Emergency First Response® (EFR®) training is continually updated to reflect the latest evidence-based first-aid and resuscitation guidance. For 2026, there are two important updates EFR Instructors should be aware of and incorporate into their training and emergency preparedness.
The first reflects updated international guidance for infant CPR, with the two-thumb-encircling technique now the preferred method for delivering chest compressions during pediatric Basic Life Support (BLS).
The second is an important reminder about Immersion Pulmonary Edema (IPE), a potentially life-threatening condition that can affect divers.
Here’s what EFR Instructors need to know.
Pediatric Basic Life Support Update
The 2025 ILCOR Pediatric Basic Life Support (BLS) Guidelines recommend chest compressions in infants (0-1 year old) to be performed using the two-thumb-encircling technique. This is now the preferred method for delivering CPR in all pediatric BLS situations, and ILCOR Member organizations have adopted this method when carrying out pediatric BLS.
Research has found that the two-thumb-encircling technique provides better systolic and diastolic blood pressure compared to the two-finger method. While the two-thumb-encircling technique is the preferred method for single-rescuer CPR, it is strongly recommended for two-rescuer CPR.
Two-Thumb CPR Technique
To conduct this technique, place both thumbs side by side or overlapping on the lower third of the sternum (just below the nipple line). Wrap both hands around the infant’s chest, with fingers supporting the back.
Compress the sternum to at least one-third the chest depth (approximately four centimetres/1.5 inches) at a rate of 100-120 compressions per minute, using a 30:2 ratio.
During two-rescuer CPR, one will perform chest compressions while the other manages the airway and delivers rescue breaths.
Infant Choking
For an unconscious choking infant with an airway obstruction, chest thrusts should be performed also using the two-thumb-encircling technique.
EFR Instructor and participant materials will be updated to reflect this change. Until then, please implement this change into your EFR training.
Immersion Pulmonary Edema (IPE) – Reminder
Immersion Pulmonary Edema (IPE) is an accumulation of fluid in the air sacs of the lungs (alveoli) caused by immersion in water. IPE is thought to happen when the pressure in the alveoli (in the lungs) is less than the pressure in the surrounding capillaries, causing fluid to fill the alveoli. Too much fluid in the alveoli causes difficulty breathing because gas exchange is impaired, which may result in hypoxia.
IPE is a life-threatening condition. Many people describe it as feeling like their breathing suddenly becomes much harder than it should be. IPE is known to affect swimmers and other water sports enthusiasts, including divers. It can occur in divers who have made many hundreds of dives previously without problems.
The reasons IPE occurs are not always understood, but some of the potential physiological contributors are:
- Heart conditions, high blood pressure and obesity
- Redistribution of fluids
- Cold exposure
- High work of breathing
- Overhydration
- Some medications
- Physical exertion
- Demographics – over 50 years old and/or female
It’s believed that IPE is more likely to occur when several of these factors apply at the same time.
How Do You Prevent IPE?
- Maintain good fitness
- Keep warm during the dive
- Limit gas density
- Avoid overexertion
- Have well-serviced equipment
What Is the Recommended First Aid for IPE?
If you notice a distressed, out-of-breath diver or swimmer and suspect they may be suffering from IPE, have them stop and rest. If they do not show signs of recovery, abort the dive and ascend. At the surface, the diver should exit the water and be given 100 percent oxygen, while you contact emergency medical services (EMS). Conscious divers may feel more comfortable sitting up rather than lying down because it reduces the stress on the heart.
Victims coughing, wheezing or with bloody froth/sputum should be treated according to first-aid protocols, including giving oxygen and calling EMS. Breathing oxygen may provide significant benefits to a diver suffering from IPE in some cases, and it won’t do any harm.
It’s a dive community standard for a dive operation to have emergency oxygen. Ensure that oxygen is available for all training and diving. Provide the patient with the highest concentration of oxygen possible as part of the normal first-aid protocol for divers. Even if a diver seems to recover fully at the surface, a medical professional should provide an assessment, and the diver should not resume diving until receiving medical approval. Divers who don’t appear to recover may also be suffering from an underlying health condition. Do not delay getting the victim to emergency medical assistance.
