BLS 2020 Instructor Update 

• Identify the BLS 2020 science and education updates
• Describe the rationale for these updates
• Apply the updates to your training

Chains of Survival

A new pediatric Chain of Survival was created for in-hospital cardiac arrest in infants, children, and adolescents.

A sixth link, recovery, was added to all four Chains of Survival.

Opioid-Associated Emergency for Healthcare Providers Algorithm

The 2020 Guidelines include an opioid-associated resuscitation emergency algorithm for trained rescuers, shown here. A version for lay rescuers is also included in the Guidelines.

Changes include:

• Respiratory arrest is more prominently addressed in the beginning, with “Is the person breathing normally?” as an initial decision.
• An initial assessment with action steps is more clearly laid out with the initial “Is the person breathing normally?” question. If yes, the algorithm provides clear steps to prevent deterioration.
• Naloxone is not as emphasized as before. In the 2015 algorithm, it was a stand-alone box with doses. For 2020, it is under “Prevent deterioration” and “Start CPR” as “Consider naloxone,” with no doses.
  • For the respiratory arrest steps, the algorithm states “give” rather than “consider” naloxone.

Cardiac Arrest in Pregnancy

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  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.

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 (mammary 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: Systematic reviews suggest that the 2-thumb–encircling hands technique may improve CPR quality when compared with 2-finger compressions, particularly for depth. 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.

Debriefings 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.

Stroke Recognition

2020 (Updated): To recognize a possible stroke, first aid providers can use the signs of weakness in the face (eg, droop), arm, or grip on one side of the body or speech disturbance and should activate emergency services as quickly as possible if any of these signs are present.

Why: Stroke outcomes improve with the prompt recognition of stroke signs and early access to time-sensitive interventions. Several stroke-recognition tools identify stroke based on the following signs: weakness in the face, arm, or grip on one side of the body or speech disturbance.

The F.A.S.T. acronym can be helpful in recognizing a stroke:

F—Facial drooping

A—Arm weakness

S—Speech difficulty

T—Time to call 9-1-1

Observational studies of stroke-recognition tools found reductions in the time from symptom onset to treatment among patients with stroke, improved stroke diagnosis rates, and improved time to definitive treatment, especially thrombolysis.

Aspirin for Adults With Nontraumatic Chest Pain

2020 (Updated): While awaiting the arrival of emergency services, first aid providers may encourage alert adults experiencing nontraumatic chest pain to chew and swallow aspirin, unless the person experiencing pain has a known aspirin allergy or has been advised by a healthcare provider not to take aspirin.

Why: Aspirin, when given early to a patient having a heart attack, can improve survival. In prior versions of the Guidelines, first aid providers were advised to offer aspirin only to persons with chest pain symptoms suggestive of a heart attack. However, it can be difficult to distinguish chest pain due to a heart attack from other causes of chest pain. While there are no studies that evaluate the benefits or risks of first aid providers administering aspirin to individuals experiencing nontraumatic chest pain, it was the opinion of the First Aid Writing Group that the potential benefits of early administration of aspirin outweighs the potential risk of a single dose of aspirin.

Deliberate Practice and Mastery Learning

2020 (New): Incorporating a deliberate practice and mastery learning model into basic or advanced life support courses may be considered for improving skill acquisition and performance.

Why: Deliberate practice is a training approach where learners are given (1) a discrete goal to achieve, (2) immediate feedback on their performance, and (3) ample time for repetition to improve performance. Mastery learning is defined as the use of deliberate practice training along with testing that uses a set of criteria to define a specific passing standard that implies mastery of the tasks being learned. Evidence suggests that incorporating a deliberate practice and mastery learning model into basic or advanced life support courses improves multiple learning outcomes.

Booster Training and Spaced Learning

2020 (New): It is recommended to implement booster sessions when using a massed learning approach for resuscitation training.

2020 (New): It is reasonable to use a spaced learning approach in place of a massed learning approach for resuscitation training.

Why: The addition of booster training sessions (ie, brief, frequent sessions focused on repetition of prior content) vs massed learning (ie, large amounts of content in a single setting) to resuscitation courses improves the retention of CPR skills.

Studies show that spaced learning courses (ie, separation of training into multiple sessions) are of equal or greater effectiveness when compared with courses delivered as a single training event. Learner attendance across all sessions is required to ensure course completion because new content is presented at each session.

Opioid Overdose Training for Lay Rescuers

2020 (New): It is reasonable for lay rescuers to receive training in responding to opioid overdose, including provision of naloxone.

Why: Multiple studies have found that targeted resuscitation training (for opioid users and their families and friends) is associated with higher rates of naloxone administration in witnessed overdoses.

EMS Practitioner Experience and Exposure to Out-of-Hospital Cardiac Arrest

2020 (New): It is reasonable for EMS systems to monitor clinical personnel’s exposure to resuscitation to ensure treating teams have members competent in the management of cardiac arrest cases. Competence of teams may be supported through staffing or training strategies.

Why: A recent systematic review found that EMS provider exposure to cardiac arrest cases is associated with improved patient outcomes including rates of return of spontaneous circulation and survival. Because exposure can be variable, the AHA recommends that EMS systems monitor provider exposure and develop strategies to address low exposure.

Willingness to Perform Bystander CPR

2020 (New): It is reasonable to increase bystander willingness to perform CPR through CPR training, mass CPR training, CPR awareness initiatives, and promotion of Hands-Only CPR.

Why: Prompt delivery of bystander CPR doubles the victim’s chances of survival from cardiac arrest. CPR training, mass CPR training, CPR awareness initiatives, and promotion of Hands-Only CPR are all associated with increased rates of bystander CPR.

Course Formats

There are 3 delivery options for BLS training with the new science.

Instructor-led training is held in a classroom setting and includes both the instructional portion and skills practice.

The HeartCode blended-learning format uses online learning to deliver the instructional portion of the course. This online technology adapts to the learner’s knowledge and then presents content specifically to further the learner’s development. A hands-on session with an instructor or a HeartCode-compatible manikin completes the course requirements.

Resuscitation Quality Improvement, or RQI®, is an AHA program that uses low-dose, high-frequency training to deliver quarterly coursework and practice to support the mastery of high-quality CPR skills.

Online Exams

• Exam security
• Key performance data

While administering exams electronically is the preferred method, there may occasionally be a need to administer a paper exam.

See the AHA Instructor Network website for more information.

Online Course Videos

Course Video Formats

Available in digital format online and on DVD

Instructor Manual Part 1: General Concepts

• Science and educational principles of resuscitation training
• Basic logistics for conducting any AHA course

High-Performance Teams

The High-Performance Teams section of the course has been modified. The video below highlights some of these important changes.

Provider Manual Updates

New BLS Provider Manual content:

• CPR Coach
• CPR for pregnant women
• Heart attack
• Stroke
• Drowning
• Anaphylaxis

eCards

Course completion cards are available in eCard format.

Cards may only be issued from a valid AHA Training Center and instructors aligned with that Training Center.

Conclusion

2020 Guidelines and Guidelines Highlights summary:
eccguidelines.heart.orgOpens in a new window

Resuscitation Education resources:
cpr.heart.orgOpens in a new window

Interim training materials:
AHA Instructor Network websiteOpens in a new window

Select Exit Exercise at the top right to return to the course home page, where you will

• Complete the course evaluation
• Obtain your certificate of completion
• Claim continuing education (CME/CE) credit if applicable

The American Heart Association thanks the following people for their contributions to the development of this course: Sallie Johnson, PharmD, BCPS; Kelly D. Kadlec, MD, MEd; Jeanette Previdi, MPH, RN; Deborah Torman, MBA, MEd, AT, ATC, EMT-P; Principled Technologies; and the AHA 2020 Instructor Update Project Team.