HSI Updated Training Guidelines 2010

• Basic Life Support (BLS):
Education and Implementation

• Layperson Adult CPR and AED
• Layperson Pediatric CPR and AED
• Emergency Care / First Aid
• Healthcare Provider Adult BLS
• Healthcare Provider Pediatric BLS
Updated Training Guidelines ©2010 Health and Safety Institute 

Table of Contents
 
Introduction ...................................................................................................................................................2 
About The Health & Safety Institute (HSI) ....................................................................................................2 
Integrating 2010 Science, Treatment Recommendations, and Guidelines ..................................................3 
Planned Release Dates for Updated Training Programs...............................................................................3 
Update Subjects by Brand .............................................................................................................................4 
American Safety & Health Institute (ASHI) ........................................................................................4 
MEDIC First Aid ..................................................................................................................................4 
Update Subjects by Area and Training Level 
TABLE 1: Basic Life Support (BLS): Education and Implementation ..................................................5 
TABLE 2: Layperson Adult CPR and AED ............................................................................................7 
TABLE 3: Layperson Pediatric CPR and AED ......................................................................................10 
TABLE 4: Emergency Care/First Aid ...................................................................................................12 
TABLE 5: Healthcare Provider Adult BLS............................................................................................17 
TABLE 6: Healthcare Provider Pediatric BLS ......................................................................................22 
HSI Advisory Group ........................................................................................................................................24 
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Introduction
This document has been developed to provide you with information about the recently released changes in emergency 
medical care and how those changes affect your authorization as an American Safety & Health Institute (ASHI) or MEDIC 
First  Aid  Instructor.  The  purpose  of  the  document  is  to  highlight  the  major  changes  in  science,  treatment 
recommendations, and guidelines. We are hopeful that it and other resources related to the process will provide helpful 
guidance to both instructors and students during the transition. 
 
On October 18th, 2010, the International Liaison Committee on Resuscitation, or ILCOR, released the 2010 International
Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment
Recommendations. On the same day the American Heart Association®, Inc. (AHA) released updated treatment guidelines 
based on the ILCOR Consensus on Science. In addition, the International First Aid Science Advisory Board released the 
2010 American Heart Association and American Red Cross International Consensus on First Aid Science With Treatment
Recommendations. The Consensus on Science process occurs every five years with the purpose to identify and review 
international  science  and  knowledge  relevant  to  cardiopulmonary  resuscitation,  emergency  cardiac  care,  and  first  aid 
treatment. These publications provide updated treatment recommendations for emergency medical care based on the 
most current scientific evidence and are now being integrated into updated ASHI and MEDIC First Aid training materials. 

About The Health & Safety Institute (HSI)
HSI unites the recognition and expertise of the American Safety & Health Institute and MEDIC FIRST AID International to 
create the largest privately held training organization in the industry. For more than 30 years, and in partnership with 
16,000 approved training centers and 200,000 professional emergency care, safety, and health educators, HSI 
authorized instructors in the U.S. and more than 100 countries throughout the world have certified more than 19 million 
emergency care providers. 
 
Though organizational structures differ, the AHA, the American Red Cross (ARC), and HSI share a similar business 
configuration. Each organization develops and markets commercially‐available, proprietary training programs, products, 
and services to their Training Centers, Authorized Providers, and qualified Instructors. Instructors are then authorized to 
certify course participants who successfully complete a training program. 
 
In collaboration with these and other emergency care training organizations, an HSI representative participated in the 
2010 ILCOR Conference, hosted by the AHA. HSI representatives for ASHI and MEDIC First Aid were volunteer members 
of the 2005 National and 2010 International First Aid Advisory Board founded by the AHA and ARC, and contributed to 
the 2005 and 2010 Consensus on First Aid Science and Treatment Recommendations.  
 
HSI  is  an  accredited  organization  of  the  Continuing  Education  Board  for  Emergency  Medical  Services  (CECBEMS),  the 
national accreditation body for Emergency Medical Service Continuing Education programs. CECBEMS is an organization 
established  to  standardize  the  review  and  approval  of  EMS  continuing  education  activities.  To  ensure  accepted 
standards, CECBEMS accreditation requires an evidence‐based peer‐review process for continuing education programs 
comparable  to  all  healthcare  accreditors.  HSI’s  professional  level  resuscitation  programs  and  Instructor  Development 
Course  are  CECBEMS‐approved  and  meet  the  requirements  of  the  Joint  Commission  and  the  Commission  on 
Accreditation of Medical Transport Systems. 
 
HSI’s  basic  and  professional  level  programs  are  nationally  approved  by  the  Department  of  Homeland  Security,  United 
States  Coast  Guard,  and  are  endorsed,  accepted,  approved,  or  meet  the  requirements  of  more  than  1800  state 
regulatory  agencies  and  occupational  licensing  boards.  HSI  is  a  member  of  the  American  National  Standards  Institute 
and ASTM International, two of the largest voluntary standards‐development and conformity‐assessment organizations 
in the world. 
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Integrating the 2010 Science, Treatment Recommendations, and Guidelines
In order to integrate the 2010 science, treatment recommendations, and guidelines, time is required to make systematic 
and organized changes to our training products. We are currently revising all of our emergency care training materials 
and will incorporate the updated information into our basic and advanced training program materials throughout 2011. 
 
Updated ASHI and MEDIC First Aid training program materials will be based upon these publications: 
2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
With Treatment Recommendationsi 
2010 American Heart Association and American Red Cross International Consensus on First Aid Science With
Treatment Recommendationsii
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Careiii  
2010 American Heart Association and American Red Cross Guidelines for First Aidiv
 
We  have  created  interim  training  materials  that  allow  Instructors  to  immediately  incorporate  some  of  the  most 
significant  changes  in  science  and  treatment  recommendations  into  current  (2005)  training  materials.  The  interim 
materials  are  only  intended  to  be  used  until  the  new  training  programs  are  made  available.  The  use  of  these  interim 
materials  is  an  option  and  not  a  requirement.  Instructors  can  also  continue  to  use  the  current  (2005)  materials  as 
designed. 
 
The  release  of  new  science  and  treatment  recommendations  does  not  imply  that  emergency  care  or  instruction 
involving the use of previous recommendations is unsafe. There is no need to raise undue concern among your Training 
Center staff, customers, or students.  
 
NOTE:  THE  NEW  SCIENCE  AND  TREATMENT  RECOMMENDATIONS  DO  NOT  IMPLY  THAT  CARE  INVOLVING  THE  USE  OF  EARLIER  SCIENCE  AND 
TREATMENT  RECOMMENDATIONS  IS  UNSAFE.  YOU  MAY  CONTINUE  TO  PURCHASE  AND  TEACH  USING  THE  CURRENT  (2005)  TRAINING 
MATERIALS UNTIL DECEMBER 31, 2011, OR UNTIL THE CURRENT MATERIALS ARE DEPLETED. 

Planned Release Dates for Updated Training Programs
2nd Quarter 2011 Release:  ASHI CPR and AED  
ASHI Basic First Aid  
ASHI CPR, AED, and Basic First Aid Combination  
ASHI CPR Pro  
MEDIC First Aid BasicPlus CPR, AED, and First Aid  
MEDIC First Aid CarePlus CPR and AED  
3rd Quarter 2011 Release:  ASHI Advanced Cardiac Life Support (ACLS)* 
ASHI Bloodborne and Airborne Pathogens  
MEDIC First Aid PediatricPlus CPR, AED, and First Aid for Children, Adults, and Infants  
MEDIC First Aid CPR and AED Child/Infant Supplement  
MEDIC Bloodborne and Airborne Pathogens  
4th Quarter 2011 Release:  ASHI Pediatric Advanced Life Support (PALS)* 
ASHI Child and Babysitting Safety Course (CABS)  
*Release dates are dependent on third party production.
 
 
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Update Subjects by Brand
Every Instructor needs to understand the guideline changes that affect the program(s) he or she is authorized to teach. 
On the following pages the most significant guideline changes are organized into tables by area and training level. For 
each identified change, the guideline tables provide the 2005 guideline for reference, the updated 2010 guideline, and 
the reason for the change.  
 
To assist Instructors, the program tables immediately below reference the guideline tables an Instructor must review in 
relation to the current programs he or she is authorized to teach. Instructors for the ASHI Advanced Cardiac Life Support 
(ACLS)  and  the  Pediatric  Advanced  Life  Support  (PALS)  training  programs  can  find  specific  guideline  tables  for  those 
programs in the separate 2010 HSI Updated Training Guidelines Supplement. 
 
 
American Safety & Health Institute Training Programs
If you teach:   Related changes are in: 
   
Basic First Aid  Tables 1, 2, 3, 4 
Basic Wilderness & Wilderness First Aid  Tables 1, 2, 3, 4 
Child and Babysitting Safety  Tables 1, 2, 3, 4 
CPR/AED  Tables 1, 2, 3 
Emergency Oxygen Administration  Tables 1, 2, 3, 4 
EMR for Adults  Tables 1, 2, 3, 4 
First Responder  Tables 1, 5, 6 
Wilderness First Responder  Tables 1, 5, 6 
Wilderness EMT Upgrade  Tables 1, 5, 6 
CPR Pro  Tables 1, 5, 6 
ACLS  Tables 1, 5, 6, and Updated Training Guidelines Supplement 
PALS  Tables 1, 5, 6, and Updated Training Guidelines Supplement 
 
 
MEDIC First Aid Training Programs
If you teach:   Related changes are in: 
   
Basic Training Programs  Tables 1, 2, 3, 4  
Emergency Care First Aid  Tables 1, 2, 3, 4 
CarePlus CPR and AED  Tables 1, 2, 3 
Child/Infant CPR and AED Supplement  Tables 1, 2, 3 
Oxygen First Aid for Emergencies  Tables 1, 2, 3, 4 
Pediatric Training Programs  Tables 1, 2, 3, 4 
 
 
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TABLE 1: Basic Life Support (BLS): Education and Implementation
Topic  2005  2010  Reason for Change 
Skills  Not addressed.  “While the optimal mechanism for  Retention of skills deteriorates very quickly 
Reassessment  maintenance of competence is not known,  after training. Frequent skill refreshers 
the need to move toward more frequent  should help to maintain reasonable skill 
assessment and reinforcement of skills is  performance. 
clear. Skill performance should be assessed 
during the 2‐year certification with 
reinforcement provided as needed (Class I, 
LOE B). The optimal timing and method for 
this assessment and reinforcement are not 
known.” 
 
(Bhanji, et al. Circulation. 2010;122;S920‐
S933) 
Self Instruction   “Instruction methods should not be limited  “Short video instruction combined with  Studies have demonstrated that lay rescuer 
to traditional techniques; newer training  synchronous hands‐on practice is an  CPR skills can be acquired and retained at 
methods (e.g., “watch‐while‐you practice”  effective alternative to instructor‐led basic  least as well (and sometimes better) through 
video programs) may be more effective.”  life support courses.”  interactive computer‐ and video‐based 
    synchronous practice when compared with 
  (Bhanji, et al. Circulation. 2010;122;S920‐ instructor‐led courses. 
(Circulation. 2005;112:III‐100‐III‐108)  S933) 
Skills Competency   “Training programs should be evaluated to  “Successful course completion should be  Reflecting the emerging trends supporting 
verify that they enable effective skills  based on the ability of the learner to  continuous maintenance of competence and 
acquisition and retention.”  demonstrate achievement of course  continuing professional development in the 
  objectives rather than attendance in a  healthcare professions, there is support to 
  course/program for a specific time period.”  move away from a time‐related certification 
    standard and toward a more competency‐
    based approach to resuscitation education 
  (Bhanji, et al. Circulation. 2010;122;S920‐ for all rescuers. 
(Circulation. 2005;112:III‐100‐III‐108)  S933) 
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TABLE 1: Basic Life Support (BLS): Education and Implementation
Prompting and  “A CPR prompt device may be useful in both  “Training in CPR skills using a feedback  The evidence has shown prompting and 
Feedback Devices  out‐of‐hospital and in‐hospital settings  device improves learning and/or retention.  feedback devices to be effective in CPR 
(Class IIb).”  The use of a CPR feedback device can be  training and during actual resuscitations. 
  effective for training (Class IIa, LOE A). CPR  Commercially‐produced devices are now 
  prompting and feedback devices can be  more readily available for use.  
  useful as part of an overall strategy to 
  improve the quality of CPR during actual 
  resuscitations (Class IIa, LOE B).” 
   
  (Bhanji, et al. Circulation. 2010;122;S920‐
(Circulation. 2005; 112: IV19‐IV34)  S933) 
 
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TABLE 2: Layperson Adult CPR and AED
Emphasis on High‐ “The available evidence suggests that blood  “To provide effective chest compressions,  The importance of high‐quality chest 
Quality CPR  flow is optimized by using the recommended  push hard and push fast. It is reasonable for  compressions within CPR remains a critical 
chest compression force and duration and  laypersons and healthcare providers to  focal point. Well‐performed compressions 
maintaining a chest compression rate of  compress the adult chest at a rate of at least  increase the likelihood of survival.  
approximately 100 compressions per  100 compressions per minute (Class IIa, LOE 
minute. These guidelines recommend that  B) with a compression depth of at least 2 
all rescuers minimize interruption of chest  inches/5 cm (Class IIa, LOE B). Rescuers 
compressions for checking the pulse,  should allow complete recoil of the chest 
analyzing rhythm, or performing other  after each compression, to allow the heart 
activities (Class IIa). CPR instruction should  to fill completely before the next 
emphasize the importance of allowing  compression (Class IIa, LOE B). Rescuers 
complete chest recoil between  should attempt to minimize the frequency 
compressions.”  and duration of interruptions in 
  compressions to maximize the number of 
  compressions delivered per minute (Class 
  IIa, LOE B).” 
   
   
  (Berg, et al. Circulation. 2010;122;S685‐
Compression Rate  “There is insufficient evidence from human  “It is reasonable for laypersons and  It has been found that higher survival rates 
studies to identify a single optimal chest  healthcare providers to compress the adult  are associated with an increase in the 
compression rate. Animal and human  chest at a rate of at least 100 compressions  number of compressions provided per 
studies support a chest compression rate of  per minute (Class IIa, LOE B) with a  minute.  
>80 compressions per minute to achieve  compression depth of at least 2 inches/5 cm 
optimal forward blood flow during CPR. We  (Class IIa, LOE B).” 
recommend a compression rate of about   
100 compressions per minute (Class IIa).”   
   
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Compression  “Depress the sternum approximately 1 ½ to  “It is reasonable for laypersons and  Research indicates the tendency for CPR 
Depth  2 inches (approximately 4 to 5 cm) and then  healthcareproviders to compress the adult  providers to not compress deep enough, 
allow the chest to return to its normal  chest at a rate of at least 100 compressions  even with the emphasis to "push hard." 
position.”  per minute (Class IIa, LOE B) with a  There is not enough evidence to provide a 
  compression depth of at least 2 inches/5  recommended specific upper limit for chest 
  cm (Class IIa, LOE B).”  compression depth. Research also indicates 
    the 2‐inch depth for adult compression is 
  (Berg, et al. Circulation. 2010;122;S685‐ more effective than a depth of 1 ½ inches. 
Compression Hand  “The rescuer should compress the lower half  “The rescuer should place the heel of one  Use of the nipple line as a landmark for hand 
Position  of the victim’s sternum in the center  hand on the center (middle) of the victim’s  placement was found to be unreliable. 
(middle) of the chest, between the nipples.  chest (which is the lower half of the 
The rescuer should place the heel of the  sternum) and the heel of the other hand on 
hand on the sternum in the center (middle)  top of the first so that the hands are 
of the chest between the nipples and then  overlapped and parallel (Class IIa, LOE B).” 
place the heel of the second hand on top of   
the first so that the hands are overlapped   
and parallel (LOE 6; Class IIa).”   
   
Breathing  “While maintaining an open airway, look,  “After activation of the emergency response  There is a high likelihood of agonal, or 
Assessment  listen, and feel for breathing.”  system, all rescuers should immediately  irregular gasping, breaths occurring early in 
  begin CPR for adult victims who are  cardiac arrest. These reflex actions make the 
  unresponsive with no breathing or no  recognition of cardiac arrest confusing for 
  normal breathing (only gasping).”  rescuers who have never seen agonal 
    breaths before. Simplifying the breathing 
    assessment to looking for no breathing or no 
    normal breathing is intended to help 
    laypersons respond more quickly with chest 
  (Berg, et al. Circulation. 2010;122;S685‐ compressions and CPR. 
8| P a g e  
 
CPR Sequence  For an unresponsive person who is not  For an unresponsive person who is not  The science indicates the importance of not 
breathing or not breathing normally, begin  breathing or not breathing normally, begin  delaying chest compressions to perform 
CPR by opening the airway and giving 2  CPR with 30 compressions followed by  rescue breaths. Early chest compression can 
rescue breaths followed with 30 chest  opening the airway and giving 2 rescue  immediately circulate oxygen that is still in 
compressions. Repeat cycles of 30:2 (ABC  breaths. Repeat cycles of 30:2 (CAB  the bloodstream.  
method).  method). 
   
   
   
   
(Summary from Circulation. 2005; 112: IV19‐ (Summary from Berg, et al. Circulation. 
IV34)  2010;122;S685‐S705) 
Chain of Survival   “• Early recognition of the emergency and  “These actions are termed the links in the  Links in the “Chain of Survival” indicate the 
activation of the emergency medical services  ‘Chain of Survival.’ For adults they include:  individual actions that must be strong in 
(EMS) or local emergency response system  Immediate recognition of cardiac arrest  order for a person to survive a sudden 
• Early bystander CPR  and activation of the emergency  cardiac arrest. The addition of the fifth link, 
• Early delivery of a shock with a defibrillator  response system  integrated post‐cardiac arrest care, further 
• Early advanced life support followed by  Early CPR that emphasizes chest  emphasizes the additional dependence on 
post resuscitation care delivered by  compressions  longer‐term care for long‐term survival. 
healthcare providers.”  Rapid defibrillation if indicated 
  Effective advanced life support 
  Integrated post– cardiac arrest care.” 
   
  (Travers, et al. Circulation. 2010;122;S676‐
BLS Provider  “Responders are split into layperson  “Responders are split into untrained  With the introduction of compression‐only 
Levels  providers and healthcare providers.”  layperson providers, trained layperson  CPR and improved emergency medical 
  providers, and healthcare providers.”  dispatcher training, people who have had no 
    formal training are more likely to attempt to 
    perform CPR for cardiac arrest. This level of 
    care needs to be recognized in the overall 
    public approach to dealing with this 
  (Berg, et al. Circulation. 2010;122;S665‐ common medical emergency.  
9| P a g e  
 

TABLE 3: Layperson Pediatric CPR and AED
Child and Infant  “Push fast; push at a rate of approximately  “Push fast; push at a rate of at least 100  It has been found that higher survival rates 
Compression Rate  100 compressions per minute.”  compressions per minute.”  are associated with an increase in the 
    number of compressions provided per 
    minute.  
   
Child Compression  “‘Push hard’: push with sufficient force to  “Chest compressions of appropriate rate and  Research indicates there is a common 
Depth  depress the chest approximately one third  depth. ‘Push fast’: push at a rate of at least  tendency for CPR providers to not compress 
to one half the anterior‐posterior diameter  100 compressions per minute. ‘Push hard’:  deep enough, even with the emphasis to 
of the chest.”  push with sufficient force to depress at least  "push hard." 
  one third the anterior‐posterior (AP) 
  diameter of the chest or approximately 1 ½ 
  inches (4 cm) in infants and 2 inches (5 cm) 
  in children (Class I, LOE C).” 
   
Infant  “‘Push hard’: push with sufficient force to  “Chest compressions of appropriate rate and  Research indicates there is a common 
Compression  depress the chest approximately one third  depth. ‘Push fast’: push at a rate of at least  tendency for CPR providers to not compress 
Depth  to one half the anterior‐posterior diameter  100 compressions per minute. ‘Push hard’:  deep enough, even with the emphasis to 
of the chest.”  push with sufficient force to depress at least  "push hard." 
  one third the anterior‐posterior (AP) 
  diameter of the chest or approximately 1 ½ 
  inches (4 cm) in infants and 2 inches (5 cm) 
  in children (Class I, LOE C).” 
   
(Circulation. 2005; 112: IV156‐IV166)   S875) 
10| P a g e  
 
TABLE 3: Layperson Pediatric CPR and AED
Child and Infant  “While maintaining an open airway, take no  “If the victim is unresponsive and breathing  There is a high likelihood of agonal, or 
Breathing  more than 10 seconds to check whether the  (or only gasping), begin CPR. Sometimes  irregular gasping, breaths occurring early in 
Assessment  victim is breathing: Look for rhythmic chest  victims who require CPR will gasp, which  cardiac arrest. These reflex actions make the 
and abdominal movement, listen for exhaled  may be misinterpreted as breathing. Treat  recognition of cardiac arrest confusing for 
breath sounds at the nose and mouth, and  the victim with gasps as though there is no  rescuers who have never seen them before. 
feel for exhaled air on your cheek. Periodic  breathing and begin CPR.”  Simplifying the breathing assessment to 
gasping, also called agonal gasps, is not    looking for no breathing or only gasping is 
breathing.”    intended to help laypersons respond more 
    quickly with chest compressions and CPR. 
  (Berg, et al. Circulation. 2010;122;S862‐  
Child and Infant  For an unresponsive child who is not  For an unresponsive child who is not  The recommended sequence for children 
CPR Sequence   breathing or not breathing normally, begin  breathing or not breathing normally, begin  and infants is the same as the adult to help 
CPR by opening the airway and giving 2  CPR with 30 compressions followed by  simplify learning. Ventilations are very 
rescue breaths followed with 30 chest  opening the airway and giving 2 rescue  important in child or infant CPR. It is not 
compressions. Repeat cycles of 30:2 (ABC  breaths. Repeat cycles of 30:2 (CAB  known whether starting with compressions 
method).  method).  or breaths makes a difference in the 
    outcome. Starting CPR with compressions 
    should only delay rescue breaths about 18 
(Summary from Circulation. 2005; 112:  (Summary from Berg, et al. Circulation.  seconds. 
IV156‐IV166)   2010;122;S862‐S875) 
Use of an AED on  “There is insufficient data to make a  “Many AEDs have high specificity in  AEDs designed to be used on adults have 
an Infant   recommendation for or against the use of  recognizing pediatric shockable rhythms,  been successful when used on infants with 
AEDs for infants 1 year of age (Class  and some are equipped to decrease (or  out‐of‐hospital cardiac arrest when coupled 
Indeterminate).”  attenuate) the delivered energy to make  with bystander CPR. Minimal heart muscle 
  them suitable for infants and children < 8  damage and good neurological outcomes 
  years of age. For infants a manual  were reported. 
  defibrillator is preferred. If a manual 
  defibrillator is not available, an AED 
  equipped with a pediatric attenuator is 
  preferred for infants. If neither is available, 
  an AED without a dose attenuator may be 
  used (Class IIb, LOE C).” 
   
(Circulation. 2005; 112: IV156‐IV166)   (Link, et al. Circulation. 2010;122;S706‐S719) 
11| P a g e  
 

TABLE 4: Emergency Care/First Aid
Control of  “There is insufficient evidence to  “Elevation and use of pressure points are  Evidence indicates that direct pressure is the 
Bleeding:  recommend for or against the first aid use of  not recommended to control bleeding (Class  single most effective method for controlling 
Elevation and  pressure points or extremity elevation to  III, LOE C).”  bleeding. Elevation and pressure points are 
Pressure Points  control hemorrhage.”    unproven procedures that may compromise 
    the proven intervention of direct pressure, 
  (Markenson, et al. Circulation.  so they could be harmful. 
(Circulation. 2005; 112: IV196‐IV203)  2010;122;S934‐S946) 
Control of  “The effectiveness, feasibility, and safety of  “Because of the potential adverse effects of  Tourniquets have been shown to control 
Bleeding:  tourniquets to control bleeding by first aid  tourniquets and difficulty in their proper  bleeding effectively and without 
Tourniquets  providers are unknown, but the use of  application, use of a tourniquet to control  complications on the battlefield, during 
tourniquets is potentially dangerous.”  bleeding of the extremities is indicated only  surgery, and when used by paramedics in a 
  if direct pressure is not effective or possible  civilian setting. There are no studies on 
  (Class IIb, LOE B). Specifically designed  controlling bleeding with first aid provider 
  tourniquets appear to be better than ones  use of a tourniquet.  
  that are improvised, but tourniquets should 
  only be used with proper training (Class IIa, 
  LOE B).” 
   
  (Markenson, et al. Circulation. 
Control of  Not addressed.  “Routine use of hemostatic agents in first aid  The use of commercially available 
Bleeding:  cannot be recommended at this time  hemostatic agents to control bleeding is not 
Hemostatic Agents  because of significant variation in  recommended because the agent and 
effectiveness by different agents and their  conditions for its application are not known. 
potential for adverse effects, including tissue 
destruction with induction of a proembolic 
state and potential thermal injury (Class IIb, 
LOE B).” 
 
(Markenson, et al. Circulation. 
2010;122;S934) 
12| P a g e  
 
Leg Elevation for  Not addressed.  “If a victim shows evidence of shock, have  Elevating the legs can be beneficial in cases 
Shock   the victim lie supine. If there is no evidence  such as fainting, dehydration, and heat 
of trauma or injury, raise the feet about 6 to  exhaustion in which the mechanism of shock 
12 inches (about 30° to 45°). (Class IIb, LOE  is related to factors other than injury. The 
C). Do not raise the feet if the movement or  risk of further injury outweighs the benefit 
the position causes the victim any pain.”  of elevation when a person is injured.  
 
2010;122;S934‐S946) 
Injured Extremity  “If you are far from definitive health care,  “If you are far from definitive health care,  Expert opinion suggests that splinting for an 
you may stabilize the extremity in the  stabilize the extremity with a splint in the  extremity injury may reduce pain and 
position found.”   position found (Class IIa, LOE C). If a splint is  prevent further injury, especially when 
  used, it should be padded to cushion the  professional care is delayed or it is decided 
  injury.”  to move the injured person. 
   
(Circulation. 2005; 112: IV196‐IV203)   2010;122;S934‐S946) 
Aspirin for Chest  Not addressed.   “While waiting for EMS to arrive, the first aid  Evidence from two large, randomized 
Discomfort  provider may encourage the victim to chew  studies clearly demonstrated that the 
1 adult (not enteric coated) or 2 low‐dose  administration of aspirin within the first 
‘baby’ aspirin if the patient has no allergy to  hours of onset of chest discomfort in people 
aspirin or other contraindication to aspirin,  with acute coronary syndromes reduced 
such as evidence of a stroke or recent  mortality. 
bleeding (Class IIa, LOE A).” 
 
2010;122;S934‐S946) 
13| P a g e  
 
Second Dose of  "First aid providers should be familiar with  “First aid providers are advised to seek  If medical assistance is available, it is less 
Epinephrine for  the epinephrine auto‐injector so that they  medical assistance if symptoms persist,  likely that an unnecessary second dose of 
Anaphylaxis  can help someone having an anaphylactic  rather than routinely administering a second  epinephrine will be given. 
reaction self‐administer the epinephrine.  dose of epinephrine. In unusual 
First aid providers should be able to  circumstances, when advanced medical 
administer the auto‐injector if the victim is  assistance is not available, a second dose of 
unable to do so, provided that the  epinephrine may be given if symptoms of 
medication has been prescribed by a  anaphylaxis persist (Class IIb, LOE C).” 
physician and state law permits [second   
dose not addressed]."   
(Circulation. 2005;112:IV‐196‐IV‐203)  2010;122;S934‐S946) 
Chemical Burns   “In case of an acid or alkali exposure to the  “Rinse eyes exposed to toxic substances  Immediate irrigation of eyes exposed to a 
skin or eye, immediately irrigate the affected  immediately with a copious amount of water  toxin with large amounts of tap water is 
area with copious amounts of water.”  (Class I, LOE C), unless a specific antidote is  recommended. Specialized therapeutic 
  available.”  rinsing solutions that have been properly 
    tested and approved may be available and 
    should be used when available. 
Heat Stroke  Not addressed.  “The most important action by a first aid  Complete immersion in cold water has been 
provider for a victim of heat stroke is to  found to be the most effective method of 
begin immediate cooling, preferably by  cooling the body in heat stroke. 
immersing the victim up to the chin in cold 
water.” 
 
2010;122;S934‐S946) 
Supplemental  Not addressed.  “Supplementary oxygen administration may  There is evidence oxygen may be beneficial 
Oxygen for Diving   be beneficial as part of first aid for divers  for divers with a decompression injury.  
with a decompression injury (Class IIb, LOE 
C22).” 
 
2010;122;S934‐S946) 
14| P a g e  
 
Poisoning:  “There is insufficient evidence to  “Do not administer activated charcoal to a  There is no evidence that activated charcoal 
Activated Charcoal  recommend for or against the use of  victim who has ingested a poisonous  is effective as a component of first aid. It 
activated charcoal as first aid for ingestions  substance unless you are advised to do so by  may be safe to administer, but it has not 
(Class Indeterminate).”  poison control center or emergency medical  been shown to be beneficial, and there are 
  personnel (Class IIb, LOE C).”  reports of it causing harm. 
   
Snakebite:  “In case of an elapid (e.g., coral) snakebite,  “Applying a pressure immobilization  Applying a pressure immobilization bandage 
Pressure  wrap a bandage snugly (comfortably tight  bandage with a pressure between 40 and 70  has shown to be an effective way to slow 
Immobilization  but loose enough to slip or fit a finger under  mm Hg in the upper extremity and between  the dissemination of venom for all 
Bandage  it) around the entire length of the bitten  55 and 70 mm Hg in the lower extremity  venomous snake bites, not just those from 
extremity, immobilize the extremity, and get  around the entire length of the bitten  elapids. 
definitive medical help as rapidly as  extremity is an effective and safe way to 
possible.”  slow the dissemination of venom by slowing 
  lymph flow (Class IIa, LOE C). For practical 
  purposes pressure is sufficient if the 
  bandage is comfortably tight and snug but 
  allows a finger to be slipped under it. Initially 
  it was theorized that slowing lymphatic flow 
  by external pressure would only benefit 
  victims bitten by snakes producing 
  neurotoxic venom, but the effectiveness of 
  pressure immobilization has also been 
  demonstrated for bites by non‐neurotoxic 
  American snakes.” 
   
(Circulation. 2005; 112: IV196‐IV203)   2010;122;S934‐S946) 
15| P a g e  
 
Jellyfish Stings  Not addressed.  “To inactivate venom load and prevent  A number of topical treatments have been 
further envenomation, jellyfish stings should  identified for jellyfish stings, but a critical 
be liberally washed with vinegar (4% to 6%  evaluation of the evidence shows vinegar is 
acetic acid solution) as soon as possible for  most effective for inactivation of the 
at least 30 seconds (Class IIa, LOE B). For the  nematocysts. In addition, immersion in 
treatment of pain, after the nematocysts are  water, as hot as tolerated for about 20 
removed or deactivated, jellyfish stings  minutes, has been found to be the most 
should be treated with hot‐water immersion  effective treatment for the pain. 
when possible (Class IIa, LOE B).” 
 
2010;122;S934‐S946) 
16| P a g e  
 

TABLE 5: Healthcare Provider Adult BLS
Emphasis on High‐ “The available evidence suggests that blood  “To provide effective chest compressions,  The importance of high‐quality chest 
Quality CPR  flow is optimized by using the recommended  push hard and push fast. It is reasonable for  compressions within CPR remains a critical 
chest compression force and duration and  laypersons and healthcare providers to  focal point. Well‐performed compressions 
maintaining a chest compression rate of  compress the adult chest at a rate of at least  increase the likelihood of overall survival. 
approximately 100 compressions per  100 compressions per minute (Class IIa, LOE  Recommendations center on improving the 
minute. These guidelines recommend that  B) with a compression depth of at least 2  parts of the compression skill found to have 
all rescuers minimize interruption of chest  inches/5 cm (Class IIa, LOE B). Rescuers  the most influence on quality. 
compressions for checking the pulse,  should allow complete recoil of the chest 
analyzing rhythm, or performing other  after each compression, to allow the heart 
activities (Class IIa). CPR instruction should  to fill completely before the next 
emphasize the importance of allowing  compression (Class IIa, LOE B). Rescuers 
complete chest recoil between  should attempt to minimize the frequency 
compressions.”  and duration of interruptions in 
  compressions to maximize the number of 
  compressions delivered per minute (Class 
  IIa, LOE B).” 
   
Compression Rate  “There is insufficient evidence from human  “It is reasonable for laypersons and  It has been found that higher survival rates 
studies to identify a single optimal chest  healthcare providers to compress the adult  are associated with an increase in the 
compression rate. Animal and human  chest at a rate of at least 100 compressions  number of compressions provided per 
studies support a chest compression rate of  per minute (Class IIa, LOE B) with a  minute and lower survival rates are 
>80 compressions per minute to achieve  compression depth of at least 2 inches/5 cm  associated with a decrease in that number. 
optimal forward blood flow during CPR. We  (Class IIa, LOE B).”  Recommending a base‐level compression 
recommend a compression rate of about    rate instead of a fixed rate allows for the 
100 compressions per minute (Class IIa).”    benefit of an increased compression rate. 
    There is not enough evidence to provide a 
    recommended specific upper limit for 
  (Berg, et al. Circulation. 2010;122;S685‐ compression rate. 
(Circulation. 2005; 112: IV19‐IV34)  S705)   
17| P a g e  
 
Compression  “Depress the sternum approximately 1 ½ to  “It is reasonable for laypersons and  Research indicates the tendency for CPR 
Depth  2 inches (approximately 4 to 5 cm) and then  healthcare providers to compress the adult  providers to not compress deep enough, 
allow the chest to return to its normal  chest at a rate of at least 100 compressions  even with the emphasis to "push hard." 
position.”  per minute (Class IIa, LOE B) with a  There is not enough evidence to provide a 
  compression depth of at least 2 inches/5  recommended specific upper limit for chest 
  cm (Class IIa, LOE B).”  compression depth. The research also 
    indicates the 2‐inch depth for adult 
    compression is more effective than a depth 
  (Berg, et al. Circulation. 2010;122;S685‐ of 1 ½ inches. 
(Circulation. 2005; 112: IV19‐IV34)  S705)    
Compression Hand  “The rescuer should compress the lower half  “The rescuer should place the heel of one  Use of the nipple line as a landmark for hand 
Position  of the victim’s sternum in the center  hand on the center (middle) of the victim’s  placement was found to be unreliable. 
(middle) of the chest, between the nipples.  chest (which is the lower half of the 
The rescuer should place the heel of the  sternum) and the heel of the other hand on 
hand on the sternum in the center (middle)  top of the first so that the hands are 
of the chest between the nipples and then  overlapped and parallel (Class IIa, LOE B).” 
place the heel of the second hand on top of   
the first so that the hands are overlapped   
and parallel (LOE 6; Class IIa).”   
(Circulation. 2005; 112: IV19‐IV34)  S705)  
Breathing  “While maintaining an open airway, look,  “After activation of the emergency response  There is a high likelihood of agonal or 
Assessment  listen, and feel for breathing.”  system, all rescuers should immediately  irregular gasping breaths to occur early in 
  begin CPR for adult victims who are  cardiac arrest. These reflex actions make the 
  unresponsive with no breathing or no  recognition of cardiac arrest confusing for 
  normal breathing (only gasping).”  rescuers who have never seen agonal 
    breaths before. Simplifying the breathing 
    assessment to looking for no breathing or no 
    normal breathing helps rescuers respond 
    more quickly with chest compressions and 
  (Berg, et al. Circulation. 2010;122;S685‐ CPR. 
18| P a g e  
 
CPR Sequence  For an unresponsive person who is not  For an unresponsive person who is not  The science indicates the importance of not 
breathing or not breathing normally, begin  breathing or not breathing normally, and has  delaying chest compressions to perform 
CPR by opening the airway and giving 2  no obvious pulse, begin CPR with 30  rescue breaths. Early chest compression can 
rescue breaths followed with 30 chest  compressions followed by opening the  immediately circulate oxygen that is still in 
compressions. Repeat cycles of 30:2 (ABC  airway and giving 2 rescue breaths. Repeat  the bloodstream. By changing the sequence, 
method).  cycles of 30:2 (CAB method).  chest compressions are initiated sooner and 
    the delay in ventilation should be minimal.   
(Summary from Circulation. 2005; 112: IV19‐ (Summary from Berg, et al. Circulation. 
IV34)  2010;122;S685‐S705) 
Cricoid Pressure   “Cricoid pressure should be used only if the  “The routine use of cricoid pressure in adult  Regardless of expertise, rescuers cannot 
victim is deeply unconscious.”  cardiac arrest is not recommended (Class III,  effectively apply cricoid pressure. Teaching 
  LOE B).”  the skill is difficult. Cricoid pressure can 
    complicate or prevent the placement of an 
    advanced airway. It has been found that 
    some aspiration can still occur, even with 
    the application of cricoid pressure. 
Pad Placement  “Rescuers should place AED electrode pads  “Four pad positions (anterolateral,  New data demonstrates that four pad 
on the victim’s bare chest in the  anteroposterior, anterior‐left infrascapular,  positions (anterior‐lateral, anterior‐
conventional sternal‐apical (anterolateral)  and anterior‐right infrascapular) are equally  posterior, anterior‐left infrascapular, and 
position (Class IIa). The right (sternal) chest  effective to treat atrial or ventricular  anterior‐right infrascapular) appear to be 
pad is placed on the victim’s right superior  arrhythmias. All four positions are equally  equally effective to treat atrial or ventrical 
anterior (infraclavicular) chest and the apical  effective in shock success and reasonable for  arrhythmias. 
(left) pad is placed on the victim’s inferior‐ defibrillation (Class IIa, LOE B). For ease of 
lateral left chest, lateral to the left breast  placement and education, anterolateral is a 
(Class IIa). Other acceptable pad positions  reasonable default electrode placement 
are placement on the lateral chest wall on  (Class IIa, LOE C). Alternative pad positions 
the right and left sides (biaxillary) or the left  may be considered based on individual 
pad in the standard apical position and the  patient characteristics. Lateral pads/paddles 
other pad on the right or left upper back  should be placed under breast.” 
(Class IIa).”   
   
(Circulation. 2005; 112: IV35‐IV46)  (Link, et al. Circulation. 2010;122;S706‐S719) 
19| P a g e  
 
Chain of Survival   “• Early recognition of the emergency and  “These actions are termed the links in the  Links in the “Chain of Survival” indicate the 
activation of the emergency medical services  ‘Chain of Survival.’ For adults they include:  individual actions that must be strong in 
(EMS) or local emergency response system  Immediate recognition of cardiac arrest  order for a person to survive a sudden 
• Early bystander CPR  and activation of the emergency  cardiac arrest. The addition of the fifth link, 
• Early delivery of a shock with a defibrillator  response system  integrated post‐cardiac arrest care, further 
• Early advanced life support followed by  Early CPR that emphasizes chest  emphasizes the additional dependence on 
post resuscitation care delivered by  compressions  longer‐term care for long‐term survival. 
healthcare providers.”  Rapid defibrillation if indicated  
  Effective advanced life support  
  Integrated post– cardiac arrest care 
   
   
   
  (Travers, et al. Circulation. 2010;122;S676‐
Team Approach  “When multiple rescuers are present, they  “The intent of the algorithm is to present  Some resuscitations start with a lone rescuer 
should rotate the compressor role about  the steps of BLS in a logical and concise  who calls for help, whereas other 
every 2 minutes. The switch should be  manner that is easy for all types of rescuers  resuscitations begin with several willing 
accomplished as quickly as possible (ideally  to learn, remember and perform. These  rescuers. Training should focus on building a 
in less than 5 seconds) to minimize  actions have traditionally been presented as  team and performing tasks simultaneously 
interruptions in chest compressions.”  a sequence of distinct steps to help a single  as each rescuer arrives, or on designating a 
  rescuer prioritize actions. However, many  team leader if multiple rescuers are present. 
  workplaces and most EMS and in‐hospital 
  resuscitations involve teams of providers 
  who should perform several actions 
  simultaneously (e.g.: one rescuer activates 
  the emergency response system while 
  another begins chest compressions, and a 
  third either provides ventilations or retrieves 
  the bag‐mask for rescue breathing, and a 
  fourth retrieves and sets up a defibrillator).”  
   
   
(Circulation. 2005;112:IV‐12‐IV‐17)  S705)  
20| P a g e  
 
BLS Termination   “Rescuers who start BLS should continue  “Rescuers who start BLS should continue  The BLS termination of resuscitation rule can 
until one of  the following occurs:  resuscitation until one of the following  reduce the rate of hospital transport to 37% 
Restoration of effective, spontaneous  occurs:  of cardiac arrests without compromising the 
circulation and ventilation.  Restoration of effective, spontaneous  care of potentially viable patients. 
Care is transferred to a more senior‐ circulation 
level emergency medical professional  Care is transferred to a team providing 
who may determine that the patient is  advanced life support 
unresponsive to the resuscitation  The rescuer is unable to continue 
attempt.  because of exhaustion, the presence of 
Reliable criteria indicating irreversible  dangerous environmental hazards, or 
death are present.  because continuation of the 
The rescuer is unable to continue  resuscitative efforts places others in 
because of exhaustion or the presence  jeopardy 
of dangerous environmental hazards or  Reliable and valid criteria indicating 
because continuation of resuscitative  irreversible death are met, criteria of 
efforts places other lives in jeopardy.  obvious death are identified, or criteria 
A valid DNAR order is presented to  for determination of resuscitation are 
rescuers.”  met. 
  One set of reliable and valid criteria for 
  termination of resuscitation is termed the 
  ‘BLS termination of resuscitation’ Rule:  
  1. Arrest was not witnessed by EMS 
  provider or first responder 
  2. No return of spontaneous circulation 
  (ROSC) after 3 full rounds of CPR and 
  automated external defibrillator (AED) 
  analysis 
  3. No AED shocks were delivered.” 
   
21| P a g e  
 

TABLE 6 Healthcare Provider Pediatric BLS
Child and Infant  “Push fast; push at a rate of approximately  “Push fast; push at a rate of at least 100  It has been found that higher survival rates 
Compression Rate  100 compressions per minute.”  compressions per minute.”  are associated with an increase in the 
    number of compressions provided per 
    minute.  
   
Child Compression  “‘Push hard’: push with sufficient force to  “The following are characteristics of high‐ Research indicates there is a common 
Depth  depress the chest approximately one third  quality CPR: Chest compressions of  tendency for CPR providers to not compress 
to one half the anterior‐posterior diameter  appropriate rate and depth. ‘Push fast‘: push  deep enough, even with the emphasis to 
of the chest.”  at a rate of at least 100 compressions per  "push hard."  
  minute. ‘Push hard’: push with sufficient 
  force to depress at least one third the 
  anterior‐posterior (AP) diameter of the chest 
  or approximately 1 ½ inches (4 cm) in infants 
  and 2 inches (5 cm) in children (Class I, LOE 
  C).” 
   
Infant  “‘Push hard’: push with sufficient force to  “The following are characteristics of high‐ Research indicates there is a common 
Compression  depress the chest approximately one third  quality CPR: Chest compressions of  tendency for CPR providers to not compress 
Depth  to one half the anterior‐posterior diameter  appropriate rate and depth. ‘Push fast’: push  deep enough, even with the emphasis to 
of the chest.”  at a rate of at least 100 compressions per  "push hard."  
  minute. ‘Push hard’: push with sufficient 
  force to depress at least one third the 
  anterior‐posterior (AP) diameter of the chest 
  or approximately 1 ½ inches (4 cm) in 
  infants and 2 inches (5 cm) in children (Class 
  I, LOE C).” 
   
22| P a g e  
 
TABLE 6 Healthcare Provider Pediatric BLS
Child and Infant  “While maintaining an open airway, take no  “If the victim is unresponsive and breathing  There is a high likelihood of agonal, or 
Breathing  more than 10 seconds to check whether the  (or only gasping), begin CPR. Sometimes  irregular gasping, breaths occurring early in 
Assessment  victim is breathing: Look for rhythmic chest  victims who require CPR will gasp, which  cardiac arrest. These reflex actions make the 
and abdominal movement, listen for exhaled  may be misinterpreted as breathing. Treat  recognition of cardiac arrest confusing for 
breath sounds at the nose and mouth, and  the victim with gasps as though there is no  rescuers who have never seen them before. 
feel for exhaled air on your cheek. Periodic  breathing and begin CPR.”  Simplifying the breathing assessment to 
gasping, also called agonal gasps, is not    looking for no breathing or only gasping is 
breathing.”    intended to help rescuers respond more 
  (Berg, et al. Circulation. 2010;122;S862‐ quickly with chest compressions and CPR. 
(Circulation. 2005; 112: IV156‐IV166)  S875)   
Child and Infant  For an unresponsive child who is not  For an unresponsive child who is not  The recommended sequence for children 
CPR Sequence   breathing or not breathing normally, begin  breathing or not breathing normally, begin  and infants is the same as the adult to help 
CPR by opening the airway and giving 2  CPR with 30 compressions followed by  simplify learning. Ventilations are very 
rescue breaths followed with 30 chest  opening the airway and giving 2 rescue  important in child or infant CPR. It is not 
compressions. Repeat cycles of 30:2 (ABC  breaths. Repeat cycles of 30:2 (CAB  known whether starting with compressions 
method).  method).  or breaths makes a difference in the 
    outcome. Starting CPR with compressions 
    should only delay rescue breaths about 18 
(Summary from Circulation. 2005; 112:  (Summary from Berg, et al. Circulation.  seconds. 
IV156‐IV166)   2010;122;S862‐S875) 
Use of an AED on  “There is insufficient data to make a  “Many AEDs have high specificity in  AEDs designed to be used on adults have 
an Infant  recommendation for or against the use of  recognizing pediatric shockable rhythms,  been successful when used on infants with 
AEDs for infants 1 year of age (Class  and some are equipped to decrease (or  out‐of‐hospital cardiac arrest when coupled 
Indeterminate).”  attenuate) the delivered energy to make  with bystander CPR. Minimal heart muscle 
  them suitable for infants and children < 8  damage and good neurological outcomes 
  years of age. For infants a manual  were reported. 
  defibrillator is preferred. If a manual 
  defibrillator is not available, an AED 
  equipped with a pediatric attenuator is 
  preferred for infants. If neither is available, 
  an AED without a dose attenuator may be 
  used (Class IIb, LOE C).” 
   
(Circulation. 2005; 112: IV35‐IV46)  (Link, et al. Circulation. 2010;122;S706‐S719) 
23| P a g e  
 

HSI Advisory Group
HSI’s interpretations of the most significant recent changes to emergency care science and instruction included review 
and input of HSI’s Medical Director, Chief Learning Officer, Medical Board, Program Advisory Groups, and professional 
staff. 
 
HSI Medical Director 
Gregory R. Ciottone, M.D, FACEP 
 
HSI Chief Learning Officer 
Jeffrey T. Lindsey, PhD, PM, CFOD, EFO 
 
HSI Medical Board  
Barbara Aehlert, RN, BSPA 
Richard Abraham, M.D. 
Gregory R. Ciottone, M.D  
Raymond Jarris, M.D.  
Marvin Wayne, M.D.  
 
ASHI and Medic First Aid Program Advisory Group 
Jimmy W. Allen 
Kim Dennison, RN, BSN, COHN‐S, ACLS 
Bradford A. Dykens, EMT‐P 
Howard Main, CCEMTP 
John F. Mateus RN, EMT‐B 
Kira A. Miller, EMT‐B 
Mark Register, EMT‐P  
W. Daniel Rosenthal R.N., B.S. 
Tana Sawzak, EMT‐B 
Marcy Thobaben, LPN, EMT‐B 
 
HSI Professional Staff 
William Clendenen 
Ralph Shenefelt 
William Rowe 
Corey Abraham 
Jeff Myers 

                                                             
i
Hazinski  MF,  Nolan  JP,  et  al.,  Circulation.  2010;122  [suppl  2]:  Part  1‐12,  S250  –  S581.  ©  2010  American  Heart  Association®,  Inc., 
European Resuscitation Council, and International Liaison Committee on Resuscitation. 
ii
Markenson  D,  Ferguson  JD,  et  al.,  Circulation.  2010;122  [suppl  2]:Part  13,  S582–S605.  ©  2010  American  Heart  Association®,  Inc., 
and American Red Cross. 
iii
Field JM, Hazinski MF, et al., Circulation. 2010;122 [suppl 3]:Part 1‐16, S640‐ S933.© 2010 American Heart Association®, Inc.  
iv
Markenson D, Ferguson JD, et al., Circulation. 2010;122 [suppl 3]:Part 17, S934 –S946. © 2010 American Heart Association®, Inc., 
and American Red Cross. 
24| P a g e  
 

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