guidelines 2015 - ems safety · science update •basic first aid •cpr, aed for community...

Guidelines 2015New Science and Transitional Materials

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www.emssafety.com/g2015‐update

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• Email questions to [email protected]

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When we’re done today…

www.emssafety.com/g2015‐approvals

Take update exam to complete update

Start teaching new guidelines!• Use new Instructor kit• Or, use interim exams, sheets, pages (www.emssafety.com/login)

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Course Completion Requirements

Requirements are simplified to focus training time and effort on learning skills and applying them to real‐life scenarios.

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www.emssafety.com/course‐completion‐requirements

Course Completion Options

• 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)

http://www.emssafety.com/course‐completion‐requirements

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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.

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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 Safety CPR/AED for Professional Rescuers– Dental CEH

• When in doubt, give the written exam!

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Updated Skill Sheets: Scenario‐Based

Instructions for Instructors: how to test…

Instructions for students, what’s expected. “…provide multiple cycles of CPR until you’re told to stop.”

Brief scenario sets the scene, identifies available resources and guides rescuer actions

Uses G2015 recommendations

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1 and 2 rescuer testing option for CPR, AED

Course Completion Web Page

• 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)

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www.emssafety.com/course‐completion‐requirements

Basic First AidWhat is changing and the rationale behind it…

Aspirin Positioning Concussion Bleeding

Dental avulsion Open chest wound Allergic

reaction

Burns Diabetic emergency

Exercise dehydration

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Aspirin Administration

Rationale • 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.

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Positioning: Unresponsive Person, Breathing Normally

Rationale• 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, unlessthe 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.

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Concussion

Rationale• 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

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Bleeding: Use of Hemostatic Dressings

Rationale • Hemostatic dressings are widely used in the military, and becoming commonly used to control bleeding even in civilian settings.

• Newer‐generation hemostatic agent‐impregnated 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

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Bleeding: Tourniquets

Rationale • 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

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Dental Avulsion (Knocked‐Out Adult Tooth)

Rationale • 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

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Open Chest Wound (Sucking Chest Wound)

Rationale• 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 9‐1‐1 (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.

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Allergic Reaction

Rationale • 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 9‐1‐1 (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 straight‐edged 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.

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Burns

Rationale• 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.

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Diabetic Emergencies

Rationale• Review of evidence demonstratesfaster relief of symptomatic hypoglycemia with glucose tabletswhen 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

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Exercise‐Related Dehydration

Rationale• New evidence shows that Ingestion of 5% to 8% carbohydrate‐electrolyte (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

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Naloxone in First Aid Settings

Rationale• 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.

22Auto‐InjectorNasal Spray

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

• Email your questions to [email protected]

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CPR/AED for Community RescuersC‐A‐B sequence

Chest Compression

Rates Avoid Leaning Immediate AED

Use

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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 opioid‐associated emergencies. 25

C‐A‐B Sequence; Mobile Phone

Rationale• 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

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Compression Rate

Rationale• 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 maximumcompression rate is recommended for all ages

• Perform CPR compressions at a rate of 100 to 120 compressions per minute

• 15‐18 Seconds to perform 30 compressions

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Quality CPR: Avoid Leaning

Rationale • 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 (100‐120)• Minimize interruptions to chest compressions

• “Avoid leaning” on the chest between compressions

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When to Use an AED (Witnessed Arrest)

Rationale• 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.

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CPR/AED Questions





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CPR/AED for Professional Rescuers Chain of Survival C‐A‐B Sequence

FlexibilityCompression Fraction

Rescue breathing with an

Advanced Airway

Naloxone for Suspected Opioid

Overdose

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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).

32Professional Rescuers and Healthcare Providers

Chain of Survival: In‐Hospital Cardiac Arrest (IHCA)

Rationale• 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


C‐A‐B Sequence

Rationale • 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


High Quality CPR: Targeted Chest Compression Fraction

Rationale • 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%.

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)


Rescue Breathing with an Advanced Airway

Rationale • “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 100‐120 compressions/minute without pauses for breaths.


Naloxone for Suspected Opioid Overdose

Rationale• 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.

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.


Science Update Questions?





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Interim Course MaterialsTeaching the new guidelines today…

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Interim Materials

• Available now… use to incorporate the new guidelines into your current training materials

• http://www.emssafety.com/g2015‐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!

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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!

• http://www.emssafetyservices.com/g2015‐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• Email guideline questions to [email protected]

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guidelines 2015 - ems safety · science update •basic first aid •cpr, aed for community...

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