Guidelines New Science and Transitional Materials. update

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1 Guidelines 2015 New Science and Transitional Materials update 1

2 What we re doing today Introduction Course Completion Requirements Optional written exam Scenario based testing Science Update Basic First Aid CPR, AED for Community Rescuers CPR, AED for Professional Rescuers Transitional Materials Interim Course Resource Skill Sheets Written Exams Questions? Use question feature during the meeting; will pause for questions questions to 2

3 When we re done today approvals Take update exam to complete update Start teaching new guidelines! Use new Instructor kit Or, use interim exams, sheets, pages ( 3

4 Course Completion Requirements Requirements are simplified to focus training time and effort on learning skills and applying them to real life scenarios. completion requirements 4

5 Course Completion Options completion requirements Course completion options have been simplified Written exams are optional in most settings Scenario based skill sheets are available Can use for G2010 and G2015 The changes are in effect now. The next few slides will cover: When to issue the written exam A look at the updated skill sheets Where you can find detailed information (hint, it s at the top of this slide) 5

6 Optional Written Exams The written exams for the CPR, AED for Community Rescuers and Basic First Aid courses are now optional. Information previously tested in a written exam must be demonstrated in a scenario based skills exam. Some agencies or employers may still require an exam. It is the responsibility of the instructor to become familiar with the regulations. 6

7 When to Issue the Exam: Always defer to state, local and employer regulations. It's up to you to become familiar with the regulations. Some employers may desire their employees take a written exam Written exams are required for EMS SafetyCPR/AED for Professional Rescuers Dental CEH When in doubt, give the written exam! 7

8 Updated Skill Sheets: Scenario Based Instructions for Instructors: how to test 1 and 2 rescuer testing option for CPR, AED Instructions for students, what s expected. provide multiple cycles of CPR until you re told to stop. Uses G2015 recommendations Brief scenario sets the scene, identifies available resources and guides rescuer actions 8

Course Completion Web Page www.emssafety.

completion requirements can be found online Quick and helpful videos When to

9 Course Completion Web Page completion requirements All information about the updated course completion requirements can be found online Quick and helpful videos When to issue the exam Required course records Remediation defined Course completion options (initial, recertification, participation) 9

10 Basic First Aid What is changing and the rationale behind it Aspirin Positioning Concussion Bleeding Dental avulsion Burns Open chest wound Diabetic emergency Allergic reaction Exercise dehydration 10

Aspirin Administration Aspirin administration can significantly reduce mortality due to heart attack, especially when given in the first few hours after onset of symptoms.

No restriction to use uncoated aspirin, as long as the person chews the aspirin before swallowing.

11 Aspirin Administration Aspirin administration can significantly reduce mortality due to heart attack, especially when given in the first few hours after onset of symptoms. It is unclear whether first aid providers can recognize heart attack. Giving aspirin for non cardiac causes of chest pain may cause harm. No restriction to use uncoated aspirin, as long as the person chews the aspirin before swallowing. Recommendation Chew either 1 adult or 2 low dose aspirin to improve the chance of survival while waiting for EMS responders. Coated or uncoated. Do not give aspirin if the victim has an allergy, signs of a stroke, recent bleeding problems, or is not alert. Rescuers may consider not giving aspirin if the chest pain is not from a cardiac origin or if the responder is uncertain or uncomfortable with the administration of aspirin. Defer to the advice of the EMS dispatcher or responders. 11

Positioning: Unresponsive Person, Breathing Normally Evidence shows that a sidelying position may help maintain an open airway and make it easier to breathe.

12 Positioning: Unresponsive Person, Breathing Normally Evidence shows that a sidelying position may help maintain an open airway and make it easier to breathe. An injured person should not be moved when spine, pelvis or hip injury is suspected. Recommendation A lateral, sidelying position is the preferred recovery position. Extend one arm above the head Grasp the shoulder and hip and log roll the person to the side Head should rest on the extended arm Bend both knees for support Do not move the person if spine, pelvis or hip injury is suspected. Leave the person in the position found, unless the position causes the person s airway to be blocked or if the area is unsafe. Move only as needed to open the airway and/or to reach a safe location. 12

Concussion A concussion is a mild, traumatic brain injury Recognition of concussion is difficult: changes may be subtle and yet progressive First aid providers are often faced with the

There are no clinical studies to support the use of a simple concussion scoring system by first aid providers.

13 Concussion A concussion is a mild, traumatic brain injury Recognition of concussion is difficult: changes may be subtle and yet progressive First aid providers are often faced with the decision as to what advice to give to a person after minor head trauma, and it is now widely recognized that an incorrect decision can have long term serious or even fatal consequences. There are no clinical studies to support the use of a simple concussion scoring system by first aid providers. Recommendation All head injuries should be evaluated by a healthcare provider or EMS as soon as possible. Especially when: A head injury has resulted in a change in level of consciousness Development of signs or symptoms over time There is any cause for concern 13

Bleeding: Use of Hemostatic Dressings Hemostatic dressings are widely used in the military, and becoming commonly used to control bleeding even in civilian settings.

effects may include wound infection and exothermic burns Recommendation Expose the wound Apply firm direct pressure with sterile gauze.

14 Bleeding: Use of Hemostatic Dressings Hemostatic dressings are widely used in the military, and becoming commonly used to control bleeding even in civilian settings. Newer generation hemostatic agentimpregnated dressing are: Safer than older, granular form Effective in up to 90% of participants in case studies Complications and adverse effects may include wound infection and exothermic burns Recommendation Expose the wound Apply firm direct pressure with sterile gauze. Add dressings as they become soaked Consider the use of hemostatic dressings when direct pressure is not effective. Follow manufacturer specific instructions. Treat for shock Bandage the dressing once bleeding has stopped 14

Bleeding: Tourniquets Tourniquet use has been studied in both the military and civilian settings. Low rate of adverse events from tourniquet application.

15 Bleeding: Tourniquets Tourniquet use has been studied in both the military and civilian settings. Low rate of adverse events from tourniquet application. Tourniquets control bleeding effectively in most cases. Recommendation Use a tourniquet to control severe arm or leg bleeding when standard treatment has not worked. A tourniquet may be considered as an initial treatment to control severe bleeding for: Mass casualty incidents A person with multiple severe injuries Unsafe environments When a wound cannot be accessed 15

16 Dental Avulsion (Knocked Out Adult Tooth) Dental avulsion can result in permanent loss of a tooth. The dental community agrees: immediate re implantation affords the greatest changes of tooth survival, but it may not be an option. Certain solutions may improve chances of tooth survival. Recommendation Re implantation of the tooth is best. Re implantation may not be possible by a first aid provider due to lack of protective gloves, training and skill or fear of causing pain. Certain solutions can prolong dental cell viability from 30 to 120 minutes. Hanks Balanced Salt Solution Propolis ( bee glue ) Egg white Coconut water Ricetral (medication solution; Potassium Chloride, Rice Extruded, Sodium Chloride, Sodium Citrate) Whole milk If these solutions are not available, store the tooth in the person s saliva, but not in their mouth 16

If a non occlusive dressing, such as a dry gauze dressing, is applied for active bleeding, care must be taken to ensure that saturation of the dressing does not lead to partial or complete occlusion.

17 Open Chest Wound (Sucking Chest Wound) Management of an open chest wound in out of hospital settings is challenging for all rescuers. For first aid responders, the greatest concern is improper use of a dressing leading to fatal tension pneumothorax. If a non occlusive dressing, such as a dry gauze dressing, is applied for active bleeding, care must be taken to ensure that saturation of the dressing does not lead to partial or complete occlusion. Recommendation Call (activate EMS) Calm and reassure; keep the person still. Control external bleeding with direct pressure. When bleeding is controlled, consider leaving the wound exposed or cover with a non occlusive dressing. Ensure the dressing does not become occlusive from saturation. Monitor response, breathing and appearance. 17

Allergic Reaction Epinephrine is recommended for anaphylaxis, and persons at risk typically carry a prescribed epinephrine auto injector There is no change in the 2010 recommendation that first aid

18 Allergic Reaction Epinephrine is recommended for anaphylaxis, and persons at risk typically carry a prescribed epinephrine auto injector There is no change in the 2010 recommendation that first aid providers assist with or administer to persons with symptoms of anaphylaxis their own epinephrine. A second dose of epinephrine has been found to be beneficial for persons not responding to a first dose. Recommendation Send a bystander to call (activate EMS). Help the person locate and use the epinephrine auto injector. If the allergic reaction is from a bee sting, quickly scrape off the stinger with a straightedged object. Monitor response, breathing, and signs of shock. Consider a repeat dose if symptoms persist and EMS is not expected to arrive within 5 to 10 minutes. 18

Burns Cooling (but not freezing) burns helps: Reduce risk of injury Reduces depth of the burn Honey, when used as a dressing, has been shown to: Decrease the risk of infection Decrease time to

19 Burns Cooling (but not freezing) burns helps: Reduce risk of injury Reduces depth of the burn Honey, when used as a dressing, has been shown to: Decrease the risk of infection Decrease time to healing Recommendation Cool thermal burns with cool or cold potable water as soon as possible for at least for 10 minutes, or until the pain is resolved. If cool water is not available, use a clean, cool (not freezing) compress. In remote areas where topical antibiotics are not available, consider applying honey to decrease the chance of infection. 19

Diabetic Emergencies Review of evidence demonstrates faster relief of symptomatic hypoglycemia with glucose tablets when compared with various

Recommendation Assess responsiveness, breathing and appearance. If the person is alert enough to sit up and swallow, give sugar to eat or drink.

20 Diabetic Emergencies Review of evidence demonstrates faster relief of symptomatic hypoglycemia with glucose tablets when compared with various evaluated dietary sugars, such as sucrose or fructose containing candies or foods, orange juice, or milk. Recommendation Assess responsiveness, breathing and appearance. If the person is alert enough to sit up and swallow, give sugar to eat or drink. Glucose tablets are the preferred form of sugar. Other sugars include: juice, regular soda, sugar dissolved in water, and honey. Call 911 in 15 minutes if no improvement or sooner if getting worse 20

Exercise Related Dehydration New evidence shows that Ingestion of 5% to 8% carbohydrateelectrolyte (CE) solutions: Facilitates rehydration after exercise induced dehydration Is well tolerated No

21 Exercise Related Dehydration New evidence shows that Ingestion of 5% to 8% carbohydrateelectrolyte (CE) solutions: Facilitates rehydration after exercise induced dehydration Is well tolerated No change to treatment of severe dehydration Recommendation Encourage oral rehydration with a 5% to 8% Carbohydrate Electrolyte (CE) Solution If not available, use potable water Do not give fluids if signs of shock, confusion or inability to swallow 21

Naloxone in First Aid Settings First aid providers are not trained in recognition of cardiac arrest or pulse checks.

should not be delayed for naloxone administration.

use. Recommendation Empiric administration of naloxone to unresponsive opioid associated patients, may be reasonable as an

22 Naloxone in First Aid Settings First aid providers are not trained in recognition of cardiac arrest or pulse checks. Easy to administer IM in pre measured doses Auto Injector Nasal spray Standard resuscitation, including activation of EMS, should not be delayed for naloxone administration. Family members and friends (of those known to be addicted to opiates) may be likely to have naloxone available and ready to use. Recommendation Empiric administration of naloxone to unresponsive opioid associated patients, may be reasonable as an adjunct to standard first aid and non healthcare provider BLS protocols. Ideally, provide access to advanced health services for persons who respond to naloxone administration. Auto Injector Nasal Spray 22

23 First Aid Questions Time for questions Please use the question feature to ask your questions. All questions may not get answered. Be sure to visit the update page and check out the FAQs your questions to 23

24 CPR/AED for Community Rescuers C A B sequence Chest Compression Rates Avoid Leaning Immediate AED Use 24

25 Overview: Lay Rescuer Changes The out of hospital adult Chain of Survival is unchanged from 2010 The Adult CPR sequence has been modified to reflect the fact that people have mobile telephones and can activate EMS without leaving the victim s side. It is recommended that communities with people at risk for cardiac arrest implement PAD programs. Increased emphasis on the rapid identification of potential cardiac arrest by dispatchers, with immediate provision of CPR instructions to the caller. Compressions: Range of 100 to 120/min. Compression depth for adults at least 2 inches (5 cm) but should not exceed 2.4 inches (6 cm). To allow full chest wall recoil after each compression, rescuers must avoid leaning on the chest between compressions. Consider immediate AED use for witnessed cardiac arrest Bystander administered naloxone may be considered for suspected life threatening opioidassociated emergencies. 25

C A B Sequence; Mobile Phone For lay providers New guidelines recognize the ubiquitous presence of mobile phones that can allow the rescuer to activate the emergency response system without leaving

26 C A B Sequence; Mobile Phone For lay providers New guidelines recognize the ubiquitous presence of mobile phones that can allow the rescuer to activate the emergency response system without leaving the victim s side. For healthcare providers Mobile phones and new guidelines allow flexibility for activation of the emergency response to better match the provider s clinical setting and protocols Recommendation If alone with a mobile phone, stay with the person Activate EMS from your mobile phone Retrieve AED if immediately available If alone with no mobile phone, leave the person Activate EMS from the closest phone Retrieve AED if immediately available Return quickly 26

Compression Rate There is a sweet spot for compression rate When compressions are too fast They become too shallow Not enough blood is pumped Evidence shows increased survival when chest compressions

27 Compression Rate There is a sweet spot for compression rate When compressions are too fast They become too shallow Not enough blood is pumped Evidence shows increased survival when chest compressions are performed at a rate of 100 to 120 compressions per minute. Recommendation A minimum and maximum compression rate is recommended for all ages Perform CPR compressions at a rate of 100 to 120 compressions per minute Seconds to perform 30 compressions 27

Incomplete recoil has many negative effects and could potentially influence resuscitation outcomes.

28 Quality CPR: Avoid Leaning Observational studies indicate that leaning is common during CPR in adults and children. Leaning on the chest wall between compressions prevents full chest wall recoil. Incomplete recoil has many negative effects and could potentially influence resuscitation outcomes. For simplicity and consistency, the language allow full recoil is changed to avoid leaning. Recommendation Quality Chest Compressions: Push hard and fast ( ) Minimize interruptions to chest compressions Avoid leaning on the chest between compressions 28

When to Use an AED (Witnessed Arrest) For witnessed adult cardiac arrest: when an AED is immediately available, the defibrillator should be used as soon as possible.

29 When to Use an AED (Witnessed Arrest) For witnessed adult cardiac arrest: when an AED is immediately available, the defibrillator should be used as soon as possible. For adults with unmonitored cardiac arrest or for whom an AED is not immediately available, initiate CPR while the defibrillator equipment is being retrieved and applied. When 2 or more rescuers are present, one rescuer should begin chest compressions while a second rescuer activates the emergency response system and gets the AED. Recommendation If an AED is immediately available, use the AED. If a second rescuer is present and an AED is immediately available: The first rescuer should continue CPR while the second rescuer powers on the AED and applies the pads. The second rescuer will clear the victim (make sure no one is touching the victim or his clothes) before shocking. 29

30 CPR/AED Questions Time for questions Please use the question feature to ask your questions. All questions may not get answered. Be sure to visit the update page and check out the FAQs your questions to 30

31 CPR/AED for Professional Rescuers Chain of Survival C A B Sequence Flexibility Compression Fraction Rescue breathing with an Advanced Airway Naloxone for Suspected Opioid Overdose 31

32 Overview: Professional Rescuer Changes Allow flexibility for activation of the emergency response system to match clinical settings and protocols Simultaneously check for breathing and pulse to reduce the time to first chest compression. To improve the CPR Fraction and CPR outcomes, integrated team CPR choreographs multiple steps and assessments simultaneously rather than the sequential manner used by individual rescuers ( Pit Crew CPR, everyone has a job and we need to train for that job). Targeted minimum chest compression fraction of 60%. Compressions: Range of 100 to 120/min. Compression depth for adults at least 2 inches (5 cm) but should not exceed 2.4 inches (6 cm). To allow full chest wall recoil after each compression, rescuers must avoid leaning on the chest between compressions. Immediate AED use for witnessed arrest Where EMS systems have adopted bundles of care involving continuous chest compressions, the use of passive ventilation techniques may be considered as part of that bundle for victims of OHCA. For CPR with an advanced airway in place, ventilation rates are simplified to a single rate of 1 breath every 6 seconds (10 breaths per minute). Professional Rescuers and Healthcare Providers 32

Chain of Survival: In Hospital Cardiac Arrest (IHCA)

surveillance IHCA systems should include rapid response or

Recommendation Improved chain of survival for IHCA,

monitoring: Surveillance and protection (RRT/Early warning

response system Immediate high quality CPR Rapid

33 Chain of Survival: In Hospital Cardiac Arrest (IHCA) Patients who have an IHCA depend on a system of appropriate surveillance IHCA systems should include rapid response or early warning system to prevent cardiac arrest. Recommendation Improved chain of survival for IHCA, includes emphasis on rapid identification of pre arrest monitoring: Surveillance and protection (RRT/Early warning systems) Recognition and activation of the emergency response system Immediate high quality CPR Rapid defibrillation Advanced life support and post arrest care Professional Rescuers and Healthcare Providers 33

34 C A B Sequence Algorithm updated for mobile phones Healthcare providers are capable of simultaneous actions (e.g. checking breathing and pulse) to improve the time to the first compression Flexibility in the guidelines will allow for local protocols Can active response team via mobile phone, if unresponsive. Must activate response after pulse check. Rounds of CPR before defibrillation (as opposed to immediate defibrillation) Delayed ventilations with CPR compressions Recommendation If no response, yell for nearby help. Send bystander to activate response team and retrieve AED If alone with a mobile phone, activate response team (Flex Point: or activate response after pulse check) Check breathing AND pulse for 5 10 seconds Visually scan the person s chest. Check for no breathing or only gasping Check pulse If alone without a mobile phone, leave to activate response, retrieve AED if one is immediately available and quickly return Professional Rescuers and Healthcare Providers 34

35 High Quality CPR: Targeted Chest Compression Fraction Good team CPR can improve the total time compressions are being performed during a resuscitation Chest compression fraction indicates the percentage of time compressions are being performed during CPR 80% is achievable with good team CPR. The minimum acceptable compression fraction is 60%. Professional Rescuers and Healthcare Providers Recommendation Chest compression fraction goal at least 60% Measured during team CPR training Use 2 stopwatches One times the entire code One starts and stops to calculate the time compressions are performed Divide the compression time by the total code time (e.g. 140 seconds of compressions / 180 seconds of total code time = 78% compression fraction) 35

Rescue Breathing with an Advanced Airway This represents a simplification of the 2010 Guidelines recommendations, to provide a single number that rescuers will need to remember for ventilation rate,

36 Rescue Breathing with an Advanced Airway This represents a simplification of the 2010 Guidelines recommendations, to provide a single number that rescuers will need to remember for ventilation rate, rather than a range of numbers. Recommendation For victims of all ages provide: 1 breath every 6 seconds (10 breaths/minute) At compressions/minute without pauses for breaths. Professional Rescuers and Healthcare Providers 36

37 Naloxone for Suspected Opioid Overdose All studies reported improvement in level of consciousness and spontaneous breathing after naloxone administration in the majority of patients treated. Complication rates were low. Patients with no definite pulse may be in cardiac arrest or may have an undetected weak or slow pulse. These patients should be managed as cardiac arrest patients. Professional Rescuers and Healthcare Providers Recommendations For respiratory arrest and known or suspected opioid overdose, in addition to providing standard BLS care, rescuers can administer naloxone (intramuscular or intranasal). For cardiac arrest, naloxone administration may be considered after initiation of CPR. Responders should activate advanced medical services while awaiting the patient s response to naloxone or other interventions. Unless further care is refused, persons who respond to naloxone should contact advanced healthcare services. 37

38 Science Update Questions? Time for questions Please use the question feature to ask your questions. All questions may not get answered. Be sure to visit the update page and check out the FAQs your questions to 38

39 Interim Course Materials Teaching the new guidelines today 39

40 Interim Materials Available now use to incorporate the new guidelines into your current training materials update Will be updated as new resources and videos are produced Visit often! Materials include: Instructor Summary: 1 page summary of key changes Instructor Supplement: Topic by topic breakdown for Instructors Interim Written Exams and Skill Sheets This webinar! 40

materials to begin teaching the new guidelines today! http://www.emssafetyservices.

41 Conclusion How do I get credit for this update? Visit the update page and TAKE THE UPDATE EXAM Upon successful completion, you can use the transition materials to begin teaching the new guidelines today! update Do I have to take a skills test? No, just an online written quiz. What if I have questions? See the FAQ s on the update page guideline questions to quality@emssafety.com 41

G2015: Instructor Supplement

G2015: Instructor Supplement Use this resource to bridge the gap between EMS Safety G2010 and the newly released G2015 CPR and First Aid treatment recommendations until new course materials are available. There are no changes to the