Emergency First Response Article Excerpts

from PADI Training Bulletins 1Q 2010 – 1Q 2019

If you wish to obtain the complete versions of PADI Training Bulletins
(2010 – 2019), please contact your Regional Training Consultant
First Quarter 2010
EFR Instructor Prerequisites Standards change:
Revise EFR Instructor prerequisite to read:
1. EFR Primary and Secondary Care (or qualifying training) within the past 24 months.
2. 18 years old.

Fourth Quarter 2010

EFR Meets Workplace Requirements in Two Canadian
Provinces
Effective immediately, EFR instructors using the Canadian EFR materials can teach EFR
workplace programs in the Canadian provinces of Alberta and Newfoundland and Labrador

Additional Accreditations
In Switzerland EFR Training recognized as meeting first Aid and CPR requirements for drivers
license.

First Quarter 2011

New CPR Guidelines for EFR and PADI courses
European Resuscitation Council Changes

New Guideline Old Guideline Rationale for Change

When obtaining help, ask
someone to call for an
ambulance and to bring an
automated external
defibrillator
(AED), if one is available
Compress adult chest to at
least 5 cm at a rate of at least
100 compressions per minute
Compress infant chest to
approximately 4 cm and child
chest to approximately 5cm at
a rate of 100-120 compressions
per minute
To minimise interruptions in
chest compressions, if there is
more than one rescuer present,
continue CPR while the AED is
switched on and the pads are
When obtaining help, ask for
someone to call for an
ambulance
Compress adult chest 4-5 cm
and a rate of 100 compressions
per minute
Compress infant or child chest
to approximately one third
the depth of the chest at 100
compressions per minute
No reference to continuing
chest compressions while
preparing the AED
With more AEDs in public
places, it’s common to have
one accessible when
administering
CPR
Emphasis is on good quality
chest compressions with an
attempt to reduce the number
and duration of pauses during
compressions
Emphasis is on providing
quality compressions of an
adequate depth
Emphasis is on reducing the
number and duration of pauses
during chest compressions
being placed on the patient
American Heart Association Changes
New Guideline
No “Look, listen, and feel” for
breathing
Begin CPR by providing 30
chest compressions, then
open the airway and give two
breaths.
If you suspect possible
drowning, begin CPR with
rescue breaths before chest
compressions
Compress adult chest to a
depth
of at least 2 inches
(5 cm)
Compression depth for
children and infants is one third
the diameter of the chest. This
corresponds to approximately
2 inches (5cm) for children and
1ó inches (4cm) for infants
Give compressions at a rate of
at least 100 per minute
To minimize interruptions in
chest compressions, if there is
more than one rescuer present,
continue CPR while the AED is
switched on and the pads are
being placed on the patient
For infants (less than 1 year
of age) use of an AED with
pediatric dose reducer is
recommended.
An AED without a
dose attenuator may be used if
a pediatric one is not available.
Reduced emphasis on barrier
use when providing CPR.
Although still recommended,
treatment should not be
delayed if barriers are not
available.
Old Guideline
“Look, listen and feel” for
breathing before administering
rescue breaths and chest
compressions
Give two rescue breaths prior
to giving 30 chest compressions
Compress adult chest to a
depth of 1ó to 2 inches
Administer chest compressions
at one third to one half of the
diameter of the chest for child
and infant CPR
Give compression at a rate of
approximately 100 per minute
No reference to continuing
chest compressions while
preparing the AED
AED use for infants (less than
1 year of age) was not
recommended
Emphasized use of barriers
Rationale for Change
Minimize the delay in
providing chest compressions
Existing oxygen in the lungs
and in the circulatory system is
sufficient to provide
immediate benefits provided by
chest compressions
Emphasis is on providing good
quality chest compressions
with sufficient depth to provide
adequate circulation
Emphasis is on providing
quality compressions of an
adequate depth
Emphasis is on good quality
chest compressions at a rate to
provide adequate circulation
Emphasis is on reducing the
number and duration of pauses
during chest compressions
Use of AED on infants has
shown to be effective
Research has shown that
disease transmission is very
rare when providing CPR
AHA First Aid Changes
Allergic Reactions
• For patients carrying an epinephrine kit, help patient use it following directions. If
symptoms of anaphylaxis persist despite epinephrine administration, seek medical
assistance before administering a second dose of epinephrine. In unusual circumstances,
when advanced medical assistance is not available, a second dose of epinephrine may be
given if symptoms of anaphylaxis persist.

Heart Attack
• Advise the patient to chew one adult (nonenteric- coated) or two low dose aspirins, if the
patient is complaining of chest pains and does not have a history of allergy to aspirin and no
recent gastrointestinal bleeding. This may be performed after activating the EMS system.

Venomous Bites and Stings

• For snake bites, apply a pressure immobilization bandage around the entire length of the
bitten extremity. This is an effective and safe way to slow the dissemination of venom. Care
must be taken to ensure the pressure bandage is not too tight. You should be able to slide a
finger under the bandage.

• Treat jellyfish stings by liberally washing the affected area with vinegar (4-6% acetic acid
solution) for at least 30 seconds to inactivate venom and prevent further envenomation.
After the nematocysts are removed or deactivated, treat pain with hot-water immersion
when possible.

Second Quarter 2011

Q. Is rescue breathing still a part of CPR in EFR courses?

A. Yes. For laypeople, the recommendations still include teaching compressions with rescue
breathing. While compression-only CPR is better than no CPR, it is a recommended
procedure for untrained lay rescuers, or trained rescuers who choose not to provide rescue
breaths.

EFR First Aid at Work (Asia Pacific edition) Changes

The Australian Resuscitation Council flow chart for Basic Life Support now includes S for
Send for help – DRSABCD. Therefore, the EFR First Aid at Work (FAW) Patient’s LIFELINE now
is as follows:
D = Danger?
R = Responsive?
S = Send for Help
A = Airway Open?
B = Breathing Normally?
C = Start CPR! Compressions first, then breaths (30:2)
D = Defibrillation
 ILCOR Organizations Publish Guidelines:
Australian Resuscitation Council and New Zealand
Resuscitation Council CPR Changes
New Guideline
Emergency priorities state that
the rescuer must “send for
help”
Lower half of sternum should
be
depressed by 1/3 chest depth
with each compression. This
is more than 5 cm in adults,
approximately 5 cm in children
and 4 cm in infants.
New focus on maintenance of
CPR quality including
recommendations
to change rescuers
every 2 minutes to decrease
rescuer fatigue and maintain
depth and rate of
compressions.
Automated External
Defibrillators
(AEDs) has made defibrillation
part of basic life support.
AEDs can accurately identify
cardiac rhythm as “shockable”
or “nonshockable.”
In victims who need
resuscitation,
bystander CPR dramatically
increases the chance of
survival. It rarely leads to harm
in victims who are eventually
found not to have suffered
cardiac arrest: bystander CPR
should be actively encouraged.
CPR skills should be refreshed
at least annually.
BLS Flowchart
Steps in resuscitation are:
DRSABCD
D – check for Danger
R – check for Response
S – Send for help (added)
A – open the Airway
B – check Breathing but no
need to deliver two rescue
Old Guideline
Emergency priorities state that
the rescuer must “call for help”
Lower half of sternum should
be
depressed by 1/3 chest depth
with each compression. This is
at least 4-5 cm in adults.
NONE
The Australian Resuscitation
Council (ARC) recommends the
use of an AED if available
NONE
ARC recommends that all those
trained in CPR undertake at
least an annual competency
assessment in CPR
BLS Flowchart
Steps in resuscitation are:
DRABCD
D – check for Danger
R – check for Response
A – open the Airway
B – deliver two rescue Breaths
C – perform 30 Compressions
on victims who are
Rationale for Change
Minimize the delay in
providing chest compressions
Emphasis is on providing
quality compressions of an
adequate depth.
Emphasis is on good quality
chest compressions.
Recognizes the role of AEDs as
part of BLS in both out of
hospital
and in hospital environments.
Clear recommendations
that training in AED use should
be part of BLS education.
Increase emphasis on bystander
CPR as lifesaving intervention.
Recommendation to refresh
CPR skills at least annually (as
opposed to undertake annual
competency assessment).
CPR starts with compressions
rather than breaths for
unresponsive/ not breathing
normally patients. Emphasis is
on minimizing chest
compression delay.
Facilitates compression-only
CPR for those unable/unwilling
to perform rescue breaths.
breaths unresponsive
C – perform 30 Compressions and not breathing
on victims who are normally, followed by two
unresponsive breaths
and not breathing D – attach an AED if it is
normally, followed by two available
breaths
D – attach an AED as soon as it
is available

Third Quarter 2011

The traditional ABCs order of priority care has been adjusted to AB-CABS

First Quarter 2012

Primary and Secondary Care Participant Exam Answer Key
Changes
The EFR Primary and Secondary Care Participant Exam answer key (Product No. 71827 v1.0)
errors have been corrected, and a revised version of the exam key (v1.01) is available for
download from the PADI Pros’ Site and the EFR Instructor site.

Primary Care Exam

Question 4 – answers should be A, C and D
Question 8 – answer should be False
Question 13 – answers should be A and D

Secondary Care Exam

Question 3 – answers should be A and C
Please contact an Educational Consultant at your
PADI Regional Headquarters if you have any questions.

Exam and Form Changes

Please correct question 1 of the EFR Instructor Course Exam answer key (Product
No. 71852 v1.0) – mark Option A as a correct answer as well.

Making this correction updates the answer key to v1.01. EFR Instructor Trainers can order an
updated Instructor Course Exam Answer Keys (v1.01) from your PADI Regional
Headquarters.

EFR Primary and Secondary Care Participant Final Exam

Please correct the typographical error on page 6, question 1, answer option a of the EFR
Primary and Secondary Care Participant Exam (Product No. 71825 v1.0):
“Heart attack or sudden cardiac arrest” Change “attach” to “attack.”

Second Quarter 2012

Care for Children
It may be conducted as a stand-alone course or may be integrated with the Primary Care
(CPR) and Secondary Care (First Aid) courses to prepare participants to assist people of all
ages.

First Quarter 2014

Shift to Annual Renewal Cycle
Historically, the EFR® professional credential renewal cycle has been every two years, while
PADI Membership is renewed annually. To make things simpler and more streamlined for
you, EFR Instructor and Instructor Trainer credential renewals are transitioning to an annual
cycle, aligned with PADI’s membership renewal cycle.

Update Your EFR Materials

Change the following EFR renewal references from “every two years” to “every year:”

Emergency First Response Instructor Trainer Guide “Course Overview and Standards”

Section heading: “Emergency First Response Instructor Renewal,” first paragraph.

Section heading: “Instructor Trainer Qualifications and Renewal,” sub heading
“Renewal Requirements,” first paragraph.

“Appendix”
EFR Instructor Course Exam: question 42, answer “C.”

Emergency First Response Primary & Secondary Care Instructor Guide

“Course Overview and Standards” Section heading: “Emergency First Response
Instructor Renewal,” first paragraph.

EFR Instructor Course Exam booklet Question 42, answer “C.”

Second Quarter 2014

EFR Materials Requirement Change
You’ve always had the option of combining the Emergency First Response (EFR) Primary and
Secondary Care Course with the Care for Children program. If you are teaching both
programs, combining them saves time, because many guidelines for adults are the same for
children. Up until now, students have been required to have both participant manuals.
Effective immediately, you have the option of offering the Care for Children course in
conjunction with your Primary Care (CPR) and/or Secondary Care (First Aid) course using
only the Emergency First Response Primary and Secondary Care Participant Manual.

When combining these two programs using the one manual, you must use the Knowledge
Development Outlines from the Care for Children Instructor Guide to elaborate on necessary
information specific to the care of children and infants. Then, incorporate the Care for
Children Skills and Scenario Practice as outlined in the recommended sequence for teaching
both courses combined found in the EFR Care for Children Instructor Guide. Upon
completion of all performance requirements, you fill out the Course Completion
Authorization, marking that the student has completed Primary Care (CPR) and Secondary
Care (First Aid) and Care for Children courses.

Please note this change in Section One of the Emergency First Response Care for Children
Instructor Guide, Course Overview and Standards, first paragraph under “Integrating
Emergency First Response Courses,” second sentence. It should now read: “The Primary and
Secondary Care Participant Manual is required when teaching the combined courses,
however, both manuals are recommended.”

Fourth Quarter 2014

Emergency First Response (EFR®) Compressions-Only CPR
Program
Over the last few years, many articles have been published about the benefits of
compression-only (or “hands-only”) CPR. This technique involves providing continuous chest
compressions, without stopping to provide ventilations. Compression-only CPR can
effectively circulate unused oxygen left in the patient’s lungs and blood stream to the vital
organs of the body.

Effective immediately, EFR Instructors can now offer Compression-only CPR training using
the current CPR & AED Participant Manual and instructor guide.

First Quarter 2016

New CPR Guidelines for EFR and PADI Courses
Member organizations of the International Liaison Committee on Resuscitation (ILCOR) have
begun
to release new cardiopulmonary resuscitation (CPR) and emergency cardiovascular care
(ECC) guidelines.
Emergency First Response® (EFR) and PADI courses follow these guidelines and
implement changes whenever protocols are revised. The latest updates from ILCOR indicate
relatively small changes to the way CPR and first aid is conducted by lay-people; this is a
reflection of the success of CPR in modern times. Please update your Emergency First
Response courses to including the following information:

CPR
✦Perform chest compressions at a rate of 100 – 120 per minute for adult, child, and
infant.
✦Perform compressions to a depth of 5 centimetres/2 inches for an average adult while
avoiding excessive chest compression depths (greater than 6 centimetres/2.4 inches).
✦Do not interrupt chest compressions for more than 10 seconds.
✦Always call EMS immediately for anyone with chest pain or other signs of a heart attack,
rather than trying to personally transport the person to a healthcare facility.

The use of mannequins that provide feedback on depth and rate of compressions is now
encouraged.
However, other mannequin types are still acceptable. Also, consider using auditory
guidance (metronome or music) to improve compression rate.

Diabetic Problems (low blood sugar, hypoglycemia)

✦If a person with diabetes reports low blood sugar or exhibits signs or symptoms of mild
hypoglycemia
and is able to follow simple commands and swallow, oral glucose should be given to
attempt to resolve the hypoglycemia. If these tablets are not available, you may provide the
patient with fruit juice, soda or candy if available.
✦Symptoms may not resolve until 10 to 15 minutes after ingesting glucose tablets or dietary
sugars.
Emergency responders should wait at least 10 to 15 minutes before calling EMS and
retreating a diabetic with additional oral sugars. If the diabetic’s status deteriorates during
that time or does not improve, call EMS.

Serious bleeding
✦A tourniquet may now be considered for initial care when an emergency provider is
unable to use direct pressure to control bleeding, such as during a mass casualty incident,
with a person who has multisystem trauma, in an unsafe environment, or with a wound that
can’t be accessed. Tourniquets can be effective for severe external limb bleeding.
✦Note the time that a tourniquet is first applied and communicate this information to EMS
providers.
Tourniquets use in the prehospital setting have been found to control bleeding effectively in
most cases and have a low rate of complications.

Burns
✦If cool or cold water is not available, a clean cool or cold but not freezing, compress can
be useful as a substitute for cooling burns. Care should be taken to monitor for
hypothermia when cooling large burns.

You can implement these changes into your course immediately. The required
implementation is no later than 31 March 2016. To keep EFR and PADI courses current and
internationally applicable, course materials are being revised to reflect these recent
guidelines.
To assist you in updating your EFR knowledge and teaching techniques, you’ll find a
series of pre-recorded webinars that are free of charge and available in a range of languages
on the EFR and PADI Pros’ Sites.
As other resuscitation council national guidelines are released, you will find more
detailed information about them and how they apply to EFR and PADI courses in The
Responder.
For detailed references, see the full 2015 American Heart Association Guidelines for
CPR and ECC and the ILCOR document in the journal Circulation at
circ.ahajournals.org/content/132/16_suppl_1.toc, and view the ERC Guidelines 2015 at
www.cprguidelines.eu/.

Second Quarter 2016

EFR Guidelines 2015 Update Australia and New Zealand
Following the release of the 2015 guidelines for CPR and emergency cardiovascular care by
the International Liaison Committee on Resuscitation (ILCOR) the Australian and New
Zealand Committee on Resuscitation (ANZCOR) released its new guidelines mid-January
2016. These now replace all earlier existing Australian and New Zealand Resuscitation
Council guidelines and are endorsed by both councils.
With this new release, the only change to ANZCOR basic life support guidelines is
related to the rate of chest compressions, which changed from approximately 100 to a range
of 100 - 120 compressions per minute.
For detailed references on the new ANZCOR guidelines please refer to resus.org.au
when teaching in Australia and to nzrc.org.nz when teaching in New Zealand.
 As announced in First Quarter 2016 Training Bulletin, PADI, EFR and RTO materials
are being revised to reflect all recent changes. Remember, the required implementation
date of all new CPR and first aid guidelines was no later than 31 March 2016.

Third Quarter 2016

New Emergency First Response® Instructor Guide
Errata Available
Make sure that your Emergency First Response (EFR) Instructor Guides are up-to-date by
referencing the
2016 errata document on the EFR and PADI Pros’ Site. This document outlines changes to
the instructor
guides resulting from ILCOR Guidelines 2015. Related updates to the English version
Emergency
First Response Primary and Secondary Care student manuals are available now. The EFR
Quick Reference Card, Care for Children manual and CPR/AED manuals will be updated soon.

Fourth Quarter 2016

Q. Emergency First Response® (EFR®) courses mention that if for some reason an
emergency responder can’t or won’t provide rescue breaths in a real emergency requiring
CPR, giving compressions alone may still help. How does that relate to CPR given for
drowning victims?
A. Giving rescue breaths is emphasized for drowning victims. Because lack of breathing due
to drowning is often suspected in dive accidents, rescue breathing remains a key skill in diver
rescue. The PADI Rescue Diver course teaches divers to provide in water rescue breaths, and
once on a stable platform, to start CPR – including both rescue breaths and compressions to
aid non-breathing dive accident victim. In many countries, protocol for suspected drowning
is immediate CPR if possible; giving breaths first, followed by chest compressions.
Following base ILCOR recommendations, in other countries the local ILCOR
representatives emphasize the need for rescue breathing with suspected drowning, but do
not specify starting CPR with breaths. Experts in the medical community don’t agree on how
important giving breaths first is in drowning cases, but virtually all agree that beginning CPR
(breaths and compressions) as soon as possible is important.
Giving chest compressions with rescue breaths continues to be the standard of care
(best chance for successful outcome) for layperson CPR, which is why both skills are taught
as a two-step CPR process in EFR courses. In any emergency with a non-breathing patient,
giving chest compressions alone is not ideal, but if for some reason the rescuer can’t, or has
fears about giving rescue breaths, then giving chest compressions alone is still considered
beneficial.

Second Quarter 2018

United States Coast Guard Renews EFR® Recognition
Soon after Emergency First Response released the Primary and Secondary Care program in
2002, the United States Coast Guard (USCG) approved it to meet the first aid and CPR
requirement for the USCG merchant mariner licensure. To maintain this approval, the USCG
requires a program review every five years. The result of this re-evaluation extended USCG
approval of EFR Primary and Secondary Care courses another five years to 28 February 2023.
To meet merchant mariner licensure requirements, Primary and Secondary Care
training needs to be completed within one year of merchant mariner application. The
student must be issued a certificate of training containing the following information:
 ⮚ Name and code of the course as First Aid & CPR (Emergency First Response-Primary
and Secondary, code- EMERFR-197)
⮚ Name of the educational institution (Emergency First Response)
⮚ Date of completion and location where the training was conducted
⮚ Name of the student
⮚ Signature of an authorized representative of the school (instructor’s signature)

EFR Certificates (Product No. 40021) may be ordered through your local PADI/EFR Office to
meet this need. EFR Instructors can take advantage of this approval by actively reaching out
to those seeking CPR and first aid training to meet USCG licensure requirements.
In addition to this approval, EFR courses and programs have been rigorously
evaluated
by other respected third party authorities in a number of countries and achieved significant
accreditation and approval. You can review a list of these recognitions at
http://www.emergencyfi rstresponse.com/pros/accreditations.aspx . To learn more about
the United States Coast Guard go to www.uscg.mil.

Third Quarter 2018

EFR Primary and Secondary Care Participant Manual – Korean
Please note the following error in the EFR Primary Care Knowledge Review, Question 17,
page
1-37 of the EFR Primary and Secondary Care Participant Manual – Korean (70370K Rev.
07/17 Version 1.02). The question should correctly ask: “Why is defibrillation important to a
patient with cardiac arrest?” The answer choices and the answer key are correct.

Please make sure your students are aware of the correct text for this question, which, in
Korean, should read:

The manual will be corrected upon reprint.

Fourth Quarter 2018 RRECTIONS

ILCOR CONSENSUS MARCH 2018
Emergency First Response and PADI courses keep pace with current research and treatment
recommendations in emergency care. The most recent news indicates that no changes to
CPR procedures are necessary in EFR courses. After reevaluation of science and research,
the International Liaison Committee on Resuscitation’s (ILCOR) most recent Consensus on
Science and Treatment Recommendations do not include any changes to bystander CPR.
ILCOR reaffirmed three areas of bystander treatment as published in the journal,
Resuscitation 121 (2017) 201-214:

● We continue to recommend that bystanders perform chest compressions for all

patients in cardiac arrest. We suggest that bystanders who are trained, able, and
willing to give rescue breaths and chest compressions do so for all adult patients in
cardiac arrest.
 ● We suggest a compression/ventilation (CV) ratio of 30:2 compared with any other CV
ratio in patients with cardiac arrest.
● We suggest that bystanders provide CPR with ventilation for infants and children less
than 18 years of age with cardiac arrest. We continue to recommend that if
bystanders cannot provide rescue breaths as part of CPR for infants and children
under 18 years of age with cardiac arrest, they should at least provide chest
compressions.

First Quarter 2019

Immediate Feedback Devices in CPR Training
Q. May I use feedback manikins or devices that let students know if their
compression rate and depth is appropriate in EFR® courses?
A. Absolutely. At least one resuscitation council, the American Heart Association,
recommends the use of quality CPR feedback devices to teach adult CPR based on research.

Though CPR skill repetition is essential, there is speculation that the use of feedback devices
may reduce mastery time as participants self-correct in response to the device’s real-time
feedback. ILCOR Guidelines in recent years have re-emphasized compression rate, depth and
recoil, which make these devices an interesting teaching aid for skill mastery evaluation.

The important aspect of using manikins that provide immediate results on compression rate,
depth and recoil in EFR courses is to do so in a reassuring way, so the competent-versus-
perfect philosophy outlined in the EFR Instructor course is not compromised. Keep in mind
that CPR students often feel intimidated by the practical skills and can feel performance
anxiety, particularly when they’re not able to achieve great feedback results right away.

Unless a level of comfort and support is achieved by the instructor in the CPR classroom, the
participant’s ability to learn and retain skills and be willing to offer them in an emergency
can be severely reduced. However, used properly, compression feedback devices are a
teaching tool that can effectively help EFR students bring their practical CPR skills in line with
current compression rate, depth and recoil guidelines. A variety of feedback devices are
available, some built into the manikin, and others can be added to and used with existing
manikins.

If you wish to obtain the complete versions of the Training Bulletins

(2010 – 2019), please contact your local Training Consultant