are many
other clinical recommendations that do not apply to the Before Giving CPR:
prehospital environment, although they do contribute to 1. Check the scene and the person
overall survivability. In addition, over the past decade -Make sure the setting is safe Tap the
or so, researchers have directed considerable resources person on the shoulder and shout, “Are you
into using research to guide resuscitation education OK?” to make sure the person needs help
practices as well as driving system of care changes to
help optimize survival. Over the next few weeks, we
2. Call 911 for assistance
will explore all of these recommendations in more
-If it's clear help is needed, call 911 (or ask a
detail.
bystander to call) Send someone to get an
AED if one is available If there is no AED
What Are the Seven Steps of CPR? available or there is no bystander to access
The seven steps of CPR (cardiopulmonary it, stay with the victim, call 911, and prepare
resuscitation) involve checking the scene and the to give assistance
person, calling 911 for assistance, opening the
airway, checking for breathing, chest 3. Open the airway
compressions, delivering rescue breaths, and -With the person lying on his or her back,
repeating CPR steps.  tilt the head back slightly to lift the chin

Medical Editor: John P. Cunha, DO, FACOEP 4. Check for breathing

-Listen carefully for sounds of breathing,
Reviewed on 9/15/2022 for no more than 10 seconds (occasional
Privacy & Trust Info gasping sounds are not the same as
breathing) If there is no breathing, begin
CPR Red Cross CPR Steps

5. Begin chest compressions

-Position hands one on top of the other in
the middle of the chest Push hard, push fast
Cardio Pulmonary Resuscitation (CPR) - First
Aid Use your body weight to help administer
compressions at least 2 inches deep and
delivered at a rate of at least 100
compressions per minute

6. Deliver rescue breaths

-With the person's head tilted back slightly
and the chin lifted, pinch the nose shut and
The seven steps of CPR (cardiopulmonary resuscitation) place your mouth over the person's mouth
involve checking the scene and the person, calling 911 for to make a complete seal Blow into the
assistance, opening the airway, checking for breathing, person's mouth to make the chest rise
chest compressions, delivering rescue breaths, and Deliver two rescue breaths, then continue
repeating CPR steps. compressions Note: If the chest does not
rise with the initial rescue breath, re-tilt the
CPR stands for Cardio Pulmonary Resuscitation, an head before delivering the second breath. If
emergency procedure that is a combination of chest the chest doesn't rise with the second
compressions and artificial ventilation (breathing) breath, the person may be choking. After
each subsequent set of 30 chest
used to save a person’s life when a person’s heart
compressions, and before attempting
stops beating or breathing ceases. When performed breaths, look for an object (inner mouth)
right away, CPR can increase a person’s chances of and, if seen, remove it.
survival after cardiac arrest.
*Note: Rescue breaths are recommended by the minutes during an out-ofhospital sudden
American Red Cross. The American Heart cardiac arrest for an adult victim (please
Association recommends calling 911 and delivering read the Hands-Only CPR vs. CPR with
chest compressions only. Breaths section below to learn more.)

7. Continue CPR steps Q: Does learning Hands-Only CPR increase the

Continue with cycles of chest compressions and chance of a bystander taking action in a cardiac
breathing until: emergency?
Yes. Most Americans (70 percent) feel
The person exhibits signs of life, such as
helpless to act during a cardiac emergency
breathing An AED becomes available, once it is because they don’t know how to administer
applied continue CPR if the patient is still CPR or they’re afraid of hurting the victim.
unresponsive According to the American Heart
Association, people are more likely to
EMS or a trained medical responder arrives on the remember the correct pace when trained to
scene and takes over the beat of the disco classic “Stayin’ Alive"
or another familiar song with 100 to 120
Note: End the cycles if the scene becomes unsafe or beats per minute – the rate you should push
you are unable to continue performing CPR due to on the chest during CPR. HANDS-ONLY CPR
exhaustion CAMPAIGN

Q: Who can learn Hands-Only CPR?

Anyone can learn Hands-Only CPR and save a life.
Hands-Only CPR has just two easy steps: If you see a
teen or adult suddenly collapse, (1) Call 9-1-1; and (2)
Push hard and fast in the center of the chest to the beat of
the disco song “Stayin’ Alive.” You can view these
materials at heart.org/handsonlycpr or heart.org/rcp
(Spanish resources). 2 HANDS-ONLY CPR KIOSKS

Q: Can music help people learn Hands-Only CPR?

Music is a great learning tool in any
NICE TO KNOW NOTES ABOUT CPR situation, especially when training for an
Hands-Only CPR has just two easy steps: If you see a emergency. During CPR, you should push on
teen or adult suddenly collapse(AHA guidelines) the chest at a rate of 100 to 120
compressions per minute. The beat of
“Stayin’ Alive" is a perfect match for this,
(1) Call 9-1-1; and
and research shows that people are more
(2) Push hard and fast in the center of the chest to the likely to remember the correct pace when
beat of the disco song “Stayin' Alive.” trained to the beat of a familiar song. The
American Heart Association recommends
FAQ: Hands-Only CPR that you take a CPR course to practice and
HANDS-ONLY CPR learn the full skills of CPR, including rescue
Q: What is Hands-Only CPR? breaths and high-quality chest
Hands-Only CPR is CPR without rescue breaths. compressions.
If you see a teen or adult collapse, you can
perform Hands-Only CPR with just two easy The American Heart Association also recommends CPR
steps: 1) Call 911 and 2) Push hard and fast in the with compressions and breaths for infants; children;
center of the chest to the beat of the Bee Gees’ victims of drowning or drug overdose; or people who
classic disco song “Stayin’ Alive.” The song is 100 collapse due to breathing problems. People who have had
beats per minute – the minimum rate you should CPR training are more 3 likely to give high-quality chest
push on the chest during HandsOnly CPR. compressions and are more confident about their skills
than those who have not been trained (or have not trained
Q: Why would you use Hands-Only CPR? in the last 5 years).
With 70 percent of all out-of-hospital
cardiac arrests happening at home, if you’re Q: Not all people who suddenly collapse are in
called on to perform Hands Only CPR, you’ll cardiac arrest. Will CPR seriously hurt them?
likely be trying to save the life of someone Adults who suddenly collapse and are not
you know and love. Hands-Only CPR carried responsive are likely experiencing sudden
out by a bystander has been shown to be as cardiac arrest. Their chance of survival is
effective as CPR with breaths in the first few nearly zero unless someone takes action
 immediately. According to the American that automatically analyzes the heart rhythm
Heart Association, about 90 percent of in people who are experiencing cardiac
people who suffer out-of-hospital cardiac arrest.When appropriate, it delivers an
arrests die. Hands-Only CPR is an easy, electrical shock to the heart to restore its
effective way for any bystander, especially
normal rhythm.Feb 9, 2021
if they act immediately, to double or triple a
cardiac arrest victim’s chance of survival.
You should call 9-1-1 and start pushing What Is an Automated External Defibrillator?
hard and fast in the center of the chest An automated external defibrillator (AED) is
with minimal interruptions. If an adult has a lightweight, portable device that delivers
collapsed for reasons other than cardiac an electric shock through the chest to the
arrest, Hands-Only CPR could still help by heart. The shock can potentially stop an
causing the person to respond (begin to irregular heart beat (arrhythmia) and allow a
move, breathe normally or speak). If that normal rhythm to resume following sudden
occurs, Hands-Only CPR can be stopped. cardiac arrest (SCA). SCA occurs when the
Otherwise, chest compressions should heart malfunctions and stops beating
continue until EMS providers arrive. Q: Is
unexpectedly. If not treated within minutes, it
there a danger in jumping in and giving
CPR without being trained? In the majority
quickly leads to death. Most SCAs result
of cases, any attempt to provide CPR to a from ventricular fibrillation (VF). VF is a
victim is better than no attempt to provide rapid and unsynchronized heart rhythm that
help. HANDS-ONLY CPR vs. CPR WITH originates in the heart’s lower chambers (the
BREATHS ventricles). The heart must be “defibrillated”
quickly, because a victim’s chance of
Q: What is the difference between Hands-Only CPR surviving drops by seven to 10 percent for
and CPR with breaths? Which one am I supposed to every minute a normal heartbeat isn’t
do in an emergency? restored.
Hands-Only CPR performed by a
bystander has been shown to be as Why are AEDs important?
effective as CPR with breaths in the first AEDs make it possible for more people to
few minutes of an out-of-hospital sudden respond to a medical emergency where
cardiac arrest for an adult victim. If you do defibrillation is required. Because AEDs are
not know how to administer CPR with portable, they can be used by nonmedical
breaths, don’t be afraid to act in an people (lay-rescuers). They can be made
emergency; your actions can only help. Any part of emergency response programs that
attempt at CPR is better than no attempt. If also include rapid use of 9-1-1 and prompt
you see an unconscious, unresponsive delivery of cardio pulmonary resuscitation
adult, call 9-1-1 and push hard and fast in (CPR). All three of these activities are vital to
the center of the chest to the beat of the improving survival from SCA. How does an
classic disco song “Stayin’ Alive.” This song, AED work? A built-in computer checks a
and other songs with a rhythm of 100 to 120 victim’s heart rhythm through adhesive
beats per minute, mimic the rate you should electrodes. The computer calculates
push on the chest during CPR. The AHA still whether defibrillation is needed. If it is, a
recommends CPR with compressions and recorded voice prompts the rescuer to press
breaths for infants, children, victims of the shock button on the AED. This shock
drowning or drug overdose, or people who momentarily stuns the heart and stops all
collapse due to breathing problems. activity. It gives the heart the chance to
resume beating effectively. Audible prompts
AED – AUTOMATED EXTERNAL guide the user through the process. AEDs
DEFIBRILLATOR An AED, or automated external advise a shock only for ventricular
defibrillator, is used to help those experiencing fibrillation or another life-threatening
sudden cardiac arrest. It's a sophisticated, yet easy-to- condition called pulseless ventricular
use, medical device that can analyze the heart's Tachycardia.
rhythm and, if necessary, deliver an electrical shock,
or defibrillation, to help the heart re-establish an Who can use an AED?
effective rhythm. Non-medical personnel such as police, fire
service personnel, flight attendants, security
What is an AED and how does it work? guards and other lay rescuers who have
An AED is a type of computerized defibrillator been trained in CPR can use AEDs. Although
 formal training in the use of an AED is not
required, it is recommended to help the
rescuer increase their comfort and level of
confidence. However, AEDs are intended for
use by the general public. Most AEDs use
audible voice prompts to guide the user
through the process. Are AEDs safe to use?
AEDs are safe to use by anyone. Some
studies have shown that 90% of the time
AEDs are able to detect a rhythm that should
be defibrillated. This data suggests that
AEDs are highly effective in detecting when
(or when not) to deliver a shock.

Where should AEDs be placed?

All first-response vehicles, including
ambulances, lawenforcement vehicles and
many fire engines should have an AED. AEDs
also should be placed in public areas such
as sports venues, shopping malls, airports,
airplanes, businesses, convention centers,
hotels, schools and doctors’ offices. They
should also be in any other public or private
place where large numbers of people gather
or where people at high risk for heart
attacks live. They should be placed near
elevators, cafeterias, main reception areas,
and on walls in main corridors