Heartsaver® 2020 Instructor Update

The American Heart Association has made many new science and education recommendations that are relevant to the Heartsaver courses.

These updates are documented in the 2020 AHA Guidelines for CPR and ECC.

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

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.

Why: Most communities experience low rates of bystander CPR and AED use.

A recent systematic review from the International Liaison Committee on Resuscitation (ILCOR) found that notification of lay rescuers via a smartphone app or text message alert is associated with shorter bystander response times, higher bystander CPR rates, shorter time to defibrillation, and higher rates of survival to hospital discharge for individuals who experience out-of-hospital cardiac arrest.

Chains of Survival

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

Opioid Overdose Response for Lay Rescuers

• If a person is unresponsive and not breathing normally, and you suspect that the person has had an opioid overdose, phone 9-1-1. Get an AED and naloxone, if they are available.
• Start CPR and use the AED. Give the naloxone as soon as you can, but do not delay CPR to give naloxone.

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.

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.

Removal of Clothing

Quickly move bulky clothes out of the way. If a person’s clothes are difficult to remove, you can still provide compressions over clothing.

If an AED becomes available, remove all clothes that cover the chest. AED pads must not be placed over any clothing.

Removal of Jewelry

It is not necessary to remove jewelry as long as it does not interfere with the placement of AED pads, because it will not cause a shock hazard to either the person or the rescuer.

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.

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.

Control of Life-Threatening Bleeding: Packing a Wound

If the bleeding is life-threatening and is located on a body part that is not the arm or leg — like the head, neck, chest, or abdomen, — you should pack a wound and then apply pressure. Packing can also be done if they tourniquet does not stop the bleeding in the arms and legs.

Packing the wound means taking a material like gauze or clean cloth and placing it tightly into the wound. Continue to apply direct pressure until the bleeding stops. You would then apply pressure and a compression dressing.

Hypoglycemia

2020 (New): For an individual with suspected hypoglycemia who is awake and able to swallow, the first aid provider should encourage the individual to swallow oral glucose. Emergency services should be activated if symptoms do not resolve within 10 minutes or if symptoms worsen.

For children with suspected hypoglycemia who are awake but unwilling or unable to swallow oral glucose, it may be reasonable to apply a slurry of granulated sugar and water under the tongue.

Why: Timely treatment of individuals with mild symptoms of hypoglycemia prevents progression to more severe symptoms. Studies found that oral glucose that is swallowed has been shown to raise blood glucose levels higher than glucose absorbed through the mouth. For children, when needed, a slurry of sugar has been shown to be absorbed better than granulated sugars.

Cooling Techniques for Exertional Hyperthermia and Heat Stroke

2020 (New): For adults and children with exertional hyperthermia or heat stroke, first aid providers should move the individual from the hot environment, remove excess clothing, limit exertion, and activate emergency services.

2020 (New): For adults and children with exertional hyperthermia or heat stroke, it is reasonable to initiate immediate active cooling by using whole-body (neck-down) cool-to-cold water-immersion techniques (1-26°C [33.8-78.8°F]), when safe, until a core body temperature of less than 39°C (102.2°F) is reached or neurologic symptoms resolve.

2020 (New): For adults and children with exertional hyperthermia or heat stroke, it may be reasonable to initiate other forms of active cooling, including commercial ice packs, cold showers, ice sheets and towels, cooling vests and jackets, fanning, or a combination of techniques when water immersion is not available.

Why: Exertional heat stroke (confusion, seizures, coma) is an emergency condition characterized by a core body temperature greater than 40°C (104°F) and central nervous system dysfunction.

Existing evidence shows that it is important to bring the body’s temperature down as quickly as possible to reduce the risk of organ injury or death.

Studies show that for adults, cold-water, whole-body immersion (from the neck down) is the most effective technique for rapidly reducing core temperature.

Other techniques, including commercial ice packs, cold showers, ice sheets and towels, cooling vests and jackets, or fanning, are also effective, but do not lower body temperature as fast as cold-water immersion.

Treatment recommendations were extrapolated to children because no studies of cooling techniques in children were identified.

Dental Avulsion

2020 (Updated): If an avulsed permanent tooth cannot be immediately replanted, it can be beneficial to place the tooth in Hanks’ Balanced Salt Solution or in oral rehydration salt solutions or wrap the tooth in cling film to prevent dehydration and improve the likelihood of successful replantation by a dental professional, which should be done as soon as possible. If those items are unavailable, storage of the tooth in cow’s milk or saliva may be considered. An avulsed permanent tooth should not be stored in tap water.

Why: Transporting an avulsed tooth in an efficacious storage medium can improve tooth viability and subsequent replantation success. This recommendation was updated to reflect the most scientifically supported mediums to ensure better outcomes for the individual.

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) following 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.

Lay Rescuer Training

New (2020): A combination of self-instruction and instructor-led teaching with hands-on training is recommended as an alternative to instructor-led courses for lay rescuers. If instructor-led training is not available, self-directed training is recommended for lay rescuers.

New (2020): It is recommended to train middle school– and high school–aged children in how to perform high-quality CPR.

Why: Studies have found that self-instruction or video-based instruction is as effective as instructor-led training for lay rescuer CPR training.

A shift to more self-directed training may lead to a higher proportion of trained lay rescuers, thus increasing the chances that a trained lay rescuer will be available to provide CPR when needed. Training school-aged children to perform CPR instills confidence and a positive attitude toward providing CPR. Targeting this population with CPR training helps to build the future cadre of community-based, trained lay rescuers.

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.

Disparities in Education

2020 (New): It is recommended to target and tailor layperson CPR training to specific racial and ethnic populations and low-socioeconomic-status neighborhoods.

2020 (New): It is reasonable to address barriers to bystander CPR for female victims through educational training and public awareness efforts.

Why: Communities with low socioeconomic status and those with predominantly Black and Hispanic populations have lower rates of bystander CPR and CPR training in the United States.

Women are also less likely to receive bystander CPR. The targeting of specific racial, ethnic, and low-socioeconomic populations for CPR education and modification of education to address gender differences could eliminate disparities in CPR training and bystander CPR and potentially enhance outcomes from cardiac arrest in these populations.

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.

Online Course Videos

Course Video Formats

Available in digital format online and on DVD

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.