What's New in the 2015
American Heart Association (AHA) Guidelines
Understanding New Guidelines for CPR and ECC
Since first establishing guidelines in 1966, American Heart Association has led evaluation and dissemination of the latest resuscitation science to help inform and modernize the lifesaving practice of CPR. These guidelines have been used to train millions in CPR, basic and advanced cardiovascular care, and first aid around the world.
The guidelines are based on an international evaluation process that involved hundreds of resuscitation scientists and experts worldwide, who evaluated thousands of peer-reviewed publications. The 2015 update provides recommendations on high-priority resuscitation topics for which there is sufficient new evidence or controversy requiring a systematic review.
- The 2015 Guidelines validate what we already know about performing CPR and offer a scientific basis for optimizing CPR quality to save more lives.
- The latest science says quick action, quality training, use of mobile technology, and coordinated efforts can increase survival from cardiac arrest -- a leading cause of death in the United States.
- The guidelines recommend more training to develop better systems of care. Everyone from bystanders to advanced healthcare providers should know what to do at every step of a cardiovascular emergency.
The highlights below are compiled from information provided by American Heart Association, and are intended to offer an overview of the most notable changes in CPR and ECC recommendations to assist you in understanding new guidelines.
Key Changes in the 2015 CPR and ECC Guidelines
Basic Life Support (BLS) and CPR Quality
- For adult victims of cardiac arrest, it is reasonable for lay rescuers and healthcare providers (HCPs) to perform chest compressions at a rate of 100 to 120 per minute.
- The 2015 Guidelines Update adds an upper limit of recommended heart rate, based on preliminary data suggesting that excessive compression rate adversely affects outcomes.
- During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches [6 cm]).
- While a compression depth of at least 2 inches (5 cm) is recommended, the 2015 Guidelines Update incorporates new evidence about the potential for complications to occur beyond an upper threshold of compression depth (greater than 2.4 inches [6 cm]). Compression depth may be difficult to judge without the use of feedback devices, and identification of upper limits of compression depth may be challenging.
- Untrained lay rescuers should provide compression-only (Hands-Only™) CPR, with or without dispatcher guidance, for adult victims of cardiac arrest. The rescuer should continue compression-only CPR until the arrival of an AED or rescuers with additional training. All lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest. In addition, if a trained lay rescuer is able to give rescue breaths, he or she should add rescue breaths in a ratio of 30 compressions to 2 breaths. The rescuer should continue CPR until an AED arrives and is ready for use, EMS providers take over care of the victim, or the victim starts to move.
- Compression-only CPR is easy for an untrained rescuer to perform and can be more effectively guided by dispatchers over the telephone. Moreover, survival rates from adult cardiac arrests of cardiac etiology are similar with either compression-only CPR or CPR with both compressions and rescue breaths when provided before EMS arrival. However, for the trained lay rescuer who is able, the recommendation remains for the rescuer to perform both compressions and breaths.
- To help bystanders recognize cardiac arrest, dispatchers should inquire about a victim's absence of responsiveness and quality of breathing (normal versus not normal). If the victim is unresponsive with absent or abnormal breathing, the rescuer and the dispatcher should assume that the victim is in cardiac arrest. Dispatchers should be educated to identify unresponsiveness with abnormal and agonal gasps across a range of clinical presentations and descriptions.
- This change from the 2010 Guidelines emphasizes the role that emergency dispatchers can play in helping the lay rescuer recognize absent or abnormal breathing. Dispatchers should be specifically educated to help bystanders recognize that agonal gasps are a sign of cardiac arrest. Dispatchers should also be aware that brief generalized seizures may be the first manifestation of cardiac arrest. Thus, in addition to activating professional emergency responders, the dispatcher should ask straightforward questions about whether the patient is unresponsive and whether breathing is normal or abnormal in order to identify patients with possible cardiac arrest and enable dispatcher-guided CPR.
- For unresponsive patients with known or suspected opioid addiction who are not breathing normally but have a pulse, it is reasonable for appropriately trained lay rescuers and BLS providers, in addition to providing standard BLS care, to administer intramuscular (IM) or intranasal (IN) naloxone. Opioid overdose response education with or without naloxone distribution to persons at risk for opioid overdose in any setting may be considered.
- There is substantial epidemiologic data demonstrating the large burden of disease from lethal opioid overdoses, as well as some documented success in targeted national strategies for bystander-administered naloxone for people at risk. In 2014, the naloxone autoinjector was approved by the U.S. Food and Drug Administration for use by lay rescuers and HCPs. The resuscitation training network requested information about the best way to incorporate such a device into the adult BLS guidelines and training. This recommendation incorporates the newly approved treatment.
Healthcare Provider BLS
- An HCP must call for nearby help upon finding a victim unresponsive, but it would be practical for the HCP to continue to assess the breathing and pulse simultaneously before fully activating the emergency response system (or calling for backup).
- The intent of the recommendation change is to minimize delay and to encourage fast, efficient simultaneous assessment and response, rather than a slow, methodical, step-by-step approach.
- It is reasonable for HCPs to provide chest compressions and ventilation for all adult patients in cardiac arrest, whether from a cardiac or a noncardiac cause. Moreover, it is realistic for HCPs to tailor the sequence of rescue actions to the most likely cause of arrest.
- Compression-only CPR is recommended for untrained rescuers because it is relatively easy for dispatchers to guide with telephone instructions. It is expected that HCPs are trained in CPR and can effectively perform both compressions and ventilation. However, the priority for the provider, especially if acting alone, should still be to activate the emergency response system and to provide chest compressions. There may be circumstances that warrant a change of sequence, such as the availability of an AED that the provider can quickly retrieve and use.
- It may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (i.e., during CPR with an advanced airway).
- This simple single rate for adults, children, and infants -- rather than a range of breaths per minute -- should be easier to learn, remember, and perform.
Advanced Cardiovascular Life Support (ACLS)
- The combined use of vasopressin and epinephrine offers no advantage to using standard-dose epinephrine in cardiac arrest. Also, vasopressin does not offer an advantage over the use of epinephrine alone. Therefore, to simplify the algorithm, vasopressin has been removed from the Adult Cardiac Arrest Algorithm -- 2015 Update.
- Both epinephrine and vasopressin administration during cardiac arrest have been shown to improve return of spontaneous circulation (ROSC). Review of the available evidence shows that efficacy of the two drugs is similar and that there is no demonstrable benefit from administering both epinephrine and vasopressin as compared with epinephrine alone.
- There is inadequate evidence to support the routine use of lidocaine after cardiac arrest. However, the initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT).
- While earlier studies showed an association between giving lidocaine after myocardial infarction and increased mortality, a recent study of lidocaine in cardiac arrest survivors showed a decrease in the incidence of recurrent VF/pVT but did not show either long-term benefit or harm.
- There is inadequate evidence to support the routine use of a beta-blocker after cardiac arrest. However, the initiation or continuation of an oral or IV beta-blocker may be considered for individual patients following hospitalization from cardiac arrest due to VF/pVT.
- In an observational study of patients who had ROSC after VF/pVT cardiac arrest, beta-blocker administration was associated with higher survival rates. However, this finding is only an associative relationship, and the routine use of beta-blockers after cardiac arrest is potentially hazardous because beta-blockers can cause or worsen hemodynamic instability, exacerbate heart failure, and cause bradyarrhythmias. Therefore, providers should evaluate patients individually for their suitability for beta-blockers.
- Targeted temperature management (TTM) recommendations have been updated with new evidence suggesting that a wider range of temperatures (32°C to 36°C) may be acceptable to target in the post-cardiac arrest period. After TTM is complete, fever may develop. While there are conflicting observational data about the harm of fever after TTM, the prevention of fever is considered benign and is therefore reasonable to pursue.
- A recent high-quality study compared temperature management at 36°C and at 33°C and found outcomes to be similar for both. Given these outcomes, clinicians can select from a wider range of target temperatures. In some studies, fever after rewarming from TTM was associated with worsened neurologic injury. Therefore, preventing fever is suggested.
Pediatric Basic Life Support and CPR Quality
- The C-A-B sequence has been reaffirmed in 2015.
- In the absence of new data, the 2010 sequence has not been changed. Consistency in the order of compressions, airway, and breathing when performing CPR on victims of all ages may be easiest for rescuers who treat people of all ages to remember and perform. Maintaining the same sequence for adults and children offers consistency in teaching.
- It is reasonable to use the recommended adult chest compression rate of 100 to 120 per minute for infants and children.
- One adult registry study demonstrated inadequate chest compression depth when extremely rapid compression rates were employed. To maximize educational consistency and retention in the absence of pediatric data, pediatric experts adopted the same recommendation for compression rate as was adopted for adult BLS.
Pediatric Advanced Life Support
- Early, rapid IV administration of isotonic fluids is widely accepted as a cornerstone of therapy for septic shock. For children in shock, an initial fluid bolus of 20 mL/kg is reasonable. However, for children with febrile illness in settings with limited access to critical care resources (i.e., mechanical ventilation and inotropic support), administration of bolus IV fluids should be undertaken with extreme caution, as it may be harmful.
- This recommendation continues to emphasize the administration of IV fluid for children with septic shock. Additionally, it emphasizes individualized treatment plans for patients based on frequent clinical assessment before, during, and after fluid therapy is given, and it presumes the availability of other critical care therapies. Excessive fluid boluses given to febrile children in certain resource-limited settings may lead to complications where the appropriate equipment and expertise to effectively address them might not be present.
- There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations. It may be considered in situations in which there is an increased risk of bradycardia. However, there is no evidence to support a minimum dose of atropine when used as a premedication for emergency intubation.
- Previously, a minimum atropine dose of 0.1 mg given intravenously was recommended because of reports of paradoxical bradycardia occurring in very small infants who received low doses of atropine. Recent evidence is conflicting as to whether atropine prevents bradycardia and other arrhythmias during emergency intubation in children. However, these recent studies did use atropine doses of less than 0.1 mg without an increase in the likelihood of arrhythmias.
- Fever should be aggressively avoided when caring for comatose children with ROSC after out-of-hospital cardiac arrest (OHCA). A large randomized trial of therapeutic hypothermia for children with OHCA showed no difference in outcomes whether a period of moderate therapeutic hypothermia (with temperature maintained at 32°C to 34°C) or the strict maintenance of normothermia (with temperature maintained at 36°C to 37.5°C) was provided.
- A prospective, multicenter study of pediatric OHCA victims randomized to receive either therapeutic hypothermia (32°C to 34°C) or normothermia (36°C to 37.5°C) showed no difference in functional outcome at one year between the two groups. This and other observational studies demonstrated no additional complications in the group treated with therapeutic hypothermia. Results are currently pending from a large multicenter, randomized controlled trial of therapeutic hypothermia for patients who are comatose after ROSC following pediatric in-hospital cardiac arrest (IHCA) (see Therapeutic Hypothermia After Pediatric Cardiac Arrest website: www.THAPCA.org).
- After ROSC, fluids and inotropes/vasopressors should be used to maintain a systolic blood pressure above the fifth percentile for the patient's age. Intra-arterial pressure monitoring should be used to continuously monitor blood pressure and identify and treat hypotension.
- No studies were identified that evaluated specific vasoactive agents in post-ROSC pediatric patients. Recent observational studies found that children who had post-ROSC hypotension had worse survival to hospital discharge and worse neurologic outcomes.
- Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not require resuscitation at birth. There is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation at birth.
- In infants who do not require resuscitation at birth, delayed cord clamping is associated with less intraventricular hemorrhage, higher blood pressure and blood volume, less need for transfusion after birth, and less necrotizing enterocolitis. The only adverse consequence found was a slightly increased level of bilirubin, associated with an increased need for phototherapy.
- If an infant born through meconium-stained amniotic fluid presents with poor muscle tone and inadequate breathing efforts, the initial steps of resuscitation should be completed under a radiant warmer. Positive-pressure ventilation (PPV) should be initiated if the infant is not breathing or if the heart rate is less than 100 beats per minute after the initial steps are completed. Routine intubation for tracheal suction in this setting is not suggested, as there is insufficient evidence to continue recommending this practice. However, a team that includes someone skilled in intubation of a newborn should still be present in the delivery room.
- Review of the evidence suggests that resuscitation should follow the same principles for infants with meconium-stained fluid as for those with clear fluid; that is, if poor muscle tone and inadequate breathing effort are present, the initial steps of resuscitation (warming and maintaining the infant's temperature, positioning the infant, clearing the airway of secretions if needed, drying the infant, and stimulating the infant) should be completed under an overbed warmer. PPV should be initiated if the infant is not breathing or if the heart rate is less than 100 beats per minute after the initial steps are completed. Experts are placing greater value on harm avoidance (delays in providing bag-mask ventilation, potential harm of the procedure) than on the unknown benefit of routine tracheal intubation and suctioning. Appropriate intervention to support ventilation and oxygenation should be initiated as indicated for each individual infant. This may include intubation and suction if the airway is obstructed.
Systems of Care and Continuous Quality Improvement
- Universal elements of a system of care have been identified to provide stakeholders with a common framework with which to assemble an integrated resuscitation system.
- Healthcare delivery requires a structure (people, equipment, education) and a process (policies, protocols, procedures) that, when integrated, produce a system (programs, organizations, cultures) that leads to optimal patient outcomes (patient survival and safety, quality, satisfaction). An effective system of care comprises all these elements -- structure, process, system, and optimal patient outcomes -- in a framework of continuous quality improvement.
- Separate Chains of Survival have been recommended that identify the different pathways of care for patients who experience cardiac arrest in the hospital and those who experience it in out-of-hospital settings.
- The care for all post-cardiac arrest patients, regardless of where their arrests occur, converges in the hospital, generally in an intensive care unit, where post-cardiac arrest care is provided. The elements of structure and process that are required before that convergence are very different for the two settings.
- Patients who have an OHCA depend on their community for support. Lay rescuers must recognize the arrest, call for help, and initiate CPR and provide defibrillation (i.e., public-access defibrillation [PAD]) until a team of professionally trained EMS providers assumes responsibility and then transports the patient to an emergency department and/or cardiac catheterization lab. The patient is ultimately transferred to a critical care unit for continued care.
- It may be reasonable for communities to incorporate mobile technologies that summon rescuers who are in close proximity to a victim of suspected OHCA and are willing and able to perform CPR.
- There is limited evidence to support the use of mobile technologies by dispatchers to notify potential rescuers of a possible cardiac arrest nearby, and activation of mobile technologies has not been shown to improve survival from OHCA. However, in a recent study in Sweden, there was a significant increase in the rate of bystander-initiated CPR when a mobile-phone dispatch system was used. Given the low harm and the potential benefit, as well as the ubiquitous presence of digital devices, municipalities could consider incorporating these technologies into their OHCA systems of care.
Frequently Asked Questions
Q: What is the overarching theme of the 2015 AHA Guidelines Update for CPR and ECC?
A: Key points from the 2015 Guidelines Update provide bystanders, dispatchers, and communities with practical guidance to improve the effectiveness of their teamwork. The latest science says quick action, quality training, use of mobile technology, and coordinated efforts can increase survival from cardiac arrest.
The guidelines recommend more training to develop better systems of care. Everyone from bystanders to advanced healthcare providers should know what to do at every step of a cardiovascular emergency. The guidelines emphasize creating a culture of action that benefits the entire community in which it operates, inside and outside the hospital setting.
Q: What are the most significant updates in the 2015 AHA Guidelines Update for CPR and ECC?
A: Key new or updated recommendations include:
- Universal elements of a system of care have been identified to provide stakeholders with a common framework with which to assemble an integrated resuscitation system for cardiac arrest in the hospital as distinct from out-of-hospital settings.
- New OHCA and IHCA Chains of Survival have been developed. Separate Chains of Survival have been recommended that identify the different pathways of care for patients who experience cardiac arrest in the hospital and those who experience it in out-of-hospital settings.
- There is emphasis on the use of mobile technologies by bystanders to aid in calling 911 sooner and receiving dispatch-assisted CPR instructions. Additionally, mobile technology and social media applications that notify rescuers of a nearby cardiac arrest may increase the rate of bystander-initiated CPR. Bystanders should use mobile phones to immediately call 911, placing the phones on speaker so that the dispatcher can help bystanders check for breathing, get the precise location, and provide instructions for performing CPR.
- Untrained bystanders should still call 911 and provide Hands-Only CPR, or CPR without breaths, pushing hard and fast in the center of the chest to the rate of 100-120 compressions per minute. However, if the bystander is trained in CPR and can perform breaths, he or she should add breaths in a 30:2 compressions-to-breaths ratio.
- Dispatchers should be trained to help bystanders check for breathing and recognize cardiac arrest. Dispatchers should also be aware that brief generalized seizures may be an early sign of cardiac arrest.
- Mobile-phone dispatch systems that notify potential rescuers of a nearby presumed cardiac arrest can improve the rate of bystander CPR and shorten the time to first chest compressions. Communities may want to consider this service to improve the Chain of Survival.
- Components of high-quality CPR have been updated. These include the following range for compression rate and depth:
- In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120 per minute and to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches [6 cm]).
- The new Education section targets resuscitation education of both lay rescuers and healthcare providers. Emphasis on frequent training intervals and the use of feedback devices/manikins will optimize performance of CPR in training and practice.
- A new lay provider algorithm is introduced for opioid-associated life-threatening emergencies, which incorporates naloxone administration with CPR and AED.
- Updates to targeted temperature management (TTM, formerly called "therapeutic hypothermia") suggest a range of temperatures may be acceptable to target in the post-cardiac arrest period.
- This 2015 AHA Guidelines Update for CPR and ECC marks the transition from periodic review and publication of new science-based recommendations to a more continuous process of evidence evaluation and guideline optimization designed to more rapidly translate new science into resuscitation practice that will save more lives.
Q: Do the 2015 Guidelines include recommendations for bystanders?
A: The guidelines confirm that, for bystanders, Hands-Only CPR, or compression-only CPR, remains an effective and empowering tool in saving lives from cardiac arrest. However, new guidelines recommend that if a bystander is trained in CPR and can perform breaths, he or she should add breaths in a 30:2 compressions-to-breaths ratio.
Q: What is the significance of the new "Systems of Care" chapter?
A: This new section emphasizes that everyone has a role to play in cardiac arrest survival. The guidelines are taking the first steps in creating a universal system of care that communities can implement.
Q: Why are there now different Chains of Survival for in-hospital and out-of-hospital cardiac arrest?
A: The 2015 Guidelines represent the first time recommendations do not take a "one size fits all" approach to treating a victim of cardiac arrest. The way resuscitation is approached is different depending on whether the arrest occurred in or out of the hospital.
Q: Why are there new limits for depth and rate of chest compressions?
A: New to the 2015 Guidelines Update are upper limits of recommended heart rate and compression depth, based on preliminary data suggesting that excessive compression rate and depth adversely affect outcomes.
Q: What are the key changes for 911 dispatchers?
To help bystanders recognize cardiac arrest, dispatchers should inquire about a victim's absence of responsiveness and quality of breathing (normal versus not normal). If the victim is unresponsive with absent or abnormal breathing, the rescuer and the dispatcher should assume that the victim is in cardiac arrest. Dispatchers should be educated to identify unresponsiveness with abnormal and agonal gasps across a range of clinical presentations and descriptions.
Q: What are the key changes in advanced cardiovascular life support?
A: Key recommendations for ACLS include the following:
- Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest. Therefore, to simplify the algorithm, vasopressin has been removed from the Adult Cardiac Arrest Algorithm -- 2015 Update.
- There is inadequate evidence to support the routine use of lidocaine after cardiac arrest. However, the initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT.
- There is inadequate evidence to support the routine use of a beta-blocker after cardiac arrest. However, the initiation or continuation of an oral or IV beta-blocker may be considered for individual patients following hospitalization from cardiac arrest due to VF/pVT.
- Targeted temperature management (TTM, formerly known as "therapeutic hypothermia") recommendations have been updated with new evidence suggesting that a range of temperatures may be acceptable to target in the post-cardiac arrest period (target temperature between 32°C and 36°C selected and achieved, then maintained constantly for at least 24 hours).
Q: What are the key recommendations for pediatric basic and advanced cardiovascular life support?
A: For pediatrics, the guidelines update reaffirmed the C-A-B sequence and that compressions and ventilation are needed for pediatric arrest. Additional key updates follow.
Pediatric basic cardiovascular life support recommendations:
- Compression rate change to 100-120 compressions/min
- Compression depth at least 1/3 the anterior-posterior diameter of the chest
- Infants: approximately 1.5 inches (4 cm)
- Children: approximately 2 inches (5 cm)
- Adolescents: at least 2 inches (5 cm), but no greater than 2.4 inches (6 cm)
- If rescuers are unwilling or unable to deliver breaths, they should perform compression-only CPR.
- Updated 1-rescuer and multi-rescuer algorithms
Pediatric advanced cardiovascular life support recommendations:
- For children with febrile illness in settings with limited access to critical care resources, administration of bolus IV fluid should be undertaken with extreme caution.
- There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia.
- Amiodarone or lidocaine is equally acceptable for VF/pVT.
- For children who are comatose, maintain either 5 days of normothermia (36°C to 37.5°C) or 2 days of initial continuous hypothermia (32°C to 34°C) followed by 3 days of normothermia.
Q: What are the key recommendations on CPR education?
A: Key recommendations in the Education section include the following:
- Two-year training intervals are not optimal.
- To minimize the time to defibrillation for cardiac arrest victims, deployment of AEDs should not be limited to only trained people (although training is still recommended).
- Training primary caregivers and/or family members of high-risk patients may be reasonable.
Q: What are the key recommendations on first aid?
A: The 2015 Guidelines Update for First Aid was again co-sponsored by the American Red Cross. Key updates include the following:
- The use of stroke assessment systems can assist first aid providers with identifying signs and symptoms of stroke.
- Glucose tablets are the preferred care for mild hypoglycemia.
- If symptoms of anaphylaxis do not resolve with an initial dose of epinephrine, a second dose may be considered.
- There is no evidence for or against routine use of oxygen as a first aid measure for chest pain.
- The High Arm in Endangered Spine (HAINES) position is no longer recommended due to the paucity and low quality level of evidence. The recommended recovery position is a lateral side-lying position.
- There is no longer a restriction to chew only non-enteric coated aspirin. Adults experiencing chest pain may chew one or two low-dose aspirins.
For additional information about changes to the 2015 Guidelines, download the free document "Highlights Of The 2015 American Heart Association Guidelines Update For CPR And ECC" here.