2020 AHA ECC and CPR Guidelines and Recommendations at Palm Desert Resuscitation Education LLC (PDRE): 2020 AHA Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS)

 

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2020 AHA Guidelines Basic Life Support (BLS) Provider and Renewal Course

The 2020 AHA Guidelines Basic Life Support (BLS) Provider and Renewal Course provides our Palm Desert Resuscitation Education (PDRE) student updates on new science and key changes published in the 2020 AHA Guidelines for CPR and ECC.

Summary

What does this course teach?

The 2020 AHA Guidelines Basic Life Support (BLS) Provider and Renewal Course provides Palm Desert Resuscitation Education (PDRE) student updates on new science and key changes published in the 2020 AHA Guidelines for CPR and ECC. They also deliver Interim Training Materials and guidance on how to use these materials to incorporate 2020 science and education updates.  All US AHA Instructors must complete their required science update by February 1, 2021, to continue teaching AHA courses.

Chains of Survival

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

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

Changes and updates include:

• A new pediatric Chain of Survival was created for IHCA in infants, children, and adolescents (e.g., Early Recognition and Prevention).
• A sixth link, recovery, was added to all four Chains of Survival. The process of recovery from cardiac arrest extends long after the initial hospitalization.
• Support is needed during recovery to ensure optimal physical, cognitive, and emotional well-being and return to social or role functioning.
• This process should be initiated during the initial hospitalization and continue for as long as needed.

Opioid-Associated Emergency for Healthcare Providers Algorithm

The 2020 Guidelines include an opioid-associated resuscitation emergency algorithm for trained rescuers, shown here.

A version for lay rescuers is also included in the Guidelines.

Changes and updates include:

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

Cardiac Arrest in Pregnancy

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.

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.

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.

Changes and updates include:

• A single rescuer may now use 2 thumbs or the heel of 1 hand for infant compressions.
• 2020 (New): For infants, single rescuers (whether lay rescuers or healthcare providers) should compress the sternum with 2 fingers or 2 thumbs placed just below the nipple line (mammary line).
• 2020 (New): For infants, if the rescuer is unable to achieve guideline-recommended depths (at least one third the diameter of the chest), it may be reasonable to use the heel of 1 hand.
• Why: Systematic reviews suggest that the 2-thumb–encircling hands technique may improve CPR quality when compared with 2-finger compressions, particularly for depth. However, there are limited data comparing the various hand positions.

Changes to the Pediatric Assisted Ventilation Rate

For infants and children with a pulse but absent or inadequate respiratory effort, it is reasonable to give 1 breath every 2 to 3 seconds, 20 to 30 breaths/min.

When performing CPR in infants and children with an advanced airway, it may be reasonable to target a respiratory rate range of 1 breath every 2 to 3 seconds, 20 to 30 breaths/min, accounting for age and clinical condition.

Rates exceeding these recommendations may compromise hemodynamics.

Changes and updates include:

• Rescue Breathing
  • 2020 (Updated): For infants and children with a pulse but absent or inadequate respiratory effort, it is reasonable to give 1 breath every 2 to 3 seconds (20 to 30 breaths/min).
• Ventilation Rate During CPR With an Advanced Airway
  • 2020 (Updated): When performing CPR in infants and children with an advanced airway, it may be reasonable to target a respiratory rate range of 1 breath every 2 to 3 seconds (20 to 30 breaths/ min), accounting for age and clinical condition. Rates exceeding these recommendations may compromise hemodynamics.
  • Why: New data show that higher ventilation rates (at least 30 breaths/min in infants less than 1 year of age and at least 25 breaths/min in older children) are associated with improved rates of ROSC and survival in pediatric in-hospital cardiac arrest.
  • Although there are no data about the ideal ventilation rate during CPR without an advanced airway, or for children in respiratory arrest with or without an advanced airway, for simplicity of training, the respiratory arrest recommendation was standardized for all situations.

Real-Time Audiovisual Feedback

It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance.

Changes and updates include:

• 2020 (Unchanged/Reaffirmed): It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance.
• Why: A recent randomized controlled trial (RCT) reported a 25% increase in survival to hospital discharge from in-hospital cardiac arrest with audio feedback on compression depth and recoil.

Debriefings for Rescuers

Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial.

Changes and updates include:

• 2020 (New): Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial.
• Why: Rescuers may experience anxiety or post-traumatic stress about providing or not providing basic life support.
• Hospital-based care providers may also experience emotional or psychological effects of caring for a patient with cardiac arrest.
• Team debriefings may allow a review of team performance (education, quality improvement), as well as recognition of the natural stressors associated with caring for a patient near death.

Stroke Recognition

To recognize a possible stroke, first aid providers can use the signs of weakness in the face, 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.

Changes and updates include:

• 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

While awaiting the arrival of emergency services, first aid providers may encourage alert adults experiencing non-traumatic 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.

Changes and updates include:

• 2020 (Updated): While awaiting the arrival of emergency services, first aid providers may encourage alert adults experiencing non-traumatic 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 non-traumatic 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.

Education Updates

The 2020 AHA Guidelines for CPR and ECC examines best practices in education and applies them to resuscitation science.

In this section, we’ll review the education updates related to BLS training.

When implemented in training, these strategies raise the quality of care and increase survival from cardiac arrest.

Deliberate Practice and Mastery Learning

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

Changes and updates include:

• 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

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.

It is recommended to implement booster sessions when using a massed learning approach for resuscitation training. It is reasonable to use a spaced learning approach in place of a massed learning approach for resuscitation training.

Changes and updates include:

• 2020 (New): It is recommended to implement booster sessions when using a massed learning approach for resuscitation training.
• 2020 (New): It is reasonable to use a spaced learning approach in place of a massed learning approach for resuscitation training.
• Why: The addition of booster training sessions (ie, brief, frequent sessions focused on repetition of prior content) vs massed learning (ie, large amounts of content in a single setting) to resuscitation courses improves the retention of CPR skills.

Opioid Overdose Training for Lay Rescuers

It is reasonable for lay rescuers to receive training in responding to opioid overdose, including provision of naloxone.

Changes and updates include:

• 2020 (New): It is reasonable for lay rescuers to receive training in responding to opioid overdose, including provision of naloxone.
• Why: Multiple studies have found that targeted resuscitation training (for opioid users and their families and friends) is associated with higher rates of naloxone administration in witnessed overdoses.

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

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

Changes and updates include:

• 2020 (New): It is reasonable for EMS systems to monitor clinical personnel’s exposure to resuscitation to ensure treating teams have members competent in the management of cardiac arrest cases. Competence of teams may be supported through staffing or training strategies.
• Why: A recent systematic review found that EMS provider exposure to cardiac arrest cases is associated with improved patient outcomes including rates of return of spontaneous circulation and survival. Because exposure can be variable, the AHA recommends that EMS systems monitor provider exposure and develop strategies to address low exposure.

Willingness to Perform Bystander CPR

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.

Changes and updates include:

• 2020 (New): It is reasonable to increase bystander willingness to perform CPR through CPR training, mass CPR training, CPR awareness initiatives, and promotion of Hands-Only CPR.
• Why: Prompt delivery of bystander CPR doubles the victim’s chances of survival from cardiac arrest. CPR training, mass CPR training, CPR awareness initiatives, and promotion of Hands-Only CPR are all associated with increased rates of bystander CPR.

Course Updates

That completes our review of the education recommendations. Finally, let’s take a look at some changes in the new BLS course and materials.

Course Formats

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

 

Instructor-Led Training

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

HeartCode^®

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

Resuscitation Quality Improvement^®

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

Online Exams

• Exam security
• Key performance data

While administering exams electronically is the preferred method, there may occasionally be a need to administer a paper exam. See the AHA Instructor Network website for more information.

The AHA now offers online exams. This will improve exam security and allows the AHA
to collect key performance data. Exams are just one way the AHA ensures that
cardholders around the world have met the same course completion requirements. While administering exams electronically is the preferred method, there may occasionally be a need to administer a paper exam.

See the AHA Instructor Network website or your Training Center Coordinator for more information.

Online Course Videos

• Course Video Formats
• Available in digital format online and on DVD

AHA course videos now come in a digital format online, as well as the traditional DVD set. Regardless of the method you use to present the course videos, the concepts covered will provide the foundation for your course.

Instructor Manual Part 1: General Concepts

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

We’ve included a new introductory section in the instructor manuals for healthcare courses.

This section discusses the science and educational principles of resuscitation training.

It also describes basic logistics for conducting any AHA course for healthcare providers.

The remaining parts of the instructor manual cover course-specific information.

High-Performance Teams

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

Provider Manual Updates

New BLS Provider Manual content:

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

Conclusion

• 2020 Guidelines and Guidelines Highlights summary
• Resuscitation Education resources
• Interim training materials

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.

Technical Requirements

Compatible Devices/Operating System

Web Browsers	Latest versions of Chrome, Firefox, Edge, Safari
Operating Systems	Windows 10 as minimum or newer, Mac OS 10.7 or newer, iOS and Android (mobile and tablet compatible)
Computing Hardware	Intel Core 2 Duo Processor or equivalent
Internet Connection	Broadband – Fiber, wireless, DSL, cable modem

For accessibility purposes, this course has been tested with Voiceover, JAWs, NVDA, Talkback, and Voiceover for iOS.

 

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2020 AHA Guidelines Advanced Cardiac Life Support (ACLS) Provider and Renewal Course

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

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

Preparation and keeping current are fundamental parts of being an AHA Instructor.

This course will focus on these updates so you’re prepared to teach them and provide a
quality learning experience for your students.

Course Information

At the end of this course, you’ll be able to identify the ACLS science and education updates, describe the rationale for the updates, and apply them during training.

Science Updates

We’ll start with the updated science for ACLS.

Systems of Care: Using Mobile Devices to Summon Rescuers

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.

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.

Changes and updates include:

• 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.

Systems of Care: Data Registries to Improve System Performance

It is reasonable for organizations that treat cardiac arrest patients to collect processes-of-care data and outcomes.

Changes and updates include:

• 2020 (New): It is reasonable for organizations that treat cardiac arrest patients to collect processes-of-care data and outcomes.
• Why: Many industries, including healthcare, collect and assess performance data to measure quality and identify opportunities for improvement. This can be done through participation in data registries that collect information on processes of care (CPR performance data, defibrillation times, adherence to guidelines) and outcomes of care (return of spontaneous circulation [ROSC], survival) associated with cardiac arrest. The AHA Get With the Guidelines^®-Resuscitation registry (for in-hospital cardiac arrest) and the Resuscitation Outcomes Consortium Cardiac Epistry and AHA Cardiac Arrest Registry to Enhance Survival registry (for out-of-hospital cardiac arrest) are 3 such initiatives, and many regional databases also exist.

Adult Chains of Survival

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

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

The process of recovery from cardiac arrest extends long after the initial hospitalization.

Support is needed during recovery to ensure optimal physical, cognitive, and emotional well-being and return to social/role functioning.

This process should be initiated during the initial hospitalization and continue for as long as needed.

Adult Cardiac Arrest Algorithm

The Adult Cardiac Arrest Algorithm was modified to emphasize the role of early epinephrine administration for patients with non-shockable rhythms.

Changes include:

• Amiodarone and lidocaine are now equivalent as antiarrhythmics in cardiac arrest
• Added a step to consider appropriateness of continued resuscitation
• Moved epinephrine to as soon as possible for nonshockable rhythms to emphasize early administration after starting CPR

Text-only content for Adult Cardiac Arrest Algorithm

Adult Cardiac Arrest Algorithm Cascading numbered boxes correspond to actions the provider should perform in sequence. Each box is separated by an arrow that signifies the pathway the provider should take. Some boxes are separated by 2 arrows that lead to different boxes, meaning that the provider should take a different pathway depending on the outcome of the previous action. Pathways are hyperlinked. Box 1 Start CPR • Give oxygen • Attach monitor/defibrillator Rhythm shockable? Yes, proceed to Box 2 for VF/pVT. Box 2 VF/pVT Box 3 Deliver shock. Box 4 CPR 2 minutes • IV/IO access Is rhythm shockable? If Yes, proceed to Box 5. If No, proceed to Box 12. Box 5 Deliver shock. Box 6 CPR 2 minutes • Epinephrine every 3 to 5 minutes. • Consider advanced airway, capnography. Is rhythm shockable? If Yes, proceed to Box 7. If No, proceed to Box 12. Box 7 Deliver shock. Box 8 CPR 2 minutes • Amiodarone or lidocaine. • Treat reversible causes. Box 9 Asystole/PEA. Give Epinephrine ASAP. Box 10 CPR 2 minutes • IV/IO access. • Epinephrine every 3 to 5 minutes. • Consider advanced airway, capnography. Is rhythm shockable? If Yes, proceed to Box 5 or Box 7. If No, proceed to Box 11. Box 11 CPR 2 minutes. • Treat reversible causes. Is rhythm shockable? If Yes, proceed to Box 5 or Box 7. If No, proceed to Box 12. Box 12 • If no signs of return of spontaneous circulation (ROSC), go to Box 10 or Box 11 • If ROSC, go to Post–Cardiac Arrest Care • Consider appropriateness of continued resuscitation Sidebar CPR Quality • Push hard (at least 2 inches [5 cm]) and fast (100-120/min) and allow complete chest recoil. • Minimize interruptions in compressions. • Avoid excessive ventilation. • Change compressor every 2 minutes, or sooner if fatigued. • If no advanced airway, 30 to 2 compression-ventilation ratio, or 1 breath every 6 seconds. • Quantitative waveform capnography – If PETCO2 is low or decreasing, reassess CPR quality. Shock Energy for Defibrillation • Biphasic: Manufacturer recommendation (eg, initial dose of 120-200 Joules); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered. • Monophasic: 360 Joules Drug Therapy • Epinephrine IV/IO dose: 1 milligram every 3 to 5 minutes • Amiodarone IV/IO dose: First dose: 300 milligram bolus. Second dose: 150 milligram. or Lidocaine IV/IO dose: First dose: 1-1.5 milligrams per kilogram. Second dose: 0.5-0.75 milligrams per kilogram. Advanced Airway • Endotracheal intubation or supraglottic advanced airway • Waveform capnography or capnometry to confirm and monitor ET tube placement • Once advanced airway in place, give 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions Return of Spontaneous Circulation (ROSC) • Pulse and blood pressure • Abrupt sustained increase in PETCO2 (typically greater than or equal to 40 millimeters of mercury) • Spontaneous arterial pressure waves with intra-arterial monitoring Reversible Causes • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-/hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardiac • Toxins • Thrombosis, pulmonary • Thrombosis, coronary

The Adult Cardiac Arrest Algorithm was modified to emphasize the role of early epinephrine administration for patients with non-shockable rhythms.

Additionally, the intervention of amiodarone and lidocaine are now equivalent.

Post–Cardiac Arrest Care Algorithm

The Post–Cardiac Arrest Care Algorithm is updated to emphasize the need to prevent hyperoxia, hypoxemia, and hypotension.

Changes and updates include:

• Oxygen saturation of 92% to 98%
• Separated out initial stabilization phase to include “Manage airway,” “Manage respiratory parameters,” and “Manage hemodynamic parameters”
• Added step to consider emergent cardiac interventions
• Added “Obtain brain CT,” “EEG monitoring,” and “Other critical care management” if patient is comatose
• Added guidance on reversible etiologies
• Removed Doses and Details boxes on right
• Added sections on Initial Stabilization Phase and Continued Management and Additional Emergent Activities on right

Text-only content for Post–Cardiac Arrest Care Algorithm

ACLS Healthcare Provider Post-Cardiac Arrest Care Algorithm Cascading numbered boxes correspond to actions the provider should perform in sequence. Each box is separated by an arrow that signifies the pathway the provider should take. Some boxes are separated by 2 arrows that lead to different boxes, meaning that the provider should take a different pathway depending on the outcome of the previous action. Pathways are hyperlinked. Boxes 1 through 3 show the Initial Stabilization Phase. Boxes 4 through 8 show Continued Management and Additional Emergent Activities. Box 1 ROSC obtained Box 2 Manage airway Early placement of endotracheal tube then Manage respiratory parameters Start 10 breaths per minute SPO2 92% to 98% PaCO2 35 to 45 millimeters of mercury then Manage hemodynamic parameters Systolic blood pressure greater than 90 millimeters of mercury Mean arterial pressure greater than 65 millimeters of mercury Box 3 Obtain 12-lead ECG Box 4 Consider for emergent cardiac intervention if • STEMI present • Unstable cardiogenic shock • Mechanical circulatory support required Box 5 Follows commands? If Yes, proceed to Box 7. If No, proceed to Box 6. Box 6 Comatose • TTM • Obtain brain CT • EEG monitoring • Other critical care management Proceed to Box 8. Box 7 Awake Other critical care management Proceed to Box 8. Box 8 Evaluate and treat rapidly reversible etiologies Involve expert consultation for continued management Initial Stabilization Phase Sidebar Initial Stabilization Phase Resuscitation is ongoing during the post-ROSC phase, and many of these activities can occur concurrently. However, if prioritization is necessary, follow these steps: • Airway management: Waveform capnography or capnometry to confirm and monitor endotracheal tube placement • Manage respiratory parameters: Titrate FIO2 for Spo2 92% to 98%; start at 10 breaths per minute; titrate to PaCO2 of 35 to 45 millimeters of mercury • Manage hemodynamic parameters: Administer crystalloid and/or vasopressor or inotrope for goal systolic blood pressure greater than 90 millimeters of mercury or mean arterial pressure greater than 65 millimeters of mercury Continued Management and Additional Emergent Activities These evaluations should be done concurrently so that decisions on targeted temperature management (TTM) receive high priority as cardiac interventions. • Emergent cardiac intervention: Early evaluation of 12-lead electrocardiogram (ECG); consider hemodynamics for decision on cardiac intervention • TTM: If patient is not following commands, start TTM as soon as possible; begin at 32 to 36 degrees Celsius for 24 hours by using a cooling device with feedback loop • Other critical care management – Continuously monitor core temperature (esophageal, rectal, bladder) – Maintain normoxia, normocapnia, euglycemia – Provide continuous or intermittent electroencephalogram (EEG) monitoring – Provide lung-protective ventilation H’s and T’s Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypokalemia/hyperkalemia Hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary

The Post–Cardiac Arrest Care Algorithm is updated to emphasize the need to prevent hyperoxia, hypoxemia, and hypotension.

Opioid-Associated Emergency for Healthcare Providers Algorithm

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

Changes and updates include:

• There is a clear step now to prevent deterioration, with an initial assessment more clearly laid out.
• Respiratory arrest is more prominently addressed in the beginning, with “Is the person breathing normally?” as an initial decision.
• Although naloxone is still recommended for opioid-associated emergencies, it should be considered for preventing deterioration and cardiac arrest, and given during respiratory arrest.

A version for lay rescuers is also included in the Guidelines.

Adult Bradycardia Algorithm

The Adult Bradycardia Algorithm includes updates to dosages.

Changes and updates include:

• Atropine dose changed from 0.5 mg to 1 mg
• Dopamine dose changed from 2-20 mcg/kg per minute to 5-20 mcg/kg per minute
• Under “Identify and treat underlying cause,” added “Consider possible hypoxic and toxicologic causes”

Adult Tachycardia With a Pulse Algorithm

The Adult Tachycardia With a Pulse Algorithm includes updates to IV access and provided additional guidance if refractory.

Changes and updates include:

• Moved IV access and 12-lead ECG to step 2 (earlier in the algorithm)
• Added step 5 to guide on what to do if refractory (if synchronized cardioversion is not working, or if have wide QRS and adenosine/antiarrhythmic infusion is not working)

The Adult Tachycardia With a Pulse Algorithm includes updates to timing of IV access
and provides additional guidance if refractory.

Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm

A revised algorithm is provided for cardiac arrest in pregnancy.

Changes and updates include:

• Layout is more streamlined
• Added step for administering 100% O₂ and avoiding excessive ventilation
• Removed step to assess for hypovolemia/treatment
• Changed “If no ROSC in 4 minutes” to “5 minutes”
• Maternal Cardiac Arrest box that highlights:
  • Team planning
  • Priorities of high-quality CPR and relief of aortocaval compressions with lateral uterine displacement
  • Goal of perimortem cesarean delivery
  • Deliver in 5 minutes (depending on provider resources and skill sets)

Acute Coronary Syndromes Algorithm

An updated algorithm is provided for acute coronary syndromes.

Changes and updates include:

• Upon EMS arrival at the hospital, transport to the emergency department or cath lab per protocol. Best practice is to deliver directly to the cath lab, as long as personnel are present for the procedure, to shorten the time to treatment
• First medical contact–to–balloon inflation (percutaneous coronary intervention) goal of 90 minutes or less
• 12-lead electrocardiographic analysis is now classified into 2 main categories, ST-segment elevation myocardial infarction (STEMI) and non–ST-segment elevation acute coronary syndromes (NSTE-ACS). NSTE-ACS has 2 branches under it, attempting to have emergency departments conduct further testing before release

Adult Suspected Stroke Algorithm

An updated algorithm is provided for adult suspected stroke.

Changes and updates include:

• EMS should now use a stroke severity tool after performing a stroke screening to determine if a large-vessel occlusion exists
• New EMS stroke routing algorithm should be used to determine the hospital destination
• Upon EMS arrival at the hospital, transport to the emergency department or imaging lab per protocol. Best practice is to deliver directly to the imaging lab to shorten the time to treatment
• Patients can be treated with alteplase and endovascular therapy if time goals are met and contraindications do not exist
• The window for conducting endovascular therapy has been extended to up to 24 hours

Neuroprognostication

A diagram is provided to guide and inform neuroprognostication.

Because any single method of neuroprognostication has an intrinsic error rate and may be subject to confounding, multiple modalities should be used to improve decision-making accuracy.

Real-Time Audiovisual Feedback

It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance.

Changes and updates include:

• 2020 (Unchanged/Reaffirmed): It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance.
• Why: A recent randomized controlled trial (RCT) reported a 25% increase in survival to hospital discharge from in-hospital cardiac arrest with audio feedback on compression depth and recoil.

Physiologic Monitoring of CPR Quality

It may be reasonable to use physiologic parameters such as arterial blood pressure or end-tidal CO2 when feasible to monitor and optimize CPR quality.

Changes and updates include:

• 2020 (Updated): It may be reasonable to use physiologic parameters such as arterial blood pressure or end-tidal CO₂ when feasible to monitor and optimize CPR quality.
• 2015 (Old): Although no clinical study has examined whether titrating resuscitative efforts to physiologic parameters during CPR improves outcome, it may be reasonable to use physiologic parameters (quantitative waveform capnography, arterial relaxation diastolic pressure, arterial pressure monitoring, and central venous oxygen saturation) when feasible to monitor and optimize CPR quality, guide vasopressor therapy, and detect ROSC.
• Why: Similar to the above, although the use of physiologic monitoring such as arterial blood pressure and/or end-tidal CO₂ to monitor CPR quality is an established concept, new data support its inclusion in the Guidelines. Data from the AHA Get With the Guidelines-Resuscitation registry show higher likelihood of ROSC when CPR quality is monitored by using either end-tidal CO₂ or diastolic blood pressure. This monitoring depends on the presence of an endotracheal tube or arterial line, respectively. Targeting compressions to an end-tidal CO₂ value of at least 10 mmHg, and ideally 20 mm Hg or greater, may be useful as a marker of CPR quality. An ideal target has not been identified.

Double Sequential Defibrillation Not Supported

The usefulness of double sequential defibrillation for refractory shockable rhythm has not been established.

Changes and updates include:

• 2020 (New): The usefulness of double sequential defibrillation for refractory shockable rhythm has not been established.
• Why: Double sequential defibrillation is the practice of applying near-simultaneous shocks with 2 defibrillators. Although some case reports have shown good outcomes, a 2020 ILCOR systematic review found no evidence to support double sequential defibrillation and recommended against its routine use. Existing studies are subject to multiple forms of bias, and observational studies do not show improvements in outcome. A recent pilot randomized clinical trial suggested that changing the direction of defibrillation current by repositioning the pads may be as effective as double sequential defibrillation, while avoiding the risks of harm from increased energy and damage to defibrillators. Based on current evidence, it is not known whether double sequential defibrillation is beneficial.

Intravenous Access Preferred Over Intraosseous

Changes and updates include:

• 2020 (New): It is reasonable for providers to first attempt establishing IV access for drug administration in cardiac arrest.
• 2020 (Updated): IO access may be considered if attempts at IV access are unsuccessful or not feasible.
• 2010 (Old): It is reasonable for providers to establish IO access if IV access is not readily available.
• Why: A 2020 ILCOR systematic review comparing IV vs IO (principally pretibial placement) drug administration during cardiac arrest found the IV route was associated with better clinical outcomes in 5 retrospective studies; subgroup analyses of RCTs that focused on other clinical questions found comparable outcomes when IV or IO were used for drug administration. Although IV access is preferred, there are situations in which IV access is difficult, and in such situations IO access is a reasonable option.

Do Not Use Point-of-Care Ultrasonography for Prognostication During Resuscitation

The AHA suggests against the use of point-of-care ultrasound for prognostication during cardiopulmonary resuscitation. This recommendation does not preclude the use of ultrasound to identify potentially reversible causes of cardiac arrest or detect ROSC.

Changes and updates include:

• 2020 (New): The AHA suggests against the use of point-of-care ultrasound for prognostication during cardiopulmonary resuscitation. This recommendation does not preclude the use of ultrasound to identify potentially reversible causes of cardiac arrest or detect ROSC.
• 2020 (New): If an experienced sonographer is present and use of ultrasound does not interfere with the standard cardiac arrest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation, although its usefulness has not been well established.
• Why: Point-of-care cardiac ultrasound can identify cardiac tamponade or other potentially reversible causes of cardiac arrest and identify cardiac motion in patients with pulseless electrical activity. However, cardiac ultrasound is also associated with longer interruptions in chest compressions. A single small RCT found no improvement in outcomes with use of cardiac ultrasound during CPR. A recent systematic review found that no sonographic finding had consistently high sensitivity for clinical outcomes to be used as the sole criterion to terminate cardiac arrest resuscitation.
• If an experienced sonographer is present and use of ultrasound does not interfere with the standard cardiac arrest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation, although its usefulness has not been well established.

Care and Support During Recovery

The AHA recommends that cardiac arrest survivors have multimodal rehabilitation assessment and treatment for physical, neurologic, cardiopulmonary, and cognitive impairments before discharge from the hospital. The AHA recommends that cardiac arrest survivors and their caregivers receive comprehensive, multidisciplinary discharge planning, to include medical and rehabilitative treatment recommendations and return
to activity/work expectations.

Changes and updates include:

• 2020 (New): The AHA recommends that cardiac arrest survivors have multimodal rehabilitation assessment and treatment for physical, neurologic, cardiopulmonary, and cognitive impairments before discharge from the hospital.
• 2020 (New): The AHA recommends that cardiac arrest survivors and their caregivers receive comprehensive, multidisciplinary discharge planning, to include medical and rehabilitative treatment recommendations and return to activity/work expectations.
• Why: The process of recovery from cardiac arrest extends long after the initial hospitalization. Support is needed during recovery to ensure optimal physical, cognitive, and emotional wellbeing and return to social/role functioning. This process should be initiated during the initial hospitalization and continue as long as needed. These themes are explored in greater detail in a 2020 AHA Scientific Statement (Sawyer 2020).

Debriefing for Rescuers

Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial.

Changes and updates include:

• 2020 (New): Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial.
• Why: Rescuers may experience anxiety or post-traumatic stress about providing or not providing basic life support. Hospital-based care providers may also experience emotional or psychological effects of caring for a patient with cardiac arrest. Team debriefings may allow a review of team performance (education, quality improvement), as well as recognition of the natural stressors associated with caring for a patient near death.

Cardiac Arrest in Pregnancy

Because pregnant patients are more prone to hypoxia, oxygenation and airway management should be prioritized during resuscitation from cardiac arrest in pregnancy.

Because of potential interference with maternal resuscitation, fetal monitoring should not be undertaken during cardiac arrest in pregnancy.

Changes and updates include:

• 2020 (New): Because pregnant patients are more prone to hypoxia, oxygenation and airway management should be prioritized during resuscitation from cardiac arrest in pregnancy.
• 2020 (New): Because of potential interference with maternal resuscitation, fetal monitoring should not be undertaken during cardiac arrest in pregnancy.
• Why: Recommendations for the management of cardiac arrest in pregnancy were reviewed in the 2015 Guidelines Update and a 2015 AHA Scientific Statement (Jeejeebhoy 2015). Airway, ventilation, and oxygenation are particularly important in the setting of pregnancy due to increased maternal metabolism, decreased functional reserve capacity due to the gravid uterus, and the risk of fetal brain injury from hypoxemia. Evaluation of the fetal heart is not helpful during maternal cardiac arrest and may distract from necessary resuscitation elements.

Cardiac Arrest in Pregnancy (continued)

The AHA recommends targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest.

During targeted temperature management of pregnant patients, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought.

Changes and updates include:

• 2020 (New): The AHA recommends targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest.
• 2020 (New): During targeted temperature management of pregnant patients, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought.
• Why: In the absence of data to the contrary, pregnant women who survive cardiac arrest should receive targeted temperature management as any other survivors, with attention paid to the status of the fetus, who may remain in utero.

Ventilation in Respiratory and Cardiac Arrest

For respiratory and cardiac arrest provide one breath every 6 seconds, or 10 breaths per minute.

This does not include the 30:2 CPR ratio/protocol.

Respiratory Arrest

If an adult victim with spontaneous circulation (ie, strong and easily palpable pulses) requires support of ventilation, it may be reasonable for the healthcare provider to give rescue breaths at a rate of about 1 breath every 6 seconds, or about 10 breaths/min.

Cardiac Arrest

It may be reasonable for EMS providers to use a rate of 10 breaths/min (1 breath every 6 seconds) to provide asynchronous ventilation during continuous chest compressions before placement of an advanced airway.

If an advanced airway is in place, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths/min) while continuous chest compressions are being performed.

Why: Studies have indicated that 1 breath every 6 seconds (10 breaths/min) improves survival and neurologic outcomes.

Epinephrine Administration in Cardiac Arrest

For educational purposes, instructors and healthcare providers can administer epinephrine in cardiac arrest by using a mid range of every 4 minutes to match every other rhythm check.

 

Oxygen Administration

There are minimal changes for oxygen administration. The recommendation is now greater than 94% for stroke and general care, and 92 to 98% for post–cardiac arrest care.

• Greater than 94% for stroke and general care
• 92% to 98% for post–cardiac arrest care
• 90% or greater for ACS

Waveform Capnography

The AHA now recommends the use of waveform capnography with a bag-mask device to increase the use of waveform capnography which can lead to better outcomes.

 

Education Updates

The 2020 AHA Guidelines for CPR and ECC examines best practices in education and applies them to resuscitation science.

In this section, we’ll review the education updates related to ACLS training.

When implemented in training, these strategies raise the quality of care and increase survival from cardiac arrest.

Deliberate Practice and Mastery Learning

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

Changes and updates include:

• Recommendation: 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

It is recommended to implement booster sessions when using a massed learning approach for resuscitation training. It is reasonable to use a spaced learning approach in place of a massed learning approach for resuscitation training.

Changes and updates include:

• 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) 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.

In Situ Education

It is reasonable to conduct in situ simulation-based resuscitation training in addition to, or in place of, traditional training.

Changes and updates include:

• 2020 (New): It is reasonable to conduct in situ simulation-based resuscitation training in addition to, or in place of, traditional training.
• Why: In situ simulation refers to training activities that are conducted in actual patient care areas. New evidence shows that training in the in situ environment, either alone or in combination with traditional training, can have a positive impact on learning outcomes (eg, faster time to perform critical tasks and team performance) and patient outcomes. When conducting in situ simulation, instructors should be wary of potential risks, such as mixing training supplies with real medical supplies.

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

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

Changes and updates include:

• 2020 (New): It is reasonable for EMS systems to monitor clinical personnel’s exposure to resuscitation to ensure treating teams have members competent in the management of cardiac arrest cases. Competence of teams may be supported through staffing or training strategies.
• Why: A recent systematic review found that EMS provider exposure to cardiac arrest cases is associated with improved patient outcomes, including rates of return of spontaneous circulation and survival. Because exposure can be variable, the AHA recommends that EMS systems monitor provider exposure and develop strategies to address low exposure.

ACLS Course Participation

It is reasonable for healthcare professionals to take an adult ACLS course or equivalent.

Changes and updates include:

• 2020 (New): It is reasonable for healthcare professionals to take an adult ACLS course or equivalent.
• Why: For more than 3 decades, the ACLS course has been recognized as an essential component of resuscitation training for acute care providers. Studies show that resuscitation teams with 1 or more team members trained in ACLS have better patient outcomes.

Course Updates

That completes our review of the education recommendations. Finally, let’s take a look at some changes in the new ACLS course and materials.

Course Formats

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

Instructor-Led Training

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

HeartCode^®

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

Resuscitation Quality Improvement^®

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

Online Exams

• Exam security
• Key performance data

While administering exams electronically is the preferred method, there may occasionally be a need to administer a paper exam. See the AHA Instructor Network website for more information.

The AHA now offers online exams. This will improve exam security and allows the AHA
to collect key performance data. Exams are just one way the AHA ensures that
cardholders around the world have met the same course completion requirements. While administering exams electronically is the preferred method, there may occasionally be a need to administer a paper exam.

See the AHA Instructor Network website or your Training Center Coordinator for more information.

Online Course Videos

• Course Video Formats
• Available in digital format online and on DVD

AHA course videos now come in a digital format online, as well as the traditional DVD set. Regardless of the method you use to present the course videos, the concepts covered will provide the foundation for your course.

Instructor Manual Part 1: General Concepts

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

We’ve included a new introductory section in the instructor manuals for healthcare courses.

This section discusses the science and educational principles of resuscitation training.

It also describes basic logistics for conducting any AHA course for healthcare providers.

The remaining parts of the instructor manual cover course-specific information.

Precourse Work

A new feature of the ACLS instructor-led course is an option for precourse work.

Before students enter the classroom, they review the cognitive content through online course videos.

This format allows more classroom time for hands-on skills training—and leads to students being better prepared to participate as soon as they enter the classroom.

Instructors may also choose the traditional course option, without precourse work.

Learning Stations

The AHA has made significant changes to some of the learning stations.

CPR Coach

• New role
• Promotes the delivery of high-quality CPR
• Focuses on only the BLS skills being performed by the team
• Allows the Team Leader to focus on other areas of critical care

We’ve introduced the new role of CPR Coach. This new role is designed to promote the delivery of high-quality CPR.

The CPR Coach focuses on only the BLS skills being performed by the team, which allows the Team Leader to focus on other areas of critical care.

Audiovisual feedback devices

• Required since 2018
• Provide immediate guidance and encouragement on both compressions and ventilation

The AHA has required the use of audiovisual feedback devices since 2018.

Audiovisual feedback devices provide immediate guidance and encouragement on both compressions and ventilation.

Included in the following stations

• High-Quality BLS Learning and Testing Station
• Airway Management Learning and Testing Station
• Cariac Arrest and Post–Cardiac Arrest Care Learning Station
• Megacode Practice and Testing Station

Both the CPR Coach role and an audiovisual feedback device are included in the High Quality BLS Learning and Testing Station, Airway Management Learning and Testing Station, Cardiac Arrest and Post–Cardiac Arrest Care Learning Station, and Megacode Practice and Testing Station.

High-Quality BLS Skills

• Focuses on continuous high-quality chest compressions
• Use of a required audiovisual feedback device to increase quality

The High-Quality BLS Learning Station includes a focus on continuous compressions.
A required audiovisual feedback device will be used to guide the instructor, CPR Coach, and student performing compressions.

Airway Management Skills

• Focuses on the timing and volume of ventilations
• CPR Coaches will focus on rate and volume of ventilations
• Optional use of a feedback device for rate and volume or a timer for rate of ventilations

The Airway Management Learning Station focuses on the timing and volume of ventilations.

As part of their role, one CPR Coach will focus on rate of ventilations, while the other will focus on volume of ventilations.

Megacode Testing Stations

At the end of the course, students will participate in a Megacode Testing Station to validate their achievement of the course objectives.

Megacode Testing Station Objectives

• CPR quality and timing (meeting objective goals by using a feedback device/timer)
• Achieving a chest compression fraction of greater than 80% (objective measure)
• Team communication
• Knowledge of core case material and skills
• Knowledge of algorithms
• Arrhythmia interpretation
• Use of appropriate basic ACLS drug therapy
• Performance as an effective member of a high-performance team (within the team member’s scope of practice)
• Performance of the team working together to achieve prebriefing goals

Before Megacode Testing Station

• There is ample opportunity for an instructor to evaluate and decide if a student should continue the class. If a student is having trouble mastering skills, the instructor should address this well before the student reaches the Megacode Test.
• For more information on Megacode Testing, consult your ACLS Instructor Manual.

High-Quality BLS Skills Testing Station

• The High-Quality BLS Skills Testing Station includes a focus on continuous compressions.

Airway Management Testing Station

• All ACLS Course students must pass the Airway Management Skills Test that includes bag-mask ventilation with OPA/NPA insertion, regardless of the method of preparation or prior airway training. Ventilation should be timed to meet objective testing criteria. The focus should be on timing the breaths to make sure they’re 1 every 6 seconds.

Megacode Testing Updates

• Megacode Testing now focuses more on testing as a team, rather than testing only the Team Leader.
• The team needs to work together to achieve a new objective goal of chest compression fraction of greater than 80% to pass the Megacode Test.
• Megacode Testing is focused more on objective testing than on subjective testing.

Provider Manual Updates

The AHA has revised the ACLS Provider Manual to highlight 2 main themes:
preventing arrest and high-performance teams.

We also added new information in the “Cardiac Arrest: Selected Special Situations” section. It now includes maternal cardiac arrest and ventricular assist devices.

The ACLS Provider Manual contains new and revised illustrations as well as information on the new CPR Coach role and expanded information on high-performance teams.

In addition, the manual now has the latest AHA Guidelines science, including significant updates to information on stroke.

New ACLS Provider Manual:

• Highlights 2 main themes: preventing arrest and high-performance teams
• New information under “Cardiac Arrest: Selected Special Situations”
  • Maternal cardiac arrest
  • Ventricular assist devices
• Revised illustrations
• CPR Coach
• Expanded information on high-performance teams

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
• Resuscitation Education resources
• Interim training materials

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; Kenneth Navarro, MEd, LP; Jeanette Previdi, MPH, RN; Principled Technologies; and the AHA 2020 Instructor Update Project Team.

Technical Requirements

Compatible Devices/Operating System

Web Browsers	Latest versions of Chrome, Firefox, Edge, Safari
Operating Systems	Windows 10 as minimum or newer, Mac OS 10.7 or newer, iOS and Android (mobile and tablet compatible)
Computing Hardware	Intel Core 2 Duo Processor or equivalent
Internet Connection	Broadband – Fiber, wireless, DSL, cable modem

For accessibility purposes, this course has been tested with Voiceover, JAWs, NVDA, Talkback, and Voiceover for iOS.

 

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