2020 AHA Basic Life Support Guidelines

Systems of Care: Using Mobile Devices to Summon Rescuers

2020 (New): The use of mobile phone technology by emergency dispatch systems to alert willing bystanders to nearby events that may require CPR or AED use is reasonable.

Adult Chains of Survival

A sixth link, recovery, was added to the in-hospital and out-of-hospital Chains of Survival.

Opioid-Associated Emergency for Healthcare Providers Algorithm

The 2020 Guidelines include an opioid-associated resuscitation emergency algorithm for healthcare providers, shown here. A version for lay rescuers is also included in the Guidelines. This algorithm is for both adults and pediatrics.

Changes include:

• There is a clear step now to prevent deterioration, with an initial assessment more clearly laid out.
• Respiratory arrest is more prominently addressed in the beginning, with “Is the person breathing normally?” as an initial decision.
• Although naloxone is still recommended for opioid-associated emergencies, it should be considered for preventing deterioration and cardiac arrest, and given during respiratory arrest.

Cardiac Arrest in Pregnancy

Do not delay providing chest compressions for a pregnant woman in cardiac arrest. High-quality CPR can increase the mother’s and the infant’s chance of survival. If you do not perform CPR on a pregnant woman when needed, the lives of both the mother and the infant are at risk.

Perform high-quality chest compressions for a pregnant woman in cardiac arrest as you would for any victim of cardiac arrest. Use an AED for a pregnant woman in cardiac arrest as you would for any victim of cardiac arrest. If the woman begins to move, speak, blink, or otherwise react, stop CPR and roll her onto her left side.

2020 (New): Because pregnant patients are more prone to hypoxia, oxygenation and airway management should be prioritized during resuscitation from cardiac arrest in pregnancy.

2020 (New): Because of potential interference with maternal resuscitation, fetal monitoring should not be undertaken during cardiac arrest in pregnancy.

Why: Recommendations for the management of cardiac arrest in pregnancy were reviewed in the 2015 Guidelines Update and a 2015 AHA Scientific Statement (Jeejeebhoy 2015). 

Airway, ventilation, and oxygenation are particularly important in the setting of pregnancy due to increased maternal metabolism, decreased functional reserve capacity due to the gravid uterus, and the risk of fetal brain injury from hypoxemia. Evaluation of the fetal heart is not helpful during maternal cardiac arrest and may distract from necessary resuscitation elements.

2020 (New): The AHA recommends targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest.

2020 (New): During targeted temperature management of pregnant patients, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought.

Why: In the absence of data to the contrary, pregnant women who survive cardiac arrest should receive targeted temperature management as any other survivors, with attention paid to the status of the fetus, who may remain in utero.

Infant Compressions

A single rescuer may now use 2 thumbs or the heel of 1 hand for infant compressions.

2020 (New): For infants, single rescuers (whether lay rescuers or healthcare providers) should compress the sternum with 2 fingers or 2 thumbs placed just below the nipple line (intermammary line).

2020 (New): For infants, if the rescuer is unable to achieve guideline-recommended depths (at least one third the diameter of the chest), it may be reasonable to use the heel of 1 hand.

Why: With proper placement on the chest, the 2-thumb and heel-of-1-hand techniques have shown good chest compression depth with reduced provider fatigue, leading to better outcomes in studies. However, there are limited data comparing the various hand positions.

Changes to the Pediatric Assisted Ventilation Rate

Rescue Breathing

2020 (Updated): For infants and children with a pulse but absent or inadequate respiratory effort, it is reasonable to give 1 breath every 2 to 3 seconds (20 to 30 breaths/min).

Ventilation Rate During CPR With an Advanced Airway

2020 (Updated): When performing CPR in infants and children with an advanced airway, it may be reasonable to target a respiratory rate range of 1 breath every 2 to 3 seconds (20 to 30 breaths/min), accounting for age and clinical condition. Rates exceeding these recommendations may compromise hemodynamics.

Why: New data show that higher ventilation rates (at least 30 breaths/min in infants less than 1 year of age and at least 25 breaths/min in older children) are associated with improved rates of ROSC and survival in pediatric in-hospital cardiac arrest. Although there are no data about the ideal ventilation rate during CPR without an advanced airway, or for children in respiratory arrest with or without an advanced airway, for simplicity of training, the respiratory arrest recommendation was standardized for all situations.

Real-Time Audiovisual Feedback

2020 (Unchanged/Reaffirmed): It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance.

Why: A recent randomized controlled trial (RCT) reported a 25% increase in survival to hospital discharge from in-hospital cardiac arrest with audio feedback on compression depth and recoil.

Debriefing for Rescuers

2020 (New): Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial.

Why: Rescuers may experience anxiety or post-traumatic stress about providing or not providing basic life support. Hospital-based care providers may also experience emotional or psychological effects of caring for a patient with cardiac arrest. Team debriefings may allow a review of team performance (education, quality improvement), as well as recognition of the natural stressors associated with caring for a patient near death.

Control of Life-Threatening Bleeding

2020 (New): A manufactured tourniquet should be used as first-line therapy for life-threatening extremity bleeding and should be placed as soon as possible after the injury.

2020 (New): If a manufactured tourniquet is not immediately available or if a properly applied manufactured tourniquet fails to stop bleeding, direct manual pressure, with the use of a hemostatic dressing if available, should be used to treat life-threatening extremity bleeding.

2020 (New): For individuals with life-threatening external bleeding, direct manual pressure should be applied to achieve initial bleeding cessation for wounds not amenable to a manufactured tourniquet or when a manufactured tourniquet is not immediately available.

2020 (New): If a hemostatic dressing is available, it can be useful as adjunctive therapy to direct manual pressure for the treatment of life-threatening external bleeding.

2020 (New): If a manufactured tourniquet is not available and direct manual pressure with or without the use of a hemostatic dressing fails to stop life-threatening bleeding, a first aid provider trained in the use of an improvised tourniquet may consider using one.

Why: Prior versions of the Guidelines have provided recommendations for the control of bleeding. The 2020 Focused Update provides new recommendations for the subset of people with life-threatening bleeding associated with rapid blood loss. Life-threatening bleeding can be recognized by pooling of blood on the ground, blood that is rapidly flowing or spurting from a wound, or bleeding that continues despite direct manual pressure. Several studies have shown that tourniquets can stop extremity bleeding safely and reduce mortality. Because a tourniquet may not always be immediately available, direct manual pressure should be used until a tourniquet is available. Direct manual pressure should also be applied in cases of life-threatening bleeding from wounds that are not amenable to tourniquet use. Existing evidence suggests that hemostatic dressings, which are materials that help promote blood clotting, result in more rapid control of bleeding and decreased blood loss compared with direct pressure alone. Hemostatic dressings can be used by first aid providers as adjunctive therapy to direct manual pressure.