eccguidelines.heart.org

2015 Highlights: Lay Rescuer CPR

Summary of Key Issues and Major Changes

Key issues and major changes in the 2015 Guidelines Update recommendations for adult CPR by lay rescuers include the following:

These changes are designed to simplify lay rescuer training and to emphasize the need for early chest compressions for victims of sudden cardiac arrest. More information about these changes appears below.

In the following topics, changes or points of emphasis that are similar for lay rescuers and HCPs are noted with an asterisk (*).

Dispatcher Identification of Agonal Gasps

Cardiac arrest victims sometimes present with seizure-like activity or agonal gasps that can confuse potential rescuers. Dispatchers should be specifically trained to identify these presentations of cardiac arrest to enable prompt recognition and immediate dispatcher-guided CPR.

2015 (Updated): To help bystanders recognize cardiac arrest, dispatchers should inquire about a victim’s absence of responsiveness and quality of breathing (normal versus not normal). If the victim is unresponsive with absent or abnormal breathing, the rescuer and the dispatcher should assume that the victim is in cardiac arrest. Dispatchers should be educated to identify unresponsiveness with abnormal and agonal gasps across a range of clinical presentations and descriptions.

2010 (Old): To help bystanders recognize cardiac arrest, dispatchers should ask about an adult victim’s responsiveness, if the victim is breathing, and if the breathing is normal, in an attempt to distinguish victims with agonal gasps (ie, in those who need CPR) from victims who are breathing normally and do not need CPR.

Why: This change from the 2010 Guidelines emphasizes the role that emergency dispatchers can play in helping the lay rescuer recognize absent or abnormal breathing.

Dispatchers should be specifically educated to help bystanders recognize that agonal gasps are a sign of cardiac arrest. Dispatchers should also be aware that brief generalized seizures may be the first manifestation of cardiac arrest. In summary, in addition to activating professional emergency responders, the dispatcher should ask straightforward questions about whether the patient is unresponsive and if breathing is normal or abnormal in order to identify patients with possible cardiac arrest and enable dispatcher-guided CPR.

Emphasis on Chest Compressions* 2015

2015 (Updated): Untrained lay rescuers should provide compression-only (Hands-Only) CPR, with or without dispatcher guidance, for adult victims of cardiac arrest. The rescuer should continue compression-only CPR until the arrival of an AED or rescuers with additional training. All lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest. In addition, if the trained lay rescuer is able to perform rescue breaths, he or she should add rescue breaths in a ratio of 30 compressions to 2 breaths. The rescuer should continue CPR until an AED arrives and is ready for use, EMS providers take over care of the victim, or the victim starts to move.

2010 (Old): If a bystander is not trained in CPR, the bystander should provide compression-only CPR for the adult victim who suddenly collapses, with an emphasis to “push hard and fast” on the center of the chest, or follow the directions of the EMS dispatcher. The rescuer should continue compression-only CPR until an AED arrives and is ready for use or EMS providers take over care of the victim. All trained lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest. In addition, if the trained lay rescuer is able to perform rescue breaths, compressions and breaths should be provided in a ratio of 30 compressions to 2 breaths. The rescuer should continue CPR until an AED arrives and is ready for use or EMS providers take over care of the victim.

Why: Compression-only CPR is easy for an untrained rescuer to perform and can be more effectively guided by dispatchers over the telephone. Moreover, survival rates from adult cardiac arrests of cardiac etiology are similar with either compression only CPR or CPR with both compressions and rescue breaths when provided before EMS arrival. However, for the trained lay rescuer who is able, the recommendation remains for the rescuer to perform both compressions and breaths.

Chest Compression Rate*

2015 (Updated): In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min.

2010 (Old): It is reasonable for lay rescuers and HCPs to perform chest compressions at a rate of at least 100/min.

Why: The number of chest compressions delivered per minute during CPR is an important determinant of return of spontaneous circulation (ROSC) and survival with good neurologic function. The actual number of chest compressions delivered per minute is determined by the rate of chest compressions and the number and duration of interruptions in compressions (eg, to open the airway, deliver rescue breaths, allow AED analysis). In most studies, more compressions are associated with higher survival rates, and fewer compressions are associated with lower survival rates. Provision of adequate chest compressions requires an emphasis not only on an adequate compression rate but also on minimizing interruptions to this critical component of CPR. An inadequate compression rate or frequent interruptions (or both) will reduce the total number of compressions delivered per minute. New to the 2015 Guidelines Update are upper limits of recommended compression rate and compression depth, based on preliminary data suggesting that excessive compression rate and depth adversely affect outcomes. The addition of an upper limit of compression rate is based on 1 large registry study analysis associating extremely rapid compression rates (greater than 140/min) with inadequate compression depth. Box 1 uses the analogy of automobile travel to explain the effect of compression rate and interruptions on total number of compressions delivered during resuscitation.

Box 1
Number of Compressions Delivered
Affected by Compression
Rate and by Interruptions
The total number of compressions delivered during resuscitation is an important determinant of survival from cardiac arrest.
  • The number of compressions delivered is affected by the compression rate (the frequency of chest compressions per minute) and by the compression fraction (the portion of total CPR time during which compressions are performed). Increases in compression rate and fraction increase the total number of compressions delivered. Compression fraction is improved by reducing the number and duration of any interruptions in compressions.
  • An analogy can be found in automobile travel. When traveling in an automobile, the number of miles traveled in a day is affected not only by the speed (rate of travel) but also by the number and duration of any stops (interruptions in travel). Traveling 60 mph without interruptions translates to an actual travel distance of 60 miles in an hour. Traveling 60 mph except for a 10-minute stop translates to an actual travel of 50 miles in that hour. The more frequent and the more prolonged the stops, the lower the actual miles traveled.
  • During CPR, rescuers should deliver effective compressions at an appropriate rate (100 to 120/min) and depth while minimizing the number and duration of interruptions in chest compressions. Additional components of high-quality CPR include allowing complete chest recoil after each compression and avoiding excessive ventilation.

Chest Compression Depth*

2015 (Updated): During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches [6 cm]).

2010 (Old): The adult sternum should be depressed at least 2 inches (5 cm).

Why: Compressions create blood flow primarily by increasing intrathoracic pressure and directly compressing the heart, which in turn results in critical blood flow and oxygen delivery to the heart and brain. Rescuers often do not compress the chest deeply enough despite the recommendation to “push hard.” While a compression depth of at least 2 inches (5 cm) is recommended, the 2015 Guidelines Update incorporates new evidence about the potential for an upper threshold of compression depth (greater than 2.4 inches [6 cm]), beyond which complications may occur. 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 the recommendation about the upper limit of compression depth is based on 1 very small study that reported an association between excessive compression depth and injuries that were not life-threatening. Most monitoring via CPR feedback devices suggests that compressions are more often too shallow than they are too deep.

Bystander Naloxone in Opioid-Associated Life-Threatening Emergencies*

2015 (New): For patients with known or suspected opioid addiction who are unresponsive with no normal breathing but a pulse, it is reasonable for appropriately trained lay rescuers and BLS providers, in addition to providing standard BLS care, to administer intramuscular (IM) or intranasal (IN) naloxone. Opioid overdose response education with or without naloxone distribution to persons at risk for opioid overdose in any setting may be considered. This topic is also addressed in the Special Circumstances of Resuscitation section.

Why: There is substantial epidemiologic data demonstrating the large burden of disease from lethal opioid overdoses, as well as some documented success in targeted national strategies for bystander-administered naloxone for people at risk. In 2014, the naloxone autoinjector was approved by the US Food and Drug Administration for use by lay rescuers and HCPs.1 The resuscitation training network has requested information about the best way to incorporate such a device into the adult BLS guidelines and training. This recommendation incorporates the newly approved treatment.

Accessibility version Download PDF

1
References

  1. FDA approves new hand-held auto-injector to reverse opioid overdose [news release]. Silver Spring, MD: US Food and Drug Administration; April 3, 2014. http://www.fda.gov/NewsEvents/ Newsroom/PressAnnouncements/ucm391465.htm. Accessed July 27, 2015.
Close OutlineOutline
Numbering
2015 Highlights: Lay Rescuer CPR

1