https://www.sciencedirect.

com/journal/resuscitation/vol/161/suppl/C

Volume 161, Pages 1-432 (April 2021) ISSN: 0300-9572

Official Journal of the European Resuscitation Council
also affiliated with the American Heart Association, the Australian Resuscitation Council, the New Zealand
Resuscitation Council, the Resuscitation Council of Southern Africa and the Japan Resuscitation Council

EDITOR-IN-CHIEF: Jerry P. Nolan, Bath, UK

EDITORS: Joseph P. Ornato, Richmond, Virginia, USA
Michael Parr, Sydney, Australia
Gavin D. Perkins, Warwick, UK
Jasmeet Soar, Bristol, UK

EDITOR EMERITUS: Douglas Chamberlain, Brighton, UK

EDITORIAL BOARD

Benjamin Abella (USA) Hans Domanovits (Austria) Vincent Mosesso (USA)

Cristian Abelairas-Gomez (Spain) Michael Donnino (USA) Vinay Nadkarni (USA)
Lars Andersen (Denmark) Judith Finn (Australia) Ziad Nehme* (Australia)
Anders Aneman (Denmark) Martina Fiori* (UK) Robert Neumar (USA)
Richard Arntz (Germany) Hans Friberg (Sweden) Mauro Oddo (Switzerland)
Tom P. Aufderheide (USA) Cornelia Genbrugge (Belgium) Theresa Olasveengen (Norway)
Charles Babbs (USA) Romergryko Geocadin (USA) Andrew Padkin (UK)
Wayne Barbee (USA) Corina de Graaf** (The Netherlands) Mary Ann Peberdy (USA)
Tomás Barry* (UK) Ximena Grove (Chile) Timothy Rainer (Hong Kong)
Ben Beck (Australia) Kyle Gunnerson (USA) Joshua Reynolds (USA)
Lance B. Becker (USA) Alfred Hallstrom (USA) Guy Rutty (UK)
Robert Berg (USA) Anthony J. Handley (UK) Claudio Sandroni (Italy)
Farhan Bhanji (Canada) Kirstie Haywood (UK) Kelly Sawyer (USA)
Leo Bossaert (Belgium) Johan Herlitz (Sweden) Markus Skrifvars (Finland)
Martin Botha (South Africa) Karl B. Kern (USA) Karen Smith (Australia)
Bernd Böttiger (Germany) Rudi W. Koster (The Netherlands) Kjetil Sunde (Norway)
Janet Bray (Australia) Peter Kudenchuk (USA) Sergio Timerman (Brazil)
Clif Callaway (USA) Freddy Lippert (Denmark) Joseph Varon (USA)
Alain Cariou (France) Andrew Lockey (UK) Myron L. Weisfeldt (USA)
Pierre Carli (France) David Lockey (UK) Lars Wiklund (Sweden)
Maaret Castrén (Finland) Carsten Lott (Germany) Myra H. Wyckoff (USA)
Sheldon Cheskes (Canada) Matthew Huei-Ming Ma (Taiwan) G. Bryan Young (Canada)
David C. Cone (USA) Spyros Mentzelopoulos (Greece) Kai Zacharowski (Germany)
Keith Couper (UK) Koen Monsieurs (Belgium) David Zideman (UK)
Tobias Cronberg (Sweden) Peter Morley (Australia)
Charles Deakin (UK) Laurie Morrison (Canada)
Alan De Caen (Canada) Marion Moseby-Knappe** (Sweden)

STATISTICAL ADVISOR
Robin Prescott (UK)

* Young Investigator, Ljubljana, 2019

** Young Investigator, 2020

AMSTERDAM—BOSTON—LONDON—NEW YORK—OXFORD—PARIS—SAN DIEGO—ST. LOUIS

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Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Executive summary

Gavin D. Perkins a,b, * , Jan-Thorsen Gräsner c , Federico Semeraro d ,

Theresa Olasveengen e , Jasmeet Soar f , Carsten Lott g , Patrick Van de Voorde h,i ,
John Madar j , David Zideman k , Spyridon Mentzelopoulos l , Leo Bossaert m ,
Robert Greif n,o , Koen Monsieurs p , Hildigunnur Svavarsdóttir q,r , Jerry P. Nolan a,s ,
on behalf of the European Resuscitation Council Guideline Collaborators 1
a
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
b
University Hospitals Birmingham, Birmingham, B9 5SS, UK
c
University Hospital Schleswig-Holstein, Institute for Emergency Medicine, Kiel, Germany
d
Department of Anaesthesia, Intensive Care and Emergency Medical Services, Maggiore Hospital, Bologna, Italy
e
Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
f
Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
g
Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany
h
Department of Emergency Medicine, Faculty of Medicine Ghent University, Ghent, Belgium
i
EMS Dispatch Center, East-West Flanders, Federal Department of Health, Belgium
j
Department of Neonatology, University Hospitals Plymouth, Plymouth, UK
k
Thames Valley Air Ambulance, Stokenchurch, UK
l
National and Kapodistrian University of Athens Medical School, Athens, Greece
m
University of Antwerp, Antwerp, Belgium
n
Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
o
School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
p
Department of Emergency Medicine, Antwerp University Hospital and University of Antwerp, Belgium
q
Akureyri Hospital, Akureyri, Iceland
r
University of Akureyri, Akureyri, Iceland
s
Royal United Hospital, Bath BA1 3NG, UK

Abstract
Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021
European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The
guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support,
resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education.

includes producing up-to-date evidence-based European guidelines

Introduction for the prevention and treatment of cardiac arrest and life threatening
emergencies.
The European Resuscitation Council (ERC) objective is to preserve The first ERC guidelines were presented in Brighton in 1992 and
human life by making high quality resuscitation available to all.1 This covered basic2 and advanced life support.3 In 1994, Guidelines for

* Corresponding author.
E-mail address: g.d.perkins@warwick.ac.uk (G.D. Perkins).
1
See Appendix A.
https://doi.org/10.1016/j.resuscitation.2021.02.003

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
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Paediatric Life Support (PLS)4 and Guidelines for the Management of
Peri-arrest Arrhythmias5 followed at the second Congress in Mainz,
with Guidelines for the Basic and Advanced Management of the
Airway and Ventilation during Resuscitation at the third Congress in
Seville in 1996,6 and updated Guidelines at the 4th Scientific
Congress of the ERC in Copenhagen in 1998.7,8 In 2000, international
guidelines were produced in collaboration with the International
Liaison Committee on Resuscitation (ILCOR)9 which the ERC went on
to summarise in 2001.10 After this, ERC guidelines were produced
every 5 years: 2005,11 201012 and 2015.13 From 2017 the ERC has
published annual updates14,15 linked to the publications of ILCOR
Consensus on Science and Treatment Recommendation (CoSTR)
publications.16,17 In 2020, guidelines were published covering
resuscitation in the context of coronavirus disease 2019 (COVID-
19).18 These 2021 ERC Guidelines present a major update on
resuscitation science and provide the most up to date evidence-based
guidelines for by laypersons, healthcare providers and those
responsible for health policy across Europe.
International Liaison Committee on Resuscitation
ILCOR exists to save more lives globally through resuscitation.19,20
This vision is pursued through promoting, disseminating and
advocating for international implementation of evidence-informed
resuscitation and first aid, using transparent evaluation and consen-
sus summary of scientific data. The ERC as one of the founding
members of ILCOR and continues to work closely with ILCOR in
pursuit of those goals.
A key activity of ILCOR is the systematic assessment of evidence to
produce international consensus on science with treatment recommen-
dations. Produced initially every 5 years, ILCOR transitioned to a
continuous evidence evaluation in 2017. The 2020 CoSTR was published
in October 2020 and comprises 184 structured reviews of resuscitation
science21
29 which inform the ERC Guidelines presented here.
Guideline development process
Healthcare systems rely increasingly on high-quality, evidence-
informed clinical practice guidelines. As the influence of such
guidelines has grown and the rigour of the evidence evaluation
process informing the content of guidelines has increased, attention
has turned to raising the standards and transparency for the guideline
development process.30
The Institute of Medicine established quality standards for clinical
practice guidelines in 2011,31 shortly followed by the Guidelines
International Network.32 The ERC Guidelines followed the principles
for guideline development developed by the Guidelines International
Network.32 This includes guidance on panel composition, decision-
making process, conflicts of interest, guideline objective, develop-
ment methods, evidence review, basis of recommendations, ratings of
evidence and recommendations, guideline review, updating process-
es, and funding. A written protocol describing the guideline
development process was developed and approved by the ERC
Board before the start of the guideline development process.
Composition of Guideline Development Group
The ERC Articles of Incorporation and Bylaws (https://erc.edu/about)
set out the formal process by which the ERC appoints its Guideline
Development Committees. The Director of Guidelines and ILCOR is
elected by the General Assembly of the ERC and mandated to co-
ordinate the guideline process. They were supported by a Guideline
Development Committee comprising: Director Guidelines and ILCOR
(Chair), Co-chair Science for the four standing committees (BLS/AED;
ALS; PLS; NLS), Other members (Director of Training, Director of
Science, ERC Vice Chair, ERC Chair, Editor-in-Chief Resuscitation,
Writing group chairs) and ERC staff.
The ERC Board identified the topics included in the ERC Guidelines
and appointed the writing group chairs and members. Following a
review of conflicts of interest (as described below) writing group chairs
and members were appointed by the Board. Members were appointed
based on their credibility as leading (or emerging) resuscitation
scientists/clinicians/methodologists and to ensure a balance of
professions (medicine, nursing, paramedicine), early career members,
gender and ethnicity, geographical balance across Europe and
representatives of key stakeholder organisations. The appointed
writing groups ranged in size from 12
15 members. Most writing
group members were physicians (88%), who worked alongside
clinicians from a nursing, physiotherapy and occupational therapy
backgrounds as well as research scientists. A quarter of the writing
group members were female, and 15% were early in their careers. The
writing groups came from 25 countries including Austria, Belgium,
Croatia, Cyprus, Czech Republic, Denmark, France, Germany,
Greece, Holland, Iceland, Ireland, Italy, Netherlands, Norway, Poland,
Romania, Russia, Serbia, Spain, Sudan, Sweden, Switzerland, United
States of America and United Kingdom.
The role description for writing group members comprised:
 Provide clinical and scientific expertise to the guideline writing
group.
 Actively participate in the majority of guideline writing group
conference calls.
 Systematically review the published literature on specific topics at
the request of the guideline writing group.
 Present review findings and lead discussions within the group on
specific topics.
 Develop and refine clinical practice algorithms and guidelines.
 Fulfil the International Committee of Medical Journal Editors
(ICMJE) requirements for authorship.
 Be prepared to be publicly accountable for the contents of the
guidelines and promote their adoption.
 Comply with the ERC conflict of interest policy.
Decision making processes
The ERC guidelines are based on the ILCOR CoSTRs.21
29 Where
treatment recommendations are provided by ILCOR, these have been
adopted by the ERC. In areas where no relevant treatment
recommendation existed the method used to arrive at recommenda-
tions was based on review and discussion of the evidence by the
working group until consensus was achieved. The writing group chairs
ensured that each individual on the working group had the opportunity
to present and debate their views and ensured that discussions were
open and constructive. All members of the group needed to agree to
endorse any recommendations. Any failure to reach consensus is
made clear in the final wording of the recommendation. The quorum
for conducting writing group business and reaching consensus will be
at least 75% of the writing group.
The guideline scope and final guidelines were presented to and
approved by the ERC General Assembly.
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Conflict of interest
Conflict of interest (COI) was managed according to the ERC policy for
COI (see supplemental material). Writing group members completed
an annual COI declaration. The COI declaration was reviewed by the
Governance Committee and a report prepared for the ERC Board.
Writing group member conflicts were posted on the ERC website
through the guideline development process.33
The writing group chair and at least 50% of the writing group were
required to be free of commercial conflicts of interest. At the chair's
discretion, writing group members with a COI were still able to
participate in discussions that relate to this topic, but were not involved
in drafting or approving recommendation.
The ERC has financial relationships with business partners who
support the overall work of the ERC.34 The development of the ERC
guidelines occur entirely independently from the influence of business
partners.
Scope of guidelines
The ERC guidelines provide guidance through its network of 33
national resuscitation councils. The intended audience are lay-
persons, first aiders, first responders, community healthcare staff,
ambulance staff, hospital staff, trainers and instructors, and those
responsible for healthcare policy and practice. The guidelines are
relevant for use in both the community (out-of-hospital) and hospital
(in-hospital) settings. The scope of individual guideline sections was
developed by the writing groups at the start of 2019. The guideline
scopes were posted for public consultation for 2 weeks in May 2019
prior to being finalised and approved by the ERC General Assembly in
June 2019.
The Guidelines cover the following topics
 Epidemiology35
 Systems saving lives36
 Adult basic life support37
 Adult advanced life support38
 Special circumstances39
 Post resuscitation care (in collaboration with the European Society
of Intensive Care Medicine)40
 First Aid41
 Neonatal life support42
 Paediatric life support43
 Ethics44
 Education45
Methods
The step-by-step process for guideline development is summarised in
Fig. 1. In brief the ERC Board defined the topic areas that would be
covered in the guidelines and appointed the writing groups. The
writing groups developed the scope using a standardised template.
The scope contained the overall objective, intended audience, setting
for their use and the key topics that would be covered. The guideline
scopes were presented for public comment, revised, and then
approved as described in the previous section. Writing groups then
proceeded to identify and synthesise the relevant evidence which
were then summarised and presented as the guideline recommen-
dations. The draft guidelines underwent a further period of public
consultation before peer review and approval by the General
Assembly.
3
Fig. 1 – Step-wise process for development of the ERC
guidelines.
Evidence reviews
The ERC Guidelines are informed by the ILCOR Evidence Evaluation
process which is described in detail elsewhere.23 In summary, ILCOR
has undertaken three styles of evidence evaluation since 2015
comprising systematic reviews, scoping reviews and evidence
updates.
The ILCOR systematic reviews follow the methodological
principles described by the Institute of Medicine, Cochrane Collabo-
ration, and Grading of Recommendations Assessment, Development,
and Evaluation (GRADE).46 The reviews are presented according to
the Preferred Reporting Items for a Systematic Review and Meta-
Analysis (PRISMA) (Table 1).47
ILCOR systematic reviews were supplemented by scoping
reviews, undertaken either directly by ILCOR or by members of the
ERC writing groups. Unlike systematic reviews (which tend to have a
focused/narrow question), scoping reviews take a broader approach
to a topic and seek to examine and map the extent, range and nature of
research activity.23 This enabled the guideline group to produce
narrative summaries across a broader range of subjects than would be
possible through solely conducting systematic reviews. Scoping
reviews followed the framework outlined by ILCOR and were reported
in accordance with the PRISMA extension for scoping reviews.48
Unlike systematic reviews, neither the ILCOR nor the ERC scoping
reviews could lead to a formal CoSTR.
The final method of evidence evaluation used by ILCOR were
evidence updates.23 These were designed to address topics that had
not been formally reviewed for several years, in order to identify if any
new evidence had emerged to that should prompt a formal review.
Evidence updates either provided assurance that previous treatment
recommendations remained valid or highlighted the need to update a
previous systematic review. In themselves, evidence updates did not
lead to any changes to CoSTR.
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Table 1 – Summary outline of the process steps for the 2020 CoSTR SysRevs (reproduced from23 ).
Task forces select, prioritise, and refine questions (using PICOST format)
Task forces allocate level of importance to individual outcomes
Task forces allocate PICOST question to SysRev team*
SysRev registered with PROSPERO
SysRev team works with information specialists to develop and fine-tune database-specific search strategies
Revised search strategies used to search databases
Articles identified by the search are screened by allocated members of the SysRev team using inclusion and exclusion criteria
SysRev team agrees on final list of studies to include
SysRev team agrees on assessment of bias for individual studies
GRADE Evidence Profile table created
Draft CoSTRs created by SysRev team
Evidence-to-decision framework completed by task force
Public invited to comment on draft CoSTRs
Detailed iterative review of CoSTRs to create final version
Peer review of final CoSTR document

Footnote: CoSTR indicates Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations;
GRADE, Grading of Recommendations Assessment, Development, and Evaluation; PICOST, population, intervention, comparison, outcome, study design, time
frame; PROSPERO, International Prospective Register of Systematic Reviews; and SysRev, systematic review. *Systematic review team could be knowledge
synthesis unit, expert systematic reviewer, or task-force-led team involving content experts from the ILCOR task force(s), and delegated member of the Continuous
Evidence Evaluation Working Group and Scientific Advisory Committee.

Systematic reviews from other organisations were eligible for
inclusion if they were conducted and reported according to AMSTAR
(Assessing the methodological quality of systematic reviews)49 and
PRISMA47 recommendations, are in the public domain and have been
peer reviewed.
Where topics of interest fell outside the remit of evidence reviewed
by ILCOR, ERC writing groups undertook scoping reviews to map the
available evidence and synthesis key information and themes, using
the same approach undertaken by ILCOR.
Guideline recommendations
Concise guidelines for clinical practice
Most ERC guidelines will be used in emergencies where efficient,
timely action is critical. The concise guidelines for clinical practice
sections are intended to provide clear, succinct recommendations
with easily understood algorithms to provide the reader with
unambiguous, step by step instructions. As such, these components
of the guidelines do not include information about the level of evidence
or strength of recommendations. Instead, this information is presented
in the evidence informing the guidelines sections.
Evidence informing the guidelines
Formal ERC treatment recommendations are limited to those
informed by ILCOR CoSTR. The ILCOR CoSTRs are constructed
following a rigorous evidence evaluation informed by GRADE. The
detailed steps are described in the ILCOR Evidence Evaluation
Process Summary. In brief these treatment recommendations provide
a summary of the certainty of evidence and a strength of
recommendation. The certainty (quality) of evidence ranges from
very low to high (see Table 2).
The strength of recommendations from ILCOR reflect the extent to
which the task force was confident that the desirable effects of an
action or intervention outweighed the undesirable effects. Such
deliberations were informed by the Evidence to Decision Framework
developed by GRADE which enables consideration of the desirable
effects, undesirable effects, certainty of evidence, values, balance of
effects, resources required, certainty of evidence of required
Table 2 – Certainty (quality) of evidence for a specific
outcome (or across outcomes).
GRADE Description
certainty level
High We are very confident that the true effect lies
close to that of the estimate of the effect
Moderate We are moderately confident in the effect
estimate: The true effect is likely to be close to
the estimate of the effect, but there is a
possibility that it is substantially different
Low Our confidence in the effect estimate is limited:
The true effect may be substantially different
from the estimate of the effect
Very low We have very little confidence in the effect
estimate: The true effect is likely to be
substantially different from the estimate of effect
resources, cost effectiveness, equity, acceptability and feasibility.
There were two main strengths of recommendation
a strong
recommendation indicates that the task force was confident that
desirable effects outweigh the undesirable effects. Strong recom-
mendations typically use terms such as ‘we recommend’. Weak
recommendations (where the task force was not confident that the
desirable effects outweigh the undesirable effects) typically use the
term ‘we suggest’.
There are many areas of resuscitation science where there is
either no evidence or insufficient evidence to inform an evidence-
based treatment recommendation. When this occurs the expert
opinion of the writing group is presented. The guidelines clearly
document which aspects of the guideline are evidence informed
versus expert consensus.
Stakeholder consultation and peer review
Drafts of the ERC Guidelines were posted on the ERC website for
public comment between 21st October 2020 and 5th November 2020.
The opportunity to comment on the guidelines was advertised through
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social media (Facebook, Twitter) and the ERC network of 33 national
resuscitation councils. The guideline content for each section was also
presented via a short (15 min) video presentation as part of the ERC
2020 Virtual Conference followed by open questions and a panel
discussion. Those providing feedback had to identify themselves and
highlight any relevant conflict of interest.
164 written responses were received. Those responding com-
prised physicians (45%), nurses (8%), ambulance staff (28%), other
(11%), education (5%), lay persons (3%). 15% declared a conflict of
interest of which two thirds were commercial conflicts and one third
academic. Feedback comments were distributed to the chairs of the
relevant section and considered in full by the writing group. Where
relevant changes were made to the respective sections.
A final draft of the guidelines was submitted to members of the ERC
General Assembly for peer review in December 2020. Writing group
chairs (or their deputies) responded to queries and the final set of
guidelines was approved and submitted for publication at the end of
December 2020.
Guidance updates
ILCOR entered a continuous evidence evaluation process in 2016.
CoSTRs are published on the ILCOR website as they are completed.
This is supplemented by an annual summary published in Circulation
and Resuscitation.
The ERC welcomes the new, more responsive approach to
evidence synthesis developed by ILCOR. In embracing this approach,
the ERC has considered how best to integrate any changes prompted
by ILCOR into our guidelines.
The ERC recognises the substantial time, effort and resources
required to implement changes to resuscitation guidelines. The ERC
is also cognisant of the confusion that could be caused by frequent
changes to guidelines, which could impair technical and non-technical
skill performance and adversely impact patient outcomes. Neverthe-
less, if new science emerges which presents compelling evidence of
benefits or harms, prompt action must be taken to translate it
immediately into clinical practice.
To balance these conflicting priorities, the ERC has decided to
maintain a 5-yearly cycle for routine updates to its guidelines and
course materials. Each new CoSTR published by ILCOR will be
reviewed by the ERC Guidelines Development Committees who will
assess the likely impact of the new CoSTR on our guidelines and
education programmes. These committees will consider the potential
impact of implementing any new CoSTR (lives saved, improved
neurological outcome, reduced costs) against the challenges (cost,
logistical consequences, dis-semination and communication) of
change. CoSTRs which present compelling new data which challenge
the ERC's current guidelines or educational strategy will be identified
for high priority implementation; guidelines and course materials will
then be updated outside the 5-year review period. By contrast, new
information which will lead to less critical, incremental changes to our
guidelines will be identified for lower priority implementation. Such
changes will be introduced during the routine, 5-yearly update of
guidelines.
Availability
All ERC guidelines and updates will be freely available to access
through the ERC website and as a publication in the ERC official
journal, Resuscitation.
5
National Resuscitation Councils can translate ERC guidelines for
use locally.
Financial support and sponsoring organisation
The Guidelines are supported by the European Resuscitation Council
(ERC). The ERC is a non-profit organisation in accordance with the
Belgian Law of 27 June 1921. The articles for incorporation and
internal rules governing the ERC are available at: https://erc.edu/
about. A budget is set annually by the ERC Board to support the
Guideline Development Process.
The official journal of the ERC is Resuscitation, an international
peer reviewed journal hosted by Elsevier. The Editor in Chief
maintains the editorial independence of the journal and sits on the
ERC Board. Guidelines are usually published in Resuscitation.
COVID-19 guidelines
The ERC published guidelines to support lay persons and healthcare
professionals to continue resuscitation safely during the COVID-19
pandemic.18 Since publication of these initial guidelines, reports from
across Europe50
61 have highlighted the impact of COVID-19 on the
epidemiology and outcomes from cardiac arrest.
Impact of COVID-19 on cardiac arrest
A systematic review, summarising information from 10 studies (with
35,379 participants) reported an increase in the incidence, with out of
hospital cardiac arrest during the initial COVID-19 wave.62 There was
significant clinical and statistical heterogeneity in the studies
contained in the systematic review, hence a narrative synthesis is
presented here. The patterns of presentation of cardiac arrest
changed during the COVID-19 period with an increase in medical
causes of cardiac arrest (4 of 5 studies) and reduction in trauma-
related cardiac arrest (4 of 5 studies). More cardiac arrests occurred at
home, with a variable impact on whether arrests were witnessed or
not. The rate of bystander CPR varied between studies (6 studies
reported lower rates of bystander CPR, 4 reported higher rates of
bystander CPR). Ambulance response times increased and fewer
resuscitation attempts were initiated or continued by ambulance
crews. The proportion of patients with shockable rhythms decreased
as did the use of automated external defibrillators. The use of
supraglottic airways increased and rate of intubation decreased.
Overall the rates of return of spontaneous circulation, admission to
hospital and survival to discharge all decreased.62,63
The changes in the epidemiology, treatment and outcomes of
cardiac arrest during COVID-19 is likely to be due to a combination of
direct effects and indirect effects as summarised in Fig. 2.64,65
Data from in-hospital cardiac arrest associated with COVID-19 are
less widely reported. A multi-centre cohort study from 68 intensive
care units in the United states reported that 701 of 5019 (14%)
sustained an in-hospital cardiac arrest, amongst whom 400/701 (57%)
received CPR. Seven percent (28/400) survived to hospital discharge
with normal or mildly impaired neurological status.66 In Wuhan, China,
amongst 136 patients who sustained a cardiac arrest (83% on a ward),
4 (2.9%) survived to 30 days of whom 1 had a favourable neurological
outcome.67 It is clear that across the out-of-hospital and in-hospital
settings that COVID-19 has had a significant impact on the
epidemiology and outcome from cardiac arrest.
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Fig. 2 – Systems level factors related to OHCA incidence and mortality during the COVID-19 pandemic (Reproduced from
Christian and Couper64).
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ERC COVID-19 guidelines
The ERC guidelines were based on the ILCOR systematic review on
COVID-19 and CPR68 and corresponding CoSTR.69 Since publication of
these reviews, the search strategies have been re-run and a further four
articles identified.70
74 None of the new articles contained information
sufficient to change the previous treatment recommendations.
The ERC COVID-19 guidelines promote the continuation of
resuscitation attempts for both out-of-hospital and in-hospital cardiac
arrest, whilst seeking to reduce the risk to the person(s) providing
treatment. The COVID-19 guidelines focus specifically on patients
with suspected or confirmed COVID-19. If there is uncertainty about
the presence of COVID-19, those providing treatment should
undertake a dynamic risk assessment which may consider current
COVID-19 prevalence, the patient's presentation (e.g. history of
COVID-19 contact, COVID-19 symptoms), likelihood that treatment
will be effective, availability of personal protective equipment (PPE)
and personal risks for those providing treatment.18
Fig. 3 – Epidemiology infographic summary.
7
The COVID-19 guidelines will be kept under continuous review
and updated on-line as new evidence emerges. The main ERC
Guidelines address resuscitation of those who are low risk or
confirmed negative for COVID-19.
Concise guidelines for clinical practice
Epidemiology
In this section of the European Resuscitation Council Guidelines
2021, key information on the epidemiology and outcome of in and out
of hospital cardiac arrest are presented. Key contributions from the
European Registry of Cardiac Arrest (EuReCa) collaboration are
highlighted. Recommendations are presented to enable health
systems to develop registries as a platform for quality improvement
and to inform health system planning and responses to cardiac arrest.
Key messages from this section are presented in Fig. 3.
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Out of hospital cardiac arrest
 Twenty-nine countries participated in the European Registry of
Cardiac Arrest (EuReCa) collaboration.
 Out of hospital cardiac arrest registries exist in approximately 70%
of European countries but the completeness of data captures
varies widely.
 The annual incidence of OHCA in Europe is between 67 to 170 per
100,000 inhabitants.
 Resuscitation is attempted or continued by EMS personnel in
about 50
60% of cases (between 19 to 97 per 100,000
inhabitants).
 The rate of bystander CPR varies between and within countries
(average 58%, range 13% to 83%).
 The use of automated external defibrillators (AEDs) remains low in
Europe (average 28%, range 3.8% to 59%).
 80% of European countries provide dispatch assisted CPR and
75% have an AED registry. Most (90%) countries have access to
cardiac arrest centres for post resuscitation care.
 Survival rates at hospital discharge are on average 8%, varying
from 0% to 18%.
 Differences in EMS systems in Europe account for at least some of
the differences observed in OHCA incidence and survival rates.
In hospital cardiac arrest
 The annual incidence of IHCA in Europe is between 1.5 and 2.8 per
1000 hospital admissions.
 Factors associated with survival are the initial rhythm, the place of
arrest and the degree of monitoring at the time of collapse.
 Survival rates at 30 days/hospital discharge range from 15% to 34%.
Long term outcomes
 In European countries where withdrawal of life sustaining
treatment (WLST) is routinely practiced, a good neurological
outcome is seen in >90% of patients. Most patients are able to
return to work.
 In countries where WLST is not practiced, poor neurological
outcomes are more common (50%, 33% in a persistent vegetative
state).
 Amongst survivors with a good neurological outcome, neuro-
cognitive, fatigue and emotional problems are common and cause
reduced health related quality of life.
 Patients and relatives may develop post-traumatic stress disorder.
Post cardiac arrest rehabilitation
 There is wide variation in the provision of rehabilitation services
following cardiac arrest
 Many patients do not have access to post cardiac arrest
rehabilitation
Key recommendations (expert consensus)
 Health systems should have population-based registries which
monitor the incidence, case mix, treatment and outcomes for
cardiac arrest
 Registries should adhere to the Utstein recommendations for data
definitions and outcome reporting
 Data from registries should inform health system planning and
responses to cardiac arrest.
 European countries are encouraged to participate in the EuReCa
collaboration to enhance understanding of epidemiology and
outcomes of cardiac arrest in Europe.
 There is a need for more research and greater provision of post
resuscitation rehabilitation services
 It is expected that the clinical role of genetic and epigenetic factors
will be increasingly understood as research in this area continues
to grow. There are currently no specific resuscitation recommen-
dations for patients with known genomic predispositions.
Systems saving lives
The European Resuscitation Council has produced these Systems
Saving Lives guidelines, which are based on the 2020 International
Consensus on Cardiopulmonary Resuscitation Science with Treat-
ment Recommendations. The topics covered include chain of survival,
measuring performance of resuscitation, social media and smart-
phones apps for engaging community, European Restart a Heart Day,
World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource
setting, European Resuscitation Academy and Global Resuscitation
Alliance, early warning scores, rapid response systems, and medical
emergency team, cardiac arrest centres and role of dispatcher. Key
messages from this section are presented in Fig. 4.
Chain of survival & the formula of survival
 The actions linking the victim of sudden cardiac arrest with survival
are called the chain of survival.
 The goal of saving more lives relies not only on solid and high-
quality science but also effective education of lay people and
healthcare professionals.
 Systems engaged in the care of cardiac arrest victims should be
able to implement resource efficient systems that can improve
survival after cardiac arrest.
Measuring the performance of resuscitation systems
 Organisations or communities that treat cardiac arrest should
evaluate their system performance and target key areas with the
goal to improve performance.
Social media and smartphones apps for engaging the
community
 First responders (trained and untrained laypersons, firefighters,
police officers, and off-duty healthcare professionals) who are
near a suspected OHCA should be notified by the dispatch centre
through an alerting system implemented with a smartphone app or
a text message.
 Every European country is highly encouraged to implement such
technologies in order to:
 Improve the rate of bystander-initiated cardiopulmonary
resuscitation (CPR).
 Reduce the time to first compression and shock delivery.
 Improve survival with good neurological recovery.
European Restart a Heart Day (ERHD) & World Restart a Heart
(WRAH)
 National resuscitation councils, national governments and local
authorities should
 Engage with WRAH.
 Raise awareness of the importance of bystander CPR and
AEDs.
 Train as many citizens as possible.
 Develop new and innovative systems and policies that will save
more lives.
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Fig. 4 – System saving lives infographic summary.
KIDS SAVE LIVES
 All schoolchildren should routinely receive CPR training each year.
 Teach CHECK
CALL
COMPRESS.
 Trained schoolchildren should be encouraged to train family
members and friends. The homework for all children after such
training should be: “please train 10 other people within the next two
weeks and report back”.
 CPR training should also be delivered in higher education
institutions, in particular to teaching and healthcare students.
 The responsible people in the Ministries of Education and/or
Ministries of Schools and other leading politicians of each country
should implement a nationwide programme for teaching CPR to
schoolchildren. Training schoolchildren in CPR should be
mandatory by law all over Europe and elsewhere.
Community initiatives to promote CPR implementation
 Healthcare systems should implement community initiatives for
CPR training for large portions of the population (neighbourhood,
town, region, a part of or a whole nation)
9
Low-resource settings
Resuscitation research in low-resource settings
 Research is required to understand different populations,
aetiologies and outcome data of cardiac arrest in low-resource
settings. Research should follow Utstein guidelines.
 The level of income of countries should be included in reports. A
useful system to report level of income is the definition of the World
Bank (gross national income per capita).
 When reporting about resuscitation systems and outcome, psycholog-
ical and sociocultural views on cardiac arrest should be documented.
 Experts from all resource backgrounds should be consulted
concerning local acceptability and applicability of international
guidelines and recommendations for resuscitation.
Essential resources for resuscitation care systems in low-
resource settings
 A list with essential resuscitation care resources that is
specially adapted to low resource settings should be developed
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in collaboration with stakeholders from these low resource
settings.
European Resuscitation Academy and Global Resuscitation
Alliance
 Programmes such as the European Resuscitation Academy
programmes should be implemented to increase bystander CPR
rates and improve survival in case of OHCA.
Role of dispatcher
Dispatch-assisted recognition of cardiac arrest
 Dispatch centres should implement standardised criteria and
algorithms to determine if a patient is in cardiac arrest at the time of
the emergency call.
 Dispatch centres should monitor and track their ability to recognise
cardiac arrest and continuously look for ways to improve
recognition of cardiac arrest.
Dispatch-assisted CPR
 Dispatch centres should have systems in place to make sure call
handlers provide CPR instructions for unresponsive persons not
breathing normally.
Dispatch-assisted chest compression-only compared with
standard CPR
 Dispatchers should provide chest compression
only CPR
instructions for callers who identify unresponsive adult persons
not breathing normally.
Early warning scores, rapid response systems, and medical
emergency teams
 Consider the introduction of rapid response systems to reduce the
incidence of in-hospital cardiac arrest and in-hospital mortality.
Cardiac arrest centres
 Adult patients with non-traumatic OHCA should be considered for
transport to a cardiac arrest centre according to local protocols.
Adult basic life support
The European Resuscitation Council has produced these basic life
support guidelines, which are based on the 2020 International
Consensus on Cardiopulmonary Resuscitation Science with Treatment
Recommendations. The topics covered include cardiac arrest
recognition, alerting emergency services, chest compressions, rescue
breaths, automated external defibrillation, CPR quality measurement,
new technologies, safety, and foreign body airway obstruction.
The BLS writing group prioritised consistency with previous
guidelines75 to build confidence and encourage more people to act
when a cardiac arrest occurs. Failing to recognise cardiac arrest
remains a barrier to saving more lives. The terminology used in the
ILCOR CoSTR,76 is to start CPR in any person who is “unresponsive
with absent or abnormal breathing”. This terminology has been
included in the BLS 2021 guidelines. Those learning or providing CPR
are reminded that slow, laboured breathing (agonal breathing) should
be considered a sign of cardiac arrest. The recovery position is
included in the first aid section of the ERC guidelines 2021.41 The first
aid guidelines highlight that the recovery position should only be used
for adults and children with a decreased level of responsiveness due to
medical illness or non-physical trauma. The guidelines emphasise
that is should only be used in people who do NOT meet the criteria for
the initiation of rescue breathing or chest compressions (CPR).
Anyone placed in the recovery position should have their breathing
continuously monitored. If at any point their breathing becomes absent
or abnormal, roll them on to their back and start chest compressions.
Finally, the evidence informing the treatment of foreign body airway
obstruction has been comprehensively updated, but the treatment
algorithms remain the same.
Key messages from this section are presented in Fig. 5 and the
BLS algorithm is depicted in Fig. 6.
How to recognise cardiac arrest
 Start CPR in any unresponsive person with absent or abnormal
breathing.
 Slow, laboured breathing (agonal breathing) should be considered
a sign of cardiac arrest.
 A short period of seizure-like movements can occur at the start of
cardiac arrest. Assess the person after the seizure has stopped: if
unresponsive and with absent or abnormal breathing, start CPR.
How to alert the emergency services
 Alert the emergency medical services (EMS) immediately if a
person is unconscious with absent or abnormal breathing.
 A lone bystander with a mobile phone should dial the EMS
number, activate the speaker or another hands-free option on the
mobile phone and immediately start CPR assisted by the
dispatcher.
 If you are a lone rescuer and you have to leave a victim to alert the
EMS, activate the EMS first and then start CPR.
High quality chest compressions
 Start chest compressions as soon as possible.
 Deliver compressions on the lower half of the sternum (‘in the
centre of the chest’).
 Compress to a depth of at least 5 cm but not more than 6 cm.
 Compress the chest at a rate of 100
120 min
1 with as few
interruptions as possible.
 Allow the chest to recoil completely after each compression; do not
lean on the chest.
 Perform chest compressions on a firm surface whenever feasible.
Rescue breaths
 Alternate between providing 30 compressions and 2 rescue
breaths.
 If you are unable to provide ventilations, give continuous chest
compressions.
AED
How to find an AED
 The location of an AED should be indicated by clear signage.
When and how to use an AED
 As soon as the AED arrives, or if one is already available at the site
of the cardiac arrest, switch it on.
 Attach the electrode pads to the victim's bare chest according to
the position shown on the AED or on the pads.
 If more than one rescuer is present, continue CPR whilst the pads
are being attached.
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Fig. 5 – BLS infographic summary.

 Follow the spoken (and/or visual) prompts from the AED.
 Ensure that nobody is touching the victim whilst the AED is
analysing the heart rhythm.
 If a shock is indicated, ensure that nobody is touching the victim.
Push the shock button as prompted. Immediately restart CPR with
30 compressions.
 If no shock is indicated, immediately restart CPR with 30
compressions.
 In either case, continue with CPR as prompted by the AED. There
will be a period of CPR (commonly 2 min) before the AED prompts
for a further pause in CPR for rhythm analysis.
Compressions before defibrillation
 Continue CPR until an AED (or other defibrillator) arrives on site
and is switched on and attached to the victim.
 Do not delay defibrillation to provide additional CPR once the
defibrillator is ready.
Fully automatic AEDs
 If a shock is indicated, fully automatic AEDs are designed
to deliver a shock without any further action by the
rescuer. The safety of fully automatic AEDs have not been
well studied.
Safety of AEDs
 Many studies of public access defibrillation have shown that AEDs
can be used safely by bystanders and first responders. Although
injury to the CPR provider from a shock by a defibrillator is
extremely rare, do not continue chest compression during shock
delivery.
Safety
 Make sure you, the victim and any bystanders are safe.
 Laypeople should initiate CPR for presumed cardiac arrest without
concerns of harm to victims not in cardiac arrest.
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Fig. 6 – BLS algorithm.
 Lay people may safely perform chest compressions and use an
AED as the risk of infection during compressions and harm from
accidental shock during AED use is very low.
 Separate guidelines have been developed for resuscitation of
victims with suspected or confirmed acute respiratory syndrome
coronavirus 2 (SARS-CoV-2). See www.erc.edu/covid
How technology can help
 EMS systems should consider the use of technology such as
smartphones, video communication, artificial intelligence and
drones to assist in recognising cardiac arrest, to dispatch first
responders, to communicate with bystanders to provide dispatch-
er-assisted CPR and to deliver AEDs to the site of cardiac arrest.
Foreign body airway obstruction
 Suspect choking if someone is suddenly unable to speak or talk,
particularly if eating.
 Encourage the victim to cough.
 If the cough becomes ineffective, give up to 5 back blows:
 Lean the victim forwards.
 Apply blows between the shoulder blades using the heel of one
hand
 If back blows are ineffective, give up to 5 abdominal thrusts:
 Stand behind the victim and put both your arms around the
upper part of the victim's abdomen.
 Lean the victim forwards.
 Clench your fist and place it between the umbilicus (navel) and
the ribcage.
 Grasp your fist with the other hand and pull sharply inwards and
upwards.
 If choking has not been relieved after 5 abdominal thrusts,
continue alternating 5 back blows with 5 abdominal thrusts until it is
relieved, or the victim becomes unconscious.
 If the victim becomes unconscious, start CPR
Adult advanced life support
These European Resuscitation Council Advanced Life Support (ALS)
guidelines, are based on the 2020 International Consensus on Cardiopul-
monary Resuscitation Science with Treatment Recommendations. This
section provides guidelines on the prevention of and ALS treatments for
both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
There are no major changes in the 2021 Adult ALS Guidelines.
There is a greater recognition that patients with both in- and out-of-
hospital cardiac arrest have premonitory signs, and that many of these
arrests may be preventable. High quality chest compressions with
minimal interruption and early defibrillation remain priorities. During
CPR, start with basic airway techniques and progress stepwise
according to the skills of the rescuer until effective ventilation is
achieved. If an advanced airway is required, only rescuers with a high
tracheal intubation success rate should use tracheal intubation. The
expert consensus is that a high success rate is over 95% within two
attempts at intubation. When adrenaline is used it should be used as
soon as possible when the cardiac arrest rhythm is non-shockable
cardiac arrest, and after 3 defibrillation attempts for a shockable cardiac
arrest rhythm. The guideline recognises the increasing role of point-of-
care ultrasound (POCUS) in peri-arrest care for diagnosis, but
emphasise that it requires a skilled operator, and the need to minimise
interruptions during chest compression. The guideline reflects the
increasing evidence for extracorporeal CPR (eCPR) as a rescue
therapy for selected patients with cardiac arrest when conventional ALS
measures are failing or to facilitate specific interventions (e.g. coronary
angiography and percutaneous coronary intervention (PCI), pulmonary
thrombectomy for massive pulmonary embolism, rewarming after
hypothermic cardiac arrest) in settings in which it can be implemented.
These ERC guidelines have followed European and international
guidelines for the treatment of peri-arrest arrhythmias.
Key messages from this section are presented in Fig. 7 and the
ALS algorithm is depicted in Fig. 8.
Prevention of in-hospital cardiac arrest
 The ERC supports shared decision making and advanced care
planning which integrates resuscitation decisions with emergency
care treatment plans to increase clarity of treatment goals and also
prevent inadvertent deprivation of other indicated treatments,
besides CPR. These plans should be recorded in a consistent
manner (See Ethics section 11).44
 Hospitals should use a track and trigger early warning score
system for the early identification of patients who are critically ill or
at risk of clinical deterioration.
 Hospitals should train staff in the recognition, monitoring and
immediate care of the acutely-ill patient.
 Hospitals should empower all staff to call for help when they
identify a patient at risk of physiological deterioration. This
includes calls based on clinical concern, rather than solely on vital
signs.
 Hospitals should have a clear policy for the clinical response to
abnormal vital signs and critical illness. This may include a critical
care outreach service and, or emergency team (e.g. medical
emergency team, rapid response team).
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Fig. 7 – ALS infographic summary.
 Hospital staff should use structured communication tools to
ensure effective handover of information.
 Patients should receive care in a clinical area that has the
appropriate staffing, skills, and facilities for their severity of illness.
 Hospitals should review cardiac arrest events to identify
opportunities for system improvement and share key learning
points with hospital staff.
Prevention of out-of-hospital cardiac arrest
 Symptoms such as syncope (especially during exercise, while sitting
or supine), palpitations, dizziness and sudden shortness of breath
that are consistent with an arrhythmia should be investigated.
 Apparently healthy young adults who suffer sudden cardiac death
(SCD) can also have signs and symptoms (e.g. syncope/pre-
syncope, chest pain and palpitations) that should alert healthcare
professionals to seek expert help to prevent cardiac arrest.
 Young adults presenting with characteristic symptoms of
arrhythmic syncope should have a specialist cardiology
13
assessment, which should include an electrocardiogram (ECG)
and in most cases echocardiography and an exercise test.
 Systematic evaluation in a clinic specialising in the care of those at
risk for SCD is recommended in family members of young victims
of SCD or those with a known cardiac disorder resulting in an
increased risk of SCD.
 Identification of individuals with inherited conditions and screening
of family members can help prevent deaths in young people with
inherited heart disorders.
 Follow current European Society of Cardiology (ESC) guidelines
for the diagnosis and management of syncope.
Treatment of in-hospital cardiac arrest
 Hospital systems should aim to recognise cardiac arrest, start CPR
immediately, and defibrillate rapidly (<3 min) when appropriate.
 All hospital staff should be able to rapidly recognise cardiac arrest,
call for help, start CPR and defibrillate (attach an AED and follow
the AED prompts, or use a manual defibrillator).
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Fig. 8 – ALS algorithm.
 European hospitals should adopt a standard “Cardiac Arrest Call”
telephone number (2222).
 Hospitals should have a resuscitation team that immediately
responds to IHCAs.
 The hospital resuscitation team should include team members
who have completed an accredited adult ALS course.
 Resuscitation team members should have the key skills and
knowledge to manage a cardiac arrest including manual
defibrillation, advanced airway management, intravenous access,
intra-osseous access, and identification and treatment of revers-
ible causes.
 The resuscitation team should meet at the beginning of each shift
for introductions and allocation of team roles.
 Hospitals should standardise resuscitation equipment.
ALS considerations for out-of-hospital cardiac arrest
 Start ALS as early as possible.
 Emergency medical systems (EMS) should consider implement-
ing criteria for the withholding and termination of resuscitation
(TOR) taking in to consideration specific local legal, organisational
and cultural context (see section 11 Ethics).44
 Systems should define criteria for the withholding and termination
of CPR, and ensure criteria are validated locally (see section 11
Ethics).44
 Emergency medical systems (EMS) should monitor staff exposure
to resuscitation and low exposure should be addressed to
increase EMS team experience in resuscitation.
 Adult patients with non-traumatic OHCA should be considered for
transport to a cardiac arrest centre according to local protocols
(see Systems saving lives
Section 4).36
Manual defibrillation
Defibrillation strategy
 Continue CPR while a defibrillator is retrieved and pads applied.
 Give a shock as early as possible when appropriate.
 Deliver shocks with minimal interruption to chest compression,
and minimise the pre-shock and post-shock pause. This is
achieved by continuing chest compressions during defibrillator
charging, delivering defibrillation with an interruption in chest
compressions of less than 5 s and then immediately resuming
chest compressions.
 Immediately resume chest compressions after shock delivery. If
there is a combination of clinical and physiological signs of return
of spontaneous circulation (ROSC) such as waking, purposeful
movement, arterial waveform or a sharp rise in end-tidal carbon
dioxide (ETCO2), consider stopping chest compressions for
rhythm analysis, and if appropriate a pulse check.
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Safe and effective defibrillation
 Minimise the risk of fire by taking off any oxygen mask or nasal
cannulae and place them at least 1 m away from the patient's
chest. Ventilator circuits should remain attached.
 Antero-lateral pad position is the position of choice for initial pad
placement. Ensure that the apical (lateral) pad is positioned
correctly (mid-axillary line, level with the V6 pad position) i.e. below
the armpit.
 In patients with an implantable device, place the pad >8 cm away
from the device, or use an alternative pad position. Also consider
an alternate pad position when the patient is in the prone position
(bi-axillary), or in a refractory shockable rhythm (see below).
 A shock can be safely delivered without interrupting mechanical
chest compression.
 During manual chest compressions, ‘hands-on’ defibrillation, even
when wearing clinical gloves, is a risk to the rescuer.
Energy levels and number of shocks
 Use single shocks where indicated, followed by a 2 min cycle of
chest compressions.
 The use of up to three-stacked shocks may be considered only if
initial ventricular fibrillation/pulseless ventricular tachycardia (VF/
pVT) occurs during a witnessed, monitored cardiac arrest with a
defibrillator immediately available e.g. during cardiac catheter-
isation or in a high dependency area.
 Defibrillation shock energy levels are unchanged from the 2015
guidelines:
 For biphasic waveforms (rectilinear biphasic or biphasic
truncated exponential), deliver the first shock with an energy
of at least 150 J.
 For pulsed biphasic waveforms, deliver the first shock at
120
150 J.
 If the rescuer is unaware of the recommended energy settings of
the defibrillator, for an adult use the highest energy setting for all
shocks.
Recurrent or refractory VF
 Consider escalating the shock energy, after a failed shock and for
patients where refibrillation occurs.
 For refractory VF, consider using an alternative defibrillation pad
position (e.g. anterior
posterior)
 Do not use dual (double) sequential defibrillation for refractory VF
outside of a research setting.
Airway and ventilation
 During CPR, start with basic airway techniques and progress
stepwise according to the skills of the rescuer until effective
ventilation is achieved.
 If an advanced airway is required, only rescuers with a high
tracheal intubation success rate should use tracheal intubation.
The expert consensus is that a high success rate is over 95%
within two attempts at intubation.
 Aim for less than a 5 s interruption in chest compression for
tracheal intubation.
 Use direct or video laryngoscopy for tracheal intubation according
to local protocols and rescuer experience
 Use waveform capnography to confirm tracheal tube position.
 Give the highest feasible inspired oxygen during CPR.
 Give each breath over 1 s to achieve a visible chest rise.
15
 Once a tracheal tube or a supraglottic airway (SGA) has been
inserted, ventilate the lungs at a rate of 10 min
1 and continue chest
compressions without pausing during ventilations. With a SGA, if
gas leakage results in inadequate ventilation, pause compressions
for ventilation using a compression-ventilation ratio of 30:2.
Drugs and fluids
Vascular access
 Attempt intravenous (IV) access first to enable drug delivery in
adults in cardiac arrest.
 Consider intraosseous (IO) access if attempts at IV access are
unsuccessful or IV access is not feasible.
Vasopressor drugs
 Give adrenaline 1 mg IV (IO) as soon as possible for adult patients
in cardiac arrest with a non-shockable rhythm.
 Give adrenaline 1 mg IV (IO) after the 3rd shock for adult patients in
cardiac arrest with a shockable rhythm.
 Repeat adrenaline 1 mg IV (IO) every 3
5 min whilst ALS continues.
Antiarrhythmic drugs
 Give amiodarone 300 mg IV(IO) for adult patients in cardiac arrest
who are in VF/pVT after three shocks have been administered.
 Give a further dose of amiodarone 150 mg IV (IO) for adult patients
in cardiac arrest who are in VF/pVT after five shocks have been
administered.
 Lidocaine 100 mg IV (IO) may be used as an alternative if
amiodarone is not available or a local decision has been made to
use lidocaine instead of amiodarone. An additional bolus of
lidocaine 50 mg can also be given after five defibrillation attempts.
Thrombolytic drugs
 Consider thrombolytic drug therapy when pulmonary embolus is
the suspected or confirmed as the cause of cardiac arrest.
 Consider CPR for 60
90 min after administration of thrombolytic
drugs.
Fluids
 Give IV (IO) fluids only where the cardiac arrest is caused by or
possibly caused by hypovolaemia.
Waveform capnography during advanced life support
 Use waveform capnography to confirm correct tracheal tube
placement during CPR.
 Use waveform capnography to monitor the quality of CPR.
 An increase in ETCO2 during CPR may indicate that ROSC has
occurred. However, chest compression should not be interrupted
based on this sign alone.
 Although high and increasing ETCO2 values are associated with
increased rates of ROSC and survival after CPR, do not use a low
ETCO2 value alone to decide if a resuscitation attempt should be
stopped.
Use of ultrasound imaging during advanced life support
 Only skilled operators should use intra-arrest point-of-care
ultrasound (POCUS).
 POCUS must not cause additional or prolonged interruptions in
chest compressions.
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 POCUS may be useful to diagnose treatable causes of cardiac
arrest such as cardiac tamponade and pneumothorax.
 Right ventricular dilation in isolation during cardiac arrest should
not be used to diagnose massive pulmonary embolism.
 Do not use POCUS for assessing contractility of the myocardium
as a sole indicator for terminating CPR.
Mechanical chest compression devices
 Consider mechanical chest compressions only if high-quality
manual chest compression is not practical or compromises
provider safety.
 When a mechanical chest compression device is used, minimise
interruptions to chest compression during device use by using only
trained teams familiar with the device.
Extracorporeal CPR
 Consider extracorporeal CPR (eCPR) as a rescue therapy for
selected patients with cardiac arrest when conventional ALS
measures are failing or to facilitate specific interventions (e.g.
coronary angiography and percutaneous coronary intervention
(PCI), pulmonary thrombectomy for massive pulmonary embo-
lism, rewarming after hypothermic cardiac arrest) in settings in
which it can be implemented.
Peri-arrest arrhythmias
 The assessment and treatment of all arrhythmias addresses the
condition of the patient (stable versus unstable) and the nature of the
arrhythmia. Life-threatening features in an unstable patient include:
 Shock
appreciated as hypotension (e.g. systolic blood
pressure < 90 mmHg) and symptoms of increased sympathetic
activity and reduced cerebral blood flow.
 Syncope
as a consequence of reduced cerebral blood flow.
 Heart failure
manifested by pulmonary oedema (failure of the
left ventricle) and/or raised jugular venous pressure (failure of
the right ventricle).
 Myocardial ischaemia
may present with chest pain (angina)
or may occur without pain as an isolated finding on the 12-lead
ECG (silent ischaemia).
Tachycardias
 Electrical cardioversion is the preferred treatment for tachyar-
rhythmia in the unstable patient displaying potentially life-
threatening adverse signs.
 Conscious patients require anaesthesia or sedation, before
attempting synchronised cardioversion.
 To convert atrial or ventricular tachyarrhythmias, the shock must
be synchronised to occur with the R wave of the electrocardiogram
(ECG).
 For atrial fibrillation:
 An initial synchronised shock at maximum defibrillator output
rather than an escalating approach is a reasonable strategy
based on current data.
 For atrial flutter and paroxysmal supraventricular tachycardia:
 Give an initial shock of 70
120 J.
 Give subsequent shocks using stepwise increases in
energy.
 For ventricular tachycardia with a pulse:
 Use energy levels of 120
150 J for the initial shock.
 Consider stepwise increases if the first shock fails to achieve
sinus rhythm.
 If cardioversion fails to restore sinus rhythm and the patient
remains unstable, give amiodarone 300 mg intravenously over
10
20 min (or procainamide 10
15 mg/kg over 20 min) and re-
attempt electrical cardioversion. The loading dose of amiodarone
can be followed by an infusion of 900 mg over 24 h.
 If the patient with tachycardia is stable (no adverse signs or
symptoms) and is not deteriorating, pharmacological treatment
may be possible.
 Consider amiodarone for acute heart rate control in AF patients
with haemodynamic instability and severely reduced left ventricu-
lar ejection fraction (LVEF). For patients with LVEF < 40%
consider the smallest dose of beta-blocker to achieve a heart
rate less than 110 min
1. Add digoxin if necessary.
Bradycardia
 If bradycardia is accompanied by adverse signs, give atropine
500 mg IV (IO) and, if necessary, repeat every 3
5 min to a total of
3 mg.
 If treatment with atropine is ineffective, consider second line drugs.
These include isoprenaline (5 mg min
1 starting dose), and
adrenaline (2
10 mg min
1).
 For bradycardia caused by inferior myocardial infarction, cardiac
transplant or spinal cord injury, consider giving aminophylline (100

200 mg slow intravenous injection).
 Consider giving glucagon if beta-blockers or calcium channel
blockers are a potential cause of the bradycardia.
 Do not give atropine to patients with cardiac transplants
it can
cause a high-degree AV block or even sinus arrest
use
aminophylline.
 Consider pacing in patients who are unstable, with symptomatic
bradycardia refractory to drug therapies.
 If transthoracic pacing is ineffective, consider transvenous pacing.
 Whenever a diagnosis of asystole is made, check the ECG
carefully for the presence of P waves because unlike true asystole,
this is more likely to respond to cardiac pacing.
 If atropine is ineffective and transcutaneous pacing is not
immediately available, fist pacing can be attempted while waiting
for pacing equipment.
Uncontrolled organ donation after circulatory death
 When there is no ROSC, consider uncontrolled organ donation after
circulatory death in settings where there is an established
programme, and in accordance with local protocols and legislation.
Debriefing
 Use data-driven, performance-focused debriefing of rescuers to
improve CPR quality and patient outcomes.
Special circumstances
These European Resuscitation Council (ERC) Cardiac Arrest in
Special Circumstances guidelines are based on the 2020 International
Consensus on Cardiopulmonary Resuscitation Science with Treat-
ment Recommendations. This section provides guidelines on the
modifications required to basic and advanced life support for the
prevention and treatment of cardiac arrest in special circumstances;
specifically special causes (hypoxia, trauma, anaphylaxis, sepsis,
hypo/hyperkalaemia and other electrolyte disorders, hypothermia,
avalanche, hyperthermia and malignant hyperthermia, pulmonary
embolism, coronary thrombosis, cardiac tamponade, tension
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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pneumothorax, toxic agents), special settings (operating room,
cardiac surgery, catheter laboratory, dialysis unit, dental clinics,
transportation (in-flight, cruise ships), sport, drowning, mass casualty
incidents), and special patient groups (asthma and COPD, neurologi-
cal disease, obesity, pregnancy).
There are no major changes in the 2021 adult Special Circumstances
guidelines. There is greater emphasis on the priorisation of recognition
and management for reversible causes in cardiac arrest due to special
circumstances. The guidelines reflect the increasing evidence for
extracorporeal CPR (eCPR) as management strategy for selected
patients with cardiac arrest in settings in which it can be implemented.
This ERC guideline follows European and international guidelines for
treatment recommendations (electrolyte disorders, sepsis, coronary
thrombosis, accidental hypothermia and avalanche rescue). The trauma
section has been revised with additional measures for haemorrhage
control, the toxic agents section comes with an extensive supplement,
focusing on management of specific toxic agents. Prognostication of
successful rewarming in hypothermic patients follows more differentiated
scoring systems (HOPE score; ICE score). In avalanche rescue priority is
given to ventilations as hypoxia is the most likely reason of cardiac arrest.
Caused by the increasing number of patients from that special settings,
recommendations for cardiac arrest in the catheterisation laboratory and
in the dialysis unit have been added.
Key messages from this section are presented in Fig. 9.
Special causes
Hypoxia
 Follow the standard ALS algorithm when resuscitating patients
with asphyxial cardiac arrest.
 Treat the cause of the asphyxia/hypoxaemia as the highest priority
because this is a potentially reversible cause of the cardiac arrest.
 Effective ventilation with the highest feasible inspired oxygen is a
priority in patients with asphyxial cardiac arrest.
Hypovolaemia
Traumatic cardiac arrest (TCA)
 Resuscitation in TCA should focus on the immediate, simulta-
neous treatment of reversible causes.
 The response to TCA is time critical and success depends on a
well-established chain of survival, including focused pre-hospital
and specialised trauma centre care.
 TCA (hypovolemic shock, obstructive shock, neurogenic shock) is
different from cardiac arrest due to medical causes; this is
reflected in the treatment algorithm (Figure Trauma1).
 Use ultrasound to identify the underlying cause of cardiac arrest
and target resuscitative interventions.
 Treating reversible causes simultaneously takes priority over
chest compressions. Chest compression must not delay treatment
of reversible causes in TCA.
 Control haemorrhage with external pressure, haemostatic gauze,
tourniquets and pelvic binder.
 ‘Don’t pump an empty heart’.
 Resuscitative thoracotomy (RT) has a role in TCA and traumatic
peri-arrest.
Anaphylaxis
 Recognise anaphylaxis by the presence of airway (swelling),
breathing (wheeze or persistent coughing), or circulation
17
(hypotension) problems with or without skin and mucosal
changes. This can be in the context of a known trigger in a
patient with an allergy, or suspected anaphylaxis in a patient with
no previous history of allergy.
 Call for help early.
 Remove or stop the trigger if feasible.
 Give intramuscular (IM) adrenaline (0.5 mg (which is 0.5 mL of a
1 mg in 1 mL ampoule of adrenaline)) into the anterolateral thigh
as soon as anaphylaxis is suspected. Repeat the IM adrenaline
if there is no improvement in the patient's condition after about
5 min.
 Ensure the patient is lying and do not suddenly sit or stand the
patient up.
 Use an ABCDE approach and treat problems early (oxygen, fluids,
monitoring).
 Give an IV crystalloid fluid bolus early and monitor the response

large volumes of fluids may be needed.
 Consider IV adrenaline as a bolus (20
50 mcg) or infusion for
refractory anaphylaxis or in specialist care settings where the skills
are available.
 Consider alternative vasopressors (vasopressin, noradrenaline,
metaraminol, phenylephrine) in refractory anaphylaxis.
 Consider IV glucagon in patients taking beta-blockers.
 Start chest compressions and ALS as soon as cardiac arrest is
suspected and follow standard guidelines.
 Consider ECLS or ECPR for patients who are peri-arrest or in
cardiac arrest as a rescue therapy in those settings where it is
feasible.
 Follow existing guidelines for the investigation and follow-up care of
patients with suspected anaphylaxis and confirmed anaphylaxis.
Sepsis
Cardiac arrest prevention in sepsis
 Follow the Surviving Sepsis Guidelines Hour-1 bundle for the initial
resuscitation of sepsis and septic shock
Specifically:
 Measure lactate level.
 Obtain blood cultures prior to administration of antibiotics.
 Administer broad-spectrum antibiotics.
 Begin rapid administration of 30 ml/kg crystalloid for hypotension
or a lactate 4 mmol L
1.
 Apply vasopressors if the patient is hypotensive during or after
fluid resuscitation to maintain mean arterial pressure 65 mmHg.
Cardiac arrest treatment due to sepsis
 Follow standard ALS guidelines including giving the maximal
inspired oxygen concentration.
 Intubate the trachea if able to do so safely.
 Intravenous (IV) crystalloid fluid resuscitation with a 500 ml initial
bolus. Consider administering further boluses.
 Venepuncture for venous blood gas/lactate/electrolytes.
 Control the source of sepsis, if feasible, and give antibiotics early.
Hypo-/hyperkalaemia and other electrolyte disorders
 Consider hyperkalaemia or hypokalaemia in all patients with an
arrhythmia or cardiac arrest.
 Check for hyperkalaemia using point-of-care testing if
available.
 The ECG may be the most readily available diagnostic tool.
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Fig. 9 – Special circumstances infographic summary.

Treatment of hyperkalaemia Follow hyperkalaemia algorithm guided by the severity of hyper-

 Protect the heart. kalaemia and ECG changes.
 Shift potassium into cells. Moderate Hyperkalaemia (serum K+ 6.0
6.4 mmol/l)
 Remove potassium from the body.  Shift K+ into cells: Give 10 units short-acting insulin and 25 g glucose
 Consider dialysis initiation during CPR for refractory hyper- (250 ml glucose 10%) IV over 15
30 min (onset in 15
30 min;
kalaemic cardiac arrest. maximal effect 30
60 min; duration of action 4
6 h; monitor blood
 Consider ECPR. glucose). Follow up with 10% glucose infusion at 50 ml/h for 5 h in
 Monitor serum potassium and glucose levels. patients with a pre-treatment blood glucose <7 mmol/l.
 Prevent the recurrence of hyperkalaemia.  Remove K+ from the body: Consider oral administration of a
potassium binder, e.g. Sodium Zirconium Cyclosilicate (SZC), or a
Patient not in cardiac arrest cation exchange resin e.g., Patiromer or calcium resonium
 Use the ABCDE approach and correct any abnormalities, obtain IV according to local practice.
access.
 Check serum K+ level
use blood gas analyser if available and Severe Hyperkalaemia (serum K+ 6.5 mmol/l) without ECG changes
send a sample to the laboratory.  Seek expert help early.
 Perform an ECG
look for signs of hyperkalaemia.  Shift K+ into cells: Give insulin/glucose infusion (as above).
 Cardiac monitoring
if the serum K+ 6.5 mmol/l or if the patient  Shift K+ into cells: Give salbutamol 10
20 mg nebulised (onset
is acutely unwell. 15
30 min; duration of action 4
6 h).
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 Remove K+ from the body: Give SZC (onset in 60 min) or Patiromer
(onset in 4
7 h) and consider dialysis.
Severe Hyperkalaemia (serum K+ 6.5 mmol/l) with toxic ECG
changes
 Seek expert help early.
 Protect the heart: Give 10 ml calcium chloride 10% IV over 2

5 min (onset 1
3 min, repeat ECG, further dose if toxic ECG
changes persist).
 Shift K+ into cells: Give insulin/glucose infusion (as above).
 Shift K+ into cells: Give salbutamol 10
20 mg nebulised (as
above).
 Remove K+ from the body: Give SZC or Patiromer (see above)
and consider dialysis at outset or if refractory to medical
treatment.
Patient in cardiac arrest
 Confirm hyperkalaemia using blood gas analyser if available.
 Protect the heart: Give 10 ml calcium chloride 10% IV by rapid
bolus injection. Consider repeating dose if cardiac arrest is
refractory or prolonged.
 Shift K+ into cells: Give 10 units soluble insulin and 25 g glucose IV
by rapid injection. Monitor blood glucose. Administer 10% glucose
infusion guided by blood glucose to avoid hypoglycaemia.
 Shift K+ into cells: Give 50 mmol sodium bicarbonate (50 ml 8.4%
solution) IV by rapid injection.
 Remove K+ from the body: Consider dialysis for refractory
hyperkalaemic cardiac arrest.
 Consider the use of a mechanical chest compression device if
prolonged CPR is needed.
 Consider ECLS or ECPR for patients who are peri-arrest or in
cardiac arrest as a rescue therapy in those settings where it is
feasible.
Treatment of hypokalaemia
 Restore potassium level (rate and route of replacement guided by
clinical urgency).
 Check for any potential exacerbating factors (e.g. digoxin toxicity,
hypomagnesaemia).
 Monitor serum K+ (adjust replacement as needed depending on
level).
 Prevent recurrence (assess and remove cause).
Hypothermia
Accidental hypothermia
 Assess core temperature with a low reading thermometer,
tympanic in spontaneously breathing, oesophageal in patients
with a tracheal tube or a supraglottic device with an oesophageal
channel in place.
 Check for the presence of vital signs for up to 1 min.
 Prehospital insulation, triage, fast transfer to a hospital and
rewarming are key interventions.
 Hypothermic patients with risk factors for imminent cardiac arrest
(i.e., core temperature <30  C, ventricular arrhythmia, systolic
blood pressure <90 mmHg) and those in cardiac arrest should
ideally be directly transferred to an extracorporeal life support
(ECLS) centre for rewarming.
 Hypothermic cardiac arrest patients should receive continuous
CPR during transfer.
19
 Chest compression and ventilation rate should not be different to
CPR in normothermic patients.
 If ventricular fibrillation (VF) persists after three shocks, delay
further attempts until the core temperature is >30  C.
 Withhold adrenaline if the core temperature is <30  C.
 Increase administration intervals for adrenaline to 6
10 min if the
core temperature is >30  C.
 If prolonged transport is required or the terrain is difficult, use of a
mechanical CPR device is recommended.
 In hypothermic arrested patients <28  C delayed CPR may be used
when CPR on site is too dangerous or not feasible, intermittent CPR
can be used when continuous CPR is not possible.
 In-hospital prognostication of successful rewarming should be
based on the HOPE or ICE score. The traditional in-hospital serum
potassium prognostication is less reliable.
 In hypothermic cardiac arrest rewarming should be performed with
ECLS, preferably with extra-corporeal membrane oxygenation
(ECMO) over cardiopulmonary bypass (CPB).
 Non-ECLS rewarming should be initiated in a peripheral hospital if
an ECLS centre cannot be reached within hours (e.g. 6 h).
Avalanche rescue
 Start with five ventilations in cardiac arrest, as hypoxia is the most
likely cause of cardiac arrest.
 Perform standard ALS if burial time is <60 min.
 Provide full resuscitative measures, including ECLS rewarming, for
avalanche victims with duration of burial >60 min without evidence
of an obstructed airway or additional un-survivable injuries.
 Consider CPR to be futile in cardiac arrest with a burial time
>60 min and additional evidence of an obstructed airway.
 In-hospital prognostication of successful rewarming should be
based on the HOPE score. The traditional triage with serum
potassium and core temperature (cut-offs 7 mmol/L and 30  C,
respectively) are less reliable.
Hyperthermia and malignant hyperthermia
Hyperthermia
 Measurement of core temperature should be available to guide
treatment.
 Heat syncope
remove patient to a cool environment, cool
passively and provide oral isotonic or hypertonic fluids.
 Heat exhaustion
remove patient to a cool environment, lie them
flat, administer IV isotonic or hypertonic fluids, consider additional
electrolyte replacement therapy with isotonic fluids. Replacement
of 1
2 L crystalloids at 500 mL/h is often adequate.
 Simple external cooling measures are usually not required but
may involve conductive, convective and evaporative measures
(See section 10 First Aid).
 Heat stroke
a ‘cool and run’ approach is recommended:
 Remove patient to a cool environment.
 Lie them flat.
 Immediately active cool using whole body (from neck down)
water immersion technique (1
26  C) until core temperature
<39  C.
 Where water immersion is not available use immediately any
active or passive technique that provides the most rapid rate of
cooling.
 Administer IV isotonic or hypertonic fluids (with blood sodium 
130 mmol/L up to 3  100 mL NaCl 3%).
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 Consider additional electrolyte replacement with isotonic fluids.
Substantial amounts of fluids may be required.
 In exertional heat stroke a cooling rate faster than 0.10  C/min is
safe and desirable.
 Follow the ABCDE approach in any patient with deteriorating
vital signs.
Malignant Hyperthermia
 Stop triggering agents immediately.
 Provide oxygen.
 Aim for normocapnia using hyperventilation.
 Consider correction of severe acidosis with bicarbonate
(1
2 mmol kg
1).
 Treat hyperkalaemia (calcium, glucose/insulin, hyperventilation)
(see hyperkalaemia guideline).
 Give dantrolene (2.5 mg/kg initially, and 10 mg/kg as required).
 Start active cooling.
 Follow the ALS algorithm in cardiac arrest and continue cooling.
 After return of spontaneous circulation (ROSC) monitor the patient
closely for 48
72 h, as 25% of patients experience relapse.
 Contact an expert malignant hyperthermia centre for advice and
follow-up.
Thrombosis
Pulmonary Embolism
Cardiac arrest prevention
 Follow the ABCDE approach
Airway
 Treat life-threatening hypoxia with high-flow oxygen.
Breathing
 Consider pulmonary embolism (PE) in all patients with sudden
onset of progressive dyspnoea and absence of known pulmonary
disease (always exclude pneumothorax and anaphylaxis).
Circulation
 Obtain 12-lead ECG (exclude acute coronary syndrome, look for
right ventricle strain).
 Identify haemodynamic instability and high-risk PE.
 Perform bedside echocardiography.
 Initiate anticoagulation therapy (heparin 80 IU/kg IV) during diagnos-
tic process, unless signs of bleeding or absolute contraindications.
 Confirm diagnosis with computed tomographic pulmonary angi-
ography (CTPA).
 Set-up a multidisciplinary team for making decisions on manage-
ment of high-risk PE (depending on local resources).
 Give rescue thrombolytic therapy in rapidly deteriorating patients.
 Consider surgical embolectomy or catheter-directed treatment as
alternative to rescue thrombolytic therapy in rapidly deteriorating
patients.
Exposure
 Request information about past medical history, predisposing
factors, and medication that may support diagnosis of pulmonary
embolism:
 Previous pulmonary embolism or deep venous thrombosis
(DVT).
 Surgery or immobilisation within the past four weeks.
 Active cancer.
 Clinical signs of DVT.
 Oral contraceptive use or hormone replacement therapy.
 Long-distance flights.
Cardiac arrest management
 Cardiac arrest commonly presents as PEA.
 Low ETCO2 readings (below 1.7 kPa/13 mmHg) while performing
high-quality chest compressions may support a diagnosis of
pulmonary embolism, although it is a non-specific sign.
 Consider emergency echocardiography performed by a qualified
sonographer as an additional diagnostic tool.
 Administer thrombolytic drugs for cardiac arrest when PE is the
suspected cause of cardiac arrest.
 When thrombolytic drugs have been administered, consider
continuing CPR attempts for at least 60
90 min before termination
of resuscitation attempts.
 Use thrombolytic drugs or surgical embolectomy or percutaneous
mechanical thrombectomy for cardiac arrest when PE is the
known cause of cardiac arrest.
 Consider ECPR as a rescue therapy for selected patients with
cardiac arrest when conventional CPR is failing in settings in which
it can be implemented.
Coronary thrombosis
Prevent and be prepared:
 Encourage cardiovascular prevention to reduce the risk of acute
events.
 Endorse health education to reduce delay to first medical
contact.
 Promote layperson basic life support to increase the chances of
bystander CPR.
 Ensure adequate resources for better management.
 Improve quality management systems and indicators for better
quality monitoring.
Detect parameters suggesting coronary thrombosis and activate
the ST-elevation myocardial infarction (STEMI) network:
 Chest pain prior to arrest.
 Known coronary artery disease.
 Initial rhythm: VF, pulseless ventricular tachycardia (pVT).
 Post-resuscitation 12-lead ECG showing ST-elevation.
Resuscitate and treat possible causes (establish reperfusion
strategy):
 Patients with sustained ROSC
 STEMI patients:
➢ Primary percutaneous coronary intervention (PCI) strategy
120 min from diagnosis: activate catheterisation laborato-
ry and transfer patient for immediate PCI.
➢ Primary PCI not possible in 120 min: perform pre-hospital
thrombolysis and transfer patient to PCI centre.
 Non STEMI patients: individualise decisions considering patient
characteristics, OHCA setting and ECG findings.
➢ Consider quick diagnostic work-up (discard non-coronary
causes and check patient condition).
➢ Perform urgent coronary angiography (120 min) if ongoing
myocardial ischaemia is suspected or the patient is
hemodynamically/electrically instable.
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➢ Consider delayed coronary angiography if there is no
suspected ongoing ischaemia and the patient is stable.
 Patients with no sustained ROSC: Assess setting and patient
conditions and available resources
 Futile: Stop CPR.
 Not-futile: Consider patient transfer to a percutaneous
coronary intervention (PCI) centre with on-going CPR.
➢ Consider mechanical compression and ECPR.
➢ Consider coronary angiography.
Cardiac tamponade
 Decompress the pericardium immediately.
 Point of care echocardiography supports the diagnosis.
 Perform resuscitative thoracotomy or ultrasound guided
pericardiocentesis.
Tension pneumothorax
 Diagnosis of tension pneumothorax in a patient with cardiac arrest
or haemodynamic instability must be based on clinical examina-
tion or point of care ultrasound (POCUS).
 Decompress chest immediately by open thoracostomy when a
tension pneumothorax is suspected in the presence of cardiac
arrest or severe hypotension.
 Needle chest decompression serves as rapid treatment, it should
be carried out with specific needles (longer, non-kinking).
 Any attempt at needle decompression under CPR should be
followed by an open thoracostomy or a chest tube if the expertise is
available.
 Chest decompression effectively treats tension pneumothorax
and takes priority over other measures.
Toxic agents
Prevention
 Poisoning rarely causes cardiac arrest.
 Manage hypertensive emergencies with benzodiazepines, vaso-
dilators and pure alpha-antagonists.
 Drug induced hypotension usually responds to IV fluids.
 Use specific treatments where available in addition to the ALS
management of arrhythmias.
 Provide early advanced airway management.
 Administer antidotes, where available, as soon as possible.
Cardiac arrest treatment
 Have a low threshold to ensure your personal safety.
 Consider using specific treatment measures as antidotes,
decontamination and enhanced elimination.
 Do not use mouth-to-mouth ventilation in the presence of
chemicals such as cyanide, hydrogen sulphide, corrosives and
organophosphates.
 Exclude all reversible causes of cardiac arrest, including electrolyte
abnormalities which can be indirectly caused by a toxic agent.
 Measure the patient's temperature because hypo- or hyperther-
mia may occur during drug overdose.
 Be prepared to continue resuscitation for a prolonged time. The
toxin concentration may fall as it is metabolised or excreted during
extended resuscitation measures.
 Consult regional or national poison centres for information on
treatment of the poisoned patient.
21
 Consider ECPR as a rescue therapy for selected patients with
cardiac arrest when conventional CPR is failing in settings in which
it can be implemented.
Special settings
Healthcare facilities
Cardiac arrest in the operating room (OR)
 Recognise cardiac arrest by continuous monitoring.
 Inform the surgeon and the theatre team. Call for help and the
defibrillator.
 Initiate high-quality chest compressions and effective ventilation.
 Follow the ALS algorithm with a strong focus on reversible causes,
especially hypovolaemia (anaphylaxis, bleeding), hypoxia, ten-
sion-pneumothorax, thrombosis (pulmonary embolism).
 Use ultrasound to guide resuscitation
 Adjust the height of the OR table to enable high-quality CPR.
 Check the airway and review the EtCO2 tracing.
 Administer oxygen with a FiO2 1.0.
 Open cardiac compression should be considered as an effective
alternative to closed chest compression.
 Consider ECPR as a rescue therapy for selected patients with
cardiac arrest when conventional CPR is failing.
Cardiac surgery
Prevent and be prepared
 Ensure adequate training of the staff in resuscitation technical
skills and ALS.
 Ensure equipment for emergency re-sternotomy is available in the
ICU.
 Use safety checklists.
Detect cardiac arrest and activate cardiac arrest protocol:
 Identify and manage deterioration in the postoperative cardiac
patient.
 Consider echocardiography.
 Confirm cardiac arrest by clinical signs and pulseless pressure
waveforms.
 Shout for help and activate cardiac arrest protocol.
Resuscitate and treat possible causes
 Resuscitate according to ALS MODIFIED algorithm:
 VF/pVT ! Defibrillate: apply up to 3 consecutive shocks
(< 1 min).
 Asystole/extreme bradycardia ! Apply early pacing (< 1 min).
 PEA ! Correct potentially reversible causes. If paced rhythm,
turn off pacing to exclude VF.
! No ROSC:
 Initiate chest compression and ventilation.
 Perform early resternotomy (<5 min).
 Consider circulatory support devices and ECPR (Figure CS1).
Catheterisation laboratory
Prevent and be prepared
 Ensure adequate training of the staff in resuscitation technical
skills and ALS.
 Use safety checklists.
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Detect cardiac arrest and activate cardiac arrest protocol
 Check patient's status and monitored vital signs periodically.
 Consider cardiac echocardiography in case of haemodynamic
instability or suspected complication.
 Shout for help and activate cardiac arrest protocol.
Resuscitate and treat possible causes
 Resuscitate according to the MODIFIED ALS algorithm:
 VF/pVT cardiac arrest ! Defibrillate (apply up to 3 consecutive
shocks) ! no ROSC ! resuscitate according to ALS algorithm.
 Asystole/PEA ! resuscitate according to ALS algorithm.
 Check and correct potentially reversible causes, including the use
of echocardiography and angiography.
 Consider mechanical chest compression and circulatory support
devices (including ECPR).
Dialysis unit
 Follow the universal ALS algorithm.
 Assign a trained dialysis nurse to operate the haemodialysis (HD)
machine.
 Stop dialysis and return the patient's blood volume with a fluid
bolus.
 Disconnect from the dialysis machine (unless defibrillation-proof)
in accordance with the International Electrotechnical Committee
(IEC) standards.
 Leave dialysis access open to use for drug administration.
 Dialysis may be required in the early post resuscitation period.
 Provide prompt management of hyperkalaemia.
 Avoid excessive potassium and volume shifts during dialysis.
Dentistry
 Causes of cardiac arrest usually relate to pre-existing comorbid-
ities, complications of the procedure or allergic reactions.
 All dental care professionals should undergo annual practical
training in the recognition and management of medical emergen-
cies, including the delivery of CPR, incl. basic airway management
and the use of an AED.
 Check patient's mouth and remove all solid materials from the oral
cavity (e.g. retractor, suction tube, tampons). Prevention of foreign
body airway obstruction should precede positioning.
 Recline the dental chair into a fully horizontal position. If reduced
venous return or vasodilation has caused loss of consciousness
(e.g. vasovagal syncope, orthostatic hypotension), cardiac output
can be restored.
 Place a stool under the backrest for stabilisation.
 Start chest compressions immediately while patient lying flat on
the chair.
 Consider the over-the-head technique of CPR if access to either
side of chest is limited.
 Basic equipment for a standard CPR including a bag-valve-mask
device should be available immediately.
Transportation
Inflight cardiac arrest
 Medical professional help should be sought (in-flight
announcement).
 The rescuer should kneel in the leg-space in front of the aisle seats
to perform chest compressions if the patient cannot be transferred
within a few seconds to an area with adequate floor space (galley).
 Overhead-CPR is a possible option in limited space environments.
 Airway management should be based on the equipment available
and the expertise of the rescuer.
 If the flight plan is over open water with high possibility of ROSC
during an ongoing resuscitation consider an early diversion.
 Consider risks of diversion if ROSC is unlikely and give
appropriate recommendations to the flight crew.
 If CPR is terminated (no ROSC) a flight diversion should not
usually be performed.
Helicopter emergency medical services (HEMS) and air
ambulances
 Proper pre-flight-evaluation of the patient, early recognition and
communication within the team, early defibrillation, high-quality
CPR with minimal interruption of chest compressions, and
treatment of reversible causes before flight are the most
important interventions for the prevention of CPR during HEMS
missions.
 Check the patient status properly before flight. Sometimes
ground-based transport might be a suitable alternative, especially
for patients with high-risk of cardiac arrest.
 Check security of the airway and ventilator connections prior to
flight. For a cardiac arrest in an unventilated patient during flight
consider an SGA for initial airway management.
 Pulse oximetry (SpO2) monitoring and oxygen supplementation
should be available immediately if not already attached.
 CPR should be performed as soon as possible, over-the-head-
CPR (OTH-CPR) might be possible depending on the type of
helicopter.
 If cabin size does not allow high-quality CPR, consider immediate
landing.
 Always consider attaching a mechanical CPR device before flight.
 Consider three stacked shocks in case of shockable rhythm during
flight.
 Defibrillation during flight is safe.
Cruise ship
 Use all medical resources immediately (personal, equipment).
 Activate HEMS if close to the coastline.
 Consider early telemedicine support.
 Have all equipment needed for ALS available on board.
 In case of insufficient number of health care professionals to treat
CA, call for further medical staff via an on-board announcement.
Cardiac arrest in sport
Planning
 All sports and exercise facilities should undertake a medical risk
assessment of the risk of sudden cardiac arrest.
 Where there is a raised risk, mitigation must include resuscitation
planning to include:
 Staff and members training in the recognition and management
of cardiac arrest.
 Direct provision of an AED or clear directions to the nearest
public access AED.
Implementation
 Recognise collapse.
 Gain immediate and safe access to the Field of Play.
 Call for help and activate EMS.
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 Assess for signs of life.
 If no signs of life:
 commence CPR.
 access an AED and defibrillate if indicated.
 If ROSC occurs, carefully observe and monitor the casualty until
advanced medical care arrives.
 If there is no ROSC:
 Continue cardio-pulmonary resuscitation and defibrillation until
advanced medical care arrives.
 In a sport arena, consider moving patient to a less exposed
position and continue resuscitation. This should be accom-
plished with minimal interruption to chest compressions.
Prevention
 Do not undertake exercise, especially extreme exercise or
competitive sport, if feeling unwell.
 Follow medical advice in relation to the levels of exercise or sport
competition.
 Consider cardiac screening for young athletes undertaking high
level competitive sport.
Drowning
Initial rescue
 Undertake a dynamic risk assessment considering feasibility,
chances of survival and risks to the rescuer:
 Submersion duration is the strongest predictor of outcome.
 Salinity has an inconsistent effect on outcome.
 Assess consciousness and breathing:
 If conscious and/or breathing normally, aim to prevent cardiac
arrest.
 If unconscious and not breathing normally, start resuscitation.
Cardiac arrest prevention
Airway
 Ensure a patent airway.
 Treat life threatening hypoxia with 100% inspired oxygen until the
arterial oxygen saturation or the partial pressure of arterial oxygen
can be measured reliably.
 Once SpO2 can be measured reliably or arterial blood gas values
are obtained, titrate the inspired oxygen to achieve an arterial
oxygen saturation of 94
98% or arterial partial pressure of oxygen
(PaO2) of 10
13 kPa (75
100 mmHg).
Breathing
 Assess respiratory rate, accessory muscle use, ability to speak in
full sentences, pulse oximetry, percussion and breath sounds;
request chest X-ray.
 Consider non-invasive ventilation if respiratory distress and safe
to do so.
 Consider invasive mechanical ventilation if respiratory distress
and unsafe or unable to initiate non-invasive ventilation.
 Consider extracorporeal membrane oxygenation if poor response
to invasive ventilation.
Circulation
 Assess heart rate and blood pressure, attach ECG.
 Obtain IV access.
23
 Consider IV fluids and/or vasoactive drugs to support the
circulation.
Disability
 Assess using AVPU or GCS.
Exposure
 Measure core temperature.
 Initiate hypothermia algorithm if core temperature <35  C.
Cardiac arrest
 Start resuscitation as soon as safe and practical to do so. If
trained and able this might include initiating ventilations whilst
still in the water or providing ventilations and chest compres-
sions on a boat.
 Start resuscitation by giving 5 rescue breaths/ventilations using
100% inspired oxygen if available.
 If the person remains unconscious, without normal breathing, start
chest compressions.
 Alternate 30 chest compressions to 2 ventilations.
 Apply an AED if available and follow instructions.
 Intubate the trachea if able to do so safely.
 Consider ECPR in accordance with local protocols if initial
resuscitation efforts are unsuccessful.
Mass casualty incidents
 Identify hazards and immediately request assistance if necessary.
 Use adequate personal protection equipment (PPE) (e.g.
bulletproof vest, respirator, long-sleeved gown, eye and face
protection) depending on specific risks on scene.
 Reduce secondary risks to other patients and providers.
 Use a locally established triage system to prioritise treatment.
 Perform life-saving interventions in patients triaged as “immedi-
ate” (highest priority) to prevent cardiac arrest.
 Consider assigning a higher triage risk level to elderly and to survivors
of high-energy trauma in order to reduce preventable deaths.
 Healthcare professionals must be regularly trained to use the
triage protocols during simulations and live exercises.
Special patients
Asthma and COPD
Cardiac arrest prevention
Airway
 Ensure a patent airway.
 Treat life threatening hypoxia with high flow oxygen.
 Titrate subsequent oxygen therapy with pulse oximetry (SpO2 94

98% for asthma; 88
92% for chronic obstructive pulmonary
disease (COPD)).
Breathing
 Assess respiratory rate, accessory muscle use, ability to speak in
full sentences, pulse oximetry, percussion and breath sounds;
request chest X-ray.
 Look for evidence of pneumothorax/tension pneumothorax.
 Provide nebulised bronchodilators (oxygen driven for asthma,
consider air driven for COPD).
24 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 Administer steroids (Prednisolone 40
50 mg or hydrocortisone
100 mg).
 Consider IV magnesium sulphate for asthma.
 Seek senior advice before giving IV aminophylline or salbutamol.
Circulation
 Assess heart rate and blood pressure, attach ECG.
 Obtain vascular access.
 Consider IV fluids.
Cardiac arrest treatment
 Administer high concentration oxygen.
 Ventilate with respiratory rate (8
10 min
1) and sufficient tidal
volume to cause the chest to rise.
 Intubate the trachea if able to do so safely.
 Check for signs of tension pneumothorax and treat accordingly.
 Disconnect from positive pressure ventilation if relevant and apply
pressure to manually reduce hyper-inflation.
 Consider IV fluids.
 Consider E-CPR in accordance with local protocols if initial
resuscitation efforts are unsuccessful.
Neurological disease
 There are no modifications required in the BLS and
ALS management of cardiac arrest from a primary neurological
cause.
 Following ROSC, consider clinical features such as young age,
female sex, non-shockable rhythm and neurological antecedents
such as headache, seizures, and focal neurological deficit when
suspecting a neurological cause of cardiac arrest.
 Early identification of a neurological cause can be achieved by
performing a brain CT-scan at hospital admission, before or after
coronary angiography.
 In the absence of signs or symptoms suggesting a neurological
cause (e.g. headache, seizures or neurological deficits) or if there
is clinical or ECG evidence of myocardial ischaemia, coronary
angiography is undertaken first, followed by CT scan in the
absence of causative lesions.
Obesity
 Delivery of effective CPR in obese patients may be challenging
due to a number of factors:
 patient access and transportation
 vascular access
 airway management
 quality of chest compressions
 efficacy of vasoactive drugs
 efficacy of defibrillation
 Provide chest compressions up to a maximum of 6 cm.
 Obese patients lying in a bed do not necessarily need to be moved
down onto the floor.
 Change the rescuers performing chest compression more
frequently.
 Consider escalating defibrillation energy to maximum for repeated
shocks.
 Manual ventilation with a bag-mask should be minimised and be
performed by experienced staff using a two-person technique.
 An experienced provider should intubate the trachea early so that
the period of bag-mask ventilation is minimised.
Pregnancy
Prevention of cardiac arrest in the deteriorating pregnant
patient
 Use a validated obstetric early warning scoring system when
caring for the ill-pregnant patient.
 Use a systematic ABCDE approach to assess and treat the
pregnant patient.
 Place the patient in the left lateral position or manually and gently
displace the uterus to the left to relieve aortocaval compression.
 Give oxygen guided by pulse oximetry to correct hypoxaemia.
 Give a fluid bolus if there is hypotension or evidence of
hypovolaemia.
 Immediately re-evaluate the need for any drugs being given.
 Seek expert help early
obstetric, anaesthetic, critical care and
neonatal specialists should be involved early in the resuscitation.
 Identify and treat the underlying cause of cardiac arrest, e.g.
control of bleeding, sepsis.
 Give intravenous tranexamic acid 1 g IV for postpartum
haemorrhage.
Modification for advanced Life support in the pregnant patient
 Call for expert help early (including an obstetrician and
neonatologist).
 Start basic life support according to standard guidelines.
 Use the standard hand position for chest compressions on the
lower half of the sternum if feasible.
 If over 20 weeks pregnant or the uterus is palpable above the level
of the umbilicus:
 Manually displace the uterus to the left to remove aortocaval
compression.
 If feasible, add left lateral tilt
the chest should remain on
supported on a firm surface (e.g. in the operating room). The
optimal angle of tilt is unknown. Aim for a tilt between 15 and 30
degrees. Even a small amount of tilt may be better than no tilt.
The angle of tilt used needs to enable high-quality chest
compressions and if needed allow caesarean delivery of the
foetus.
 Prepare early for emergency hysterostomy early
the foetus will
need to be delivered if immediate (within 4 min) resuscitation
efforts fail.
 If over 20 weeks pregnant or the uterus is palpable above the level
of the umbilicus and immediate (within 4 min) resuscitation is
unsuccessful, deliver the foetus by emergency caesarean section
aiming for delivery within 5 min of collapse.
 Place defibrillator pads in the standard position as far as possible
and use standard shock energies.
 Consider early tracheal intubation by a skilled operator.
 Identify and treat reversible causes (e.g. haemorrhage). Focused
ultrasound by a skilled operator may help identify and treat
reversible causes of cardiac arrest.
 Consider extracorporeal CPR (ECPR) as a rescue therapy if ALS
measures are failing.
Preparation for cardiac arrest in pregnancy

Healthcare settings dealing with cardiac arrest in pregnancy
should:
 have plans and equipment in place for resuscitation of both the
pregnant woman and the newborn.
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 ensure early involvement of obstetric, anaesthetic, critical care
and neonatal teams.
 ensure regular training in obstetric emergencies.
Post resuscitation care
The European Resuscitation Council (ERC) and the European
Society of Intensive Care
Medicine (ESICM) have collaborated to produce these post-
resuscitation care guidelines for adults, which are based on the 2020
International Consensus on Cardiopulmonary Resuscitation Science
with Treatment Recommendations. The topics covered include the
post-cardiac arrest syndrome, control of oxygenation and ventilation,
haemodynamic targets, coronary reperfusion, targeted temperature
management, control of seizures, prognostication, rehabilitation, and
long-term outcome.
These guidelines introduce relatively few major changes from the
2015 ERC-ESICM Guidelines on Post-Resuscitation Care. Key
changes comprise guidance on general intensive care management
such as use of neuromuscular blocking drugs, stress ulcer prophylaxis
and nutrition, greater detail on the treatment of seizures, modifications
to prognostication algorithm, greater emphasis on functional assess-
ments of physical and non-physical impairments before discharge and
long-term follow up and rehabilitation. Recognition of the importance
of survivorship after cardiac arrest.
Key messages from this section are presented in Fig. 10. The post
resuscitation care algorithm is presented in Fig. 11.
Immediate post-resuscitation care
 Post-resuscitation care is started immediately after sustained
ROSC, regardless of location.
 For out-of-hospital cardiac arrest consider transport to a cardiac
arrest centre.
Diagnosis of cause of cardiac arrest
 Early identification of a respiratory or neurological cause can be
achieved by performing a brain and chest CT-scan at hospital
admission, before or after coronary angiography (see coronary
reperfusion).
 In the absence of signs or symptoms suggesting a neurological or
respiratory cause (e.g. headache, seizures or neurological
deficits, shortness of breath or documented hypoxaemia in
patients with known respiratory disease) or if there is clinical or
ECG evidence of myocardial ischaemia, undertake coronary
angiography first. This is followed by CT scan if coronary
angiography fails to identify causative lesions.
Airway and breathing
Airway management after return of spontaneous circulation
 Airway and ventilation support should continue after return of
spontaneous circulation (ROSC) is achieved.
 Patients who have had a brief period of cardiac arrest and an
immediate return of normal cerebral function and are breathing
normally may not require tracheal intubation but should be given
oxygen via a facemask if their arterial blood oxygen saturation is
less than 94%.
 Patients who remain comatose following ROSC, or who have
another clinical indication for sedation and mechanical ventilation,
25
should have their trachea intubated if this has not been done
already during CPR.
 Tracheal intubation should be performed only by experienced
operators who have a high success rate.
 Placement of the tracheal tube must be confirmed with waveform
capnography.
Control of oxygenation
 After ROSC, use 100% (or maximum available) inspired oxygen
until the arterial oxygen saturation or the partial pressure of arterial
oxygen can be measured reliably.
 After ROSC, once SpO2 can be measured reliably or arterial blood
gas values are obtained, titrate the inspired oxygen to achieve an
arterial oxygen saturation of 94
98% or arterial partial pressure of
oxygen (PaO2) of 10
13 kPa or 75
100 mmHg.
 Avoid hypoxaemia (PaO2 < 8 kPa or 60 mmHg) following ROSC.
 Avoid hyperoxaemia following ROSC.
Control of ventilation
 Obtain an arterial blood gas and use end tidal CO2 in mechanically
ventilated patients.
 In patients requiring mechanical ventilation after ROSC, adjust
ventilation to target a normal arterial partial pressure of carbon
dioxide (PaCO2) i.e. 4.5
6.0 kPa or 35
45 mmHg.
 In patients treated with targeted temperature management (TTM)
monitor PaCO2 frequently as hypocapnia may occur.
 During TTM and lower temperatures use consistently either a
temperature or non-temperature corrected approach for measur-
ing blood gas values.
 Use a lung protective ventilation strategy aiming for a tidal volume
of 6
8 mL kg
1 ideal body weight.
Circulation
Coronary reperfusion
 Emergent cardiac catheterisation laboratory evaluation (and
immediate PCI if required) should be performed in adult patients
with ROSC after cardiac arrest of suspected cardiac origin with
ST-elevation on the ECG.
 In patients with ROSC after out-of-hospital cardiac arrest
(OHCA) without ST-elevation on the ECG, emergent cardiac
catheterisation laboratory evaluation should be considered if
there is an estimated high probability of acute coronary
occlusion (e.g. patients with haemodynamic and/or electrical
instability).
Haemodynamic monitoring and management
 All patients should be monitored with an arterial line for continuous
blood pressure measurements, and it is reasonable to monitor
cardiac output in haemodynamically unstable patients.
 Perform early echocardiography in all patients to detect any
underlying pathology and quantify the degree of myocardial
dysfunction.
 Avoid hypotension (<65 mmHg). Target mean arterial pressure
(MAP) to achieve adequate urine output (>0.5 mL kg
1h
1) and
normal or decreasing lactate.
 During TTM at 33  C, bradycardia may be left untreated if blood
pressure, lactate, ScvO2 or SvO2 is adequate. If not, consider
increasing the target temperature.
26 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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Fig. 10 – Post resuscitation care infographic summary.
 Maintain perfusion with fluids, noradrenaline and/or dobutamine,
depending on individual patient need for intravascular volume,
vasoconstriction or inotropy.
 Do not give steroids routinely after cardiac arrest.
 Avoid hypokalaemia, which is associated with ventricular
arrhythmias.
 Consider mechanical circulatory support (such as intra-aortic
balloon pump, left-ventricular assist device or arterio-venous extra
corporal membrane oxygenation) for persisting cardiogenic shock
if treatment with fluid resuscitation, inotropes, and vasoactive
drugs is insufficient.
Disability (optimising neurological recovery)
Control of seizures
 To treat seizures after cardiac arrest, we suggest levetiracetam or
sodium valproate as first-line antiepileptic drugs in addition to
sedative drugs.
 We recommend using electroencephalography (EEG) to diag-
nose electrographic seizures in patients with clinical convulsions
and to monitor treatment effects.
 We suggest that routine seizure prophylaxis is not used in post-
cardiac arrest patients.
Temperature control
 We recommend targeted temperature management (TTM)
for adults after either OHCA or in-hospital cardiac arrest
(IHCA) (with any initial rhythm) who remain unresponsive after
ROSC.
 Maintain a constant target temperature between 32  C and 36  C
for at least 24 h.
 Avoid fever for at least 72 h after ROSC in patients who remain in coma.
 Do not use pre-hospital intravenous cold fluids to initiate hypothermia.
General intensive care management
 Use short acting sedatives and opioids.
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Fig. 11 – Post resuscitation care algorithm.

28 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 Avoid using a neuromuscular blocking drug routinely in patients
undergoing TTM, but it may be considered in case of severe
shivering during TTM.
 Provide stress ulcer prophylaxis routinely in cardiac arrest
patients.
 Provide deep venous thrombosis prophylaxis.
 Target a blood glucose of 5
10 mmol L
1 (90
180 mg dL
1)
using an infusion of insulin if required.
 Start enteral feeding at low rates (trophic feeding) during TTM and
increase after rewarming if indicated. If TTM of 36  C is used as the
target temperature, trophic gastric feeding may be started even
earlier.
 We do not recommend using prophylactic antibiotics routinely.
Prognostication
General guidelines
 In patients who are comatose after resuscitation from cardiac
arrest, neurological prognostication should be performed using
clinical examination, electrophysiology, biomarkers, and imaging,
to both inform patient's relatives and to help clinicians to target
treatments based on the patient's chances of achieving a
neurologically meaningful recovery.
 No single predictor is 100% accurate. Therefore, a multimodal
neuroprognostication strategy is recommended.
 When predicting poor neurological outcome, a high specificity
and precision are desirable, to avoid falsely pessimistic
predictions.
 The clinical neurological examination is central to prognostication.
To avoid falsely pessimistic predictions, clinicians should avoid
potential confounding from sedatives and other drugs that may
confound the results of the tests.
 Clinicians must be aware of the risk of a self-fulfilling prophecy
bias, occurring when the results of an index test predicting poor
outcome is used for treatment decisions, especially regarding life-
sustaining therapies.
 Index tests for neurological prognostication are aimed at
assessing the severity of hypoxic-ischaemic brain injury (hypox-
ic-ischaemic brain injury). The neurological prognosis is one of
several aspects to consider in discussions around an individual's
potential for recovery.
Clinical examination
 Clinical examination is prone to interference from sedatives,
opioids or muscle relaxants. A potential confounding from residual
sedation should always be considered and excluded.
 A Glasgow Motor Score of 3 (abnormal flexion or worse in
response to pain) at 72 h or later after ROSC may identify patients
in whom neurological prognostication may be needed.
 In patients who remain comatose at 72 h or later after ROSC the
following tests may predict a poor neurological outcome:
 The bilateral absence of the standard pupillary light reflex.
 Quantitative pupillometry
 The bilateral absence of corneal reflex
 The presence of myoclonus or status myoclonus within
96 h
 We also suggest recording the EEG in the presence of myoclonic
jerks in order to detect any associated epileptiform activity or to
identify EEG signs, such as background reactivity or continuity,
suggesting a potential for neurological recovery.
Neurophysiology
 Perform an EEG in patients who are unconscious after the arrest.
 Highly malignant EEG-patterns include suppressed background
with or without periodic discharges and burst-suppression. We
suggest using these EEG-patterns after the end of TTM and after
sedation has been cleared as indicators of a poor prognosis.
 The presence of unequivocal seizures on EEG during the first 72 h
after ROSC is an indicator of a poor prognosis.
 Absence of background reactivity on EEG is an indicator of poor
prognosis after cardiac arrest.
 Bilateral absence of somatosensory evoked cortical N20-poten-
tials is an indicator of poor prognosis after cardiac arrest.
 Always consider the results of EEG and somatosensory evoked
potentials (SSEP) in the context of clinical examination findings
and other tests. Always consider using a neuromuscular blocking
drug when performing SSEP.
Biomarkers
 Use serial measurements of neuron-specific enolase (NSE) in
combination with other methods to predict outcome after cardiac
arrest. Increasing values between 24 and 48 h or 72 h in
combination with high values at 48 and 72 h indicates a poor
prognosis.
Imaging
 Use brain imaging studies for predicting poor neurological
outcome after cardiac arrest in combination with other predictors,
in centres where specific experience in these studies is available.
 Use presence of generalised brain oedema, manifested by a
marked reduction of the grey matter/white matter ratio on brain CT,
or extensive diffusion restriction on brain MRI to predict poor
neurological outcome after cardiac arrest.
 Always consider findings from imaging in combination with other
methods for neurological prognostication.
Multimodal prognostication
 Start the prognostication assessment with an accurate clinical
examination, to be performed only after major confounders

especially residual sedation
have been excluded.
 In a comatose patient with M  3 at 72 h from ROSC, in the
absence of confounders, poor outcome is likely when two or more of
the following predictors are present: no pupillary and corneal
reflexes at 72 h, bilaterally absent N20 SSEP wave at 24 h,
highly malignant EEG at >24 h, NSE >60 mg L
1 at 48 h and/or
72 h, status myoclonus 72 h, or a diffuse and extensive anoxic
injury on brain CT/MRI. Most of these signs can be recorded before
72 h from ROSC, however their results will be evaluated only at the
time of clinical prognostic assessment.
Withdrawal of life-sustaining therapy
 Separate discussions around withdrawal of life-sustaining therapy
(WLST) and the assessment of prognosis for neurological
recovery; WLST decisions should consider aspects other than
brain injury such as age, co-morbidity, general organ function and
the patients’ preferences.
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 Allocate sufficient time for communication around the level-of-
treatment decision within the team and with the relatives.
Long-term outcome after cardiac arrest
 Perform functional assessments of physical and non-physical
impairments before discharge from the hospital to identify early
rehabilitation needs and refer to rehabilitation if necessary.
 Organise follow-up for all cardiac arrest survivors within 3 months
after hospital discharge, including:
1. Screening for cognitive problems.
2. Screening for emotional problems and fatigue.
3. Providing information and support for survivors and family
members.
Organ donation
 All decisions concerning organ donation must follow local legal
and ethical requirements.
 Organ donation should be considered in those who have achieved
ROSC and who fulfil neurological criteria for death.
 In comatose ventilated patients, when a decision to start end-of-
life care and withdrawal of life support is made, organ donation
should be considered after circulatory arrest occurs.
Cardiac arrest centres
 Adult patients with non-traumatic OHCA should be considered for
transport to a cardiac arrest centre according to local protocol.
First aid
The European Resuscitation Council has produced these first aid
guidelines, which are based on the 2020 International Consensus on
Cardiopulmonary Resuscitation Science with Treatment Recommen-
dations. The topics include the first aid management of emergency
medicine and trauma. For medical emergencies the following content
is covered: recovery position, optimal positioning for shock,
bronchodilator administration for asthma, recognition of stroke, early
aspirin for chest pain, second dose of adrenaline for anaphylaxis,
management of hypoglycaemia, oral rehydration solutions for treating
exertion-related dehydration, management of heat stroke by cooling,
supplemental oxygen in acute stroke, and presyncope. For trauma
related emergencies the following topics are covered: control of life-
threatening bleeding, management of open chest wounds, cervical
spine motion restriction and stabilisation, recognition of concussion,
cooling of thermal burns, dental avulsion, compression wrap for
closed extremity joint injuries, straightening an angulated fracture, and
eye injury from chemical exposure.
Key messages from this section are presented in Fig. 12.
Recovery position
For adults and children with a decreased level of responsiveness due to
medical illness or non-physical trauma, who do NOT meet the criteria for
the initiation of rescue breathing or chest compressions (CPR), the ERC
recommends they be placed into a lateral, side-lying, recovery position.
Overall, there is little evidence to suggest an optimal recovery position,
but the ERC recommends the following sequence of actions:
 Kneel beside the victim and make sure that both legs are straight
 Place the arm nearest to you out at right angles to the body with the
hand palm uppermost
29
 Bring the far arm across the chest, and hold the back of the hand
against the victim's cheek nearest to you
 With your other hand, grasp the far leg just above the knee and pull
it up, keeping the foot on the ground
 Keeping the hand pressed against the cheek, pull on the far leg to
roll the victim towards you onto their side
 Adjust the upper leg so that both hip and knee are bent at right
angles
 Tilt the head back to make sure the airway remains open
 Adjust the hand under the cheek if necessary, to keep the head
tilted and facing downwards to allow liquid material to drain from
the mouth
 Check regularly for normal breathing
 Only leave the victim unattended if absolutely necessary, for
example to attend to other victims.
It is important to stress the importance of maintaining a close check
on all unresponsive individuals until the EMS arrives to ensure that
their breathing remains normal. In certain situations, such as
resuscitation-related agonal respirations or trauma, it may not be
appropriate to move the individual into a recovery position.
Optimal position for shock victim
 Place individuals with shock into the supine (lying-on-back)
position.
 Where there is no evidence of trauma first aid, providers might
consider the use of passive leg raising as a temporising measure
while awaiting more advanced emergency medical care.
Bronchodilator administration for asthma
 Assist individuals with asthma who are experiencing difficulty in
breathing with their bronchodilator administration.
 First aid providers must be trained in the various methods of
administering a bronchodilator.
Recognition of stroke
 Use a stroke assessment scale to decrease the time to
recognition and definitive treatment for individual suspected of
acute stroke.
 The following stroke assessment scales are available:
 Face Arm Speech Time to call (FAST)
 Melbourne Ambulance Stroke Scale (MASS)
 Cincinnati Prehospital Stroke Scale (CPSS)
 Los Angeles Prehospital Stroke Scale (LAPSS) are the most
common.
 The MASS and LAPSS scales can be augmented by blood
glucose measurement.
Early aspirin for chest pain
 For conscious adults with non-traumatic chest pain due to
suspected myocardial infarction:
 Reassure the casualty
 Sit or lie the casualty in a comfortable position
 Call for help
 First aid providers should encourage and assist the casualty in the
self-administration of 150
300 mg chewable aspirin as soon as
possible after the onset of chest pain
 Do not administer aspirin to adults with chest pain of unclear or
traumatic aetiology
30 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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Fig. 12 – First Aid infographic summary.
 There is a relatively low risk of complications, particularly
anaphylaxis and serious bleeding. Do not administer aspirin to
adults with a known allergy to aspirin or contraindications such as
severe asthma or known gastrointestinal bleeding.
Anaphylaxis
 The management of anaphylaxis has been described in Special
Circumstances.
 If the symptoms of anaphylaxis do not resolve after 5 min of the first
injection or, if the symptoms begin to return after the first dose,
administer a second dose of adrenaline by intramuscular injection
using an autoinjector.
 Call for help.
 Train first aid providers regularly in the recognition and first aid
management of anaphylaxis.
Management of hypoglycaemia
 The signs of hypoglycaemia are sudden impaired consciousness:
ranging from dizziness, fainting, sometimes nervousness and
deviant behaviour (mood swings, aggression, confusion, loss of
concentration, signs that look like drunkenness) to loss of
consciousness.
 A person with mild hypoglycaemia typically has less severe signs
or symptoms and has the preserved ability to swallow and follow
commands.
 If hypoglycaemia is suspected in someone who has signs or
symptoms of mild hypoglycaemia and is conscious and able to
swallow:
 Give glucose or dextrose tablets (15
20 g), by mouth
 If glucose or dextrose tablets are not available give other
dietary sugars in an equivalent amount to glucose, such as
Skittles, Mentos, sugar cubes, jellybeans, or half a can of orange
juice
 Repeat the administration of sugar if the symptoms are still
present and not improving after 15 min
 If oral glucose is not available a glucose gel (partially held in the
cheek, and partially swallowed) can be given
 Call the emergency services if:
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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& the casualty is or becomes unconscious
& the casualty's condition does not improve
 Following recovery from the symptoms after taking the sugar,
encourage taking a light snack such as a sandwich or a waffle
 For children who may be uncooperative with swallowing oral
glucose:
 Consider administering half a teaspoon of table sugar (2.5
gram) under the child's tongue.
 If possible, measure and record the blood sugar levels before and
after treatment.
Oral rehydration solutions for treating exertion-related
dehydration
 If a person has been sweating excessively during a sports
performance and exhibits signs of dehydration such as feeling
thirsty, dizzy or light-headed and/or having dry mouth or dark
yellow and strong-smelling urine, give him/her 3
8% carbohy-
drate-electrolyte (CE) drinks (typical ‘sports’ rehydration drinks) or
skimmed milk.
 If 3
8% CE drinks or milk are not available or not well tolerated,
alternative beverages for rehydration include 0
3% CE drinks,
8
12% CE drinks or water.
 Clean water, in regulated quantities, is an acceptable alternative,
although it may require a longer time to rehydrate.
 Avoid the use of alcoholic beverages.
 Call the emergency services if:
 The person is or becomes unconscious
 The person shows signs of a heat stroke.
Management of heat stroke by cooling
Recognise the symptoms and signs of heat stroke (in the presence of a
high ambient temperature):
 Elevated temperature
 Confusion
 Agitation
 Disorientation
 Seizures
 Coma.
When a diagnosis of suspected exertional or classical heat stroke
is made:
 Immediately remove casualty from the heat source and com-
mence passive cooling
 Commence additional cooling using any technique immediately
available
 If the core temperature is above 40  C commence whole body
(neck down) cold water (1
26  C) immersion until the core
temperature falls below 39  C
 If water immersion is not possible use alternative methods of
cooling e.g. ice sheets, commercial ice packs, fan alone, cold
shower, hand cooling devices, cooling vests and jackets or
evaporative cooling (mist and fan)
 Where possible measure the casualty's core temperature (rectal
temperature measurement) which may require special training
 Casualties with exertional hyperthermia or non-exertional heat-
stroke will require advanced medical care and advance assistance
should be sought.
31
It is recognised that the diagnosis and management of heat stroke
requires special training (rectal temperature measurement, cold water
immersion techniques). However, the recognition of the signs and
symptoms of a raised core temperature and the use of active cooling
techniques is critical in avoiding morbidity and mortality.
Use of supplemental oxygen in acute stroke
 Do not routinely administer supplemental oxygen in suspected
acute stroke in the prehospital first aid setting.
 Oxygen should be administered if the individual is showing signs of
hypoxia.
 Training is required for first aid providers in the provision of
supplementary oxygen.
Management of presyncope
 Presyncope is characterised by light-headedness, nausea,
sweating, black spots in front of the eyes and an impending
sense of loss of consciousness.
 Ensure the casualty is safe and will not fall or injure themselves if
they lose consciousness.
 Use simple physical counterpressure manoeuvres to abort
presyncope of vasovagal or orthostatic origin.
 Lower body physical counterpressure manoeuvres are more
effective than upper body manoeuvres.
 Lower body
Squatting with or without leg crossing
 Upper body
Hand clenching, neck flexion
 First aid providers will need to be trained in coaching casualties in
how to perform physical counterpressure manoeuvres.
Control of life-threatening bleeding
Direct pressure, haemostatic dressings, pressure points and
cryotherapy for life-threatening bleeding
 Apply direct manual pressure for the initial control of severe, life-
threatening external bleeding.
 Consider the use of a haemostatic dressing when applying direct
manual pressure for severe, life-threatening bleeding. Apply the
haemostatic dressing directly to the bleeding injury and then apply
direct manual pressure to the dressing.
 A pressure dressing may be useful once bleeding is controlled to
maintain haemostasis but should not be used in lieu of direct
manual pressure for uncontrolled bleeding.
 Use of pressure points or cold therapy is not recommended for the
control of life-threatening bleeding.
Tourniquets for life-threatening bleeding
 For life-threatening bleeding from wounds on limbs in a location
amenable to the use of a tourniquet (i.e. arm or leg wounds,
traumatic amputations):
 Consider the application of a manufactured tourniquet as soon as
possible:
 Place the tourniquet around the traumatised limb 5
7 cm above
the wound but not over a joint
 Tighten the tourniquet until the bleeding slows and stops. This may
be extremely painful for the casualty
 Maintain the tourniquet pressure
 Note the time the tourniquet was applied
32 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 Do not release the tourniquet
the tourniquet must only be
released by a healthcare professional
 Take the casualty to hospital immediately for further medical care
 In some cases, it may require the application of two tourniquets in
parallel to slow or stop the bleeding.
 If a manufactured tourniquet is not immediately available, or if
bleeding is uncontrolled with the use of a manufactured tourniquet,
apply direct manual pressure, with a gloved hand, a gauze
dressing, or if available, a haemostatic dressing.
 Consider the use of an improvised tourniquet only if a
manufactured tourniquet is not available, direct manual pressure
(gloved hand, gauze dressing or haemostatic dressing) fails to
control life-threatening bleeding, and the first aid provider is
trained in the use of improvised tourniquets.
Management of open chest wounds
 Leave an open chest wound exposed to freely communicate with
the external environment.
 Do not apply a dressing or cover the wound.
 If necessary:
 Control localised bleeding with direct pressure
 Apply a specialised non-occlusive or vented dressing ensuring
a free outflow of gas during expiration (training required).
Cervical spine motion restriction and stabilisation
 The routine application of a cervical collar by a first aid provider is
not recommended.
 In a suspected cervical spine injury:
 If the casualty is awake and alert, encourage them to self-
maintain their neck in a stable position.
 If the casualty is unconscious or uncooperative consider
immobilising the neck using manual stabilisation techniques.
&
Head Squeeze:
 With the casualty lying supine hold the casualty's head
between your hands.
 Position your hands so that the thumbs are above the
casualty's ears and the other fingers are below the ear
 Do not cover the ears so that the casualty can hear.
& Trapezium Squeeze:
 With the casualty lying supine hold the casualty's
trapezius muscles on either side of the head with your
hands (thumbs anterior to the trapezius muscle). In
simple terms
hold the casualty's shoulders with the
hands thumbs up
 Firmly squeeze the head between the forearms with
the forearms placed approximately at the level of the
ears.
Recognition of concussion
 Although a simple single-stage concussion scoring system would
greatly assist first aid providers’ recognition and referral of victims
of suspected head injury there is currently no such validated
system in current practice.
 An individual with a suspected concussion must be evaluated by a
healthcare professional.
Thermal burns
Following a thermal burn injury
 Immediately commence cooling the burn in cool or cold (not
freezing) water
 Continue cooling the burn for at least 20 min
 Cover the wound with a loose sterile dressing or use cling wrap. Do
not circumferentially wrap the wound
 Seek immediate medical care.
Care must be taken when cooling large thermal burns or burns in
infants and small children so as not to induce hypothermia.
Dental avulsion
 If the casualty is bleeding from the avulsed tooth socket:
 Put on disposable gloves prior to assisting the victim
 Rinse out the casualty's mouth with cold, clean water
 Control bleeding by:
& Pressing a damp compress against the open tooth socket
& Tell the casualty to bite on the damp compress
& Do not do this if there is a high chance that the injured person
will swallow the compress (for example, a small child, an
agitated person or a person with impaired consciousness).
 If it is not possible to immediately replant the avulsed tooth at the
place of accident:
 Seek help from a specialist
&
Take the casualty and the avulsed tooth to seek expert help
from a specialist.
 Only touch an avulsed tooth at the crown. Do not touch the root
 Rinse a visibly contaminated avulsed tooth for a maximum of
10 s with saline solution or under running tap water prior to
transportation.
 To transport the tooth:
& Wrap the tooth in cling film or store the tooth temporarily in a
small container with Hank's Balanced Salt solution (HBSS),
propolis or Oral Rehydration Salt (ORS) solution
& If none of the above are available, store the tooth in cow's
milk (any form or fat percentage)
& Avoid the use of tap water, buttermilk or saline (sodium
chloride).
Compression wrap for closed extremity joint injuries
 If the casualty is experiencing pain in the joint and finds it difficult to
move the affected joint, ask him/her not to move the limb. It is
possible there is swelling or bruising on the injured joint.
 There is no evidence to support or not support the application of a
compression wrap to any joint injury.
 Training will be required to correctly and effectively apply a
compression wrap to a joint injury.
Straightening an angulated fracture
 Do not straighten an angulated long bone fracture.
 Protect the injured limb by splinting the fracture.
 Realignment of fractures should only be undertaken by those
specifically trained to perform this procedure.
Eye injury from chemical exposure
 For an eye injury due to exposure to a chemical substance
 Immediately irrigate the contaminated eye using continuous, large
volumes of clean water or normal saline for 10 to 20 min.
 Take care not to contaminate the unaffected eye.
 Refer the casualty for emergency health care professional review.
 It is advisable to wear gloves when treating eye injuries with
unknown chemical substances and to carefully discard them when
treatment has been completed.
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Neonatal life support
The European Resuscitation Council has produced these newborn life
support guidelines, which are based on the International Liaison
Committee on Resuscitation 2020 Consensus on Science and
Treatment Recommendations for Neonatal Life Support. The guide-
lines cover the management of the term and preterm infant. The topics
covered include an algorithm to aid a logical approach to resuscitation
of the newborn, factors before delivery, training and education,
thermal control, management of the umbilical cord after birth, initial
assessment and categorisation of the newborn infant, airway and
breathing and circulation support, communication with parents,
considerations when withholding and discontinuing support.
Key changes introduced with these guidelines relate to manage-
ment of the umbilical cord, initial inflations and assisted ventilation,
infants born through meconium-stained liquor air/Oxygen for preterm
resuscitation, initial inflations and assisted ventilation, laryngeal mask
use, oxygen use during chest compressions, vascular access, use of
adrenaline, glucose during resuscitation and prognostication.
Key messages from this section are presented in Fig. 13 and the
NLS algorithm is depicted in Fig. 14.
Factors before delivery
Transition and the need for assistance after birth
Most, but not all, infants adapt well to extra-uterine life but some
require help with stabilisation, or resuscitation. Up to 85% breathe
spontaneously without intervention; a further 10% respond after
drying, stimulation and airway opening manoeuvres; approximately
5% receive positive pressure ventilation. Intubation rates vary
between 0.4 and 2%. Fewer than 0.3% of infants receive chest
compressions and only 0.05% receive adrenaline.
Risk factors
A number of risk factors have been identified as increasing the
likelihood of requiring help with stabilisation, or resuscitation.
Staff attending delivery
Any infant may develop problems during birth. Local guidelines
indicating who should attend deliveries should be developed, based
on current understanding of best practice and clinical audit, and taking
into account identified risk factors. As a guide,
 Personnel competent in newborn life support should be available
for every delivery.
 If intervention is required, there should be personnel available
whose sole responsibility is to care for the infant.
 A process should be in place for rapidly mobilising a team with
sufficient resuscitation skills for any birth.
Equipment and environment
 All equipment must be regularly checked and ready for use.
 Where possible, the environment and equipment should be
prepared in advance of the delivery of the infant. Checklists
facilitate these tasks.
 Resuscitation should take place in a warm, well-illuminated,
draught-free area with a flat resuscitation surface and a radiant
heater (if available).
 Equipment to monitor the condition of the infant and to support
ventilation should be immediately available.
33
 Additional equipment, that might be required in case of more
prolonged resuscitation should be easily accessible.
Planned home deliveries
 Ideally, two trained professionals should be present at all home
deliveries.
 At least one must be competent in providing mask ventilation and
chest compressions to the newborn infant.
 Recommendations as to who should attend a planned home
delivery vary from country to country, but the decision to undergo
such a delivery, once agreed with medical and midwifery staff,
should not compromise the standard of initial assessment,
stabilisation or resuscitation at birth.
 There will inevitably be some limitations to the extent of the
resuscitation of a newborn infant in the home, due to the distance
from healthcare facilities and equipment available, and this must
be made clear to the mother at the time plans for home delivery are
made.
 When a birth takes place in a non-designated delivery area a
minimum set of equipment of an appropriate size for the newborn
infant should be available, including:
 clean gloves for the attendant and assistants,
 means of keeping the infant warm, such as heated dry towels
and blankets,
 a stethoscope to check the heart rate,
 a device for safe assisted lung aeration and subsequent ventilation
such as a self-inflating bag with appropriately sized facemask,
 sterile instruments for clamping and then safely cutting the
umbilical cord.
 Unexpected deliveries outside hospital are likely to involve
emergency services who should be trained and prepared for
such events and carry appropriate equipment.
 Caregivers undertaking home deliveries should have pre-defined
plans for difficult situations.
Briefing
 If there is sufficient time, brief the team to clarify responsibilities,
check equipment and plan the stabilisation, or resuscitation.
 Roles and tasks should be assigned
checklists are helpful.
 Prepare the family if it is anticipated that resuscitation might be
required.
Training/education
 Newborn resuscitation providers must have relevant current
knowledge, technical and non-technical skills.
 Institutions or clinical areas where deliveries may occur should
have structured educational programmes, teaching the knowl-
edge and skills required for newborn resuscitation.
 The content and organisation of such training programmes may
vary according to the needs of the providers and the organisation
of the institutions.
 Recommended programmes include:
 regular practice and drills,
 team and leadership training,
 multi-modal approaches,
 simulation-based training,
 feedback on practice from different sources (including feedback
devices),
 objective, performance focused debriefings.
34 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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Fig. 13 – NLS infographic summary.

 Ideally, training should be repeated more frequently than once per  Keep the environment in which the infant is looked after (e.g.
year. delivery room or theatre) warm at 23
25  C.
 Updates may include specific tasks, simulation and/or behavioural  For infants 28 weeks gestation the delivery room or theatre
skills and reflection. temperature should be >25  C.

Thermal control
Term and near-term infants >32 weeks gestation
 The infant's temperature should be regularly monitored after birth
and the admission temperature should be recorded as a
prognostic and quality indicator.
 The temperature of newborn infants should be maintained
between 36.5  C and 37.5  C.
 Hypothermia (36.0  C) and hyperthermia (>38.0  C) should be
avoided. In appropriate circumstances, therapeutic hypothermia
may be considered after resuscitation (see post-resuscitation care)
Environmental
 Protect the infant from draughts. Ensure windows are closed and
air-conditioning appropriately programmed.

Dry the infant immediately after delivery. Cover the head and body
of the infant, apart from the face, with a warm and dry towel to
prevent further heat loss.
 If no resuscitation is required place the infant skin-to-skin with
mother and cover both with a towel. On-going careful observation
of mother and infant will be required especially in more preterm
and growth restricted infants to ensure they both remain
normothermic.
 If the infant needs support with transition or when resuscitation is
required, place the infant on a warm surface using a preheated
radiant warmer.
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Fig. 14 – NLS algorithm.

36 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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Preterm infants 32 weeks gestation Tactile stimulation

 Completely cover with polyethylene wrapping (apart from face) Initial handling is an opportunity to stimulate the infant during
without drying and use a radiant warmer. assessment by
 If umbilical cord clamping is delayed and a radiant warmer is not  Drying the infant.
accessible at this point, other measures (such as those listed  Gently stimulating the infant as you dry them, for example by
below) will be needed to ensure thermal stability while still rubbing the soles of the feet or the back of the chest. Avoid more
attached to the placenta. aggressive methods of stimulation.
 A combination of further interventions may be required in infants
32 weeks including increased room temperature, warm Tone & colour
blankets, head cap and thermal mattress.  A very floppy infant is likely to need ventilatory support.
 Skin-to-skin care is feasible in less mature infants however caution  Colour is a poor means of judging oxygenation. Cyanosis can be
is required in the more preterm or growth restricted infant in order difficult to recognise. Pallor might indicate shock or rarely
to avoid hypothermia. hypovolaemia
consider blood loss and plan appropriate
 For infants receiving respiratory support, use of warmed intervention.
humidified respiratory gases should be considered.
 A quality improvement programme including the use of checklists and Breathing
continuous feedback to the team has been shown to significantly  Is the infant breathing?
Note the rate, depth and symmetry,
reduce hypothermia at admission in very preterm infants. work/effort of breathing as
 Adequate
Out of hospital management  Inadequate/abnormal pattern
such as gasping or grunting
 Infants born unexpectedly outside a normal delivery environment  Absent
are at higher risk of hypothermia and subsequent poorer outcomes.
 They may benefit from placement in a food grade plastic bag after Heart rate
drying and then swaddling. Alternatively, well newborns >30 Determine the heart rate with a stethoscope and a saturation monitor
weeks gestation may be dried and nursed skin-to-skin to maintain  ECG (electrocardiogram) for later continuous assessment.
their temperature whilst they are transferred as long as mothers  Fast (100 min
1)
satisfactory
are normothermic. Infants should be covered and protected from  Slow (60
100 min
1)
intermediate, possible hypoxia
draughts and watched carefully to avoid hypothermia and ensure  Very slow/absent (<60 min
1)
critical, hypoxia likely
airway and breathing are not compromised.
If the infant fails to establish spontaneous and effective breathing
Management of the umbilical cord after birth following assessment and stimulation, and/or the heart rate does not
 The options for managing cord clamping and the rationale should increase (and/or decreases) if initially fast, respiratory support should
be discussed with parents before birth. be started.
 Where immediate resuscitation or stabilisation is not required, aim
to delay clamping the cord for at least 60 s. A longer period may be Classification according to initial assessment
more beneficial. On the basis of the initial assessment, the infant can usually be placed
 Clamping should ideally take place after the lungs are aerated. into one of three groups as the following examples illustrate.
 Where adequate thermal care and initial resuscitation interven- 1.
tions can be safely undertaken with the cord intact it may be Good tone
possible to delay clamping whilst performing these interventions. Vigorous breathing or crying
 Where delayed cord clamping is not possible consider cord milking Heart rate
fast (100 min
1)
in infants >28 weeks gestation.
Assessment: Satisfactory transition
Breathing does not require
Initial assessment support. Heart rate is acceptable.
May occur before the umbilical cord is clamped and cut (typically Actions:
performed in this order):  Delay cord clamping.
 Observe Tone (& Colour)  Dry, wrap in warm towel.
 Assess adequacy of Breathing  Keep with mother or carer and ensure maintenance of temperature.
 Assess the Heart Rate  Consider early skin-to-skin care if stable.
 Take appropriate action to keep the baby warm during these initial
steps. 2.
 This rapid assessment serves to establish a baseline, identify the Reduced tone
need for support and/or resuscitation and the appropriateness and Breathing inadequately (or apnoeic)
duration of delaying umbilical cord clamping. Heart rate
slow (<100 min
1)
 Frequent re-assessment of heart rate and breathing indicates
whether the infant is adequately transitioning or whether further Assessment: Incomplete transition
Breathing requires support,
interventions are needed. slow heart rate may indicate hypoxia.
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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Actions:
 Delay cord clamping only if you are able to appropriately support
the infant.
 Dry, stimulate, wrap in a warm towel.
 Maintain the airway,
lung inflation and ventilation.
 Continuously assess changes in heart rate and breathing
 If no improvement in heart rate, continue with ventilation.
 Help may be required.
3.
Floppy  Pale
Breathing inadequately or apnoeic
Heart rate
very slow (<60 min
1) or undetectable
Assessment: Poor/Failed transition
Breathing requires support,
heart rate suggestive of significant hypoxia
Actions:
 Clamp cord immediately and transfer to the resuscitation platform.
Delay cord clamping only if you are able to appropriately support/
resuscitate the infant.
 Dry, stimulate, wrap in warm towel.
 Maintain the airway
lung inflation and ventilation.
 Continuously assess heart rate, breathing, and effect of
ventilation.
 Continue newborn life support according to response.
 Help is likely to be required.
Preterm infants
 Same principles apply.
 Consider alternative/additional methods for thermal care e.g.
polyethylene wrap.
 Gently support, initially with CPAP if breathing.
 Consider continuous rather than intermittent monitoring (pulse
oximetry  ECG)
Newborn life support
Following initial assessment and intervention, continue respiratory
support if:
 The infant has not established adequate, regular breathing, or
 The heart rate is <100 min
1.
Ensuring an open airway, aerating and ventilating the lungs is
usually all that is necessary. Without these, other interventions will be
unsuccessful.
Airway
Commence life support if initial assessment shows that the infant has
not established adequate regular normal breathing, or has a heart rate
<100 min
1
Establishing and maintaining an open airway is essential to
achieve postnatal transition and spontaneous breathing, or for further
resuscitative actions to be effective.
Techniques to help open the airway
 Place the infant on their back with the head supported in a neutral
position.
 In floppy infants, pulling the jaw forwards (jaw lift) may be essential
in opening and/or maintaining the airway and reducing mask leak.
When using a facemask, two person methods of airway support
are superior and permit true jaw thrust to be applied.
37
 An oropharyngeal airway may be useful in term infants when
having difficulty providing both jaw lift and ventilation, or where the
upper airway is obstructed, for instance in those with micrognathia.
However, oropharyngeal airways should be used with caution in
infants 34 weeks gestation as they may increase airway
obstruction.
 A nasopharyngeal airway may also be considered where there is
difficulty maintaining an airway and mask support fails to achieve
adequate aeration.
Airway obstruction
 Airway obstruction can be caused by inappropriate positioning,
decreased airway tone and/or laryngeal adduction, especially in
preterm infants at birth.
 Suction is only required if airway obstruction due to mucus, vernix,
meconium, blood clots, etc. is confirmed through inspection of the
pharynx after failure to achieve aeration.
 Any suctioning should be undertaken under direct vision, ideally
using a laryngoscope and a wide bore catheter.
Meconium
 Non-vigorous newborn infants delivered through meconium-
stained amniotic fluid are at significant risk for requiring advanced
resuscitation and a neonatal team competent in advanced
resuscitation may be required.
 Routine suctioning of the airway of non-vigorous infants is likely
to delay initiating ventilation and is not recommended. In the
absence of evidence of benefit for suctioning, the emphasis
must be on initiating ventilation as soon as possible in apnoeic or
ineffectively breathing infants born through meconium-stained
amniotic fluid.
 Should initial attempts at aeration and ventilation be unsuccessful
then physical obstruction may be the cause. In this case inspection
and suction under direct vision be considered. Rarely, an infant
may require tracheal intubation and tracheal suctioning to relieve
airway obstruction.
Initial inflations and assisted ventilation
Lung Inflation
 If apnoeic, gasping or not breathing effectively, aim to start positive
pressure ventilation as soon as possible
ideally within 60s of
birth.
 Apply an appropriately fitting facemask connected to a means of
providing positive pressure ventilation, ensuring a a good seal
between mask and face.
 Give five “inflations” maintaining the inflation pressure for up to 2
3 s.
 Provide initial inflation pressures of 30 cm H2O for term infants
commencing with air. Start with 25 cm H2O for preterm infants 32
weeks using 21
30% inspired oxygen (see ‘air/oxygen’).
Assessment
 Check the heart rate
 An increase (within 30 s) in heart rate, or a stable heart rate if
initially high, confirms adequate ventilation/oxygenation.
 A slow or very slow heart rate usually suggests continued
hypoxia and almost always indicates inadequate ventilation.
 Check for chest movement
 Visible chest movement with inflations indicates a patent airway
and delivered volume.
38 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 Failure of the chest to move may indicate obstruction of the
airway, or insufficient inflation pressure and delivered volume to
aerate the lungs.
Ventilation
If there is a heart rate response
 Continue uninterrupted ventilation until the infant begins to
breathe adequately and the heart rate is above 100 min
1.
 Aim for about 30 breaths min
1 with an inflation time of under 1 s.
 Reduce the inflation pressure if the chest is moving well.
 Reassess heart rate and breathing at least every 30 s.
 Consider a more secure airway (laryngeal mask/tracheal tube) if
apnoea continues or if mask ventilation is not effective.
Failure to respond
If there is no heart rate response and the chest is not moving with
inflations
 Check if the equipment is working properly.
 Recheck the head-position and jaw lift/thrust
 Recheck mask size, position and seal.
 Consider other airway manoeuvres:
 2-person mask support if single handed initially.
 Inspection of the pharynx and suction under direct vision to
remove obstructing foreign matter if present.
 Securing the airway via tracheal intubation or insertion of a
laryngeal mask.
 Insertion of an oropharyngeal/nasopharyngeal airway if unable
to secure the airway with other means.
 Consider a gradual increase in inflation pressure.
 If being used, check on a respiratory function monitor that expired
tidal volume is not too low or too high (target about 5 to 8 mL kg
1).
Then:
 Repeat inflations.
 Continuously assess heart rate and chest movement.
If the insertion of a laryngeal mask or tracheal intubation is
considered, it must be undertaken by personnel competent in the
procedure with appropriate equipment. Otherwise continue with
mask ventilation and call for help.
Without adequate lung aeration, chest compressions will be
ineffective; therefore, where the heart rate remains very slow, confirm
effective ventilation through observed chest movement or other measures
of respiratory function before progressing to chest compressions.
Airway adjuncts, assisted ventilation devices, PEEP and CPAP
Continuous positive airway pressure (CPAP) & Positive end
expiratory pressure (PEEP)
 In spontaneously breathing preterm infants consider CPAP as the
initial method of breathing support after delivery
using either
mask or nasal prongs.
 If equipment permits, apply PEEP at minimum of 5
6 cm H2O
when providing positive pressure ventilation (PPV) to these
infants.
Assisted ventilation devices
 Ensure a facemask of appropriate size is used to provide a good
seal between mask and face.
 Where possible use a T-piece resuscitator (TPR) capable of
providing either CPAP or PPV with PEEP when providing
ventilatory support, especially in the preterm infant.
 Nasal prongs of appropriate size may be a viable CPAP alternative
to facemasks.
 If a self-inflating bag is used it should be of sufficient volume to
deliver an adequate inflation. Care should be taken not to deliver
an excessive volume. The self-inflating bag cannot deliver CPAP
effectively.
Laryngeal mask
 Consider using a laryngeal mask
 In infants of 34 weeks gestation (about 2000 g)
although
some devices have been used successfully in infants down to
1500 g.
 If there are problems with establishing effective ventilation with
a facemask.
 Where intubation is not possible or deemed unsafe because of
congenital abnormality, a lack of equipment, or a lack of skill.
 Or as an alternative to tracheal intubation as a secondary airway.
Tracheal tube
 Tracheal intubation may be considered at several points during
neonatal resuscitation:
 When ventilation is ineffective after correction of mask
technique and/or the infant's head position, and/or increasing
inspiratory pressure with TPR or bag-mask.
 Where ventilation is prolonged, in order to establish a more
secure airway.
 When suctioning the lower airways to remove a presumed
tracheal blockage.
 When chest compressions are performed.
 In special circumstances (e.g., congenital diaphragmatic hernia
or to give surfactant).
 Exhaled CO2 detection should be used when undertaking
intubation to confirm tube placement in the airway.
 A range of differing sized tracheal tubes should be available to
permit placement of the most appropriate size to ensure adequate
ventilation with minimal leak and trauma to the airway.
 Respiratory function monitoring may also help confirm tracheal
tube position and adequate ventilation through demonstrating
adequate expired tidal volume (about 5 to 8 mL kg
1) and minimal
leak.
 The use of a video laryngoscope may aid tube placement.
 If retained, the position of the tracheal tube should be confirmed by
radiography.
Air/Oxygen
 Pulse-oximetry and oxygen blenders should be used during
resuscitation in the delivery room.
 Aim to achieve target oxygen saturation above the 25th percentile
for healthy term infants in the first 5 min after birth.
 If, despite effective ventilation, there is no increase in heart rate, or
saturations remain low, increase the oxygen concentration to
achieve adequate preductal oxygen saturations.
 Check the delivered inspired oxygen concentration and satu-
rations frequently (e.g. every 30 s) and titrate to avoid both hypoxia
and hyperoxia.
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 wean the inspired oxygen if saturations >95% in preterms. Intraosseous access

 Intraosseous (IO) access can be an alternative method of
Term and late preterm infants 35 weeks emergency access for drugs/fluids.
In infants receiving respiratory support at birth, begin with air (21%).
Support of transition/post-resuscitation care
Preterm infants <35 weeks  If venous access is required following resuscitation, peripheral
 Resuscitation should be initiated in air or a low inspired oxygen access may be adequate unless multiple infusions are required in
concentration based on gestational age: which case central access may be preferred.
 32 weeks 21%  IO access may be sufficient in the short term if no other site is
 28
31 weeks 21
30% available.
 <28 weeks 30%
Drugs
 In infants <32 weeks gestation the target should be to avoid an
oxygen saturation below 80% and/or bradycardia at 5 min of age. During active resuscitation
Both are associated with poor outcome. Drugs are rarely required during newborn resuscitation and the
evidence for the efficacy of any drug is limited. The following may be
Chest compressions considered during resuscitation where, despite adequate control of
the airway, effective ventilation and chest compressions for 30 s, there
Assessment of the need for chest compressions is an inadequate response and the HR remains below 60 min
1.
 If the heart rate remains very slow (<60 min
1) or absent after 30 s
of good quality ventilation, start chest compressions. Adrenaline
 When starting compressions:  When effective ventilation and chest compressions have failed to
 Increase the delivered inspired oxygen to 100%. increase the heart rate above 60 min
1
 Call for experienced help if not already summoned.  Intravenous or intraosseous is the preferred route:
& At a dose of 10
30 mg kg

1
(0.1
0.3 mL kg
1 of 1:10,000
Delivery of chest compressions adrenaline [1000 mg in 10 mL]).
 Use a synchronous technique, providing three compressions to  Intra-tracheally if intubated and no other access available.
& At a dose of 50
100 mg kg

1
one ventilation at about 15 cycles every 30 s. .
 Use a two-handed technique for compressions if possible.
 Re-evaluate the response every 30 s. Subsequent doses every 3
5 min if heart rate remains
 If the heart rate remains very slow or absent, continue ventilation < 60 min
1.
and chest compressions but ensure that the airway is secured
(e.g. intubate the trachea if competent and not done already). Glucose
 Titrate the delivered inspired oxygen against oxygen saturation if a  In a prolonged resuscitation to reduce likelihood of
reliable value is achieved on the pulse oximeter. hypoglycaemia.
 Intravenous or intraosseous:

1
Consider & 250 mg kg bolus (2.5 mL kg
1 of 10% glucose solution).
 Vascular access and drugs.
Volume replacement
Vascular access  With suspected blood loss or shock unresponsive to other
During the resuscitation of a compromised infant at birth peripheral resuscitative measures.
venous access is likely to be difficult and suboptimal for vasopressor  Intravenous or intraosseous:

1
administration. & 10 mL kg of group O Rh-negative blood or isotonic crystalloid.

Umbilical venous access Sodium bicarbonate

 The umbilical vein offers rapid vascular access in newborn infants  May be considered in a prolonged unresponsive resuscitation with
and should be considered the primary method during adequate ventilation to reverse intracardiac acidosis.
resuscitation.  Intravenous or intraosseous:

1
 Ensure a closed system to prevent air embolism during insertion & 1
2 mmol kg sodium bicarbonate (2
4 mL kg
1 of 4.2%
should the infant gasp and generate sufficient negative solution) by slow intravenous injection.
pressure.
 Confirm position in a blood vessel through aspiration of blood prior
In situations of persistent apnoea
to administering drugs/fluids.
 Clean, rather than sterile, access technique may be sufficient in an Naloxone
emergency.  Intramuscular
 The umbilical route may still be achievable some days after birth &
An initial 200 mg dose may help in the few infants who, despite
and should be considered in cases of postnatal collapse. resuscitation, remain apnoeic with good cardiac output when
40 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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the mother is known to have received opiods in labour. Effects
may be transient so continued monitoring of respiration is
important.
In the absence of an adequate response
Consider other factors which may be impacting on the response to
resuscitation and which require addressing such as the presence of
pneumothorax, hypovolaemia, congenital abnormalities, equipment
failure, etc.
Post-resuscitation care
Infants who have required resuscitation may later deteriorate. Once
adequate ventilation and circulation are established, the infant should
be cared cared for in, or transferred to, an environment in which close
monitoring and anticipatory care can be provided.
Glucose
 Monitor glucose levels carefully after resuscitation.
 Have protocols/guidance on the management of unstable glucose
levels.
 Avoid hyper- and hypoglycaemia.
 Avoid large swings in glucose concentration.
 Consider the use of a glucose infusion to avoid hypoglycaemia.
Thermal care
 Aim to keep the temperature between 36.5  C and 37.5  C.
 Rewarm if the temperature falls below this level and there are no
indications to consider therapeutic hypothermia (see below).
Therapeutic hypothermia
 Once resuscitated, consider inducing hypothermia to 33
34  C in
situations where there is clinical and/or biochemical evidence of
significant risk of moderate or severe HIE (hypoxic-ischaemic
encephalopathy).
 Ensure the evidence to justify treatment is clearly documented;
include cord blood gases, and neurological examination.
 Arrange safe transfer to a facility where monitoring and treatment
can be continued.
 Inappropriate application of therapeutic hypothermia, without
concern about a diagnosis of HIE, is likely to be harmful (see
temperature maintenance).
Prognosis (documentation)
Ensure clinical records allow accurate retrospective time based
evaluation of the clinical state of the infant at birth, any interventions
and the response during the resuscitation to facilitate any review and
the subsequent application of any prognostic tool.
Communication with the parents
Where intervention is anticipated
 Whenever possible, the decision to attempt resuscitation of an
extremely preterm or clinically complex infant should be taken in
close consultation with the parents and senior paediatric,
midwifery and obstetric staff.
 Discuss the options including the potential need and magnitude of
resuscitation and the prognosis before delivery in order to develop
an agreed plan for the birth.
 Record carefully all discussions and decisions in the mother's
notes prior to delivery and in the infant's records after birth.
For every birth
 Where intervention is required it is reasonable for mothers/fathers/
partners to be present during the resuscitation where circum-
stances, facilities and parental inclination allow.
 The views of both the team leading the resuscitation and the
parents must be taken into account in decisions on parental
attendance.
 Irrespective of whether the parents are present at the resuscita-
tion, ensure wherever possible, that they are informed of the
progress of the care provided to their infant.
 Witnessing the resuscitation of their infant may be distressing for
parents. If possible, identify a member of healthcare staff to
support them to keep them informed as much as possible during
the resuscitation.
 Allow parents to hold or even better to have skin-to-skin contact
with their infant as soon as possible after delivery or resuscitation,
even if unsuccessful.
 Provide an explanation of any procedures and why they were
required as soon as possible after the delivery.
 Ensure a record is kept of events and any subsequent
conversations with parents.
 Allow for further discussions at a later time to allow parents to
reflect and to aid parental understanding of events.
 Consider what additional support is required for parents following
delivery and any resuscitation.
Withholding and discontinuing resuscitation

Any recommendations must be interpreted in the light of current
national/regional outcomes.
 When discontinuing, withdrawing or withholding resuscitation,
care should be focused on the comfort and dignity of the infant and
family.
 Such decisions should ideally involve senior paediatric staff.
Discontinuing resuscitation
 National committees may provide locally appropriate recommen-
dations for stopping resuscitation.
 When the heart rate has been undetectable for longer than 10 min
after delivery review clinical factors (for example gestation of the
infant, or presence/absence of dysmorphic features), effective-
ness of resuscitation, and the views of other members of the
clinical team about continuing resuscitation.
 If the heart rate of a newborn term infant remains undetectable for
more than 20 min after birth despite the provision of all
recommended steps of resuscitation and exclusion of reversible
causes, consider stopping resuscitation.
 Where there is partial or incomplete heart rate improvement
despite apparently adequate resuscitative efforts, the choice is
much less clear. It may be appropriate to take the infant to the
intensive care unit and consider withdrawing life-sustaining
treatment if they do not improve.
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 Where life-sustaining treatment is withheld or withdrawn, infants
should be provided with appropriate palliative (comfort focused)
care.
Withholding resuscitation
 Decisions about withholding life-sustaining treatment should
usually be made only after discussion with parents in the light
of regional or national evidence on outcome if resuscitation and
active (survival focused) treatment is attempted.
 In situations where there is extremely high (>90%) predicted
neonatal mortality and unacceptably high morbidity in surviving
infants, attempted resuscitation and active (survival focused)
management is usually not appropriate.
 Resuscitation is nearly always indicated in conditions associated
with a high (>50%) survival rate and what is deemed to be
acceptable morbidity. This will include most infants with
gestational age of 24 weeks or above (unless there is evidence
of foetal compromise such as intrauterine infection or hypoxia-
ischaemia) and most infants with congenital malformations.
Resuscitation should also usually be commenced in situations
where there is uncertainty about outcome and there has been no
chance to have prior discussions with parents.
 In conditions where there is low survival (<50%) and a high rate of
morbidity, and where the anticipated burden of medical treatment
for the child is high, parental wishes regarding resuscitation should
be sought and usually supported.
Paediatric life support
These European Resuscitation Council Paediatric Life Support (PLS)
guidelines, are based on the 2020 International Consensus on
Cardiopulmonary Resuscitation Science with Treatment Recommen-
dations. This section provides guidelines on the management of
critically ill infants and children, before, during and after cardiac arrest.
There are relatively few major changes introduced in these
guidelines compared to our guidelines in 2015. Key points to note
include: PLS guidelines apply to all children, aged 0
18 years, except
for ‘newborns at birth’. Patients who look adult can be treated as an
adult. Oxygen therapy should be titrated to an SpO2 of 94
98%. Until
titration is possible, in children with signs of circulatory/respiratory
failure where SpO2 (or paO2) is impossible to measure, we advise to
start high flow oxygen. For children with circulatory failure, give 1 or
more fluid bolus(es) of 10 ml/kg. Reassess after each bolus to avoid
fluid overload. Start vasoactive drugs early. Limit crystalloid boluses
and as soon as available give blood products (whole blood or
packed red cells with plasma and platelets) in case of haemorrhagic
shock. Any person trained in paediatric BLS should use the
specific PBLS algorithm. For PBLS providers, immediately after the
5 rescue breaths, proceed with chest compressions
unless there
are clear signs of circulation. Single rescuers should first call for
help (speakerphone) before proceeding. In case of sudden
witnessed collapse, they should also try to apply an AED if easily
accessible. If they have no phone available, they should perform 1 min
of CPR before interrupting CPR. A single PBLS provider can use either
a two-thumb encircling or a two-finger technique for infant chest
compression. For PALS providers, we emphasise even more the
importance of actively searching for (and treating) reversible causes.
2-Person bag-mask ventilation is the first line ventilatory support
during CPR for all competent providers. Only if a patient is intubated,
we advise asynchronous ventilation and this at an age-appropriate
41
rate (10
25/’). For PALS providers, when in doubt, consider the
rhythm to be shockable.
Key messages from this section are presented in Fig. 15.
Recognition and management of critically ill children
Assessment of the seriously ill or injured child
 Use the Paediatric Assessment Triangle or a similar ‘quick-look’
tool for the early recognition of a child in danger.
 Follow the ABCDE approach
 Perform the necessary interventions at each step of the
assessment as abnormalities are identified.
 Repeat your evaluation after any intervention or when in doubt.
 A is for Airway
establish and maintain airway patency.
 B is for Breathing
check
 Respiratory rate (see Table 3; trends are more informative than
single readings)
 Work of breathing, e.g. retractions, grunting, nasal flaring . . .
 Tidal volume (TV)
air entry clinically (chest expansion; quality
of cry) or by auscultation
 Oxygenation (colour, pulse oximetry). Be aware that hypoxae-
mia can occur without other obvious clinical signs.
 Consider capnography
 Consider thoracic ultrasound
 C is for Circulation
check
 Pulse rate (see Table 4; trends are more informative than single
readings)
 Pulse volume
 Peripheral & end-organ circulation: capillary refill time (CRT),
urinary output, level of consciousness. Be aware that CRT is not
very sensitive. A normal CRT should not reassure providers.
Preload evaluation: jugular veins, liver span, crepitations

 Blood Pressure (see Table 5)
 Consider serial lactate measurements
 Consider point-of-care cardiac ultrasound
 D is for Disability
check
 Conscious level using the AVPU (Alert-Verbal-Pain-Unrespon-
sive) score, (paediatric) Glasgow Coma Scale (GCS) total
score, or the GCS motor score. AVPU score of P or less, a
Glasgow motor score of 4 and total GCS score of 8 or less define
a level of consciousness where airway reflexes are unlikely to be
preserved.
 Pupil size, symmetry, and reactivity to light.
 Presence of posturing or focal signs.
 Recognise seizures as a neurological emergency.
 Check blood glucose if altered consciousness and/or potential
hypoglycaemia.
 Sudden unexplained neurological symptoms, particularly those
persisting after resuscitation, warrant urgent neuroimaging.
Management of the seriously ill or injured child
Whilst ABCDE is described in a stepwise manner, in practice,
interventions are best carried out by multiple team members acting in
parallel in a coordinated manner. Teamwork is important in the
management of any seriously ill or injured child.
Key components of teamwork include:
 Anticipate: what to expect, allocate tasks . . .
 Prepare: materials, checklists to support decision making, patient
data . . .
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Fig. 15 – PLS infographic summary.

 Choreography: where to stand, how to access the child, effective

Table 3 – Normal values for age: respiratory rate.
team size.
Respiratory 1 month 1 year 2 year 5 year 10 year
 Communicate: both verbal, and non-verbal. Use closed-loop
rate for age
communication and standardised communication elements (e.g.
to count compression pauses, plan patient transfers). Keep non- Upper limit of 60 50 40 30 25
normal range
essential communications ‘as low as reasonably practicable’.
Lower limit of 25 20 18 17 14
Ensure a low-stress working environment. Implement a culture
normal range
that strongly condemns inappropriate behaviour, be it from
colleagues or family.
 Interact: Team members have pre-defined roles as per protocol
and perform tasks in parallel. The team-leader (clearly recognis-
able) monitors team performance, prioritises tasks to achieve leading to cardiac arrest if not properly treated. Quite often children will
common goals and keeps the whole team informed. Hands-off present with a combination of problems that demand a far more
leadership is preferred, if feasible. Shared situational awareness individualised approach. Treatment recommendations in children
is considered crucial. often differ from those in adults but will also differ between children of
different age and weight. To estimate a child's weight, either rely on the
We describe below the ‘first-hour’ management of different life- or parents or caretakers or use a length-based method, ideally corrected
organ-threatening emergencies in children, each of them potentially for body-habitus (e.g. Pawper MAC). Use, whenever possible,
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Table 4 – Normal values for age: heart rate. generally be avoided (except for instance in pulmonary
hypertension, CO intoxication). Do not give pre-emptive
Heart rate for 1 month 1 year 2 year 5 year 10 year
age oxygen therapy in children without signs of or immediate risk
for hypoxaemia or shock. Specific recommendations exist for
Upper limit of 180 170 160 140 120
children with certain chronic conditions.
normal range
 Where it is impossible to accurately measure SpO2 or PaO2:
Lower limit of 110 100 90 70 60
normal range start oxygen therapy at high FiO2, based upon clinical signs of
circulatory or respiratory failure, and titrate oxygen therapy as
soon as SpO2 and/or PaO2 become available.
 Where possible, competent providers should consider either
Table 5 – Normal values for age: systolic and mean high-flow nasal cannula (HFNC) or non-invasive ventilation
arterial blood pressure (MAP). Fifth (p5) and fiftieth (NIV) in children with respiratory failure and hypoxaemia not
(p50) percentile for age.
responding to low-flow oxygen.
Blood pressure for age 1 month 1 year 5 year 10 year  Tracheal intubation and subsequent mechanical ventilation
p50 for Systolic BP 75 95 100 110 enable secure delivery of FiO2 and PEEP. The decision to
p5 for Systolic BP 50 70 75 80 intubate should be balanced against the existing risks of the
p50 for MAP 55 70 75 75 procedure and the available resources (see below).
p5 for MAP 40 50 55 55  In hypoxaemic children despite high PEEP (>10) and
standard optimisation measures, consider permissive hypo-
xaemia (oxygenation goal lowered to SpO2 88
92%).
decision aids providing pre-calculated dose advice for emergency  To support ventilation, adjust respiratory rate (and expiratory
drugs and materials. time) and/or tidal volume [TV] according to age.
 Use a TV of 6 to 8 ml/kg IBW (ideal body weight), considering
Management of respiratory failure: general approach (AB) among others physiological and apparatus dead space
The transition from a compensatory state to decompensation may (especially in younger children). Apparatus dead space
occur unpredictably. Therefore, any child at risk should be monitored should be minimalised. Look for normal chest rise. Avoid
to enable early detection and correction of any deterioration in their hyperinflation, as well as hypoventilation. Aim for normocap-
physiology. Most airway procedures are considered aerosol-generat- nia. Seek early expert help.
ing and thus require proper (risk-adjusted) personal protection  In acute lung injury, consider permissive hypercapnia (pH
equipment (PPE) in cases of presumed transmittable diseases. > 7.2), thus avoiding overly aggressive ventilation. Permis-
 Open the airway and keep it patent using sive hypercapnia is not recommended in pulmonary hyper-
 Adequate head and body alignment, tension or severe traumatic brain injury [TBI].
 Head tilt
chin lift or jaw thrust,  Only use ETCO2 or venous partial carbon dioxide pressure
 Careful suctioning of secretions. (PvCO2) as a surrogate for arterial PaCO2 when correlation
has been demonstrated.
Awake children will likely assume their own optimal position.  Bag-mask ventilation (BMV) is the recommended first line method
 Consider oropharyngeal airway in the unconscious child, in whom to support ventilation.
there is no gag reflex.  Ensure a correct head position and mask size and a proper
&
Use the appropriate size (as measured from the central incisors seal between mask and face.
to the angle of the mandible) and avoid pushing the tongue  Use an appropriately sized bag for age. To provide adequate
backward during insertion. TV, the inspiratory time should be sufficiently long (approx.
 Consider nasopharyngeal airway in the semi-conscious child 1 s). However, at all times, be careful to avoid hyperinflation.
&
Avoid if there is a suspicion of a basal skull fracture or of  Use a 2-person approach, especially if ventilation is difficult or
coagulopathy. when there is a risk of disease transmission. Consider airway
& The correct insertion depth should be sized from the nostrils to adjuncts.
the tragus of the ear.  If competent, consider early placing a supraglottic airway
 In children with a tracheostomy, (SGA) or a tracheal tube (TT) in cases where BMV does not
& Check patency of the tracheostomy tube and suctioning if improve oxygenation and/or ventilation or is anticipated to be
needed. prolonged.
& In case of suspected blockage that cannot be solved by  Tracheal intubation (TI) should only be performed by a competent
suctioning, immediately remove the tracheostomy tube, and provider, following a well-defined procedure, and having the
insert a new one. If this is not possible, providers should have a necessary materials and drugs. The decision to intubate should
(pre-defined) emergency plan for airway reestablishment. always be balanced against the associated risk of the procedure.
 To support oxygenation, consider supplemental oxygen and/or  The oral route for TI is preferable during emergencies.
positive end-expiratory pressure (PEEP).  External laryngeal manipulation should only be applied at the
 Where it is possible to accurately measure SpO2 (or partial discretion of the provider performing the intubation.
oxygen pressure (PaO2)): start oxygen therapy if SpO  Use cuffed tracheal tubes for PLS (except maybe in small
2 < 94%. The goal is to reach an SpO2 of 94% or above, infants). Monitor cuff inflation pressure and limit this according
with as little supplemental FiO2 (fraction of inspired oxygen) to manufacturer's recommendations (usually < 20 to 25
as possible. Sustained SpO2 readings of 100% should cmH2O).
44 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 Use appropriate medication to facilitate intubation and
provide subsequent analgosedation in all children unless
they are in cardiorespiratory arrest.
 Monitor haemodynamics and SpO2 during intubation and be
aware that bradycardia and desaturation are late signs of
hypoxia.
 Avoid prolonged laryngoscopy and/or multiple attempts. Antici-
pate potential cardiorespiratory problems and plan an alternative
airway management technique in case the trachea cannot be
intubated.
 Competent providers should consider the (early) use of
videolaryngoscopy, in cases where direct laryngoscopy is
expected to be difficult.
 Once intubated, confirmation of proper TT position is
mandatory. Evaluate clinically and by means of imaging.
Use capnography in all intubated children for early detection
of obstruction, mal- or displacement.
 Supraglottic airways
SGAs (such as I-gel, LMA) may be an
alternative way to provide airway control and ventilation, although they
do not totally protect the airway from aspiration. Easier to insert than a
TT, an SGA should also only be inserted by a competent provider.
 Sudden rapid deterioration of a child being ventilated (via mask or
TT) is a time-critical event that demands immediate action.
Consider ‘DOPES’:
 D stands for displacement (TT, mask)
 for obstruction (TT, airway circuit, airway
head position)
 P for pneumothorax
 E for equipment (oxygen, tubing, connections, valves)
 S for stomach (abdominal compartment)
Management of status asthmaticus
 Recognition of a severe asthma crisis is based upon clinical signs,
brief history taking, as well as monitoring of SpO2.
 Lung function determination (PEF or PEV1) is of added value in
children > 6 years old, if this can be easily measured without
delaying treatment.
 Arterial blood gas analysis is not routine but might be informative
when the child does not respond to treatment or deteriorates.
Continue oxygen therapy when taking the sample. Due to
compensation, PaCO2 might initially be normal or decreased.
Hypercapnia is a sign of decompensation.
 A chest X-ray is not routine but might be indicated if an
alternative diagnosis or a complication is suspected.
 Timely, aggressive and protocolised treatment is needed in case
of status asthmaticus:
 Provide a comfortable environment and body position. Avoid
sedative drugs, even if there is agitation.
 Give supplemental oxygen titrated to achieve a SpO2 of 94

98%. Give oxygen at high dose if SpO2 cannot be measured
but only until titration is possible.
 Use short-acting beta-2 agonists (SABA) via an inhaler with
spacer (e.g. salbutamol 2
10 puffs) or nebuliser (e.g.
salbutamol 2.5
5 mg (0.15 mg/kg). Adjust doses to response
and repeat as needed (up to continuously in the first hour). The
effect of SABA begins within seconds and reaches a maximum
at 30 min (half-life 2
4 h). Add short-acting anticholinergics
(e.g. ipratropium bromide 0.25
0.5 mg) either nebulised or as
an inhaler with spacer.
 Give systemic corticosteroids within the first hour, either oral or
intravenously (IV). Providers are advised to use the corticoid
they are most familiar with (e.g. prednisolone 1
2 mg/kg, with a
maximum of 60 mg/day).
 Consider IV magnesium for severe and life-threatening asthma.
Give a single dose of 50 mg/kg over 20 min (max 2 g). In
children, isotonic magnesium might alternatively be used as
nebulised solution (2.5 ml of 250 mmol/l; 150 mg).
 Additional drugs can be considered by competent providers e.g.
IV ketamine, IV aminophylline, etc. Providers should be aware
that IV SABA carry a significant risk of electrolyte disorders,
hyperlactatemia, and more importantly cardiovascular failure. If
used, the child should be monitored carefully.
 Antibiotics are not recommended unless there is evidence of
bacterial infection.
 There is no place for routine systemic or local adrenaline in
asthma, but anaphylaxis should be excluded as an alternative
diagnosis in all children with sudden onset of symptoms.
 If available, consider NIV or HFNC in children with status
asthmaticus needing oxygenation support beyond standard
FiO2 and/or not responding to initial treatment.
 Severe exhaustion, deteriorating consciousness, poor air entry,
worsening hypoxaemia and/or hypercapnia, and cardiopulmo-
nary arrest are indications for tracheal intubation. Mechanical
ventilation of a child with status asthmaticus is extremely
challenging and expert help should be sought early on. Limit TV
and respiratory rate and use a longer expiratory time.
Management of anaphylaxis
 Early diagnosis of anaphylaxis is crucial and will guide further
treatment:
 Acute onset of an illness (minutes to hours) with involvement of the
skin, mucosal tissue, or both and at least one of the following:
a. Respiratory compromise e.g. dyspnoea, wheeze-broncho-
spasm, stridor, reduced PEF, hypoxaemia
b. Reduced blood pressure or associated symptoms of end-
organ dysfunction e.g. collapse, syncope
c. Severe gastrointestinal symptoms, especially after expo-
sure to non-food allergens
 OR
 Acute onset (minutes to several hours) of hypotension or
bronchospasm or laryngeal involvement after exposure to a
known or probable allergen, even in the absence of typical skin
involvement.
 As soon as anaphylaxis is suspected, immediately administer
intramuscular (IM) adrenaline (anterolateral mid-thigh, not
subcutaneous). Provide further ABCDE care as needed: call for
help, airway support, oxygen therapy, ventilatory support, venous
access, repetitive fluid boluses and vasoactive drugs.
 Early administration of IM adrenaline might also be considered for
milder allergic symptoms in children with a history of anaphylaxis.
 The dose for IM adrenaline is 0.01 mg/kg; this can be
administered by syringe (1 mg/ml solution) but in most settings
auto-injectable adrenaline will be the only form available
(0.15 mg (<6 y)
0.3 mg (6
12 y)
0.5 mg (>12 y)).
 If symptoms do not improve rapidly, give a second dose of IM
adrenaline after 5
10 min.
 In cases of refractory anaphylaxis competent physicians might
consider the use of IV or intraosseous (IO) adrenaline. Be
careful to avoid dosage errors.
 Prevent any further exposure to the triggering agent. In the case of
a bee sting, remove the sting as quickly as possible.
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 Recognise cardiac arrest and start standard CPR when indicated.
Rescuers only having access to IM adrenaline might consider
giving this when cardiac arrest has just occurred.
 Consider early TI in case of respiratory compromise. Anticipate
airway oedema. Airway management in case of anaphylaxis can
be very complicated and early support by highly competent
physicians is mandatory.
 In addition to IM adrenaline, consider the use of:
 Inhaled SABA (and/or inhaled adrenaline) for bronchospasm.
 IV or oral H1 and H2 antihistamines to alleviate subjective
symptoms (especially cutaneous symptoms).
 Glucocorticosteroids (e.g. methylprednisolone 1
2 mg/kg) only
for children needing prolonged observation.
 Specific treatments related to the context.
 After treatment, further observe for potential late or biphasic
symptoms. Those children who responded well to one dose of IM
adrenaline without any other risk factor can generally be
discharged after 4
8 h. Prolonged observation (12
24 h) is
advised for children with a history of biphasic or protracted
anaphylaxis or asthma, those who needed more than one dose of
IM adrenaline or had a delay between symptoms and first
adrenaline dose of more than 60 min.
 Efforts should be made to identify the potential trigger. Without
delaying treatment, take blood samples for mast cell tryptase upon
arrival and ideally 1
2 h later. Refer patients to a dedicated
healthcare professional for follow-up. Every child who had an
anaphylactic reaction should have auto-injectable adrenaline
prescribed and receive instructions how to use it (both the child, if
feasible, and their caregivers).
Management of circulatory failure [C]
 Healthcare systems should implement context-specific protocols
for the management of children with shock including strategies for
early recognition and timely emergency treatment.
 The management of a child in circulatory failure needs to be
tailored to the individual, considering aetiology, pathophysiology,
age, context, comorbidities, and available resources. The
transition from a compensated state to decompensation may be
rapid and unpredictable. No single finding can reliably identify the
severity of the circulatory failure and/or be used as a goal for
treatment. Reassess frequently and at least after every interven-
tion. Consider among others clinical signs, MAP, trends in lactate,
urine output and if competent, ultrasound findings. Competent
physicians might also measure advanced haemodynamic varia-
bles such as cardiac index, systemic vascular resistance, and
central venous oxygen saturation (ScvO2), but this is not a priority
in the first hour of care.
 The management of a child in circulatory failure, in accordance
with the ABCDE approach, should always include proper
management of airway, oxygenation and ventilation.
 Vascular Access:
 Peripheral IV lines are the first choice for vascular access.
Competent providers might use ultrasound to guide cannula-
tion. In case of an emergency, limit the time for placement to
5 min (2 attempts) at most. Use rescue alternatives earlier when
the chances of success are considered minimal.
 For infants and children, the primary rescue alternative is
intraosseous (IO) access. All paediatric advanced life support
(ALS) providers should be competent in IO placement and have
45
regular retraining in the different devices (and puncture sites)
used in their setting. Provide proper analgesia
in every child
unless comatose. Use a properly sized needle. Most standard
pumps will not infuse via IO, so use either manual infusion or a
high-pressure bag. Confirm proper placement and monitor for
extravasation which can lead to compartment syndrome.
 Fluid therapy:
 Give one or more early fluid bolus(es) of 10 ml/kg in children with
recognised shock. Repeated fluid boluses
up to 40
60 ml/kg

might be needed in the first hour of treatment of (septic) shock.
 Reassess after each bolus and avoid repeated boluses in
children who cease to show signs of decreased perfusion or
show signs of fluid overload or cardiac failure. Combine clinical
signs with biochemical values and if possible, imaging such as
cardiac and lung ultrasound to assess the need for additional
boluses. In case of repeated fluid boluses, consider vasoactive
drugs and respiratory support early on. In settings where
intensive care is not available, it seems prudent to be even more
restrictive.
 Use balanced crystalloids as first choice of fluid bolus, if
available. If not, normal saline is an acceptable alternative.
Consider albumin as second-line fluid for children with sepsis,
especially in the case of malaria or dengue fever. If not for
haemorrhagic shock, blood products are only needed when
blood values fall below an acceptable minimum value.
 Give rapid fluid boluses in children with hypovolemic non-
haemorrhagic shock. Otherwise, fluid resuscitation of severely
dehydrated children can generally be done more gradually (up
to e.g. 100 ml/kg over 8 h).
 In cases of haemorrhagic shock, keep crystalloid boluses to a
minimum (max. 20 ml/kg). Consider early blood products
or if
available, full blood- in children with severe trauma and
circulatory failure, using a strategy that focuses on improving
coagulation (using at least as much plasma as RBC and
considering platelets, fibrinogen, other coagulation factors).
Avoid fluid overload but try to provide adequate tissue perfusion
awaiting definitive damage control and/or spontaneous haemo-
stasis. Permissive hypotension (MAP at 5th percentile for age)
can only be considered in children when there is no risk of
associated brain injury.
 Give tranexamic acid (TxA) in all children requiring transfusion
after severe trauma
as soon as possible, within the first 3 h
after injury- and/or significant haemorrhage. Consider TxA in
children with isolated moderate TBI (GCS 9
13) without
pupillary abnormalities. Use a loading dose at 15
20 mg/kg
(max. 1 g), followed by an infusion of 2 mg/kg/h for at least 8 h or
until the bleeding stops (max. 1 g).
 Vasoactive/Inotropic drugs:
 Start vasoactive drugs early, as a continuous infusion (diluted
as per local protocol) via either a central or peripheral line, in
children with circulatory failure when there is no improvement
of the clinical state after multiple fluid boluses. Attention
should be given to proper dilution, dosing and infusion
management. Preferably use a dedicated line with proper
flow, avoiding inadvertent boluses or sudden dose changes.
Titrate these drugs based on a desired target MAP, which may
differ with pathology, age and patient response; in an ICU
setting other haemodynamic variables may also be taken into
account.
46 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 Use either noradrenaline or adrenaline as first-line inoconstric-
tors and dobutamine or milrinone as first-line inodilators.
Dopamine should be considered only in settings where neither
adrenaline nor noradrenaline are available. All paediatric ALS
providers should be competent in the use of these drugs during
the first hour of stabilisation of a child in circulatory failure.
 Also use vasoactive drugs in cases of hypovolemic shock, when
fluid-refractory
especially when there is loss of sympathetic
drive such as during anaesthesia
, as well as for children with
hypovolemic shock and concomitant TBI. A sufficiently high
MAP is needed to attain an adequate cerebral perfusion
pressure (e.g. MAP above 50th percentile). Evaluate and, if
necessary, support cardiac function.
 Additional therapies in septic shock:
 Consider a first dose of stress-dose hydrocortisone (1
2 mg/
kg) in children with septic shock, unresponsive to fluids and
vasoactive support, regardless of any biochemical or other
parameters.
 Give stress-dose hydrocortisone in children with septic shock
who also have acute or chronic corticosteroid exposure,
hypothalamic-pituitary-adrenal axis disorders, congenital adre-
nal hyperplasia, or other corticosteroid- related endocrinopa-
thies, or have recently been treated with ketoconazole or
etomidate.
 Start broad-spectrum antibiotics as soon as possible after initial
ABCD management. Preferably, this is within the first hour of
treatment. Obtain blood cultures (or blood samples for PCR)
before starting, if this can be done without delaying therapy.
 Obstructive shock in children:
 Tension pneumothorax requires immediate treatment by either
emergency thoracostomy or needle thoracocentesis. Use
ultrasound to confirm the diagnosis if this does not delay
treatment. For both techniques, use the 4th or 5th intercostal
space (ICS) slightly anterior to the midaxillary line as the primary
site of entry. In children, the 2nd ICS midclavicular remains an
acceptable alternative. Convert to standard chest tube drainage
as soon as practically feasible.
 Systems that do not implement immediate thoracostomy should
at least consider thoracostomy as a rescue option in paediatric
severe trauma and train their providers accordingly.
 If available, use ultrasound to diagnose pericardial tamponade.
Tamponade leading to obstructive shock demands immediate
decompression by pericardiocentesis, thoracotomy or (re)
sternotomy according to circumstances and available exper-
tise. Depending on their context, systems should have protocols
in place for this.
 Unstable primary bradycardia:
 Consider atropine (20 mcg/kg; max. 0.5 mg per dose) only in
bradycardia caused by increased vagal tone.
 Consider emergency transthoracic pacing in selected cases
with circulatory failure due to bradycardia caused by complete
heart block or abnormal function of the sinus node. Early expert
help is mandatory.
 Unstable primary tachycardia:
 In children with decompensated circulatory failure due to either
supraventricular (SVT) or ventricular tachycardia (VT), the first
choice for treatment is immediate synchronised electrical
cardioversion at a starting energy of 1 J/kg body weight. Double
the energy for each subsequent attempt up to a maximum of 4 J/
kg. If possible, this should be guided by expert help. For children
who are not yet unconscious, use adequate analgosedation
according to local protocol. Check for signs of life after each
attempt.
 In children with a presumed SVT who are not yet decom-
pensated, providers can try vagal manoeuvres (e.g. ice
application, modified Valsalva techniques). If this has no
immediate effect, proceed with IV adenosine. Give a rapid
bolus of 0.1
0.2 mg/kg (max 6 mg) with immediate saline flush
via a large vein; ensure a rhythm strip is running for later expert
evaluation. Especially in younger children, higher initial doses
are preferable. In case of persistent SVT, repeat adenosine
after at least 1 min at a higher dose (0.3 mg/kg, max 12
18 mg).
Be cautious with adenosine in children with known sinus node
disease, pre-excited atrial arrhythmias, heart transplant or
severe asthma. In such cases, or when there is no prolonged
effect of adenosine, competent providers (with expert consul-
tation) might give alternative medications.
 Wide QRS tachycardias can be either VT or SVT with bundle
branch block aberration, or antegrade conduction through an
additional pathway. In case the mechanism of the arrhythmia is
not fully understood, wide QRS arrhythmia should be treated as
VT. In a child who is haemodynamically stable, the response to
vagal manoeuvres may provide insight into the mechanism
responsible for the arrhythmia and competent providers (with
expert help) can subsequently try pharmacological treatment.
Even in stable patients, electrical cardioversion should always
be considered. In case of Torsade de pointes VT, IV magnesium
50 mg/kg is indicated.
Management of ‘neurological’ and other medical emergen-
cies [D] [E]
Recognise and treat neurological emergencies quickly, because
prognosis is worsened by secondary injury (due to e.g. hypoxia,
hypotension) and treatment delays. In accordance with the ABCDE
approach, such treatment includes proper management of airway,
oxygenation and ventilation, and circulation.
Status epilepticus
 Identify and manage underlying diagnoses and precipitant causes
including hypoglycaemia, electrolyte disorders, intoxications,
brain infections and neurological diseases, as well as systemic
complications such as airway obstruction, hypoxaemia or shock.
 If convulsions persist for more than 5 min, give a first dose of a
benzodiazepine. Immediate treatment should be considered in
specific situations. Which benzodiazepine via which route to give
will depend on the availability, context, social preference, and
expertise of the providers. Non-IV benzodiazepines should be
used if an IV line is not (yet) available. Adequate dosing is
essential, we suggest:
 IM midazolam 0.2 mg/kg (max 10 mg) or prefilled syringes: 5 mg
for 13
40 kg, 10 mg > 40 kg); intranasal/buccal 0.3 mg/kg; IV
0.15 mg/kg (max 7.5 mg)
 IV lorazepam 0.1 mg/kg (max 4 mg)
 IV diazepam 0.2
0.25 mg/kg (max 10 mg)/rectal 0.5 mg/kg
(max 20 mg)
 If convulsions persist after another 5 min, administer a second
dose of benzodiazepine and prepare a long-acting second line
drug for administration. Seek expert help.
 Not later than 20 min after convulsions started, give second line
anti-epileptic drugs. The choice of drug will again depend on
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context, availability, and expertise of the provider. Adequate
dosing is again essential:
 Levetiracetam 40
60 mg/kg IV (recent papers suggest the
higher dose; max. 4.5 g, over 150 )
 Phenytoin 20 mg/kg IV (max. 1.5 g, over 20 min; or alternatively
phosphenytoin)
 Valproic acid 40 mg/kg IV (max 3 g; over 15 min; avoid in cases
of presumed hepatic failure or metabolic diseases
which can
never be ruled out in infants and younger children-, as well as in
pregnant teenagers).
 Phenobarbital (20 mg/kg over 20 min) IV is a reasonable
second-line alternative if none of the three recommended
therapies are available.
 If convulsions continue, consider an additional second-line drug
after the first second-line drug has been given.
 Not later than 40 min after convulsions started, consider anaesthet-
ic doses (given by a competent provider) of either midazolam,
ketamine, pentobarbital/thiopental, or propofol; preferably under
continuous EEG monitoring. Prepare for adequate support of
oxygenation, ventilation and perfusion as needed.
 Non-convulsive status epilepticus can continue after clinical
convulsions cease; all children who do not completely regain
consciousness need EEG monitoring and appropriate treatment.
Hypoglycaemia
 Recognise hypoglycaemia using context, clinical signs, and
measurement (50
70 mg/dl; 2.8
3.9 mmol/L), and promptly treat
this. Also identify and treat any underlying cause. Specific dosage
of IV glucose maintenance might be indicated in specific metabolic
diseases.
 Mild asymptomatic hypoglycaemia may be treated with standard
glucose administration, either by maintenance infusion glucose (6

8 mg/kg/min) or by oral rapid acting glucose (0.3 g/kg tablets or
equivalent), followed by additional carbohydrate intake to prevent
recurrence.
 Severe paediatric hypoglycaemia (<50 mg/dl (2.8 mmol/L) with
neuroglycopenic symptoms) demands:
 IV glucose 0.3 g/kg bolus; preferably as 10% (100 mg/ml; 3 ml/
kg) or 20%-solution (200 mg/ml; 1.5 ml/kg)
 When IV glucose is not available, providers may administer
glucagon as temporary rescue, either IM or SC (0.03 mg/kg or
1 mg >25 kg; 0.5 mg <25 kg) or intranasally (3 mg; 4-16y).
 Retest blood glucose 10 min after treatment and repeat
treatment if the response is inadequate. Reasonable targets
are an increase of at least 50 mg/dl (2.8 mmol/L) and/or a target
glycaemia of 100 mg/dL (5.6 mmol/L).
 Start a glucose maintenance infusion (6
8 mg/kg/min) to
reverse catabolism and maintain adequate glycaemia.
Hypokalaemia
 For severe hypokalaemia (<2.5 mmol/L) in a pre-arrest state, give
IV boluses of 1 mmol/kg (max 30 mmol) over at least 20 min to a
monitored child and repeat until the serum potassium is above
2.5 mmol/L avoiding inadvertent hyperkalaemia. Also give IV
magnesium 30
50 mg/kg.
 In all other cases, enteral potassium is preferred for those who
tolerate enteral supplementation. The eventual dose should
depend on the clinical presentation, the value measured and the
expected degree of depletion.
47
Hyperkalaemia
 To evaluate the severity of hyperkalaemia, consider the potassium
value in the context of the underlying cause and contributing
factors, and the presence of potassium-related ECG changes.
Eliminate or treat underlying causes and contributing factors as
soon as possible.
 Tailor emergency treatment to the individual child. Consider early
expert help. In children with acute symptomatic life-threatening
hyperkalaemia give:
 Calcium (e.g. calcium gluconate 10% 0.5 ml/kg max 20 ml) for
membrane stabilisation. This works within minutes and the
effect lasts 30
60 min.
 Fast-acting insulin with glucose to redistribute potassium, which
is effective after about 15 min, peaks at 30
60 min and lasts 4

6 h (e.g. 0.1 U/kg insulin in a 1 IU insulin in 25 ml glucose 20%
solution; there is no need for initial glucose when the initial
glycaemia is > 250 mg/dl (13.9 mmol/L)). Repeated dosing
might be necessary. To avoid hypoglycaemia, once hyper-
kalaemia is treated, continue with a glucose maintenance
infusion without insulin. Monitor blood glucose levels.
 Nebulised beta-agonists at high dose (e.g. 5 times the
bronchodilation dose), however be aware that the maximal
effect is reached only after 90 min.
 Sodium bicarbonate 1 mmol/kg IV (repeat as necessary) in case
of a metabolic acidosis (pH < 7.2) and/or in cardiac arrest. The
effect of sodium bicarbonate is slow (hours).
 Continue potassium redistribution measures until potassium
removal treatments become effective. Potassium removal can
be done by potassium binding agents, furosemide (in well-
hydrated children with preserved kidney function) and/or dialysis.
Hyperthermia
 In cases of heat stroke (i.e. a central body temperature
40
40.5  C with central nervous system (CNS) dysfunction):
 Monitor central body temperature as soon as possible (rectal,
oesophageal, bladder, intravascular).
 Prehospital treatment consists of full ABCDE management and
rapid aggressive cooling. Remove the child from the heat
source. Undress and fan with cold air and mist. Apply ice packs.
Provide early evaporative external cooling. Consider cold-water
immersion for adolescents and young adults.
 Further cooling in hospital can be done by placing the child on a
cooling blanket; applying ice packs to the neck, axilla and groin
or alternatively on the smooth skin surfaces of the cheeks,
palms, and soles; and infusion of IV crystalloids at room
temperature. Stop cooling measures once the core temperature
reaches 38  C. Benzodiazepines are suggested to avoid
trembling, shivering or seizures during cooling measures.
Classic antipyretic medications are ineffective.
 All children with heat stroke should be admitted to a (paediatric)
intensive care unit to maintain adequate monitoring and to treat
associated organ dysfunction.
Paediatric basic life support
The sequence of actions in paediatric BLS (PBLS) support
(Fig. 16) will depend upon the level of training of the rescuer
attending: those fully competent in PBLS (preferred algorithm),
those trained only in ‘adult’ BLS and those untrained (dispatcher-
assisted lay rescuers).
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Sequence of actions in PBLS
 Ensure safety of rescuer and child. Check for responsiveness to
verbal and tactile stimulation. Ask bystanders to help.
 If the child does not respond, open the airway, and assess
breathing for no longer than 10 s.
 If you have difficulty opening the airway with head tilt
chin lift
or specifically in cases of trauma, use a jaw thrust. If needed,
add head tilt a small amount at a time until the airway is open.
 In the first few minutes after a cardiac arrest a child may be
taking slow infrequent gasps. If you have any doubt whether
breathing is normal, act as if it is not normal.
 Look for respiratory effort, listen and feel for movement of air
from the nose and/or mouth. If there is effort but no air
movement, the airway is not open.
 In cases where there is more than one rescuer, a second
rescuer should call the EMS immediately upon recognition of
unconsciousness, preferably using the speaker function of a
mobile phone.
 In the unconscious child, if breathing is abnormal: give five initial
rescue breaths.
 For infants, ensure a neutral position of the head. In older
children, more extension of the head will be needed (head tilt).
 Blow steadily into the child's mouth (or infant's mouth and nose)
for about 1 s, sufficient to make the chest visibly rise.
 If you have difficulty achieving an effective breath, the airway
may be obstructed (see below): remove any visible obstruction.
Do not perform a blind finger sweep. Reposition the head or
adjust airway opening method. Make up to five attempts to
achieve effective breaths, if still unsuccessful, move on to chest
compressions.
 Competent providers should use BMV with oxygen, when
available, instead of expired air ventilation. In larger children
when BMV is not available, competent providers can also use a
pocket mask for rescue breaths.
 If there is only one rescuer, with a mobile phone, he or she
should call help first (and activate the speaker function)
immediately after the initial rescue breaths. Proceed to the
next step while waiting for an answer. If no phone is readily
available perform 1 min of CPR before leaving the child.
 In cases where PBLS providers are unable or unwilling to start
with ventilations, they should proceed with compressions and
add into the sequence ventilations as soon as these can be
performed.
 Immediately proceed with 15 chest compressions, unless there
are clear signs of circulation (such as movement, coughing).
Rather than looking at each factor independently, focus on
consistent good quality compressions as defined by:
 Rate: 100
120 min
1 for both infants and children.
 Depth: depress the lower half of the sternum by at least one third
of the anterior
posterior dimension of the chest. Compressions
should never be deeper than the adult 6 cm limit (approx. an
adult thumb's length).
 Recoil: Avoid leaning. Release all pressure between compres-
sions and allow for complete chest recoil.
When possible, perform compressions on a firm surface. Move the
child only if this results in markedly better CPR conditions (surface,
accessibility). Remove clothes only if they severely hinder chest
compressions.
Preferably use a two-thumb encircling technique for chest
compression in infants
be careful to avoid incomplete recoil. Single
rescuers might alternatively use a two-finger technique.
In children older than 1 year, depending on size and hand span,
use either a one-hand or two-hand technique. In case the one-hand
technique is used, the other hand can be positioned to maintain an
open airway throughout (or to stabilise the compression arm at the
elbow).
 After 15 compressions, 2 rescue breaths should follow and then
alternating (15:2 duty cycle). Do not interrupt CPR at any
moment unless there are clear signs of circulation (movement,
coughing) or when exhausted. Two or more rescuers should
change the rescuer performing chest compressions frequently
and the individual rescuer should switch hands (the hand
compressing, the hand on top) or technique (one to 2-handed) to
avoid fatigue.
 In case there are clear signs of life, but the child remains
unconscious not breathing normally, continue to support ventila-
tion at a rate appropriate for age.
Rescuers only trained in adult BLS
BLS providers who are untrained in PBLS, should follow the adult CPR
algorithm with ventilations, as they were trained, adapting the
techniques to the size of the child. If trained, they should consider
giving 5 initial rescue breaths before proceeding with compressions.
Untrained lay rescuers
 Cardiac arrest is determined to have occurred based on the
combination of unconsciousness and abnormal breathing. As the
latter is often difficult to identify or when there are concerns about
safety (e.g. risk of viral transmission), rather than look-listen-feel,
bystanders might also be guided by specific word descriptors or by
feeling for respiratory movement.
 Bystander CPR should be started in all cases when feasible. The
EMS dispatcher has a crucial role in assisting lay untrained
bystanders to recognise CA and provide CPR. When bystander
CPR is already in progress at the time of the call, dispatchers
should probably only provide instructions when asked for or when
issues with knowledge or skills are identified.
 The steps of the algorithm for paediatric dispatcher-assisted CPR
are very similar to the PBLS algorithm. To decrease the number of
switches, a 30:2 duty cycle might be preferable. If bystanders
cannot provide rescue breaths, they should proceed with chest
compressions only.
Use of an Automated External Defibrillator (AED)
 In children with a CA, a lone rescuer should immediately start CPR
as described above. In cases where the likelihood of a primary
shockable rhythm is very high such as in sudden witnessed
collapse, if easily accessible, he or she can rapidly collect and
apply an AED (at the time of calling EMS). In case there is more
than one rescuer, a second rescuer will immediately call for help
and then collect and apply an AED (if feasible).
 Trained providers should limit the no-flow time when using an AED by
restarting CPR immediately after the shock delivery or no shock
decision; pads should be applied with minimal or no interruption in CPR.
 If possible, use an AED with a paediatric attenuator in infants and
children below 8 years. If such is not available, use a standard AED
for all ages.
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Fig. 16 – Paediatric basic life support algorithm.

50 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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PBLS in case of traumatic cardiac arrest (TCA)
 Perform bystander CPR when confronted with a child in CA after
trauma, provided it is safe to do so. Try to minimise spinal
movement as far as possible during CPR without hampering the
process of resuscitation, which clearly has priority.
 Do not routinely apply an AED at the scene of paediatric TCA
unless there is a high likelihood of shockable underlying rhythm
such as after electrocution.
 Apply direct pressure to stop massive external haemorrhage if
possible, using haemostatic dressings. Use a tourniquet (prefera-
bly manufactured but otherwise improvised) in case of an
uncontrollable, life-threatening external bleeding.
Recovery position
 Unconscious children who are not in CA and clearly have normal
breathing, can have their airway kept open by either continued
head tilt
chin lift or jaw thrust or, especially when there is a
perceived risk of vomiting, by positioning the unconscious child in
a recovery position.
 Once in recovery position, reassess breathing every minute to
recognise CA as soon as it occurs (lay rescuers might need
dispatcher guidance to do so).
 Avoid any pressure on the child's chest that may impair breathing
and regularly change side to avoid pressure points (i.e. every
30 min).
 In unconscious trauma victims, open the airway using a jaw thrust,
taking care to avoid spinal rotation.
Paediatric Foreign Body Airway Obstruction [FBAO]
 Suspect FBAO
if unwitnessed
when the onset of respiratory
symptoms (coughing, gagging, stridor, distress) is very sudden
and there are no other signs of illness; a history of eating or playing
with small items immediately before the onset of symptoms might
further alert the rescuer.
 As long as the child is coughing effectively (fully responsive, loud
cough, taking a breath before coughing, still crying, or speaking),
no manoeuvre is necessary. Encourage the child to cough and
continue monitoring the child's condition.
 If the child's coughing is (becoming) ineffective (decreasing
consciousness, quiet cough, inability to breathe or vocalise,
cyanosis), ask for bystander help and determine the child's
conscious level. A second rescuer should call EMS, preferably by
mobile phone (speaker function). A single trained rescuer should
first proceed with rescue manoeuvres (unless able to call
simultaneously with the speaker function activated).
 If the child is still conscious but has ineffective coughing, give back
blows. If back blows do not relieve the FBAO, give chest thrusts to
infants or abdominal thrusts to children. If the foreign body has not
been expelled and the victim is still conscious, continue the
sequence of back blows and chest (for infant) or abdominal (for
children) thrusts. Do not leave the child.
 The aim is to relieve the obstruction with each thrust rather than to
give many of them.
 If the object is expelled successfully, assess the child's clinical
condition. It is possible that part of the object may remain in the
respiratory tract and cause complications. If there is any doubt or if
the victim was treated with abdominal thrusts, urgent medical
follow up is mandatory.
 If the child with FBAO is, or becomes, unconscious, continue
according to the paediatric BLS algorithm. Competent providers
should consider the use of Magill forceps to remove a foreign
body.
Paediatric advanced life support
Sequence of actions in PALS
Although the sequence of actions is presented stepwise (Fig. 17), ALS
is a team activity, and several interventions will be done in parallel.
ALS teams should not only train in knowledge and skills but also in
teamwork and the ‘choreography’ of ALS interventions.
 Commence and/or continue with paediatric BLS. Recognition of
CA can be done on clinical grounds or based on monitored vital
signs (ECG, loss of SpO2 and/or ETCO2, loss of blood pressure,
etc.). Importantly, also start CPR in children who become
bradycardic with signs of very low perfusion despite adequate
respiratory support.
 If not already in place, apply cardiac monitoring as soon as
possible using ECG-electrodes or self-adhesive defibrillator pads
(or defibrillation paddles). Differentiate between shockable and
non-shockable cardiac rhythms.
 Non-shockable rhythms are pulseless electrical activity (PEA),
bradycardia and asystole. If bradycardia (<60 per minute) is the
result of hypoxia or ischaemia, CPR is needed even if there is
still a detectable pulse. Therefore, providers should rather
assess signs of life and not lose time by checking for a pulse. In
the absence of signs of life, continue to provide high-quality
CPR. Obtain vascular access and give adrenaline IV (10 mcg/
kg, max 1 mg) as soon as possible. Flush afterwards to facilitate
drug delivery. Repeat adrenaline every 3
5 min. In cases
where it is likely to be difficult to obtain IV access, immediately
go for IO access.
 Shockable rhythms are pulseless ventricular tachycardia (pVT)
and ventricular fibrillation (VF). As soon identified, defibrillation
should immediately be attempted (regardless of the ECG
amplitude). If in doubt, consider the rhythm to be shockable.
 If using self-adhesive pads, continue chest compressions while
the defibrillator is charging. Once charged, pause chest
compressions, and ensure all rescuers are clear of the child.
Minimise the delay between stopping chest compressions and
delivery of the shock (<5 s). Give one shock (4 J/kg) and
immediately resume CPR. Reassess the cardiac rhythm every
2 min (after the last shock) and give another shock (4 J/kg) if a
shockable rhythm persists. Immediately after the third shock,
give adrenaline (10 mcg/kg, max 1 mg) and amiodarone
(5 mg/kg, max 300 mg) IV/IO. Flush after each drug. Lidocaine
IV (1 mg/kg) might be used as an alternative to amiodarone by
providers competent in its use. Give a second dose of
adrenaline (10mcg/kg, max 1 mg) and amiodarone (5 mg/kg,
max 150 mg) after the 5th shock if the child still has a shockable
rhythm. Once given, adrenaline should be repeated every
3
5 min.
 Change the person doing compressions at least every 2 min.
Watch for fatigue and/or suboptimal compressions and switch
rescuers earlier if necessary.
 CPR should be continued unless:
& An organised potentially perfusing rhythm is recognised (upon
rhythm check) and accompanied by signs of return of
spontaneous circulation (ROSC), identified clinically (eye
opening, movement, normal breathing) and/or by monitoring
(etCO2, SpO2, blood pressure, ultrasound)
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& There are criteria for withdrawing resuscitation (see the ERC
guideline chapter on ethics).
Defibrillation during paediatric ALS
Manual defibrillation is the recommended method for ALS, but if this is
not immediately available an AED can be used as alternative.
 Use 4 J/kg as the standard energy dose for shocks. It seems
reasonable not to use doses above those suggested for adults
(120
200 J, depending on the type of defibrillator). Consider
escalating doses
stepwise increasing up to 8 J/Kg and max.
360 J
for refractory VF/pVT (i.e. more than 5 shocks needed).
 Defibrillation via self-adhesive pads has become the standard. If
unavailable, the use of paddles (with preformed gel pads) is still
considered an acceptable alternative yet demands specific
alterations to the choreography of defibrillation. Charging should
then be done on the chest directly, already pausing compressions
at that stage. Good planning before each action will minimise
hands-off time.
Pads should be positioned either in the antero-lateral (AL) or
the antero-posterior (AP) position. Avoid contact between pads as
this will create charge arcing. In the AL position, one pad is placed
below the right clavicle and the other in the left axilla. In the AP
position the anterior pad is placed mid-chest immediately left to the
sternum and the posterior in the middle of the back between the
scapulae.
Oxygenation and ventilation during paediatric ALS
 Oxygenate and ventilate with BMV, using a high concentration of
inspired oxygen (100%). Do not titrate FiO2 during CPR.
 Consider insertion of an advanced airway (TT, SGA) in cases
where CPR during transport or prolonged resuscitation is
anticipated and a competent provider is present. Where it is
impossible to ventilate by BMV, consider the early use of an
advanced airway or rescue technique. Use etCO2 monitoring
when an advanced airway is in place.
 Always avoid hyperventilation (due to excessive rate and/or
TV). However, also take care to ensure that lung inflation is
adequate during chest compressions. TV can be estimated by
looking at chest expansion.
 In cases of CPR with positive pressure ventilation via a TT,
ventilations can be asynchronous and chest compressions
continuous (only pausing every 2 min for rhythm check). In this
case, ventilations should approximate to the lower limit of normal
rate for age e.g. breaths/min: 25 (infants), 20 (>1 y), 15 (>8 y), 10
(>12 y).
 For children already on a mechanical ventilator, either disconnect
the ventilator and ventilate by means of a self-inflating bag or
continue to ventilate with the mechanical ventilator. In the latter
case, ensure that the ventilator is in a volume-controlled mode,
that triggers and limits are disabled, and ventilation rate, TV and
FiO2 are appropriate for CPR. There is no evidence to support any
specific level of PEEP during CPR. Ventilator dysfunction can itself
be a cause of cardiac arrest.
 Once there is sustained ROSC, titrate FiO2 to an SpO2 of 94

98%. Competent providers should insert an advanced airway,
if not already present, in children who do not regain consciousness
or for other clinical indications.
51
Measurable factors during ALS
 Capnography is mandatory for the monitoring of TT position. It
however does not permit identification of selective bronchial
intubation. When in place during CPR, it can help to rapidly detect
ROSC. ETCO2 values should not be used as quality indicator or
target during paediatric ALS, nor as an indication for or against
continuing CPR.
 Invasive blood pressure should only be considered as a target
during paediatric ALS by competent providers for children with in-
hospital CA [IHCA] where an arterial line is already in place. Blood
pressure values should not be used to predict outcome.
 Point of care ultrasound can be used by competent providers to
identify reversible causes of CA. Its use should not increase
hands-off time or impact quality of CPR. Image acquisition is best
done during pauses for rhythm check and/or for ventilations; the
team should plan and anticipate (choreography) to make the most
of the available seconds for imaging.
 Point of care serum values (of e.g. potassium, lactate, glucose,
. . . ) can be used to identify reversible causes of cardiac arrest but
should not be used for prognostication. Providers should be aware
that the measured values may differ significantly, depending on
the measurement technique and sampling site.
Special circumstances
reversible causes
 The early identification and proper treatment of any reversible
cause during CPR is a priority for all ALS providers. Use the
mnemonic “4H4T” to remember what to actively look for: Hypoxia;
Hypovolemia; Hypo- or hyperkalaemia/-calcaemia/-magnesemia
& hypoglycaemia; Hypo- or Hyperthermia; Tension pneumotho-
rax; Tamponade; Thrombosis (Cardiac
Pulmonary); Toxic
Agents.
 Unless otherwise specified, the specific treatment for each of
these causes is the same in CA as in acute life-threatening disease
(see above and the dedicated chapter on special circumstances
within these guidelines).
 Providers should consider (as per protocol and if possible, with
expert help) specific treatments for intoxications with high-risk
medications (e.g. beta-blockers, tricyclic antidepressants,
calcium channel blockers, digitalis, or insulin). For certain life-
threatening intoxications extracorporeal treatments should be
considered early on and these patients should be transferred to
a centre that can perform these in children, ideally before
cardiovascular or neurological failure occurs (based upon the
context of the intoxication rather than the actual symptoms).
 Specific conditions such as cardiac surgery, neurosurgery,
trauma, drowning, sepsis, pulmonary hypertension also demand
a specific approach. Importantly, the more widespread use of
extracorporeal life support/CPR [ECLS/eCPR] has thoroughly
redefined the whole concept of ‘reversibility’.
 Institutions performing cardiothoracic surgery in children should
establish institution-specific algorithms for cardiac arrest after
cardiothoracic surgery.
 Standard ALS may be ineffective for children with CA and
pulmonary hypertension (PHT). Actively search for reversible
causes of increased pulmonary vascular resistance such as
cessation of medication, hypercarbia, hypoxia, arrhythmias,
cardiac tamponade, or drug toxicity. Consider specific treat-
ments like pulmonary vasodilators.
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Fig. 17 – Paediatric advanced life support algorithm.

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Traumatic Cardiac Arrest TCA
 In case of TCA, start standard CPR while searching for and
treating any of the reversible causes of paediatric TCA:
 airway opening and ventilation with oxygen
 external haemorrhage control including the use of tourniquets in
exsanguinating injury to the extremities
 bilateral finger or tube thoracostomy (or needle
thoracocentesis)
 IO/IV access and fluid resuscitation (if possible, with full blood or
blood products), as well as the use of the pelvic binder in blunt
trauma.
 Chest compressions are performed simultaneously with these
interventions depending on the available personnel and proce-
dures. Based on the mechanism of injury, correction of reversible
causes might precede adrenaline administration.
 Consider emergency department (ED) thoracotomy in paediatric
TCA patients with penetrating trauma with or without signs of life
on ED arrival. In some EMS systems, highly competent
professionals might also consider pre-hospital thoracotomy for
these patients (or for children with selected blunt injury).
Hypothermic arrest
 Adapt standard paediatric ALS actions for hypothermia (see also
the chapter on special circumstances). Start standard CPR for all
victims in CA. If continuous CPR is not possible and the child is
deeply hypothermic (<28  C), consider delayed or intermittent
CPR.
 Any child who is considered to have any chance of a favourable
outcome should ideally be transported as soon as possible to a
(paediatric) reference centre with ECLS or cardiopulmonary
bypass capacity.
Extracorporeal life support
 E-CPR should be considered early for children with ED or IHCA
and a (presumed) reversible cause when conventional ALS does
not promptly lead to ROSC, in a healthcare context where
expertise, resources and sustainable systems are available to
rapidly initiate ECLS.
 For specific subgroups of children with decompensated cardiore-
spiratory failure (e.g. severe refractory septic shock or cardiomy-
opathy or myocarditis and refractory low cardiac output), pre-
arrest use of ECLS can be beneficial to provide end-organ support
and prevent cardiac arrest. IHCA shortly prior to or during
cannulation should not preclude ECLS initiation.
 Competent providers might also decide to perform E-CPR for
OHCA in cases of deep hypothermic arrest or when cannulation
can be done prehospitally by a highly trained team, within a
dedicated healthcare system.
Post-resuscitation care
The eventual outcome of children following ROSC depends on many
factors, some of which may be amenable to treatment. Secondary
injury to vital organs might be caused by ongoing cardiovascular
failure from the precipitating pathology, post-ROSC myocardial
dysfunction, reperfusion injury, or ongoing hypoxaemia.
 Haemodynamic: Avoid post-ROSC hypotension (i.e. MAP < 5th
percentile for age). Aim for a blood pressure at or above the p50,
taking into account the clinical signs, serum lactate and/or
measures of cardiac output. Use the minimum necessary doses of
parenteral fluids and vasoactive drugs to achieve this. Monitor all
53
interventions and adjust continuously to the child's physiological
responses.
 Ventilation: Provide a normal ventilatory rate and volume for the
child's age, to achieve a normal PaCO2. Try to avoid both
hypocarbia and hypercarbia. In a few children the usual values for
PaCO2 and PaO2 may deviate from the population normal values
for age (e.g. in children with chronic lung disease or congenital
heart conditions); aim to restore values to that child's normal
levels. Do not use etCO2 as a surrogate for PaCO2 when aiming
for normocapnia as part of neuroprotective care unless there is a
proven correlation.
 Oxygenation: Titrate FiO2 to achieve normoxaemia or, if arterial
blood gas is not available, maintain SpO2 in the range of 94
98%.
Maintain high FiO2 in presumed carbon monoxide poisoning or
severe anaemia.
 Use targeted temperature management TTM: Avoid fever
(37.5 ), maintain a specific set temperature, by means of, for
instance, external cooling. Lower target temperatures (e.g. 34  C)
demand appropriate systems of paediatric critical care and should
only be used in settings with the necessary expertise. Alternative-
ly, the attending team can aim for higher target temperature, e.g.
36  C.
 Glucose control: monitor blood glucose and avoid both hypo- and
hyperglycaemia. Be aware that tight glucose control may be
harmful, due to a risk of inadvertent hypoglycaemia.
Although several factors are associated with outcome after
cardiopulmonary arrest, no single factor can be used in isolation for
prognostication. Providers should use multiple variables in the pre-,
intra-, and post-CA phases in an integrated way, including biological
markers and neuroimaging.
Ethics
These European Resuscitation Council Ethics guidelines provide
evidence-based recommendations for the ethical, routine practice of
resuscitation and end-of-life care of adults and children. The guideline
primarily focus on major ethical practice interventions (i.e. advance
directives, advance care planning, and shared decision making),
decision making regarding resuscitation, education, and research.
These areas are tightly related to the application of the principles of
bioethics in the practice of resuscitation and end-of-life care.
Key messages from this section are presented in Fig. 18.
Major interventions aimed at safeguarding autonomy
Patient preferences and treatment decisions
Clinicians should:
 Use advance care planning that incorporates shared decision
making to improve consistency between patient wishes and
treatment
 Offer advance care planning to all patients at increased risk of
cardiac arrest or poor outcome in the event of cardiac arrest.
 Support advance care planning in all cases where it is requested
by the patient.
 Record advance care plans in a consistent manner (e.g. electronic
registries, documentation templates, etc.).
 Integrate resuscitation decisions with other treatment decisions,
such as invasive mechanical ventilation, in overarching advance
emergency care treatment plans to increase clarity of treatment
54 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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goals and prevent inadvertent deprivation of other indicated
treatments.
 Clinicians should not offer CPR in cases where resuscitation
would be futile.
Improving communication
 Clinicians should use evidence-based communication interven-
tions to improve end-of-life discussions and support completion of
advance directives/advance care plans.
 Clinicians should combine structured end-of-life discussions with
video decision aids for shared decision making about end-of-life
hospital transfer from nursing homes in systems where this
technology is available.
 Clinicians should consider inviting a communication facilitator to
join discussions with patients and/or their family when making
advance care plans about the appropriateness of life sustaining
treatments. This refers to systems where communication
facilitators are available.
 Healthcare systems should provide clinicians with communication
skills training interventions to improve clinicians’ skill and comfort
in delivering bad news or supporting patients to define care goals.
 Clinicians should integrate the following patient/family support
elements with shared decision making:
1. Provide information about the patient's status and prognosis in
a clear and honest manner. This may be supported by use of a
video-support tool.
2. Seek information about the patient's goals, values, and
treatment preferences.
3. Involve patients/family members in discussions about advance
care plans.
4. Provide empathic statements assuring non-abandonment,
symptom control, and decision-making support.
5. Provide the option of spiritual support.
6. Where appropriate, explain and apply protocolised patient-
centred procedures for treatment withdrawal with concurrent
symptom control and patient/family psychological support.
7. Consider recording meetings with family for the purpose of
audit/quality improvement.
Deciding when to start and when to stop cardiopulmonary
resuscitation (CPR)
Withholding and Withdrawing CPR
 Systems, clinicians, and the public should consider cardiopulmo-
nary resuscitation (CPR) a conditional therapy.
 Systems should implement criteria for the withholding and
termination of CPR for both in-hospital cardiac arrest (IHCA)
and out-of-hospital cardiac arrest (OHCA), taking into consider-
ation the specific local legal, organisational, and cultural context.
 Systems should define criteria for the withholding and termination
of CPR, and ensure criteria are validated locally. The following
criteria may be considered:
 Unequivocal criteria:
& When the safety of the provider cannot be adequately assured
& When there is obvious mortal injury or irreversible death
& When a valid and relevant advance directive becomes available
that recommends against the provision of CPR
 Further criteria to inform decision making:
& Persistent asystole despite 20 min of advanced life support
(ALS) in the absence of any reversible cause.
Unwitnessed cardiac arrest with an initial non-shockable rhythm
&
where the risk of harm to the patient from ongoing CPR likely
outweighs any benefit e.g. absence of return of spontaneous
circulation (ROSC), severe chronic co-morbidity, very poor
quality of life prior to cardiac arrest.
& Other strong evidence that further CPR would not be consistent
with the patient's values and preferences, or in their best
interests.
 Criteria that should not alone inform decision-making e.g.
& Pupil size
& CPR duration
& End-tidal carbon dioxide (CO2) value
& Co-morbid state
& Initial lactate value
& Suicide attempt.
 Clinicians should clearly document reasons for the withholding or
termination of CPR, and systems should audit this documentation.
 Systems should implement criteria for early transport to hospital in
cases of OHCA, taking into account the local context, if there are
no criteria for withholding/terminating CPR. Transfer should be
considered early in the CPR attempt and incorporate patient,
event (e.g. distance to hospital, risk of high-priority transport for
those involved), and treatment (e.g. risk of suboptimal CPR)
factors. Patients who may particularly benefit from early transport
include emergency medical services (EMS) witnessed arrest [or
by bystander performing high quality basic life support (BLS)] with
either ROSC at any moment or ventricular fibrillation/tachycardia
(VT/VF) as presenting rhythm and a presumed reversible cause
(e.g. cardiac, toxic, hypothermia).
 Systems should implement criteria for inter-hospital transfer of
IHCA patients in hospitals where advanced CPR techniques are
not offered.
 Clinicians should start CPR in patients who do not meet local
criteria for withholding CPR. Treatments may then be tailored as
more information becomes available.
 Clinicians should not partake in ‘slow codes’.
 During a pandemic, resource demand (e.g. critical care beds,
ventilators, staffing, drugs) may significantly exceed resource
availability. Healthcare teams should carefully assess each
patient's likelihood of survival and/or good long-term outcome
and their expected resource use to optimise allocation of
resources. Clinicians should not use categorical or blanket criteria
(e.g. age thresholds) to determine the eligibility of a patient to
receive treatment.
 In systems that offer uncontrolled donation after circulatory death
and other systems of organ donation, transparent criteria should
be developed for the identification of candidates and process for
obtaining consent and organ preservation.
Bystander CPR
Systems should:
 Recognise the importance of bystander CPR as a core component
of the community response to OHCA.
 Recognise bystander CPR as a voluntary act, with no perceived
moral or legal obligation to act.
 Support bystanders in minimising the impact on their own health of
performing bystander CPR. In the context of transmissible disease
(such as Covid-19), bystanders also have a responsibility of
preventing further disease transmission to other individuals in the
immediate vicinity and the wider community.
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
6 0 55

Fig. 18 – Ethics Summary infographic.

 Aim to identify cases where bystander CPR is likely to be beneficial
and cases where it is unlikely to be beneficial.
 Never evaluate the value of (bystander) CPR in isolation but as
part of the whole system of healthcare within their region.
(Bystander) CPR seems feasible in settings where resources and
organisation support the integrity of the chain of survival.
Family presence during resuscitation
Patient outcomes and ethical considerations
 When making decisions about CPR, clinicians should explore and
understand the value that a patient places on specific outcomes.
 Health systems should monitor outcomes following cardiac arrest,
and identify opportunities to implement evidence-based inter-
ventions to reduce variability in patient outcome
 Cardiac arrest research should collect core outcomes, as
described in the cardiac arrest core outcome set.

Resuscitation teams should offer family members of cardiac arrest
patients the opportunity to be present during the resuscitation attempt
in cases where this opportunity can be provided safely, and a member
of the team can be allocated to provide support to the patient's family.
Systems should provide clinicians with training on how best to provide
information and support to family members during resuscitation
attempts.
Ethics and emergency research
 Systems should support the delivery of high-quality emergency,
interventional and non-interventional research, as an essential
component of optimising cardiac arrest outcomes.
 Researchers should involve patients and members of the public
throughout the research process, including design, delivery and
dissemination of the research.
56 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
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 For observational research (e.g. in the context of registry
data collection and or DNA biobank data sampling and
analyses) we suggest consideration of a deferred and broad
consent model, with concurrent implementation of appropriate
safeguards aimed at preventing data breaches and patient re-
identification.
 Communities or population in which research is undertaken and
who bear the risk of research-related adverse events, should be
given the opportunity to benefit from its results.
 Researchers must ensure that research has been reviewed and
approved by an independent ethical review committee, in line with
local law, prior to it being commenced.
 Researchers must respect the dignity and privacy of research
subjects and their families.
 Researchers should comply with best practice guidance to ensure
transparency of research, including study protocol registration,
prompt reporting of results, and data sharing.
 Systems should ensure that funding for cardiac arrest research is
proportionate to the societal burden caused by cardiac arrest-
associated morbidity and mortality.
Education
These European Resuscitation Council Advanced Life Support (ALS)
guidelines, are based on the 2020 International Consensus on
Cardiopulmonary Resuscitation Science with Treatment Recommen-
dations. This section provides guidance to citizens and healthcare
professionals with regard to teaching and learning the knowledge,
skills and attitudes of resuscitation with the ultimate aim of improving
patient survival after cardiac arrest.
Key messages from this section are presented in Fig. 19.
The principles of medical education applied to resuscitation
The ERC, as a scientific based organisation, grounds its guidelines on
current medical evidence. The same applies for the ERC education
guidelines for resuscitation. The ERC approach to education can be
grouped into 4 themes (4 ‘I's): (1) Ideas (theories of education and how
we learn), (2) Inquiry (research which both develops from and informs
the ideas mentioned), (3) Implementation (approaches based on the
research), and (4) Impact (outcome of these educational approaches
both for learning and clinical practice).
Resuscitation education for different target groups
Every citizen should learn to provide the basic skills to save a life.
Those with a duty to respond to emergencies need to be competent
to perform resuscitation, depending on the level of rescue they
provide, from BLS to advanced life support, for children and/or
adults, according to the current ERC guidelines. Resuscitation
competencies are best maintained if training and retraining is
distributed over time, and frequent retraining is suggested between
two and twelve months. For HCPs, accredited advanced life support
training is recommended, as well as the use of cognitive aids and
feedback devices during resuscitation training. Specific team
membership and team leadership training should be a part of
advanced life support courses, and data-driven, performance-
focused debriefing needs to be taught.
Key points in resuscitation education for bystanders and first
responders are:
 Enhance willingness to perform CPR;
 Reinforce the chain of survival;
 Teach resuscitation using feedback devices;
 Distribute resuscitation training over time (spaced education)
 Maintain resuscitation competencies by frequent retraining.
Key points in resuscitation education for HCPs are:
 Teach every HCP high-quality CPR (from BLS to advanced life
support level, children and/or adults, special circumstances
depending on the workplace and patient mix);
 Teach accredited advanced life support courses and include team
and leadership training in such courses;
 Use cognitive aids;
 Teach and use debriefing.
Teaching the skills to perform high-quality resuscitation
Teaching the technical skills to perform resuscitation on every given level
is very important. Equally important, however, is the teaching of human
factors: e.g. communication, collaboration in teams and with different
professions, awareness of the critical situation, etc. Human factors are
crucial to achieving high-quality CPR and good clinical practice. Teaching
these factors will increase the willingness of trained responders to help
victims in a life-threatening situation, improve the initiation of the chain of
survival by starting BLS and gives participants of CPR courses the
confidence to attempt resuscitation whenever needed.
Technology enhanced education to teach resuscitation
Learning CPR can be supported by the use of smartphones, tablets,
etc. by using apps and social media, as well as feedback devices.
These learning modalities may be teacher independent. They
improve retention and facilitate competency assessment in CPR.
Gamified learning, (e.g. virtual and augmented reality, tablet apps
simulating monitors, etc.) may engage many learners. Virtual
learning environments are recommended to be used for pre-course
e-learning, as part of a blended learning approach, or for self-
learning options of learning independent of time and location for all
levels of CPR courses.
Simulation to educate resuscitation
High as well as low fidelity simulation in resuscitation education
facilitates contextualised learning for a variety of learners. It integrates
technical and non-technical skills and considers the environment or
context of specific learner groups and the different levels of expertise.
Hence, simulation provides the opportunity to learn to deal with human
factors in critical situations. Specific team or leadership training should
be included in advanced life support simulation. Profound learning
occurs during the reflection phase in the debriefing of a simulated
resuscitation.
Faculty development to improve education
In many areas of education, the quality of the teacher has a major
impact on learning, and this can be improved by training and ongoing
faculty development. The evidence for these effects in resuscitation
training is scarce and many recommendations on faculty development
are therefore extrapolated from other areas. Three aspects of faculty
development are important: selection of suitable instructors, initial
instructor training, and maintenance and regular update of their
teaching quality.
Effect of resuscitation education on outcome
Accredited ALS training and accredited neonatal resuscitation training
(NRT) for HCPs improve the outcome of patients. The effect of other
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
6 0 57

Fig. 19 – Education summary infographic.

life support courses on patient outcome is less clear, but it is
reasonable to recommend other accredited life support courses.
Further research is needed to quantify their actual impact on patient
outcomes.
Research gaps and future directions in educational research
There is a lack of high-quality research in resuscitation education to
demonstrate whether CPR training improves process quality (e.g.
compression rate, depth or fraction) and patient outcomes (e.g. return
of spontaneous circulation, survival to discharge or survival with
favourable neurological outcome). Successful strategies to improve
educational efficiency from the wider medical education literature
should be considered to study their value for resuscitation education.
Contextualised and tailored CPR training can prevent the decay of
resuscitation competency. There is a potential for resuscitation
courses to become less generic and to focus more on individual needs
of the learner. Future research areas include investigating optimal
training and support provided to resuscitation trainers and the role of
education in reducing emotional and psychological trauma to the
rescuer.
Conflict of interest
JN reports funding from Elsevier for his role as Editor in Chief of the
journals Resuscitation and Resuscitation Plus. He reports research
funding from the National Institute for Health Research in relation to
the PARAMEDIC2 trial and the AIRWAYS2 trial.
GDP reports funding from Elsevier for his role as an editor of the
journal Resuscitation. He reports research funding from the National
58 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1
6 0
Institute for Health Research in relation to the PARAMEDIC2 trial and
the RESPECT project and from the Resuscitation Council UK and
British Heart Foundation for the OHCAO Registry.
JTG declared speakers honorarium from Weinmann, Fresenius,
Ratiopharm, Zoll; he is Scientific Advisor for Zoll Temperature
management.
TO declares research funding from Laerdal Foundation and Zoll
Foundation.
RG declares his role as Editor of the journal Trends in Anaesthesia
and Critical Care, associate editor European Journal of Anaesthesi-
ology. He reports institutional research funding.
JS declares his role as an editor of Resuscitation; he declares
institutional research funding for the Audit-7 project.
JL reports funding for his contribution to Paramedic-2 and
OHCHAO project
JM declares occasional advice to Laerdal Medical and Brayden on
Newborn Resuscitation Equipment.
Acknowledgements
GDP is supported by the National Institute for Health Research
(NIHR) Applied Research Collaboration (ARC) West Midlands.
The views expressed are those of the author(s) and not
necessarily those of the NIHR or the Department of Health and
Social Care.
Appendix A. European Resuscitation Council
Guideline Collaborators
S. Ainsworth, S. Akin, A. Alfonzo, J. Andres, S. Attard Montalto, A.
Barelli, M. Baubin, W. Behringer, B. Bein, D. Biarent, R. Bingham, M.
Blom, A. Boccuzzi, V. Borra, L. Bossaert, B.W. Böttiger, J. Breckwoldt,
O. Brissaud, R. Burkart, A. Cariou, P. Carli, F. Carmona, P. Cassan, M.
Castren, T. Christophides, C.D. Cimpoesu, C. Clarens, P. Conaghan,
K. Couper, T. Cronberg, E. De Buck, N. de Lucas, A. De Roovere, C.D.
Deakin, J. Delchef, B. Dirks, J. Djakow, T. Djarv, P. Druwe, G. Eldin, H.
Ersdal, H. Friberg, C. Genbrugge, M. Georgiou, E. Goemans, V.
Gonzalez-Salvado, P. Gradisek, J.T. Graesner, R. Greif, A.J.
Handley, C. Hassager, K. Haywood, J.K. Heltne, D. Hendrickx, J.
Herlitz, J. Hinkelbein, F. Hoffmann, S. Hunyadi Anticevic, G.B.
Johannesdottir, G. Khalifa, B. Klaassen, J. Koppl, U. Kreimeier, A.
Kuzovlev, T. Lauritsen, G. Lilja, F. Lippert, A. Lockey, C. Lott, I. Lulic,
M. Maas, I. Maconochie, J. Madar, A. Martinez-Mejias, S. Masterson,
S.D. Mentzelopoulos, D. Meyran, K.G. Monsieurs, C. Morley, V.R.M.
Moulaert, N. Mpotos, N. Nikolaou, J.P. Nolan, T.M. Olasveengen, E.
Oliver, P. Paal, T. Pellis, G.D. Perkins, L. Pflanzl-Knizacek, K. Pitches,
K. Poole, V. Raffay, W. Renier, G. Ristagno, C.C. Roehr, F. Rosell-
Ortiz, M. Rudiger, A. Safri, L. Sanchez Santos, C. Sandroni, F. Sari, A.
Scapigliati, S. Schilder, J. Schlieber, S. Schnaubelt, F. Semeraro, S.
Shammet, E.M. Singletary, C. Skare, M.B. Skrifvars, M. Smyth, J.
Soar, H. Svavarsdottir, T. Szczapa, F. Taccone, M. Tageldin Mustafa,
A. Te Pas, K.C. Thies, I.B.M. Tjelmeland, D. Trevisanuto, A. Truhlar,
G. Trummer, N.M. Turner, B. Urlesberger, J. Vaahersalo, P. Van de
Voorde, H. Van Grootven, D. Wilkinson, J. Wnent, J.P. Wyllie, J.
Yeung, D.A. Zideman.
Appendix B. Supplementary data
Supplementary material related to this article can be found, in the
online version, at https://doi.org/10.1016/j.resuscitation.2021.02.003.
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51. Baldi E, Sechi GM, Mare C, et al. Out-of-hospital cardiac arrest during
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52. McClelland G, Shaw G, Thompson L, Wilson N, Grayling M. Impact of
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57. Paoli A, Brischigliaro L, Scquizzato T, Favaretto A, Spagna A. Out-of-
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 RESUSCITATION 161 (2021) 61 79

Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Epidemiology of cardiac arrest in Europe

Jan-Thorsten Gräsner a,n, * , Johan Herlitz b , Ingvild B.M. Tjelmeland a,c , Jan Wnent a,n,o ,
Siobhan Masterson d, Gisela Lilja e , Berthold Bein f,g , Bernd W. Böttiger h ,
Fernando Rosell-Ortiz i , Jerry P Nolan j,k , Leo Bossaert l , Gavin D. Perkins j,m
a
University Hospital Schleswig-Holstein, Institute for Emergency Medicine, Kiel, Germany
b
Prehospen-Centre for Prehospital Research, Faculty of Caring Science, Work-Life and Social Welfare, University of Borås, Borås, Sweden
c
Division of Prehospital Services, Oslo University Hospital, Norway
d
National Ambulance Service and National University of Ireland, Galway, Ireland
e
Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
f
Anaesthesiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
g
Semmelweis University, Faculty of Medicine, Hamburg, Germany
h
Medical Faculty and University Hospital of Cologne, Germany
i
Servicio de Urgencias y Emergencias 061 de La Rioja, Spain
j
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
k
Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
l
University of Antwerp, Antwerp, Belgium
m
University Hospital Birmingham, Birmingham, B9 5SS, UK
n
University Hospital Schleswig-Holstein, Department of Anesthesia and Intensive Care Medicine, Kiel, Germany
o
University of Namibia, School of Medicine, Windhoek, Namibia

Abstract
In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac
arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are
presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to
cardiac arrest.
Keywords: Cardiac arrest, Epidemiology, Incidence of cardiac arrest

differences in collecting data (e.g. case definition, ascertainment

Introduction and scope
Sudden cardiac arrest (SCA) is the third leading cause of death in
Europe.1 3 Considerable effort has been made to understand the
background and causes for cardiac arrest, and the differences in the
incidence within and between countries. Factors influencing survival
after out-of-hospital-cardiac arrest (OHCA) and in-hospital-cardiac
arrest (IHCA) are well established but there remains considerable
variation in incidence and outcome. Variation may arise from
methods and outcome verification); case-mix (e.g. age, socio-
economic status, co-morbidities), structure (e.g. different types of
emergency medical services (EMS) systems or differences in the
organisation of teams responding to IHCA; geographical variation,
use of community responder schemes), process of care (e.g. EMS
response time, time to defibrillation, post resuscitation care) as well as
differences in the quality of treatment provided by individual
practitioners (e.g. quality of CPR, interventions provided, decisions
about when to start and stop resuscitation).4 In the early 1990s, the

* Corresponding author.
https://doi.org/10.1016/j.resuscitation.2021.02.007

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
62 RESUSCITATION 161 (2021) 61
first Utstein recommendations were published to help researchers and
practitioners report the same data points using the same definitions.5
It was anticipated that this would lead to a better understanding of the
epidemiology of cardiac arrest, facilitate inter-system and intra-
system comparisons, enable comparison of the benefits of different
system approaches, act as a driver to quality improvement, identify
gaps in knowledge, and support clinical research.6
Correct and reliable data are needed to understand causes,
treatment and outcome after a cardiac arrest regardless of the
place where it occurs. In this chapter, we provide an overview of
causes, incidences and outcome of cardiac arrest in Europe. It is
important that local situations are considered when results are
benchmarked.
Search strategy
Individual search strategies were constructed for each section of this
guideline. Searches were done in Medline. Only publications in English
from the last 10 years were included, unless there was very little
literature available. Abstracts were reviewed by at least two authors and
relevant articles were read in full-text. Any studies that were obviously
not about European patients and populations were excluded.
Europe and the world
The incidence of IHCA beyond Europe is most comprehensively
described using data from the American Heart Association’s Get With
The Guidelines-Resuscitation Registry.2 From 2003 to 2007, the
estimated incidence of IHCA in the United States was approximately 6
7 cardiac arrests per 1,000 hospital admissions.7 Data also from the
Get With The Guidelines-Resuscitation Registry from 2017 was used
to estimate percentage survival to hospital discharge of 25%.8 Data
from the UK National Cardiac Arrest Audit (NCAA) and from the
Danish In-Hospital Cardiac Arrest Registry (DANARREST) both
document lower incidences of IHCA (1.6 and 1.8 per 1,000 hospital
admissions respectively) compared with the United States.9,10
Outside of Europe, multiple studies of OHCA incidence and outcome
have been published reporting survival rates between 3 6% in Asia,11
11% in USA11a and 12% in Australia and New Zealand.12 While some
of the variation observed between these studies is because of patient,
area and, country-level differences, there are calculation and
categorisation differences which add to the degree of variation.
These guidelines were drafted and agreed by the Epidemiology
Writing Group members. The methodology used for guideline
development is presented in the Executive summary. The guidelines
were posted for public comment in October 2020. The feedback was
reviewed by the writing group and the guideline was updated where
relevant. The Guideline was presented to and approved by the ERC
General Assembly on 10th December 2020.
Key facts
Out of hospital cardiac arrest
 Twenty-nine countries participated in the European Registry of
Cardiac Arrest (EuReCa) collaboration.
 Out of hospital cardiac arrest registries exist in approximately 70%
of European countries but the completeness of data captures
varies widely.
79
 The annual incidence of OHCA in Europe is between 67 to 170 per
100,000 inhabitants.
 Resuscitation is attempted or continued by EMS personnel in
about 50 60% of cases (between 19 to 97 per 100,000
inhabitants).
 The rate of bystander CPR varies between and within countries
(average 58%, range 13% 83%).
 The use of automated external defibrillators (AEDs) remains low in
Europe (average 28%, range 3.8% 59%).
 80% of European countries provide dispatch assisted CPR and
75% have an AED registry. Most (90%) countries have access to
cardiac arrest centres for post resuscitation care.
 Survival rates at hospital discharge are on average 8%, varying
from 0% to 18%.
 Differences in EMS systems in Europe account for at least some of
the differences observed in OHCA incidence and survival rates.
In hospital cardiac arrest
 The annual incidence of IHCA in Europe is between 1.5 and 2.8 per
1,000 hospital admissions.
 Factors associated with survival are the initial rhythm, the place of
arrest and the degree of monitoring at the time of collapse.
 Survival rates at 30 days / hospital discharge range from 15% to
34%.
Long term outcomes
 In European countries where withdrawal of life sustaining
treatment (WLST) is routinely practiced, a good neurological
outcome is seen in > 90% of patients. Most patients are able to
return to work.
 In countries where WLST is not practiced, poor neurological
outcomes are more common (50% with 33% in a persistent
vegetative state).
 Amongst survivors with a good neurological outcome, neuro-
cognitive, fatigue and emotional problems are common and cause
reduced health related quality of life.
 Patients and relatives may develop post-traumatic stress disorder.
Post cardiac arrest rehabilitation
 There is wide variation in the provision of rehabilitation services
following cardiac arrest.
 Many patients do not have access to post cardiac arrest
rehabilitation.
Key recommendations (expert consensus Fig. 1)
 Health systems should have population-based registries which
monitor the incidence, case mix, treatment and outcomes for
cardiac arrest.
 Registries should adhere to the Utstein recommendations for data
definitions and outcome reporting.
 Data from registries should inform health system planning and
responses to cardiac arrest.
 European countries are encouraged to participate in the EuReCa
collaboration to enhance understanding of epidemiology and
outcomes of cardiac arrest in Europe.
 RESUSCITATION 161 (2021) 61 79 63

Fig. 1 – Epidemiology infographic summary.

 There is a need for more research and greater provision of post

resuscitation rehabilitation services.
 It is expected that the clinical role of genetic and epigenetic
factors will be increasingly understood as research in this
area continues to grow. There are currently no specific
resuscitation recommendations for patients with known geno-
mic predispositions.
Out-of-hospital cardiac arrest
Incidence
The true incidence of OHCA in Europe is not known. The available
literature is largely based on reports of OHCA attended by EMS. This
64 RESUSCITATION 161 (2021) 61
Table 1 – Reported incidence of out-of-hospital cardiac arrest and the corresponding figures of resuscitation
started.
Country Incidence of cardiac Incidence of resuscitation
arrest per 100,000 attempted per 100,000
inhabitants inhabitants
Spain 19
Ireland 54
Sweden 61
Norway 64 51
Denmark 93 86
Poland 170 97
may underestimate the true incidence as in some countries, due to
culture or belief, bystanders may not call the EMS when they witness a
cardiac arrest. Other reasons for not calling EMS might be that the
event was not witnessed, the patient was considered to be dead or had
a do not attempt cardiopulmonary resuscitation (DNACPR) decision,
or the patient had such severe comorbidities that it was not considered
appropriate to request EMS resources. Cases of OHCA attended by
EMS can be divided into two groups: 1) those where resuscitation was
attempted and 2) those in whom resuscitation was not attempted.
There is more information available on the number of OHCA patients
who had resuscitation attempted by EMS than those patients who
were attended by the EMS but not treated.
The European Registry of Cardiac Arrest (EuReCa), an interna-
tional project of the European Resuscitation Council (ERC), provides
the most comprehensive information on the epidemiology of cardiac
arrest in Europe.1,13 The reported incidence of cardiac arrest varies
greatly between countries, but also between regions within countries
(Table 1).14 19 In the EuReCa ONE study the incidence of OHCA
confirmed by EMS was estimated at 84 per 100,000 inhabitants per
year, varying from 28 to 160. The estimated incidence of OHCA where
resuscitation was attempted by EMS was 49 per 100,000 inhabitants,
varying from 19 to 104.13 The follow-up study, EuReCa TWO,
collected data for three months and reported OHCA confirmed by
EMS to be 89 per 100,000 inhabitants per year, varying from 53 to 166,
with resuscitation attempted by EMS reported as 56 per 100,000
inhabitants, varying from 27 to 91.1 The studies report that
resuscitation is attempted in about 50 60% of cases attended by
EMS and considered for resuscitation. However, there is likely to be
substantial underreporting and the variability between countries is
considerable (see Table 1).
The number of reported OHCAs in Europe has increased in recent
years when compared with the situation one or two decades ago.
Whether these differences reflect an increased incidence or simply
more comprehensive reporting is unclear. It is likely, at least in part, to
be explained by improved case ascertainment methods and increased
coverage by regional and national registries in recent years.
System configuration
Variability in EMS organisation is a common theme across
international registries and epistries.12,22 25 It is therefore likely that
differences in EMS systems in Europe account for at least some of the
variation observed in OHCA survival rates. In preparation for revision
of the ERC resuscitation guidelines, a survey of EMS systems was
carried out across 28 European countries from October 2019 to
January 2020. The survey mirrored previous findings internationally,
79
Reference
Rosell-Ortiz 201720
Irish National Out of Hospital Cardiac Arrest Register, Annual Report 2019
The Swedish Cardiopulmonary Resuscitation Registry; Det Svenska Hjärt-Lung
räddningsregistret (www.hlrr.se)]
Tjelmeland 202020a
Danish Out-of Hospital Cardiac Arrest Registry www.ohca.dk
Gach 201615
in demonstrating substantial variation in the number of EMS missions,
level of training of EMS personnel, availability of helicopter emergency
medical services (HEMS) and the availability of first responders
across Europe.21
At the time of the survey, population density in participating
countries varied from 3.6 to almost 510 people/km2 . While population
characteristics explains some of the variation, there remains large
differences in fundamental metrics of EMS activity. Examples include
the number of EMS missions per 1,000 inhabitants, and response
times. Most countries reported having hospitals capable of providing
post-resuscitation care as recommended in the previous ERC
resuscitation guidelines, but there were vast differences in the
number of hospitals with 24/7 emergency departments per one million
inhabitants. This variation in availability and structure of health care
services may explain some of the differences in survival and outcomes
after cardiac arrest.
All dispatch centres were reported as being part of the EMS system
in 65% of the countries in the survey, in 14% some dispatch centres
were part of the EMS. The number of dispatch centres varied between
0.35 and 3.3 per one million inhabitants, meaning the size of the
country or the total population was not directly associated with the
number of dispatch centres. Twenty-three of 28 countries reported
offering dispatch-assisted CPR (DA-CPR) and most countries
reported using standardised dispatch protocols and dispatch-assisted
CPR instructions. Twenty-one countries reported having AED
registries, the majority of which were available in dispatch centres.
Median EMS response times for urban areas in Europe of under ten
minutes were reported to be achieved in only 32% of the countries. Less
than ten-minute median response times in rural areas were achieved in
some areas of most countries but were not achieved consistently in any
country. It is therefore encouraging that the survey identified that at least
18 European countries had established first responder systems.
However, another recent European survey described many kinds of first
responder systems and highlighted that regions within countries had
different approaches.26 The introduction of first responder systems is
positive but adds further difference which need to be considered when
explaining variation in outcomes.
On scene treatment of cardiac arrest patients was also reported to
be different in countries across Europe. Some EMS services were
obliged to start treatment when they arrived on scene and not to
terminate treatment, giving a reported incidence of EMS treated
OHCA over 90 per 100,000 inhabitants. In other countries EMS
personnel could terminate treatment and transport patients to hospital
only if they achieved return of spontaneous circulation (ROSC). Even
when termination of resuscitation on scene was permitted, most
countries permitted transport with ongoing CPR. However, for most
 RESUSCITATION 161 (2021) 61 79 65

countries, specific circumstances were stipulated to allow this
practice.
The previous ERC Resuscitation Guidelines recommended that
patients with OHCA of presumed cardiac cause are transported to a
hospital that can provide immediate cardiac revascularisation,
targeted temperature control and the ability to perform neuro-
prognostication. Since then there has been an increase in the
number of cardiac arrest centres (CAC) in several European
countries. Currently there is no unique definition of a CAC, but the
usual understanding is that this is an acute care facility capable of
providing early emergency coronary angiography (CAG) and
intervention, target temperature management (TTM) and critical care
facilities on a 24/7 basis.27 Two post-resuscitation interventions are
most closely associated with improved outcomes post-cardiac arrest:
early CAG and TTM, particularly for patients with an initial shockable
rhythm and a presumed cardiac cause of the arrest.28 37 The rationale
behind these interventions is discussed elsewhere. The rate of CAG
and TTM provided following OHCA in Europe differs, and in the survey
three countries in Europe reported that they had no hospitals that
could provide all these services for OHCA patients.
In 2012 the European Parliament published a written declaration
(0011/2012) recommending that all member states adopt common
programs for the training of lay people and implementation of AEDs in
public places, adjusting of legislation in order to facilitate CPR and
defibrillation by non-medical persons, and organization of systematic
data collection on cardiac arrest for feedback and quality management
(https://www.europarl.europa.eu/sides/getDoc.do?pubRef=-%2f%
2fEP%2f%2fNONSGML%2bWDECL%2bP7-DCL-2012-0011%
2b0%2bDOC%2bPDF%2bV0%2f%2fEN)
Registry data collection alone is not a guarantee for improved
survival, but if core data variables are not available, routine monitoring
and surveillance of OHCA outcomes is may be difficult. In the survey, 6
countries reported having a registry with full population coverage and 14
countries reported having a registry with partial population coverage. In
these 20 countries, only 13 (65%) reported that they had information on
ROSC from all participating areas, and seven (35%) reported having
information on ROSC from some areas.21 Having cardiac arrest
registries in 20 out of the 28 responding countries means that registry
data is available in many European countries. Results also suggest that
a renewed focus is needed to encourage countries to ensure that
survival data is a core component of data collection. This is essential to
enable comparison of results and benchmarking against the countries
that have achieved high survival rates (Fig. 2).6
The ILCOR systematic review found low certainty evidence that
exposure to resuscitation skills rather than years of experience are
associated with survival.38 Whether a paramedic or physician-based

Fig. 2 – National registries across Europe. The darkest colour indicates a national registry covering the whole country,
the second darkest colour indicates a national registry covering parts of the country, medium orange indicates several
local registries, light with grey indicates one local registry, grey indicates no local registries and black is unknown.
White colour indicates the country did not participate in the survey.21
66 RESUSCITATION 161 (2021) 61
EMS system effects outcomes is uncertain.39,40 Differences in EMS
practice in initiation of resuscitation and transport among 10 US sites
was found to contribute to variation in OHCA survival,41 and EMS
agencies with the highest survival rates more often had: treatment
from more than 6 EMS personnel; a shorter EMS call-response
interval; more advanced airway attempts; and treatment from an ALS-
BLS tiered system.42 The ERC survey showed differences in the types
of personnel employed as part of the EMS, and in the levels and types
of interventions that EMS personnel were allowed to carry out
independently of medical doctor supervision. Team training in CPR
involving all EMS personnel was reported for some parts of 26
countries and real-time CPR performance data was collected for
feedback and debriefing purposes in 16 countries but used in all areas
only in Cyprus. Defibrillators were available in all EMS vehicles
dispatched to OHCA while mechanical CPR devices were available in
all areas of only three countries.21
Chain of survival
In Europe, 112 is the universal emergency call number (http://data.
europa.eu/eli/dir/2002/21/oj). By dialling 112, European citizens can
reach an EMS dispatch centre either directly (1-step) or via an
emergency call answering service which will route their call to an
emergency medical dispatch centre (2-step). Most European
countries also have a local emergency call number. It has been
shown that the time from first ringtone to response from EMS dispatch
centre is significantly longer when the call is routed via an emergency
call answering service compared to directly received in an EMS
dispatch centre.43 In a French study it was shown that the 30-day
survival for patients with OHCA was better when the initial call was
received via a 1-step procedure compared with 2-step procedure.44
The Chain of Survival for victims of OHCA was initially described by
Friedrich Wilhelm Ahnefeld in 1967 to emphasise all the time-sensitive
interventions (represented as links) to maximise the chance of
survival.45 The concept was built upon in 1988 by Mary M. Newman of
the Sudden Cardiac Arrest Foundation in the United States.46 It was
subsequently modified and updated by the American Heart Associa-
tion in 1991.47 The first link in the chain of survival is early recognition
of a cardiac arrest and call to EMS. This goes hand in hand with early
CPR measures initiated by a bystander, with or without instructions
from a dispatcher (DA-CPR). Bystander CPR remains one of the key
interventions in improving survival after OHCA, it can be associated
with a threefold increase in survival with favourable neurological
outcome.48,49 Therefore, many different actions have been taken to
improve bystander CPR rate throughout Europe and the world.50 The
ILCOR systematic review found very low certainty evidence that DA-
CPR improves outcomes from cardiac arrest.51 In recent years, DA-
CPR seems to be one driver of an increased bystander CPR rate.48 It
was shown in EuReCa ONE and EuReCa TWO that the DA-CPR rate
increased from 29.9% in 2014 to 53.2% in 2017, respectively.1,13
Nevertheless, bystander CPR rate varies enormously within and
between European countries. The EuReCa ONE study estimated that
the average bystander CPR rate across the 27 participating countries
was 47.9%.13 Twenty-eight European countries were included in the
2017 EuReCa TWO study, which documented a bystander CPR rate
overall of 58%, ranging from 13% in Serbia to 83% in Norway.1
At least part of this variation in bystander CPR may be because the
definition of bystander CPR is not uniformly interpreted across
Europe. This is mainly because there has been an increasing variety of
responders and responses prior to EMS arrival in the event of OHCA,
79
meaning it has become more difficult to define whether the person
providing CPR is considered to be a bystander or lay person, or if they
are considered to be part of the EMS response.52
The use of AEDs remains infrequent in Europe. In some European
regions the rate of use of an AED is higher. For example, the region
around Amsterdam and North-Holland has achieved AED use in
23% 59% of all OHCAs that were attended by EMS.53,54 In contrast,
the use of AEDs was reported to be 15% in Sweden and in only 3.8% of
OHCA cases in Copenhagen in Denmark.55,56 New initiatives have
been proposed to increase the use of AEDs and to increase the
likelihood of having an AED deployed to the scene e.g. the use of
drones57 and the use of App-based systems to locate and send
bystanders to attend the OHCA and start CPR immediately as well as
to send a second person to get an AED.54,58 60 Whether an AED is
present also depends on the location of the OHCA. Approximately
49% of companies who took part in a questionnaire-based survey in
Belgium in 2012 and 2014 had an AED on their premises.61
Outcome after out-of-hospital cardiac arrest
Scientific recommendations and policy recommendations from the
European Parliament [Declaration of the European Parliament of 14
June 2012 on establishing a European cardiac arrest awareness
week: https://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//
EP//TEXT+TA+P7-TA-2012-0266+0+DOC+XML+V0//EN] have
highlighted the importance of each country knowing its outcomes
from OHCA and striving to improve them.62
The EuReCa TWO study reported an overall survival rate of 8%
after OHCA in Europe.1 A systematic review and meta-analysis which
included 56 studies from Europe reported a survival to discharge rate
of 11.7% (95% CI 10.5 13.0%).63 A survival rate of less than 8% (less
than 3% with good neurological outcome, Cerebral Performance
Category (CPC) 1-2) has been reported from the Pan-Asian registry,11
the Australian Aus-ROC Epistry involving Australia and New
Zealand.12 reports a survival of 12%, and the US reports about
11% (9% with good neurological status).8 These average estimates
are based on widely varying survival rates within and between
participating countries. For example, in the EuReCa ONE study,
average survival was estimated at 10.3%, ranging from 1.1% to 30.8%
among the participating European countries. The most recent data
from EuReCa TWO estimates average survival of 8% (range
0% 18%).1 In recent years, survival rates have also been reported
from individual European countries; England, 7.9%;16 France 4.9%;64
Spain 13%;20 Germany 13.2%; (https://www.reanimationsregister.
de/downloads/oeffentliche-jahresberichte/rettungsdienst/142-2019-
ausserklinischer-jahresbericht-2018/file.html) Ireland 6%;65 Sweden
11.2%;65 Denmark 16% [https://hjertestopregister.dk/?page_
id=428]; Norway 14%.21
Survival after OHCA is dependent on many factors beyond the
initial resuscitation attempt, and variation in survival rates reflect the
heterogeneous factors that have led to the OHCA. Factors that
contribute to heterogeneity in survival rate include: gender;66,67
cause; initial arrest rhythm;68 71 previous and existing comorbid-
ities;72,73 event location;74,75 socioeconomic deprivation;76,77 and
ethnicity.78 The health organisation that provides care, the available
resources and the organisation’s capacity to coordinate and act in
each and every one of the links in the chain of survival is also critical.79
The ILCOR systematic review found very low certainty evidence that
CACs improve survival from OHCA.80 The availability of specific post-
resuscitation measures, such as percutaneous coronary intervention
 RESUSCITATION 161 (2021) 61
(PCI),20,35,81 and TTM82 85 or more centralised CAC,86,87 constitute
further factors that may contribute to variability in patient survival.88 93
At a national level, public health policies, legal and strategic initiatives
that are in operation in the broader societal network will influence the
number of OHCA survivors and their subsequent quality of life.94
It is well known that even within emergency services with similar
structures or between regions of the same country, there is variability
in survival even when demographic considerations, characteristics of
the event and the community response are taken into account.13
There is also variability within the services themselves over different
time periods, usually reflecting a tendency to improve survival as
actions are implemented that have a demonstrated effect on final
survival.25,94 Variability in the percentage of attempts at resuscitation
was also observed between countries in Europe and between different
EMS systems in the same country.1,13,95 Despite awareness of all
these nuances, there remains an important part of the variability that is
difficult to explain with current data capture systems.65 Indeed, the
variability reported between results when comparing data from
prospective registries with a priori defined objectives compared with
retrospective data from more administrative registries is of note.8,96
The same happens when comparing data from registries with clinical
trials conducted by these same services.16,97 99
Robust collection of key data elements (e.g. initial arrest rhythm,
witnessed status, cause of collapse) enables analysis of survival in
specific subgroups. The most recent Utstein guidelines recommend
categorisation of patients6 and the Utstein comparator group
(bystander witnessed, shockable initial rhythm) is particularly
noteworthy as the group where the chances of patient survival is
typically higher, with approximately 20% reported for England and just
over 30% in EuReCa.1,8,100 Individual countries (Denmark, the
Netherlands, Sweden, Czech Republic and Norway) in EuReCa TWO
exceeded 40% survival for this group of patients.1
Survival for patients with a traumatic aetiology has been less
encouraging with estimated survival between 2% in the German
registry and 2.8% in EuReCa TWO and up to 6.6% with good
neurological status at discharge in a cohort from a specific Spanish
EMS.1,101,102 Attempting resuscitation after traumatic cardiac arrest
was previously considered futile,103 but since 2015 a specific ERC
algorithm provides specific recommendations and interventions that
may result in survival.104
Paediatric OHCA (POHCA)
The varying definition of paediatric age means that it is difficult to
compare survival rates in POHCA. The most widespread definition is
patients aged less than 18 years; however, some studies have
included patients up to 21 years. Depending on the age groups
analysed, there are different characteristics, causes and survival
rates.105 Most data on POHCA survival comes from American and
Japanese registries,106,107 with only partial data from local regis-
tries.108,109 The most substantial data from Europe in terms of number
of cases and trends over time, are those from the Swedish registry.110
From 1990 to 2012 the Swedish registry documented an incidence of
4.9 cases per 100,000 person-years under the age of 21 years, non
EMS-witnessed cases. Survival reported was as follows: infants (less
than 1 year) 5.1%; young children (1 4 years) 11.0%; older children
(5 12 years) 7.5%; and adolescents (12 21years) 12.6%. For EMS-
witnessed cases during 2011 and 2012, survival was 14.9%, 22.2%,
21.2% and 17.9% for the same respective age groups.111 Swedish
data suggest that POHCA survival has been progressively increasing.
79 67
In-hospital cardiac arrest
As for OHCA, the true incidence of in-hospital-cardiac arrest (IHCA) is
not known. The available literature is often from single centres, making
generalizability difficult, and ultimately all patients who die in hospital
die from a cardiac arrest. In 2019, an updated Utstein-style reporting
template for IHCA was published, emphasising the importance of a
common data set report form, to enable comparison between regions
and countries.112
Incidence
The true incidence of IHCA is difficult to assess for several reasons.
Ultimately, all patients who die in hospital have a cardiac arrest, but all
these deaths are not considered a cardiac arrest that should be
considered for resuscitation. A study from Gothenburg in Sweden
compared the total number of in-hospital deaths during one year with
the number of attempted resuscitations and found that resuscitation
was started in only 12% of all in-hospital cardiac arrests.113 In
Sweden, the ratio of OHCA to IHCA has been reported to be 1.7 to 1
(The Swedish Cardiopulmonary Resuscitation Register (Svenska Hj
ärt-Lung-räddningsregistret) [November 1 2012]; Available from:
www.hlrr.se).
Many IHCA studies have limited generalisability because they
were carried out in single centres. Differences in DNACPR policies
between countries are likely to explain some of the variation seen in
the incidence of IHCA.114 There may also be difficulties in the reporting
of IHCA due to logistic problems. For example, patients who develop
ventricular fibrillation (VF) during a coronary angiography, which is
rapidly defibrillated, may not always be reported to a registry.
There are several ways of calculating IHCA incidence: IHCA/
hospital bed, IHCA/ hospital admission, IHCA/country/region/city/
state. The incidence of IHCA per 1,000 hospital admissions has been
reported as 2.8 in Poland,115 1.8 in Denmark10 and Norway
(unpublished observation), 1.7 in Sweden,116 1.6 in the United
Kingdom,9 and 1.5 in the Piedmont region in Italy.117 A study from
Trondheim in Norway documented 72 IHCA events per 1,000 hospital
beds.118
Gender also influences incidence. The incidence ratio of men to
women for IHCA has been reported to be 1.4 1.6 to 1.118 This may
largely be explained by a higher prevalence and a higher mortality
from cardiovascular disease in men.119
In a recently performed European survey 18 of 28 countries
reported having a national registry for IHCA, but only two countries
(Sweden and Denmark) reported that all hospitals were included.21
System configuration and chain of survival
In 2017, 89.4 million people were treated on wards in hospitals
throughout Europe, a number that has increased in recent years
[Eurostat. Hospital discharges and length of stay statistics - Statistics
Explained [cited 2020 Jan 18]. Available from: https://ec.europa.eu/
eurostat/statistics-explained/index.php/Hospital_discharges_and_
length_of_stay_statistics#Hospital_discharge] Unfortunately, medi-
cal care in the hospital is not devoid of complications and serious
adverse events, which occur in approximately 10% 20% of all
patients.120 In a large European observational study which included
approximately 46,000 post surgical patients, mortality was 4%, with
large differences between countries.121 The most alarming finding
68 RESUSCITATION 161 (2021) 61
from this study however, was the high proportion of ‘failure to rescue’,
since 73% of patients who died were not admitted to critical care at any
stage after surgery. Adverse events were partly caused by sub-
optimal care but the majority were due to a deterioration of the
underlying disease. There are two main differences between IHCA
and OHCA in respect of the detection and prevention of cardiac arrest.
First, in most cases, life-threatening events in hospital are heralded by
a deterioration of vital signs hours or even days before the catastrophic
event occurs and therefore may be detectable early and therefore
preventable.120 Secondly, adequate monitoring of patients should
enable early detection of patients at risk and therefore the dedicated
resuscitation team should preferentially function as a medical
emergency team (MET) or rapid response team (RRT) instead of a
pure cardiopulmonary resuscitation (CPR) team. If these patients are
monitored inadequately the life-threatening situation may be noticed
too late, and an increase in rates of in-hospital CPR and unexpected
deaths may follow.122 This development may even accelerate due to
increasing workload in the hospitals and increasing comorbidities of
patients. The ILCOR 2020 Consensus on Science and Treatment
Recommendations found low certainty evidence that rapid response
systems reduced the incidence of IHCA and improved mortality,
leading to a weak recommendation supporting the introduction of
rapid response system (rapid response team/medical emergency
team).38 This compliments the guidance introduced by the ERC
supporting the establishment of an early warning system for
unexpected emergencies.122
IHCA - Systems to detect critical illness
On June 23, 2017, The European Resuscitation Council, the
European Board of Anaesthesiology and the European Society of
Anaesthesiology issued a joint statement calling upon European
hospitals all to use the same internal telephone number (2222) to
summon help when one of their patients has a cardiac arrest. It is
hoped that by implementing one emergency call number in hospital,
time to call for help might be reduced.123
IHCA response times
Medical emergency teams (METs) or rapid response teams (RRTs)
differ from pure resuscitation or cardiac arrest teams in that their goal
is the timely identification and treatment of in-hospital emergencies in
order to avoid cardiac arrests and unexpected deaths.124 (see
advanced life support guidelines). In contrast to OHCA, where the time
from cardiac arrest to the initiation of resuscitation efforts (either by
bystanders or the EMS) is key, data on RRT performance largely
pertain to criteria triggering the alarm, comorbidities, and pre-alarm
hospital length of stay of the affected patients.125 Delays in treatment
are associated with worse outcome.126
Data on traditional resuscitation team response times after IHCA
are also scarce. However, data from a large Swedish registry showed
that a delay of more than one minute from cardiac arrest to call or to
start of CPR, a delay of more than 2 min from call until the arrival of the
rescue team, and a delay of more than 3 min from cardiac arrest to
defibrillation were all associated with worse overall outcome.127
There have been few studies that evaluate the efficacy of METs in
decreasing the incidence of unexpected deaths, unplanned admis-
sion to the Intensive Care Unit (ICU), or both. A major problem is that
high certainty evidence cannot be achieved because randomisation of
individual patients to care delivered by a MET versus a control group is
impossible. Therefore, available evidence derives mostly from
observational studies, before-after designs or protocols where some
79
hospitals introduced a MET while other hospitals in the same area or
belonging to the same hospital organization had not. In the most
recent meta-analysis on this topic, which included 29 studies with
2,160,213 patients (1,107,492 in the intervention group and 1,1083,80
in the control group), METs were associated with a significantly
decreased hospital mortality and incidence of cardiopulmonary
arrest.124 Even though it is difficult to prove the efficacy of MET
implementation using evidence-based criteria, pathophysiological
reasoning suggests that detection and adequate treatment of patients
before a catastrophic event occurs is the right thing to do. Timing is
important in many areas of acute care such as sepsis, myocardial
infarction and stroke.
IHCA outcome
Many factors will determine the outcome of patients who have an IHCA.
Some of these factors can be modified and others cannot. Factors that
cannot be modified include patients’ age, sex and comorbidities. For
example, elderly patients have a lower chance of survival after
IHCA.128,129 In most cases, the cause of the cardiac arrest cannot be
changed. A patient who has a cardiac arrest caused by myocardial
infarction/ischaemia has a much better chance of survival than a patient
who has a cardiac arrest from other causes, e.g. heart failure.
A modifiable factor of great importance is the location in the
hospital where the cardiac arrest occurs. If the cardiac arrest occurs on
a general ward, the patient is not usually adequately monitored, and
the cardiac arrest may not be witnessed. These factors are associated
with a lower chance of survival.116,130 Monitoring of the ECG at the
time of collapse is associated with a 38% reduction in adjusted risk of
death after IHCA. Location in hospital and the geographical locality are
the main predictors of ECG monitoring being in place at the time of
cardiac arrest.131 The significant variability in ECG monitoring at
different centres may indicate the need for guidelines on the use of
ECG monitoring.
A first recorded rhythm of VF is predictive of a higher likelihood of
survival.130,132 The earlier the ECG is recorded, the higher the
likelihood that the patient will present with VF.133 Another factor that
most often cannot be influenced is the time when the arrest is taking
place. There is a higher likelihood of survival if the arrest occurs during
regular working hours Monday to Friday.133 Time to delivery of
treatment is associated with survival among IHCA patients found in a
shockable as well as a non-shockable rhythm.116
Finally, an important factor determining the chance of survival after
resuscitation is the hospital’s policy on DNACPR decisions. Hospitals in
which a very high proportion of cardiac arrest patients have a DNACPR
decision are expected to have a higher survival rate among patients with
IHCA in whom resuscitation is attempted compared with hospitals in
which resuscitation attempts in futile cases are more common. Thus, it
is not surprising that reports on ROSC and survival to hospital discharge
or 30-day survival vary considerably.9,115 118,134 137 The chance of
ROSC varies from 36%117 to 54%135 and the chance of survival to
discharge/30 days varies from 15%117 to 34%.135
Long term survival
Recovery and rehabilitation of cardiac arrest survivors
The Utstein-style template defines the variables to be collected in the
event of OHCA and the recording methodology to be used.5 Since the
 RESUSCITATION 161 (2021) 61
introduction of the Utstein-style template, patient survival and
subsequent neurological status has received increasing focus.6
The number of patients who achieve sustained ROSC has remained a
key variable as this is one of the first criteria in deciding whether post-
resuscitation care is appropriate. In the Utstein style, neurological
outcome may be reported using the Cerebral Performance Category
(CPC) or modified Rankin Scale (mRS).138,139 However, while these
variables provide a general sense of neurological status, they do not
provide specific information on the quality of life that is experienced by
OHCA survivors.
Measurement of long-term recovery in cardiac arrest patients
A systematic review from 2015 identified that 89% of randomised
controlled trials of cardiac arrest did not evaluate recovery after
hospital discharge, and none included the patient perspective in terms
of Health-Related Quality of Life (HRQoL) or societal participation.140
More recent clinical trials have included such measures, but these are
still relatively rare.141 A recent survey found few registries in Europe
included HRQoL measurements, despite collection of these data
being encouraged in the update of the Utstein reporting framework for
resuscitation registries.6,21,112
In 2018 a Core Outcome Set for Cardiac Arrest (COSCA) was
published to provide guidance for standardising outcome definition,
recovery assessment tools, and time-points for clinical trials involving
adults.141,142 More recently, further guidance for paediatric clinical
trials (P-COSCA) has been published.142a Both core outcome sets
were based on extensive work to identify outcomes that are important
from several perspectives including patients, families, health care
professionals and researchers. The adult-COSCA recommends as a
minimum assessment of survival at 30-days or hospital discharge,
neurological function at 30 days or hospital discharge with the mRS,
and assessment of HRQoL at 90 days (and later) with either the HUI-3
(Health Utilities Index version 3), SF-36 (Short-Form 36-item Health
Survey) or EQ-5D-5 L (EuroQol 5 dimensions 5 Level version).
Similarly, the P-COSCA also recommends the assessment of survival
and neurological outcome, assessed with the Paediatric Cerebral
Performance Category (PCPC). However, three further core compo-
nents of HRQoL, or life impact, are specified: cognitive function,
physical function and basic daily life skills, all to be assessed with the
PEDSQL (Pediatric Quality of Life Inventory) at six-months (and later).
A more widespread use of the COSCA recommendations can
potentially improve knowledge of long-term outcomes for cardiac
arrest survivors. A limitation of COSCA guidance is that they include
only a minimum number of measurements, therefore it is recom-
mended that symptom and condition-specific measures are also used,
depending on the aim of the study.
Neurological outcome
Severe hypoxic-ischaemic brain injury is the most detrimental
outcome for cardiac arrest survivors, commonly described by using
ordinal hierarchical functional outcome scales such as Cerebral
Performance Category scale (CPC), modified Rankin Scale (mRS) or
the Glasgow Outcome Scale/Extended (GOS/GOSE). These scales
are often simplified into a ‘good’ or ‘poor’ outcome by categorising
patients as independent for basic activities of daily living versus
dependent on others, in a vegetative state, or dead. A favourable
neurological outcome is usually considered as a CPC 1 or 2, mRS 0 to
3 or GOS 4-5/GOSE 5-8.
In most European countries where Withdrawal of Life Sustaining
Treatment (WLST) is routinely practiced, a poor neurological outcome
79 69
is seen in <10% of cardiac arrest survivors (Irish National Out-of-
Hospital Cardiac Arrest Register 2018 available from https://www.
nuigalway.ie/ohcar/).143 In situations where WLST is not applied,
severe hypoxic-ischaemic brain injury is substantially more common.
For example, an Italian study reported more than 50% (n = 119) of
survivors had a poor outcome six months post-event, with one third
(n = 68) in a persistent vegetative state.144
Among cardiac arrest survivors classified with a good outcome, the
effects of hypoxic-ischaemic brain injury may impact on everyday life.
The most frequently reported neurological sequela is neurocognitive
impairment for all survivors in the early phase145 and, in around
40-50%, in the long-term.146 150 Most improvement in cognition
occurs during the first three months,151,152 but individual improvement
has been reported up to one year post-event.151 In a Spanish study,
half of survivors (n = 79) three years post-event had cognitive
impairment.146 Cognitive impairment in the chronic phase is mostly
mild-to-moderate, but moderate-to-severe impairment is identified in
20-26% of survivors.148,150,153 Cognitive domains most often affected
include: episodic/long-term memory;146,148 150,153 attention/process-
ing speed;146,148,149,153 and executive functions.146,149,150,152,153
Impairments in other domains have also been reported.147,153
There are currently few studies covering the neurological outcome
for paediatric cardiac arrest survivors in Europe. The most
comprehensive data comes from a team in the Netherlands that
performed a neuropsychological examination on a sample of 41
paediatric cardiac arrest survivors (age 0 18) at two to eleven years
after cardiac arrest.154 At a group level general intelligence was lower
compared with normal means, and domains of memory and divided
attention were especially affected.154 Teachers (n = 15) of the cardiac
arrest survivors reported planning/organisation problems, while
parents (n = 31) and patients (n = 8) did not report dysexecutive
problems.154 The same authors also report significantly worse
attention problems among these paediatric cardiac arrest survi-
vors,155 and 15% were in need of special education.156
Patient-reported outcomes
There is no specific Patient-reported outcome measures (PROM) for
cardiac arrest.157 Patient-reported outcomes of overall generic
HRQoL indicate that cardiac arrest survivors at a group level
do not differ from the general population.158,159 Despite this, detailed
analyses showed that several HRQoL sub-domains are poorer in
cardiac arrest survivors, and symptom-specific questionnaires reveal
that nuanced cardiac, cognitive, physical and emotional problems are
common.147,160,161 In a Swiss study, only 29% of cardiac arrest
survivors (n = 50) reported no complaints,153 while in another study
almost 43% of survivors (n = 442) at 6 months post-arrest reported
their health as worse than one year ago.162 It is of note that HRQoL has
been reported to continue to improve for at least the first year after
cardiac arrest.159
The most prevalent patient-reported symptom after cardiac arrest
is fatigue, reported by 50 71% of survivors.153,159,161 Many survivors
also report cognitive problems including a perception of “slowing” or
problems with attention or memory.153,163,164 Associations between
self-reported cognitive complaints and objective cognitive perfor-
mance-based measures have been mixed.152,153
Another frequently patient-reported outcome is emotional
problems, which tend to be most severe in the first weeks post-
arrest,159,165,166 and associated with worse HRQoL.167 After three
months, emotional status was reported by different studies to be
stable,159 better,168 or worse151 compared with twelve months
70 RESUSCITATION 161 (2021) 61
post-arrest. Emotional problems were more common in
females,168 170 younger patients,162,164,168,170 those with cogni-
tive problem,170 and those with comorbidities.168
Cardiac arrest survivors with hypoxic-ischaemic brain injury also
have an increased risk of emotional problems,171 but as these
patients are often missing from analyses, the frequency of emotional
problems in cardiac arrest survivors may be underestimated.170
Larger studies in this area (>100 patients) using symptom-specific
questionnaires report anxiety in 15 24% and/or depression in
13 15% in the long-term.159,164,169,170 Symptoms of stress and
post-traumatic stress disorder (PTSD) are less well studied but
identified in 16-28% of survivors.159,166,172,173 In one study, half of
survivors reported a change in behaviour and emotion six months
post-cardiac arrest (n = 50).153 Apathy, lack of drive and motivation
were also reported in 70% of patients participating in a cognitive
rehabilitation program after cardiac arrest (n = 38), although this
finding was more closely associated with cognitive impairment than
depression.174
Relatives of cardiac arrest patients are also at significant risk of
emotional problems.175 177 One study from Switzerland found that
40% of relatives suffered from PTSD.177 Female gender, history of
depression and perception of insufficient therapeutic measures in the
ICU increased the risk for PTSD, while the patient’s outcome,
including mortality, had no association.177 Being a witness to a relation
’s cardiac arrest increased the risk for emotional problems,176 and
cognitive impairment in the survivor was associated with increased
caregiver strain.175,178
Physical problems after cardiac arrest have received limited
attention but results from HRQoL measurement show that many
cardiac arrest survivors report physical problems.158,162,175,179 Half of
cardiac arrest survivors described problems working or performing
other activities because of physical problems,162 and 30 50%
reported problems with physical health,175 physical function,162 or
mobility.159,161,169 Physical problems are more common in older
survivors162,175 and females.162
Patient/parent reported outcomes in paediatric cardiac arrest
survivors are rare. One study (n = 57) reported that the majority of
paediatric survivors (2 11 years post-ICU) have no problems,
while 30% reported physical problems, and 34% reported chronic
symptoms such as fatigue, headache and behavioural prob-
lems.156 Children (n = 8) reported a HRQoL comparable to normal
means, while proxy-reported HRQoL by a parent (n = 45) indicated
lower generic HRQoL and more physical problems. The parents
own HRQoL was however better than that of the general
population.156
Ability to return to previous activities and roles (societal
participation)
In a Finnish study the vast majority (>90%) of cardiac arrest survivors
were able to live at home and most survivors were able to return to
previous roles and high levels of participation in society.164 For those
of working age, 60 76% returned to at least some degree of work at
six to twelve months post-arrest.158,161,164,167,180 However, 47 74%
of cardiac arrest survivors report restricted societal participa-
tion,147,161 and many remain on sick leave,146,159,161,164,181 although
the amount of sick leave varies across European countries.161
Feelings of less satisfaction with family and leisure time,147 and
problems performing usual activities are also reported.150,162,169 One
study reported that driving ability was significantly lower than before
the cardiac arrest,146 while others reported only 12-27% unable to
79
resume driving.153,164 However, many patients with cognitive
impairment were still driving,146 and one quarter reported that they
did not recall being informed not to drive during a period after the
cardiac arrest.164
In a European multi-centre trial (n = 270), predictors for decreased
societal participation were depression, self-reported mobility prob-
lems, cognitive impairment and fatigue.161 Another study from the
Netherlands (n = 110) reported only pre-morbid function as a predictor
for societal participation.167 Cognitive impairment increases the risk
for not being able to return to work.146,151,161 Predictors positively
associated with return to work were male gender,180 younger
age,180,181 a higher level job, bystander-witnessed cardiac arrest
with bystander CPR180 or cardiac arrest that occurred at the
workplace.181
Several observational and cohort studies have included detailed
measures of recovery, but previous systematic reviews in this area
describe limitations that risk bias in the reported results including:
small and/or heterogeneous study samples; many missing data;
differences in assessment types and time-points used.147,182 184
Logistical and ethical challenges with collecting detailed information
beyond hospital discharge remains a critical issue for long-term
recovery reporting.141
Rehabilitation
Planning for rehabilitation after cardiac arrest requires estimation of
numbers and appreciation of the changing needs of survivors.145
Rehabilitation interventions for cardiac arrest survivors are often
provided within programs that include other patient groups e.g.
myocardial infarction or other types of acquired brain injury, e.g.
traumatic brain injury (TBI).185,186 Studies describing such interven-
tions may include few cardiac arrest survivors within mixed samples,
meaning the specific rehabilitation outcome for cardiac arrest patients
is difficult to separate. This overview of the rehabilitation programmes
in Europe therefore includes only studies specifically describing
interventions for cardiac arrest survivors.
Survivors with ‘poor’ neurological outcome suffer profound and
life-changing problems. In an Italian study, rehabilitation was provided
by an interdisciplinary team for 180 min per day.186 After a mean of
78 days (SD 55), 45% of patients with anoxic brain injury were able to
return home. While anoxic patients had poorer recovery than other
groups, they also had worse baseline cognitive impairment and
functioning. A similar individualised, multidisciplinary approach was
provided in a Turkish rehabilitation hospital.185 This study found that
when anoxic brain injured patients had similar baseline function to TBI
patients, improvement rate was still slower, but the difference in
rehabilitation outcome was not statistically significant. French
researchers described a therapeutic intervention for institutionalised
patients (n = 27) with anoxic brain injury (average 8 years since
event).187 The intervention consisted of medication, psychotherapy,
support group, and therapeutic activities provided over six months,
and improved quality of life and social participation.
The rehabilitative outcome for cardiac arrest survivors with
prolonged disorders of consciousness is poor although some may
improve, albeit rarely. A Dutch study estimated that over 50% of
patients with vegetative/unresponsive wakefulness syndrome (most
because of hypoxia during cardiac arrest) received no rehabilitation
services.188 In Germany, in-patient rehabilitation was provided to 113
cardiac arrest survivors with disorders of consciousness.189 Most
improvement was observed within the first eight weeks. A minority
(6.2%) of the patients achieved a good functional outcome while
 RESUSCITATION 161 (2021) 61
80.5% remained in a persistent unresponsive state. In another
German study, early neurological rehabilitation of 300 min of daily
therapy (e.g. physiotherapy, occupational therapy, speech/swallow-
ing therapy and specialised nursing care) was provided to 93 survivors
with hypoxic-ischaemic encephalopathy (mostly caused by cardiac
arrest).190 After a mean of 46.4 (SD68.2) days, 24.7% were
discharged with a good outcome, but in common with the previous
study, 82.1% of those comatose at admission remained comatose.
Finally, an Italian study, reported that even patients with improved
consciousness remained severely neurological impaired at two years
follow-up.191
For patients with ‘good’ neurological outcome the need for
rehabilitation may not be recognised during the acute hospital stay.27
A Swedish survey showed that in 59 out of 74 hospitals, the most
common follow-up was a patient visit to a cardiac reception unit
(n = 42, 70%), with neurological and psychological support not often
provided in a structured format. There were also major variations in
follow-up.192 In the 2015 European Resuscitation Guidelines on post-
resuscitation care structured follow-up to screen for potential cognitive
and emotional problems is recommended to identify those individuals
in need of further support and rehabilitation.27 National guidelines
have been developed in e.g. Sweden.193
The effects of follow-up and screening were described by
Moulaert and colleagues in a randomised-controlled trial (n = 185).
194 198
The intervention was performed by a trained nurse at an
outpatient clinic or the patient’s home and included screening for
cognitive and emotional problems, provision of information and
support, promotion of self-management strategies and referral to
further specialised care if indicated. The first one-hour session was
provided soon after discharge, with shorter follow-up sessions
offered. Patients who received this intervention had better mental
HRQoL one year after arrest and an earlier return to work compared
with the control group. The intervention was also found to be
cost-effective.194
The Essex Cardiothoracic Centre in the United Kingdom describes
a similar follow-up intervention including systematic psychological,
cognitive and specialised medical support for survivors and their
carers for the first six months post-arrest.166 Before hospital
discharge, patients (n = 21) were assessed by an ICU nurse and
cardiologist and provided with written and video information, and
social media links. A multidisciplinary appointment was provided at
eight weeks, and follow-up appointments at six and twelve months. Of
the patients included, 26% needed further psychological support.
Overall health improved during follow-up, but no control group was
included to evaluate the effect of the intervention.
A single centre in the Netherlands provides an integrated
rehabilitation pathway for restoration of exercise capacity and optimal
cognitive functioning.199 All cardiac arrest patients eligible for
rehabilitation were screened for cognitive and emotional problems
approximately one month after cardiac arrest. Patients without
cognitive impairment followed cardiac rehabilitation programs ‘as
usual’, while patients with cognitive impairments followed the cardiac
rehabilitation in smaller groups. After cardiac rehabilitation, a
continued program with cognitive rehabilitation was offered. The
program was not evaluated, but of 77 cardiac arrest survivors referred
for cardiac rehabilitation, 23% had cognitive problems.200
There is currently no comprehensive evaluation of the types or
numbers of rehabilitation interventions and programmes available to
cardiac arrest survivors across Europe, and there is limited evidence
of effect. This may be because there are few programmes, but it may
79 71
also reflect a need for more comprehensive reporting on interventions.
Finally, some studies group cardiac arrest survivors with other cardiac
or brain-injured patients for rehabilitation, meaning that unless the
inclusion of cardiac arrest patients is explicitly stated, the types and
frequency of rehabilitation available to cardiac arrest survivors may be
underestimated. It is also of note that no paediatric rehabilitation
studies were identified.
Genomic variations and sudden cardiac arrest
One of the major opportunities to further reduce mortality from sudden
cardiac arrest lies with individual prevention (www.escape-net.eu).201
This requires public education and early recognition of individual
patients and families at increased risk for sudden cardiac arrest. At an
individual level, genomic risk factors are most probably important202 but
understanding of their relevance is limited (www.escape-net.eu).203
However, in cases of unexplained cardiac arrest, genomic testing may
result in more than 60% diagnostic yield of pathological genomic
variations.204 Unfortunately, with the exception of selected cases in
families with Brugada and long-QT syndrome (LQTS),205 individuals
are most often not aware of their genomic disposition because of the
relative lack of cardiogenetic screening.206,207
Population-based systematic studies suggest a strong genetic
component to cardiac arrest in general202,208 and of autopsy-
negative, unexplained cardiac arrest in particular.209 213 An
individually unique pathophysiological interaction of environmental
(smoking, social stress, air pollution, chronic noise exposure, etc.)
acquired (obesity, hypertension, diabetes, myocardial ischaemia
and myocardial infarction, Takutsubo syndrome, medication used,
etc.214 216 and genomic factors (Brugada syndrome, LQTS,
arrhythmogenic right ventricular cardiomyopathy (ARVC), catechol-
aminergic polymorphic ventricular tachycardia, short QT syndrome,
etc.205 207,217 227) and their combinations228 determine the indi-
vidual risk of sudden cardiac arrest. Moreover, genetic susceptibility
to long-term alcohol effects, drug- and drug-drug interactions
induced sudden cardiac arrest i.e. pharmacogenetics may be
relevant at an individual level (www.escape-net.eu).229 232
Research in recent years has most specifically focused on patients
and families with rare inherited arrhythmia syndromes and episodes
that are associated with an increased risk of cardiac arrest. Several
molecules and mechanisms that control cardiac electrophysiology
have been identified.205 207,233,234 Most genes and their variants
discovered thus far are involved in regulating electrophysiology and
putting the heart at a higher risk for VF.202,235 237 Specific genetic
predispositions leading to cardiac arrest most often affect younger
patients (e.g. Brugada syndrome; Long QT Syndrome). In older
patients, genetic predisposition may interact with acquired and
accumulated risk factors, medication, social stress and specific
diseases.238,239 Different levels of risk will also be associated with
different genetic variations. For example, Long-QT Syndrome can
result from genetic variations in at least 12 different genes causing
mutations that give rise to different degrees of negative QT
prolongation which are subsequently associated with varying risk of
cardiac arrhythmias.206,217 In addition to the primary gene variant,
modifier genes may also determine disease severity.240 Gender
disparities in genetic risk factors have also been proposed. Data
suggest that women are at higher risk for QT prolongation.216,241
Females may also have lower expression levels of genes controlling
repolarisation.242 In contrast, males are at higher risk for Brugada
72 RESUSCITATION 161 (2021) 61
syndrome, arrhythmia syndromes that are associated with reduced
depolarisation of myocytes, and medication-induced conditions that
are associated with a reduced depolarisation reserve.243 Other data
suggest that male gender may have lower expression levels of genes
controlling depolarisation.244
Typically, genetic studies have focused on rare gene variants in
highly selected populations. However, Milano et al. were the first to
demonstrate that genetic mutations are associated with increased
risk of sudden cardiac arrest in the general population.236 Huge
amounts of DNA samples in cardiac arrest patients and their further
individual risk factors and portfolios are needed to allow further
insights into sudden cardiac arrest genomic risk stratification,
arrhythmia development and individualised prevention as well as
treatment strategies.
Current recommendations following the occurrence of sudden
cardiac arrest include screening for genetic disorders in first-degree
family members. Screening may identify relatives who might benefit
from lifestyle modification and avoidance of certain drugs. Some
relatives may benefit from medical therapy and implantation of cardiac
defibrillators may be appropriate in a selected group of patients and
family members.210 Family screening is particularly recommended if
the cardiac arrest was exercise-induced;245 occurred at a younger
age; occurred in a young athlete with Long-QT Syndrome;246 and/or
was associated with a positive family history of sudden cardiac
arrest.203,204,209,223,247 257
It is expected that the clinical role of genetic and epigenetic factors
will be increasingly understood as research in this area continues to
grow. There are currently no specific resuscitation recommendations
for patients with known genomic predispositions. There are some
instances where genotype-driven resuscitation strategies may
theoretically be appropriate e.g., in patients with Brugada syndrome
or similar conditions that are associated with reduced depolarisation,
the use of amiodarone or lidocaine may facilitate the occurrence of
asystole. However, there are no systematic studies that support such
treatment.
Conflict of interest
JTG declared speakers honorarium from Weinmann, Fresenius,
Ratiopharm, Zoll; he is Scientific Advisor for Zoll Temperature
management.
BB declared speakers honorarium from Baxalta, BayerVital,
BoehringerIngelheim, ZOLL, FomF, Bard, Stemple, NovartisPharma.
JN reports funding from Elsevier for his role as Editor in Chief of the
journals Resuscitation and Resuscitation Plus. He reports research
funding from the National Institute for Health Research in relation to
the PARAMEDIC2 trial and the AIRWAYS2 trial.
GDP reports funding from Elsevier for his role as an Editor of the
journal Resuscitation. He reports research funding the Resuscitation
Council UK and British Heart Foundation for the OHCAO Registry.
Acknowledgements
GDP is supported by the National Institute for Health Research (NIHR)
Applied Research Collaboration (ARC) West Midlands. The views
expressed are those of the author(s) and not necessarily those of the
NIHR or the Department of Health and Social Care.
79
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 RESUSCITATION 161 (2021) 80 97

Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Systems saving lives

Federico Semeraro a, * , Robert Greif b , Bernd W Böttiger c , Roman Burkart d ,

Diana Cimpoesu e , Marios Georgiou f , Joyce Yeung g, Freddy Lippert h,
Andrew S Lockey i , Theresa M. Olasveengen j , Giuseppe Ristagno k ,
Joachim Schlieber l , Sebastian Schnaubelt m , Andrea Scapigliati n ,
Koenraad G Monsieurs o
a
Department of Anaesthesia, Intensive Care and Emergency Medical Services, Maggiore Hospital, Bologna, Italy
b
Department of Anesthesiology and Pain Medicina, Bern University Hospital, University of Bern, Bern, Switzerland, School of Medicine, Sigmund
Freud University Vienna, Vienna, Austria
c
Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
d
Interassociation of Rescue Services, Bern, Switzerland
e
University of Medicine and Pharmacy Gr.T. Popa Iasi, Emergency Department, Emergency County Hospital Sf. Spiridon, Iasi, Romania
f
American Medical Center Cyprus, Nicosia, Cyprus
g
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
h
Copenhagen Emergency Medical Services, University of Copenhagen, Copenhagen, Denmark
i
Emergency Department, Calderdale Royal Hospital, Halifax, UK
j
Department of Anesthesiology, Oslo University Hospital, Norway
k
Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy, Department of Anesthesiology, Intensive Care and
Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
l
Department of Anaesthesiology and Intensive Care, AUVA Trauma Centre Salzburg, Salzburg, Austria
m
Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
n
Institute of Anaesthesia and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, IRCCS,
Rome, Italy
o
Emergency Department, Antwerp University Hospital and University of Antwerp, Edegem, Belgium

Abstract
The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International
Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring
performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS
SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid
response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

cardiac arrest patients not as a single intervention but as a

Introduction and scope system-level approach. The aim of this chapter is to provide
evidence-informed best practice guidance, about interventions
The Systems Saving Lives chapter describes numerous and which can be implemented by healthcare systems to improve
important factors that can globally improve the management of outcomes of out-of-hospital and/or in-hospital cardiac arrest

* Corresponding author.
E-mail address: f.semeraro@ausl.bologna.it (F. Semeraro).
https://doi.org/10.1016/j.resuscitation.2021.02.008

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
 RESUSCITATION 161 (2021) 80 97 81

(OHCA and IHCA). The intended audience of the chapter are
governments, managers of health and education systems,
healthcare professionals, teachers, students and laypeople.
The concept behind the Systems Saving Lives approach to
cardiac arrest is to emphasise the connections between the
different individuals involved in the chain of survival. Citizens
are involved through cardiac arrest awareness campaigns (e.g.
European Restart a Heart Day - ERHD and World Restart a Heart
- WRAH) and may be engaged by apps as first responders. The
dispatch centre that receives the alert call activates the
Emergency Medical System (EMS) vehicle. Whilst the EMS
vehicle is en-route the call operator provides pre-arrival
instructions to start cardiopulmonary resuscitation (CPR). This
chapter also describes the concept of a cardiac arrest centre and
emphasises the importance of measuring the performance of
resuscitation systems. The key role of track and trigger systems
to avoid preventable cardiac arrest and the part played by rapid
response teams is described.
In the past, the guidelines of the ERC have been developed from a
perspective of an ideal high-resource or high-income environment. Little
attention has been paid to the applicability of statements from such areas
in the daily practice of lower-income regions. In many parts of the world, a
high-resource standard of care is not available due to a lack of financial
resources. For example, low-quality performance of EMS can be a barrier

Fig. 1 – System saving lives infographic summary.

82 RESUSCITATION 161 (2021) 80
to guideline implementation. Internationally valid recommendations
should serve as a supportive structure for weaker systems.1
The Systems Saving Lives concept emphasises the interconnec-
tion between community and EMS (e.g. KIDS SAVE LIVES) and
should be implemented in each European community. Systems
Saving Lives ranges from the young student who learns CPR at
school, to a citizen who receives a cardiac arrest alert through their
mobile phone and is willing to start CPR and to use an automated
external defibrillator (AED) on the scene, to the EMS team that
continues advanced treatment to stabilise and transport the patient for
post-resuscitation care in a high-performance hospital. In Systems
Saving Lives, everyone and everything is an important link to survival
we are moving from the classical four-link chain of survival to a
multitude of links encompassed in the new System Saving Lives
concept. Every single step in this complex system is important.
These guidelines were drafted and agreed by the Systems
Saving Lives Writing Group members. The methodology used for
guideline development is presented in the Executive summary. 1a
The guidelines were posted for public comment in October 2020.
The feedback was reviewed by the writing group and the
guidelines was updated where relevant. The Guideline was
presented to and approved by the ERC General Assembly on
10th December 2020.
Key messages from this section are presented in Fig. 1.
Concise guideline for clinical practice
Chain of survival & the formula of survival
 The actions linking the victim of sudden cardiac arrest with survival
are called the chain of survival.
 The goal of saving more lives relies not only on solid and high-
quality science but also effective education of lay people and
healthcare professionals.
 Systems engaged in the care of cardiac arrest victims should be
able to implement resource efficient systems that can improve
survival after cardiac arrest.
Measuring the performance of resuscitation systems
 Organisations or communities that treat cardiac arrest should
evaluate their system performance and target key areas with the
goal to improve performance.
Social media and smartphones apps for engaging the
community
 First responders (trained and untrained laypersons, firefighters,
police officers, and off-duty healthcare professionals) who are
near a suspected OHCA should be notified by the dispatch centre
through an alerting system implemented with a smartphone app or
a text message.
 Every European country is highly encouraged to implement such
technologies in order to:
 Improve the rate of bystander-initiated cardiopulmonary
resuscitation (CPR).
 Reduce the time to first compression and shock delivery.
 Improve survival with good neurological recovery.
97
European Restart a Heart Day (ERHD) & World Restart a Heart
(WRAH)
National resuscitation councils, national governments and local
authorities should:
 Engage with WRAH.
 Raise awareness of the importance of bystander CPR and AEDs.
 Train as many citizens as possible.
 Develop new and innovative systems and policies that will save
more lives.
KIDS SAVE LIVES
 All schoolchildren should routinely receive CPR training each year.
 Teach CHECK - CALL COMPRESS.
 Trained schoolchildren should be encouraged to train family
members and friends. The homework for all children after such
training should be: "please train 10 other people within the next two
weeks and report back".
 CPR training should also be delivered in higher education
institutions, in particular to teaching and healthcare students.
 The responsible people in the Ministries of Education and/or
Ministries of Schools and other leading politicians of each
country should implement a nationwide program for teaching
CPR to schoolchildren. Training schoolchildren in CPR
should be mandatory by law all over Europe and elsewhere.
Community initiatives to promote CPR implementation
 Healthcare systems should implement community initiatives
for CPR training for large portions of the population
(neighbourhood, town, region, a part of or a whole nation).
Low-resource settings
Resuscitation research in low-resource settings
 Research is required to understand different populations,
aetiologies and outcome data of cardiac arrest in low-resource
settings. Research should follow Utstein guidelines.
 The level of income of countries should be included in reports. A
useful system to report level of income is the definition of the World
Bank (gross national income per capita).
 When reporting about resuscitation systems and outcome, psycholog-
ical and sociocultural views on cardiac arrest should be documented.
 Experts from all resource backgrounds should be consulted
concerning local acceptability and applicability of international
guidelines and recommendations for resuscitation.
Essential resources for resuscitation care systems in low-
resource settings
 A list with essential resuscitation care resources that is specially
adapted to low resource settings should be developed in
collaboration with stakeholders from these low resource settings.
European Resuscitation Academy and Global Resuscitation
Alliance
 Programmes such as the European Resuscitation Academy
programs should be implemented to increase bystander CPR
rates and improve survival in case of OHCA.
 RESUSCITATION 161 (2021) 80
Role of dispatcher
Dispatch-assisted recognition of cardiac arrest
 Dispatch centres should implement standardised criteria and
algorithms to determine if a patient is in cardiac arrest at the time of
the emergency call.
 Dispatch centres should monitor and track their ability to recognize
cardiac arrest and continuously look for ways to improve
recognition of cardiac arrest.
Dispatch-assisted CPR
 Dispatch centres should have systems in place to make sure call
handlers provide CPR instructions for unresponsive persons not
breathing normally.
Dispatch-assisted chest compression-only compared with
standard CPR
 Dispatchers should provide chest compression only CPR
instructions for callers who identify unresponsive adult persons
not breathing normally.
Early warning scores, rapid response systems, and medical
emergency teams
 Consider the introduction of rapid response systems to reduce
the incidence of in-hospital cardiac arrest and in-hospital
mortality.
Cardiac arrest centres
 Adult patients with non-traumatic OHCA should be considered
for transport to a cardiac arrest centre according to local
protocols.
Evidence informing the guidelines
Chain of survival & the formula of survival
The Chain of Survival for victims of out-of-hospital cardiac arrest
(OHCA) was initially described by Friedrich Wilhelm Ahnefeld in
1968 to emphasise all the time-sensitive interventions (represented as
links) to maximise the chance of survival.2 The concept was built upon
in 1988 by Mary M Newman of the Sudden Cardiac Arrest Foundation
in the United States.3 It was subsequently modified and adapted by
the American Heart Association in 1991.4
Designs depicting the chain of survival have been updated
frequently, but until recently the message conveyed in each link has
remained unchanged. The European Resuscitation Council (ERC)
chain of survival in its current format was first published in the 2005 ERC
guidelines and summarizes the vital links needed for successful
resuscitation: 1. Early recognition and call for help to prevent cardiac
arrest and to activate the EMS; 2. Early bystander CPR - to slow down
the rate of deterioration of the brain and heart, and to buy time to enable
defibrillation; 3. Early defibrillation - to restore a perfusing rhythm; and 4.
Early advanced life support and standardised post-resuscitation care,
to restore quality of life. The chain emphasises the interconnection and
the need for all links to be fast and effective in order to optimise the
chances of intact survival. Most of these links apply to victims of both
primary cardiac and asphyxial arrest.5,6
97 83
Early recognition and call for help
The first link indicates the importance of recognising patients at risk
of cardiac arrest and calling for help in the hope of preventing
cardiac arrest. Most patients show signs of physiological deteriora-
tion in the hours before cardiac arrest or have warning symptoms for
a significant duration before cardiac arrest.7,8 Thus, chest pain
should be recognised as a symptom of myocardial ischaemia.
Recognising the cardiac origin of chest pain, and calling the
emergency services before a victim collapses, enables
the emergency medical service to arrive sooner, hopefully before
cardiac arrest has occurred, thus leading to better survival.9,10 Once
cardiac arrest has occurred, recognising cardiac arrest can be
challenging. Both bystanders and emergency medical dispatchers
have to diagnose cardiac arrest promptly to activate the chain of
survival. Early recognition is critical to enable rapid activation of the
EMS and prompt initiation of bystander CPR. ILCOR and the ERC
BLS guidelines highlight the key observations to diagnose cardiac
arrest are that the person is unresponsive with absent or abnormal
breathing.11,12
Early bystander CPR
The immediate initiation of CPR can double or triple survival from
cardiac arrest.13 21 The emergency medical dispatcher is an
essential link in the chain of survival to help bystanders initiate
CPR. Emergency medical dispatchers are increasingly being trained
to recognise cardiac arrest, to instruct and assist bystanders in
initiating resuscitation, and to support bystanders in optimising
resuscitation efforts, while awaiting the arrival of professional
help.22 31
Early defibrillation
The benefits of early defibrillation on survival and functional
outcome, though public-access defibrillation programs and
greater accessibility and availability of AEDs in the community,
are unquestionable. 32,33 These benefits have been attributed to
the decreased time to defibrillation by bystanders versus EMS
because survival in shockable OHCA decreases significantly
with each minute of delay in defibrillation. Defibrillation within
3 5 min of collapse can produce survival rates as high as
50 70%. This can be achieved only by public access programs
and onsite AEDs.34 37 Each minute of delay to defibrillation
reduces the probability of survival to discharge by 10 12%. The
links in the chain work better together: when bystander CPR is
provided, the decline in survival is more gradual and averages
3 5% per minute delay to defibrillation. 9,13,38,39
Early advanced life support and standardised post-
resuscitation care
Advanced life support with airway management, drugs and
correction of causal factors may be needed if initial attempts at
resuscitation are unsuccessful. Prior studies suggested no addi-
tional benefit from ALS in previously optimised EMS systems of
rapid defibrillation.40 A recent prospective study comparing the
association of ALS care with OHCA outcomes in more than
35,000 patients, showed that early ALS was associated with
improved survival to hospital discharge.41 Better quality of treatment
during the post-resuscitation phase with urgent coronary angiogra-
phy, optimisation of both circulation and ventilation, targeted
temperature management, multimodal neuroprognostication, and
subsequent rehabilitation, improves outcome.42,43
84 RESUSCITATION 161 (2021) 80
The chain of survival in its current format focuses on specific
interventions rather than on the potential for the effectiveness of each
link. The contribution of each of the four links diminishes rapidly at
each stage as the number of patients decrease with progression along
the chain. Thus, a different view of the chain of survival has been
proposed to emphasise the relative contribution made by each link to
survival.44 Thus, to improve survival, greater focus should be placed
on early recognition and early CPR, and less to post-resuscitation
care. This new view of the chain of survival will help to inform clinicians,
scientists and researchers of where there is the greatest potential to
improve outcome and may provide renewed focus on research,
education and implementation, as depicted in the formula for
survival.45
The chain of survival was extended to the formula for survival
because it was realised that the goal of saving more lives relies not
only on high-quality science but also on effective education of lay
people and healthcare professionals.45,46 Ultimately, those who are
engaged in the care of cardiac arrest victims should be able to
implement resource-efficient systems that can improve survival after
cardiac arrest.
In the formula for survival, three interactive factors, guideline
quality (science), efficient education of patient caregivers (education)
and a well-functioning chain of survival at a local level (local
implementation), form multiplicands in determining survival from
resuscitation.
Science is recognised as an integral part of the other two factors:
education and implementation. Given the nature of resuscitation,
high-quality scientific evidence from randomised controlled trials is
often difficult to obtain and in many cases extrapolations from
observational studies are needed. There is also difficulty in applying
the same standards of evidence to educational recommendations
as to treatment recommendations. Resuscitation education pro-
viders and designers of teaching programs should create learning
experiences highly likely to result in acquisition and retention of
skills, knowledge and attitudes required for good performance. The
formula for survival concludes with local implementation. The
combination of medical science and educational efficiency is not
sufficient to improve survival if implementation is poor or absent.
Frequently, this implementation will also require some form of
change management to embed new visions into a local culture.
Quite often, the easy fix will not be the sustainable solution and
prolonged negotiation and diplomacy may be needed. A prime
example of this is the implementation of CPR training in the school
curriculum. In many cases, countries that eventually achieved this
goal spent years campaigning and persuading governments to
adopt this strategy.47,48
Measuring the performance of resuscitation systems
These ERC recommendations are informed by the ILCOR systematic
review, consensus on science and treatment recommendations on
system performance.49 System performance improvement is defined
as hospital-level, community-level or country-level improvement
related to structure, care pathways, process and quality of care.
According to ILCOR, two types of outcomes indicators should be
considered for measuring system performance improvement: critical
(survival with favourable neurological outcome at discharge and
survival to hospital discharge) and important (skill performance in
actual resuscitations, survival to admission and system level
variables).
97
ILCOR recommends that organisations or communities that
treat cardiac arrest should evaluate their performance and target
key areas with the goal of improving performance. (Strong
recommendation, very low certainty of evidence). The systematic
review published by ILCOR recognises that the evidence in
support of this recommendation comes from studies of mostly
moderate to very-low-certainty certainty, mainly non-randomised
controlled trials.49
The majority of these studies associated with system perfor-
mance improvement found that interventions to improve system
performance improved system level variables and skill performance
of basic life support (BLS) and advanced life support (ALS) in actual
resuscitations,50 61 leading to improved clinical outcomes following
out-of-hospital or in-hospital cardiac arrest. Several studies showed
improved survival to hospital discharge52,54,56,57,61 70 and survival
with favourable neurological outcome at discharge.52,54,61 65,68 71
Some studies have shown an association between system
performance improvement and survival to admission64,67,69 but
others have not.53,71,72
We also recognise that interventions to improve system perfor-
mance need money, personnel and stakeholders, and in this context
some systems may not have adequate resources to implement
system performance improvement.
Further work needs to be done to:
 Identify the most appropriate strategy to improve system
performance.
 Better understand the influence of local community and organisa-
tional characteristics to improve system performance.
 Evaluate the cost-effectiveness of each intervention for improving
system performance.
Social media and smartphones apps for engaging the
community
Mobile phone technology is being increasingly used to engage
bystanders in out-of-hospital cardiac arrest (OHCA) events. The use
of mobile technology, including social media, cellular networks and
smartphone applications, could soon be of great impact. The rationale
for their use is that notifying citizens as first responders to an OHCA
event by a smartphone app with a Mobile Positioning System (MPS) or
Text Message (TM)-alert system could increase early CPR and early
defibrillation, thereby improving survival.
The ERC guidelines are informed by the ILCOR systematic review,
consensus on science and treatment recommendations, led by the
Education Implementation and Teams (EIT) Task Force. The review
investigated whether in the case of OHCA (P) alerting citizen first
responders through mobile-phone technology (I) compared with no
notification and standard EMS response (C) affects survival to hospital
discharge with good neurological outcome, survival to hospital
discharge, hospital admission, return of spontaneous circulation
(ROSC), bystander CPR rates, time to first compression/shock (O).49
The general direction of effect across most studies favours the use of
mobile phone technology to alert citizens as first responders in case of
OHCA. The rate of bystander-CPR was higher in the intervention
group than the comparison group in all studies.36,73 The rate of
survival to hospital discharge, was higher in the intervention group,73
76
but survival to hospital discharge with favourable neurological
outcome was no different between the intervention and the
comparison groups.73,76 Time to first compression/shock was shorter
in the intervention group in all the studies.74,76 78 After that ILCOR
 RESUSCITATION 161 (2021) 80
Treatment Recommendation was published, another six articles and a
systematic review were published, reinforcing the general direction of
effect in favour of the intervention.76,79 83 One study demonstrated
that increasing the density of AEDs and first responders alerted with a
text message, decreased time to defibrillation in residential areas
compared with the time to defibrillation by EMS personnel. The
recommended density of AEDs and first responders for the earliest
defibrillation is two AEDs/km2 and at least 10 first responders/km2.81 A
systematic review analysed 12 different mobile-phone systems to
alert citizens as first responders and found that first responders
accepted to intervene in a median 28.7% (interquartile range (IQR)
27 29%) of alerts and reached the scene after a median of 4.6 (IQR
4.4 5.5) minutes for performing CPR and after 7.5 (IQR 6.7 8.4)
minutes if an AED was first collected. First responders arrived
before EMS, started CPR and attached an AED in a median of 47%
(IQR 34 58%), 24% (IQR 23 27%) and 9% (IQR 6 14%) of cases,
respectively. Among those victims who had an AED attached by the
first responder, the first rhythm registered was shockable in a median
of 35% (IQR 25 47%) of cases. Pooled analysis confirmed the
general direction of effect in favour of the intervention as reported
above.82
A recent European survey performed under the umbrella of the
ESCAPE-NET project collected data about first responder treatment
after OHCA in Europe.84,85 Forty-seven (92%) OHCA experts from
29 countries responded to the survey. More than half of the European
countries have at least one region with a first responder system. First
responders in Europe are mainly firefighters (professional/voluntary),
police officers, citizens and off-duty healthcare professionals (nurses,
medical doctors, paramedics) as well as taxi drivers. The survey
reported that the use of an app with a mobile positioning system (MPS)
or Text Message (TM)-alert system was implemented in some
European countries (e.g. Austria, Czech Republic, Denmark, United
Kingdom, Germany, Hungary, Italy, Netherland, Romania, Sweden,
and Switzerland). Another survey was conducted from February 6th,
2020 to February 16th, 2020 to obtain a picture of available systems to
alert citizen first responders and locate the nearest AEDs across
Europe.86 The results covered 32 European countries. More than half
of the countries (62%) had at least one system in one region to alert
citizens as first responders for a total of 34 different systems. Almost all
systems (94%) required citizens to be trained in BLS to become part of
the first responder network. Systems to map and locate the nearest
AED were available in 25 European countries (78%). Given the
considerable variability across Europe, it would be appropriate to
pursue a uniform standard of development of these systems.
Moreover, a standardised approach like the Utstein Style is highly
encouraged to obtain a uniform reporting of these systems.
Smartphone-based activation of first responders to OHCA saves
lives. The statements generated by a recent consensus conference
involving five European countries may assist the public, healthcare
services and governments to use these systems to their full potential
and direct the research community towards fields that still need to be
addressed.87
In line with ILCOR, the ERC recommends that citizens who are
near a suspected OHCA event and willing to be engaged/notified by a
smartphone app with a mobile positioning system (MPS) or Text
Message (TM)-alert system should be notified (strong recommenda-
tion, very-low-certainty evidence). As these technologies become
ubiquitous, they will play a greater role in the chain of survival. A causal
relationship between application-initiated citizen responses and
survival has not been proven. Therefore, systems using such
97 85
technologies should promote research and improve the quality of
data collection to further demonstrate the benefit of their integration
into the EMS. Privacy legislation, which has been cited as a barrier to
the implementation of such technologies, may have to be changed.
European Restart a Heart Day (ERHD) & World Restart a Heart
(WRAH)
Survival rates from OHCA around the world remain relatively low,
despite the development of guidelines and the influence of
technology.88 The exact magnitude of the burden of cardiac arrest
in Europe and worldwide is well documented.89 The ERC recognises
that an important strategy to increase survival rates from OHCA is to
increase the rate of bystander CPR. If more people were trained and
more AEDs were placed strategically, more lives could be saved from
cardiac arrest.37
Following a lobbying campaign by the ERC, the European
Parliament passed a Written Declaration in June 2012 with a majority
vote of 396 signatures calling for comprehensive training programmes
in CPR and AED use across all its member states. The Written
Declaration called for an adjustment of legislation in EU member
states to ensure national strategies for equal access to high-quality
CPR and defibrillation. The declaration also called for the establish-
ment of a European cardiac arrest awareness week. As a result of this,
and as part of its strategy to increase bystander CPR rates, the ERC
announced the establishment of an annual Cardiac Arrest Awareness
day on 16 October every year, to be named ‘Restart a Heart Day’. The
motto for the first European Restart a Heart Day (ERHD) in 2013 was
‘Children Saving Lives’. A survey conducted on behalf of the ERC
generated responses from 23 of 30 national resuscitation councils. It
identified that training in first aid incorporating CPR in the school
curricula existed in only 4 of the 23 responding countries.90 National
policies about resuscitation have the power to increase the willingness
of citizens to perform bystander CPR. The Restart a Heart initiative
actively encourages the development of national policies in all
member states throughout Europe.91
In 2018, the European Restart a Heart initiative was endorsed by
the International Liaison Committee on Resuscitation (ILCOR) and
has since taken a global dimension under the name of World Restart a
Heart (WRAH).92 94 The motto of WRAH is ‘All citizens of the world
can save a life all that is needed is two hands (CHECK CALL
COMPRESS)’. Each person trained is a potential lifesaver and the
number of additional people they inspire to also receive training is
unmeasurable. The results for WRAH 2018 exceeded expectations as
over 675,000 people were trained in CPR worldwide.95
For WRAH 2019, promotional videos were produced worldwide
in iconic places. Moreover, 191 National Red Cross Societies of the
five geographical zones of the world were invited to engage in the
campaign. The most impressive European results for 2019 were
reported from the United Kingdom, where 291,000 people were
trained in CPR. This was achieved by the participation of every EMS
organisation, as well as teaching delivered by medical students. The
subject has subsequently become mandatory in the English school
curriculum, as it is in five other European countries. This
demonstrates the power of the WRAH in helping to promote
change in national policy. In Poland, 150,562 people were trained, in
Germany 30,000, and in Italy 17,000. Overall, 493,000 people were
trained in CPR in Europe with over 5 million trained and up to
206 million reached by social media worldwide during WRAH
2019.94
86 RESUSCITATION 161 (2021) 80
In conclusion, the ERC has made a significant impact with
ERHD and WRAH. In its first two years alone, WRAH has become
so influential that it has reached countries not yet represented by
ILCOR and it has already become so dynamic and viral that over
six million people have been trained in CPR. The purpose of
WRAH is that national councils use this initiative to promote
uniformity in practice and reporting systems, create benchmarks
and, by learning from each other, define weak links in the chain of
survival in order to improve healthcare practice. The low rate of
bystander CPR may signify the lack of public awareness as part of
the problem, thus justifying it as a high priority for the ERC.
Education of the public is an essential component of the strategy to
fight the burden of OHCA.
On the basis of expert consensus, it is recommended that national
resuscitation councils, national governments and local authorities,
engage with WRAH to raise awareness of the importance of bystander
CPR and AEDs, to train as many citizens as possible, and to develop
new and innovative systems and policies that will save more lives.
KIDS SAVE LIVES
Mandatory nationwide training of schoolchildren has the highest and
most important long-term impact for improving bystander CPR
rate.96,97 In the long run, this appears to be the most successful
way to reach the entire population.98 The highest bystander CPR rates
have been reported in some Scandinavian countries, where education
of schoolchildren in CPR has been mandatory for decades, and this
concept is starting to spread all over Europe and the world.16
Following several activities by the ERC, in 2015 the World Health
Organization (WHO) endorsed the ERC ‘KIDS SAVE LIVES’ a joint
statement from the International Liaison Committee on Resuscitation
(ILCOR), the European Resuscitation Council (ERC), the European
Patient Safety Foundation (EPSF), and the World Federation of
Societies of Anaesthesiologists (WFSA).99,100 This statement rec-
ommends two hours of CPR training annually from the age of 12 years
in all schools worldwide. At this age, children are more receptive to
instructions and they learn more easily to help others. It is accepted
that younger children, whilst physically unable to perform CPR, can
also learn the principles behind CPR as it provides a foundation for
their learning and they may still be able to instruct others to do so
instead.101 As a result, we recommend teaching all schoolchildren the
concept of CHECK-CALL-COMPRESS. Additional training can be
provided for ventilation and AED particularly for, but not limited to,
older children or teenagers.102 The legal requirement for CPR
education in schools across Europe is summarised in Fig. 2.
Starting at a young age also means that performing CPR becomes
like swimming or riding a bike: the skills are retained for a lifetime and
are easily refreshed even after a prolonged absence.103 It has been
clearly demonstrated in different studies that healthcare professio-
nals, teachers trained to teach CPR, students, peers and others can
successfully teach schoolchildren, and all can serve as multipliers.104
CPR knowledge and skills can be spread further by asking children
to teach their family and friends.102 Evolving experience indicates that
even children in the kindergarten and from the age of four years are
able to successfully recognise a cardiac arrest and call the EMS.105
Teachers can and should be qualified to teach schoolchildren in
CPR.102 Educating schoolchildren in resuscitation is performed in
several countries around the world.92,98,106 108 To date, education of
schoolchildren in resuscitation is mandatory by law in six countries in
Europe, and it is a recommendation in another 24 countries. However,
97
implementation has not yet been achieved nationwide in all these
countries, all over Europe and the world. 48,94 CPR education for
schoolchildren may hugely improve public health, since lay resusci-
tation is the most important factor for high-quality survival following
sudden cardiac arrest.102
The principles of KIDS SAVE LIVES can be extended to higher
education institutions as well. Teacher training courses should include
tuition of CPR competencies to enable teachers to deliver CPR
education to schoolchildren.109 All healthcare students should get
high quality resuscitation education to enable them to teach CPR and
act as first CPR responders.97
Community initiatives to promote CPR implementation
The role of the community in providing the first response to OHCA
through bystander CPR is critically important but in most systems is
still far from optimal. Many interventions have been implemented to
improve the community response to OHCA and have been described
in other sections of these guidelines. Several initiatives have been
implemented with the aim to increase the engagement of the
community, which is the general population of a studied area (i.e. a
group of neighbourhoods, one or more cities/towns or regions, a part
of or a whole Nation), consisting of individuals with no specific duty to
respond.
ILCOR led a scoping review to identify relevant studies. Nineteen
studies were identified which described community initiatives
amongst the adult population only.
The main community initiatives identified were grouped in three
categories:
 Community CPR instructor-led training interventions.20,110 114
 Mass-media interventions.115,116
 Bundled interventions.16,56,117 125 The impact of the three groups
of community initiatives on specific outcomes can be summarised
as follows:
Instructor-led training
All the studies that implemented instructor-led training reported
bystander CPR rate as an outcome, with 67% of the studies showing
a benefit of the intervention.20,110,112,114 Survival to discharge was
reported in 83% of cases and improved in 40% of these
studies.20,114 Survival with good neurological outcome was reported
in 67% of these studies and showed benefit of the intervention in
only 25% of cases.112 ROSC was assessed in 33% of these studies
and in half of the cases showed improvement with the
intervention.114
Mass-media
The two studies assessing the impact of this type of intervention
reported only the outcome bystander CPR rate, with one study
showing benefit and the other showing no benefit.115,116
Bundled intervention
None of these studies reported survival with good neurological
outcome or ROSC. Survival to discharge was reported in 25% of these
studies and showed no benefit of the intervention.120,124 Bystander
CPR rate was reported in 89% of these studies, showing benefit in all
cases,56,117 119 except one.122
In conclusion, the only outcome that was assessed in almost
all the included studies was bystander CPR rate and almost all
the studies showed a benefit with the implementation of
 RESUSCITATION 161 (2021) 80 97 87

Fig. 2 – Kids save lives: legal requirement for CPR education in schools across Europe.

community initiatives. This benefit was more frequent when the discharge. Therefore, despite low certainty of evidence and
type of intervention was a bundle compared with instructor-led some conflicting results, we consider it worthwhile to implement
training or mass-media. Furthermore, there was a slight benefit community initiatives such as CPR training involving a large
(only 40% of studies that reported it) in survival at hospital proportion of the population or bundled interventions in order to
88 RESUSCITATION 161 (2021) 80
improve the bystander CPR rate among laypersons in case of
OHCA.
Low-resource settings
In 2015, ILCOR published a systematic review on resuscitation
training in developing countries.126 This review showed that
resuscitation training in low-resource settings is well-received and
has significantly reduced the mortality of cardiac arrest However,
limited information is available about the outcome of resuscitation in
low-resource settings. A recent ILCOR scoping review of OHCA in
low-resource settings showed wide variability in outcomes.1 The
scoping review recommended future studies to be undertaken in
specific (sub-) populations and aetiologies of cardiac arrest including
paediatric cardiac arrest, traumatic cardiac arrest, cardiac arrest in
disaster or conflict zones, or even cardiac arrest in single neighbour-
hoods or areas within an otherwise high-resource setting.1
The definition of low resource settings varies. Therefore, a
comprehensive approach such as classifying countries according to
their gross domestic product (GDP) per capita based on the World
Bank definitions (https://data.worldbank.org) was applied.49
Considering the scarcity of resources in low-income coun-
tries, the feasibility of full ALS and post-resuscitation care is
controversial. There is debate whether it is ethically acceptable
that ALS for OHCA patients is not available in certain countries or
areas. 127 Moreover, longer-term outcomes such as 30-day
survival or neurological performance after cardiac arrest in
low-resource countries tend to be worse than those reported in
patients from high-resource countries. 1,128 A list of essential
resuscitation equipment and resources like the 2009 World
Health Organization statement on the quality of trauma care may
help improving the chain of survival to improve outcome after
OHCA. 129
European Resuscitation Academy (ERA) and Global
Resuscitation Alliance (GRA)
The European Resuscitation Academy aims to improve survival from
cardiac arrest through a focus on healthcare system improvements that
bring the individual links in the chain of survival and the formula for
survival together. Entire EMS staff (managers, administrative and
medical directors, physicians, EMTs and dispatchers) from different
healthcare systems and countries are invited to learn from the ERA
Program (derived from the Seattle (US) based Resuscitation Academy
ten steps for improving cardiac arrest survival) together with the local
host health institutions.130 The ERA puts emphasis on defining the local
cardiac arrest survival rate by understanding the importance of
reporting data in a standardised Utstein template. Participating EMS
systems are encouraged to develop concrete measures to improve
cardiac arrest survival followed by appropriate measurements of these
action plans. ‘It takes a system to save a life’ summarises the essentials
(the core) of every Resuscitation Academy program globally - to
acknowledge that all medical science and educational efficiency won’t
result in positive outcomes from OHCA and IHCA itself without a clear
strategic plan to foster the local implementation in our systems. This is
reflected in the formula for survival in resuscitation. The Global
Resuscitation Alliances (GRA) mission is “to advance resuscitation
through the Resuscitation Academy model by accelerating community
implementation of effective programs through a quality improvement
strategy to measure and improve.”
97
Role of dispatcher
ILCOR recommends that dispatch centres implement a standardised
algorithm and/or standardised criteria to determine immediately if a
patient is in cardiac arrest at the time of the emergency call and to
monitor and track their diagnostic capability. ILCOR also recommends
that dispatch centres look for ways to optimise their sensitivity to
recognise cardiac arrest (minimise false negatives).11 This strong
recommendation was based on very-low certainty evidence drawn
from 46 observational studies which included 789,004 adult OHCAs
reporting recognition of arrest varying between 46% and 98% and a
specificity varying between 32% and 100%.27,28,79,131 172 The review
concluded that the studies were too heterogeneous for head-to-head
comparisons of different criteria, algorithms, dispatcher background
or training, and the diagnostic capabilities varied greatly within all the
various categories with no clear patterns emerging.
The strong recommendation for dispatch centres to implement a
standardised algorithm and/or standardised criteria to immediately
determine if a patient is in cardiac arrest despite very-low-certainty
evidence is outweighed by the benefits related to early recognition and
early bystander CPR. Further, ILCOR found the large variation in the
reported diagnostic capabilities across all systems to underline the
need for systems to monitor and track their diagnostic capabilities and
continuously look for ways to improve.
Consistent with ILCOR, the ERC recommends dispatch centres to
implement a standardised algorithm and/or standardised criteria to
immediately determine if a patient is in cardiac arrest at the time of
emergency call. The ERC supports the need for high-quality research
that examines gaps in this area.
Dispatch-assisted CPR
ILCOR recommends that emergency medical dispatch centres have
systems in place to enable call handlers to provide CPR instructions
for adult patients in cardiac arrest.22 This strong recommendation was
based on very-low certainty evidence drawn from 30 observational
studies; 16 studies comparing outcomes from patients when
dispatch-assisted CPR instruction was offered with outcomes from
patients when dispatch-assisted CPR instruction was not of-
fered23,31,135,140,148,151,153,173 181 and 14 studies comparing out-
comes from patients when dispatch-assisted CPR instruction was
received with outcomes from patients when dispatch-assisted CPR
instruction was not received.135,140,148,173 176,179,180
Six studies reported survival with good neurological outcome
when dispatch-assisted CPR instructions were offered compared
with when dispatch-assisted CPR instructions were not offered.
Survival with good neurological outcome at hospital discharge
(5533 patients) was higher among those offered CPR instructions
(relative risk (RR) 1.67 (95% CI 1.21, 2.31); p = 0.002).151,174
Survival with good neurological outcome at 1 month (44,698 pa-
tients) was higher among those offered CPR instructions (RR 1.09
(95% CI 1.03 1.15;p = 0.004).175,179,181 Survival with good neuro-
logical outcome at 6 months (164 patients) was not significantly
higher among those offered CPR instructions (RR 1.27 (95% CI
0.72, 2.27); p = 0.14).180
Five studies reported adjusted analysis for survival with good
neurological outcome when dispatch-assisted CPR instruction was
received compared with when dispatch-assisted CPR instruction was
not received.24 26,178,179 Survival with good neurological outcome at
hospital discharge (35,921 patients) was higher among those
receiving dispatch-assisted CPR compared with no bystander CPR
 RESUSCITATION 161 (2021) 80
(adjusted odds ratio (ORadj) 1.54 (95% CI 1.35, 1.76)).24 26 Survival
with good neurological outcome at 1 month (4306 patients) was higher
among those receiving dispatch-assisted CPR compared with no
bystander CPR (ORadj 1.81 (95% CI 1.23, 1.76)).179
Survival with good neurological outcome at hospital discharge
(17,209 patients) was similar among those receiving dispatch-
assisted CPR compared with unassisted bystander CPR (ORadj
1.12 (95% CI 0.94, 1.34)).25 Survival with good neurological outcome
at 1 month (78,112 patients) was similar among those receiving
dispatch-assisted CPR compared to unassisted bystander CPR
(ORadj 1.00 (95% CI 0.91, 1.08)).178
The science evaluating the effect of dispatcher-assisted CPR is
complex as it compares outcomes for patients who have been offered
or received dispatch-assisted CPR with outcomes for both patients
who received no bystander CPR and patients who received
unassisted bystander CPR. Taken together, ILCOR found that these
studies supported dispatch-assisted CPR as outcomes are generally
better for patients who receive dispatch-assisted CPR compared with
no bystander CPR, and for some outcomes as good as unassisted
bystander CPR. ILCOR placed a greater value on studies providing
adjusted analysis, as cohorts of patients who received unassisted
CPR generally had more favourable prognostic characteristics, and
cohorts of patients who did not receive any bystander CPR generally
has less favourable prognostic characteristics.
Consistent with ILCOR, the ERC recommends emergency medical
dispatch centres have systems in place to enable call handlers to
provide CPR instructions for adult patients in cardiac arrest, and that
emergency call takers provide CPR instructions (when required) for
adult patients in cardiac arrest. The ERC supports research into the role
of new technologies such as locating and distributing AEDs and their
interphase with bystanders and first responders.
Dispatch-assisted chest compression-only CPR compared
with standard CPR
ILCOR recommends dispatchers provide instructions to perform
compression-only CPR to callers for adults with suspected OHCA.182
This strong recommendation was based on low-certainty evidence from
three randomised controlled trials which included 3728 adult OHCAs.183
185
Only one study reported the outcome survival with favourable
neurological outcome, and did not demonstrate any benefit of chest
compression-only CPR over standard CPR (RR 1.25 (95% CI 0.94, 1.66);
p = 0.13).184 [Rea 2010 423] Survival to hospital discharge was similarly
not significantly different (RR 1.20 (95% CI 1.00, 1.45); p = 0.05).183 185
In making these recommendations, ILCOR recognised that the
evidence in support of these recommendations was of low certainty and
performed at a time when the ratio of ventilations to chest compressions
was 15:2, which leads to greater interruptions of chest compressions
than the currently recommended ratio of 30:2. However, the signal from
every trial is consistently in favour of dispatch-assisted CPR protocols
that use a compression-only CPR instruction set. Reviewing the totality
of available evidence and considering current common practice,
training and quality assurance experiences, the ILCOR BLS task force
has kept the strong recommendation for compression-only for
dispatcher-assisted CPR despite low-certainty evidence. In making
these recommendations, ILCOR placed a higher value on the initiation
of bystander compressions, and a lower value on possible harms of
delayed ventilation.
Consistent with ILCOR, the ERC recommends that dispatchers
provide instructions to perform compression-only CPR to callers for
adults with suspected OHCA. The ERC supports high-quality
97 89
research to address unresolved issues relating to optimal instruction
sequence, identifying key words, and the impact of dispatch-assisted
CPR instructions on non-cardiac aetiology arrests such as drowning,
trauma, and asphyxia in adults and children.
Rapid response systems including early warning scores and
medical emergency teams
Unwell patients admitted to hospital are at risk of deterioration and may
progress to cardiorespiratory arrest. Patients commonly show signs and
symptoms of deterioration for hours or days before cardiorespiratory
arrest.7 Rapid response systems (RRSs) are programs that are designed
to improve the safety of hospitalised patients whose condition is
deteriorating quickly.186 A successful RRS may be defined as a hospital-
wide system that ensures observation, detection of deterioration, and
tailored response to ward patients that may include rapid response teams
(RRTs), also called medical emergency teams (METs).187
The ILCOR treatment recommendation suggests that hospitals
consider the introduction of rapid response systems (rapid response
team/medical emergency team) to reduce the incidence of in-hospital
cardiac arrest and in-hospital mortality based on a systematic review
(weak recommendation, low-quality evidence).49 A total of 57 observa-
tional studies63,188 242 and 2 randomised trials243,244 were included in the
systematic review. There are low-certainty data to suggest improved
hospital survival and reduced incidence of cardiac arrests in those
hospitals that introduce a RRS, and a suggestion of a dose-response
effect, with higher-intensity systems (e.g. higher RRS activation rates,
senior medical staff on RRS teams) being more effective.
Consistent with ILCOR, the ERC suggests that hospitals consider
the introduction of a rapid response system (rapid response team/
medical emergency team) to reduce the incidence of IHCA and
in-hospital mortality.
Cardiac arrest centres
There is wide variation among hospitals in the availability and type of
post resuscitation care, as well as clinical outcomes.245,246 Cardiac
arrest centres are hospitals providing evidence-based resuscitation
treatments including emergency interventional cardiology, and
bundled critical care with targeted temperature management, and
protocolised cardiorespiratory support and prognostication.247,248
ILCOR suggests that wherever possible, adult patients with non-
traumatic OHCA cardiac arrest should be treated in cardiac arrest
centres.49,249 This weak recommendation is based on very low
certainty evidence from a systematic review that included 21 obser-
vational studies 250 270 and 1 pilot randomized trial.271 Of these,
17 observational studies were ultimately included in a meta-
analysis.250 256,261 270 This meta-analysis found that patients cared
for in cardiac arrest centres had improved survival to hospital
discharge with favourable neurological outcomes and survival to
hospital discharge. This survival benefit from care at cardiac arrest
centres did not extend to long term survival (survival to 30 days with
favourable neurological outcome and survival to 30 days).
The resulting ILCOR treatment recommendations included:22
 We suggest adult non-traumatic OHCA cardiac arrest patients be
cared for in cardiac arrest centres rather than in non-cardiac arrest
centres.
 We cannot make a recommendation for or against regional triage
of OHCA patients to a cardiac arrest centre by primary EMS
transport (bypass protocols) or secondary interfacility transfer.
90 RESUSCITATION 161 (2021) 80
Consistent with ILCOR, the ERC suggests that adult patients with
non-traumatic OHCA cardiac arrest be cared for in cardiac arrest
centres rather than in non-cardiac arrest centres. In 2020 the main
European organisations involved in OHCA reached a consensus that
patients with OHCA of presumed cardiac aetiology should be
transported directly to a hospital with 24/7 coronary angiography.272
Conflicts of interest
TMO declares research funding from Laerdal Foundation and Zoll
Foundation
BB declared speakers honorarium from Baxalta, BayerVital,
BoehringerIngelheim, ZOLL, FomF, Bard, Stemple, NovartisPharma
RG declares his role as Editor of the journal Trends in Anaesthesia
and Critical Care, associate editor European Journal of Anaesthesi-
ology. He reports institutional research funding.
GR declares his role of consultant for Zoll; he reports research
grant from Zoll for the AMSA trial and other Institutional grants: EU
Horizon 2020 support for ESCAPE-NET, Fondazione Sestini support
for the project “CPArtrial”, EU Horizon 2020 and also Coordination and
support for the action “iProcureSecurity”
AL reports his role of Medical advisor First on Scene training
company
AS declares research funding from EU Horizon 2020 for “I procure
security project”
JY declares research grants from National Institute for Health
Research and Resuscitation Council UK.
FL declares research funding from Laerdal foundation, Zoll
foundation, NovoNordic foundation and Danish Trygfonden.
Acknowledgement
The Writing Group acknowledges the significant contributions to this
chapter by Tommaso Scquizzato and Zace Drieda. TS and ZD gave
an important contribution in the social media and smartphones apps
for engaging the community paragraphs, in organising the European
survey about the use of apps, and in reviewing statistical analysis and
level of evidence. Thanks to Gavin D. Perkins and Jerry P. Nolan for
editorial oversight.
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 RESUSCITATION 161 (2021) 98 114

Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Basic Life Support

Theresa M. Olasveengen a, * , Federico Semeraro b , Giuseppe Ristagno c,d ,

Maaret Castren e , Anthony Handley f , Artem Kuzovlev g , Koenraad G. Monsieurs h ,
Violetta Raffay i , Michael Smyth j,k , Jasmeet Soar l , Hildigunnur Svavarsdottir m,n ,
Gavin D. Perkins o,p
a
Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
b
Department of Anaesthesia, Intensive Care and Emergency Medical Services, Maggiore Hospital, Bologna, Italy
c
Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milano, Italy
d
Department of Pathophysiology and Transplantation, University of Milan, Italy
e
Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
f
Hadstock, Cambridge, United Kingdom
g
Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Research Institute of General
Reanimatology, Moscow, Russia
h
Department of Emergency Medicine, Antwerp University Hospital and University of Antwerp, Belgium
i
Department of Medicine, School of Medicine, European University Cyprus, Nicosia, Cyprus
j
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
k
West Midlands Ambulance Service and Midlands Air Ambulance, Brierly Hill, West Midlands DY5 1LX, United Kingdom
l
Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
m
Akureyri Hospital, Akureyri, Iceland
n
Institute of Health Science Research, University of Akureyri, Akureyri, Iceland
o
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
p
University Hospitals Birmingham, Birmingham B9 5SS, United Kingdom

Abstract
The European Resuscitation Council has produced these basic life support guidelines, which are based on the 2020 International Consensus on
Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include cardiac arrest recognition, alerting emergency
services, chest compressions, rescue breaths, automated external defibrillation (AED), CPR quality measurement, new technologies, safety, and
foreign body airway obstruction.
Keywords: Guidelines, Basic Life support, Cardiopulmonary Resuscitation, Chest compression, Ventilation, Rescue breaths, Automated External
Defibrillator, Emergency Medical Services, Emergency Medical Dispatch

Introduction and scope Recommendations (CoSTR) for BLS.1 For these ERC Guidelines the
ILCOR recommendations were supplemented by focused literature
These guidelines are based on the International Liaison Committee on reviews undertaken by the ERC BLS Writing Group for those topics not
Resuscitation (ILCOR) 2020 Consensus on Science and Treatment reviewed in the 2020 ILCOR CoSTR. When required, the guidelines

* Corresponding author.
E-mail address: t.m.olasveengen@medisin.uio.no (T.M. Olasveengen).
https://doi.org/10.1016/j.resuscitation.2021.02.009

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
 RESUSCITATION 161 (2021) 98 114 99

were informed by the expert consensus of the writing group

membership.
The BLS writing group prioritised consistency with previous
guidelines to build confidence and encourage more people to act
when a cardiac arrest occurs. Failing to recognise cardiac arrest
remains a barrier to saving more lives. The terminology used in the
ILCOR CoSTR,5 is to start CPR in any person who is “unresponsive with
absent or abnormal breathing”. This terminology has been included in
the BLS 2021 guidelines. Those learning or providing CPR are
reminded that slow, laboured breathing (agonal breathing) should be
considered a sign of cardiac arrest. The recovery position is included in
the first aid section of the ERC guidelines 2021. The first aid guidelines
highlight that the recovery position should only be used for adults and
children with a decreased level of responsiveness due to medical illness
or non-physical trauma. The guidelines emphasise that it should only be
used in people who do NOT meet the criteria for the initiation of rescue
breathing or chest compressions (CPR). Anyone placed in the recovery
position should have their breathing continuously monitored. If at any
point their breathing becomes absent or abnormal, roll them on to their
back and start chest compressions. Finally, the evidence informing the
treatment of foreign body airway obstruction has been comprehensively
updated, but the treatment algorithms remain the same.
The ERC has also produced guidance on cardiac arrest for patients
with coronavirus disease 2019 (COVID-19),2 which is based on an
ILCOR CoSTR and systematic review.3,4 Our understanding of the
optimal treatment of patients with COVID-19 and the risk of virus
transmission and infection of those providing CPR is poorly understood
and evolving. Please check ERC and national guidelines for the latest Fig. 1 – BLS infographic summary.
guidance and local policies for both treatment and rescuer precautions.
These guidelines were drafted and agreed by the Basic Life
Support Writing Group members. The methodology used for guideline
development is presented in the Executive summary.4a The guide-
lines were posted for public comment in October 2020. The feedback
was reviewed by the writing group and the guidelines was updated
where relevant. The Guideline was presented to and approved by the
ERC General Assembly on 10th of December 2020.
Key messages from this section are presented in Fig. 1.

Concise guideline for clinical practice

The BLS algorithm is presented in Fig. 2 and step by step instructions

are provided in Fig. 3.

How to recognise cardiac arrest

 Start CPR in any unresponsive person with absent or abnormal

breathing.
 Slow, laboured breathing (agonal breathing) should be considered
a sign of cardiac arrest.
 A short period of seizure-like movements can occur at the start of
cardiac arrest. Assess the person after the seizure has stopped: if
unresponsive and with absent or abnormal breathing, start CPR.

How to alert the emergency services

Fig. 2 – BLS algorithm.

 Alert the emergency medical services (EMS) immediately if a mobile phone and immediately start CPR assisted by the
person is unconscious with absent or abnormal breathing. dispatcher.
 A lone bystander with a mobile phone should dial the EMS  If you are a lone rescuer and you have to leave a victim to alert the
number, activate the speaker or another hands-free option on the EMS, activate the EMS first and then start CPR.
100 RESUSCITATION 161 (2021) 98 114

Fig. 3 – BLS step by step instructions.

RESUSCITATION 161 (2021) 98 114 101

Fig. 3 – (continued).
102 RESUSCITATION 161 (2021) 98 114

Fig. 3 – (continued).

High quality chest compressions Rescue breaths

 Start chest compressions as soon as possible.  Alternate between providing 30 compressions and 2 rescue
 Deliver compressions on the lower half of the sternum (‘in the breaths.
centre of the chest’).  If you are unable to provide ventilations, give continuous chest
Compress to a depth of at least 5 cm but not more than 6 cm. compressions.
 Compress the chest at a rate of 100 120 min 1 with as few

interruptions as possible. AED
 Allow the chest to recoil completely after each compression; do not
lean on the chest. How to find an AED
 Perform chest compressions on a firm surface whenever feasible.  The location of an AED should be indicated by clear signage.
 RESUSCITATION 161 (2021) 98
When and how to use an AED
 As soon as the AED arrives, or if one is already available at the site
of the cardiac arrest, switch it on.
 Attach the electrode pads to the victim's bare chest according to
the position shown on the AED or on the pads.
 If more than one rescuer is present, continue CPR whilst the pads
are being attached.
Lean the victim forwards.
 Follow the spoken (and/or visual) prompts from the AED.
Apply blows between the shoulder blades using the heel of one
 Ensure that nobody is touching the victim whilst the AED is
analysing the heart rhythm.
If a shock is indicated, ensure that nobody is touching the victim.
 Push the shock button as prompted. Immediately restart CPR with
Stand behind the victim and put both your arms around the
30 compressions.
 If no shock is indicated, immediately restart CPR with 30
Lean the victim forwards.
compressions.
Clench your fist and place it between the umbilicus (navel) and
 In either case, continue with CPR as prompted by the AED.
There will be a period of CPR (commonly 2 min) before
Grasp your fist with the other hand and pull sharply inwards and
the AED prompts for a further pause in CPR for rhythm
analysis.
Compressions before defibrillation
 Continue CPR until an AED (or other defibrillator) arrives on site
and is switched on and attached to the victim.
 Do not delay defibrillation to provide additional CPR once the
defibrillator is ready.
Fully automatic AEDs
 If a shock is indicated, fully automatic AEDs are designed to deliver
a shock without any further action by the rescuer. The safety of fully
automatic AEDs have not been well studied.
Safety of AEDs
 Many studies of public access defibrillation have shown that AEDs
can be used safely by bystanders and first responders. Although
injury to the CPR provider from a shock by a defibrillator is
extremely rare, do not continue chest compression during shock
delivery.
Safety
 Make sure you, the victim and any bystanders are safe.
 Laypeople should initiate CPR for presumed cardiac arrest without
concerns of harm to victims not in cardiac arrest.
 Lay people may safely perform chest compressions and use an
AED as the risk of infection during compressions and harm from
accidental shock during AED use is very low.
 Separate guidelines have been developed for resuscitation of
victims with suspected or confirmed acute respiratory syndrome
coronavirus 2 (SARS-CoV-2). See www.erc.edu/covid.
How technology can help
 EMS systems should consider the use of technology such as
smartphones, video communication, artificial intelligence and
drones to assist in recognising cardiac arrest, to dispatch first
responders, to communicate with bystanders to provide dispatch-
er-assisted CPR and to deliver AEDs to the site of cardiac arrest.
114 103
Foreign body airway obstruction
 Suspect choking if someone is suddenly unable to speak or talk,
particularly if eating.
 Encourage the victim to cough.
 If the cough becomes ineffective, give up to 5 back blows:
hand
 If back blows are ineffective, give up to 5 abdominal thrusts:
upper part of the victim's abdomen.
the ribcage.
upwards.
 If choking has not been relieved after 5 abdominal thrusts,
continue alternating 5 back blows with 5 abdominal thrusts until it is
relieved, or the victim becomes unconscious.
 If the victim becomes unconscious, start CPR
Evidence informing the guidelines
How to recognise cardiac arrest
The practical, operational definition of cardiac arrest is when a person
is unresponsive with absent or abnormal breathing.5 Earlier guidelines
included the absence of a palpable pulse as a criterion, but reliably
detecting peripheral pulses in stressful medical emergencies proved
difficult for professionals and lay people alike.6 10 Unresponsiveness
and abnormal breathing obviously overlap with other potentially life-
threatening medical emergencies, but have very high sensitivity as
diagnostic criteria for cardiac arrest. Using these criteria will
moderately overtriage for cardiac arrest, but the risk of starting
CPR in an unresponsive individual with absent or abnormal breathing
and not in cardiac arrest is believed to be far outweighed by the
increased mortality associated with delayed CPR for cardiac arrest
victims.1
Agonal breathing
Agonal breathing is an abnormal breathing pattern observed in about
50% of cardiac arrest victims. It indicates the presence of brain
function and is associated with improved outcomes.11,12 Agonal
breathing is commonly misinterpreted as a sign of life, presenting a
challenge to lay people and emergency medical dispatchers.
Common terms used by lay people to describe agonal breathing
include: gasping, barely or occasionally breathing, moaning, sighing,
gurgling, noisy, groaning, snorting, heavy or laboured breath-
ing.11,13,14 Agonal breathing remains the biggest barrier to recognition
of OHCA.15 22 Early recognition of agonal breathing is a prerequisite
for early CPR and defibrillation, and failure by dispatchers to recognise
cardiac arrest during emergency calls is associated with decreased
survival.18,23
104 RESUSCITATION 161 (2021) 98
When focusing on the recognition of agonal breathing for both lay
rescuer and professional CPR providers, it is important to underline
that the risk of delaying CPR for a cardiac arrest victim far outweighs
any risk from performing CPR on a person not in cardiac arrest. (See
also Safety section) The misinterpretation of agonal breathing as a
sign of life may prompt bystanders to erroneously place cardiac arrest
victims in the recovery position instead of starting CPR.
Seizures
Seizure-like movements of short duration among patients in cardiac
arrest pose another important barrier to recognition of cardiac arrests.
Seizures are common medical emergencies and are reported to
constitute about 3 4% of all emergency medical calls.24 26 Only
0.6 2.1% of these calls are also cardiac arrest.25,27 A recent
observational study including 3502 OHCAs identified 149 (4.3%)
victims with seizure-like activity.28 Patients presenting with seizure-
like activity were younger (54 vs. 66 years old; p < 0.05), were more
likely to have a witnessed arrest (88% vs. 45%; p < 0.05), more likely
to present with an initial shockable rhythm (52% vs. 24%; p < 0.05),
and more likely to survive to hospital discharge (44% vs. 16%;
p < 0.05). Similar to agonal respiration, seizures complicate the
recognition of cardiac arrest for both lay people and professionals
(median time to dispatcher identification of the cardiac arrest; 130 s vs.
62 s; p < 0.05).28
Recognising cardiac arrest after a seizure episode when the victim
remains unresponsive with abnormal breathing is important to prevent
delayed CPR. The risk of delaying CPR for a cardiac arrest victim far
outweighs any risk from performing CPR on a person not in cardiac
arrest. (See also Safety section)
Alert emergency services
The practical question of whether to ‘call first’ or do ‘CPR first’ has been
debated and is particularly relevant when a phone is not immediately
available in a medical emergency. As mobile phones have become the
dominant form of telecommunication, calling the emergency services
does not necessarily mean delaying CPR. After evaluating and
discussing the results of a recent systematic review, ILCOR made a
recommendation that lone bystanders with a mobile phone dial EMS,
activate the speaker or other hands-free option on the mobile phone
and immediately start CPR.1 This recommendation was based on
expert consensus and very-low certainty evidence drawn from a single
observational study.29 The observational study from Japan included
5446 OHCAs and compared outcomes between patients treated with
a ‘CPR first’ or ‘call first’ strategy. Overall survival rates were very
similar between ‘call first’ and ‘CPR first’ strategies, but adjusted
analyses performed on various subgroups suggested improved
survival with a favourable neurological outcome with a ‘CPR first’
strategy compared with a ‘call first’ strategy. Improved outcomes were
observed in subgroups of non-cardiac aetiology (adjusted odds ratio
(aOR) 2.01 [95% CI 1.39 2.9]); under 65 years of age (aOR 1.38 [95%
CI 1.09 1.76]); under 20 years of age (aOR 3.74 [95% CI 1.46 9.61])
and; both under 65 years of age and non-cardiac aetiology together
(aOR 4.31 [95% CI 2.38 8.48]).29
The observational study supporting a ‘CPR first’ strategy was
limited by only including cases where lay people witnessed the OHCA
and spontaneously performed CPR (without the need for dispatcher
assistance), and the groups compared were different with respect to
age, gender, initial rhythm, bystander CPR characteristics and EMS
intervals. Despite the very low certainty evidence, ILCOR made a
114
discordant strong recommendation to emphasise the importance of
early bystander CPR.
Despite widespread availability of mobile phones, there are
situations where a lone rescuer might have to leave a victim to alert
emergency services. Choosing to either start CPR or alert EMS first
would be dependent on exact circumstances, but it would be
reasonable to prioritise prompt activation of EMS before returning
to the victim to initiate CPR.
High quality chest compressions
Chest compressions are the key component of effective CPR as the
widely available means to provide organ perfusion during cardiac
arrest. The effectiveness of chest compressions is dependent on
correct hand position and chest compression depth, rate, and degree
of chest wall recoil. Any pauses in chest compressions mean pauses
in organ perfusion, and consequently need to be minimised to prevent
ischaemic injury.
Hand position during compressions
The evidence for optimal hand position was reviewed by ILCOR in
2020.1 Although the recommendations for hand position during
compressions have been modified over time, these changes have
been based solely on low- or very-low-certainty evidence, with no data
demonstrating that a specific hand position was optimal in terms of
patient survival. In the most recent systematic review, no studies
reporting critical outcomes such as favourable neurologic outcome,
survival, or ROSC were identified.
Three very-low-certainty studies investigated effect of hand
position on physiological end points.30 32 One crossover study in
17 adults with prolonged resuscitation from non-traumatic cardiac
arrest documented improved peak arterial pressure during compres-
sion systole and ETCO2 when compressions were performed over the
lower third of the sternum compared with the centre of the chest.31
Similar results were observed in a crossover study in 10 children when
compressions were performed on the lower third of the sternum
compared with the middle of the sternum, with higher peak systolic
pressure and higher mean arterial pressure.30 A third crossover study
in 30 adults with cardiac arrest documented no difference in ETCO2
values resulting from changes in hand placement.32
Imaging studies were excluded from the ILCOR systematic review
as they do not report clinical outcomes for patients in cardiac arrest, but
they do provide some supportive background information on the optimal
position for compressions based on the anatomical structures
underlying the recommended and alternative hand positions. Evidence
from recent imaging studies indicates that, in most adults and children,
the maximal ventricular cross-sectional area underlies the lower third of
the sternum/xiphisternal junction, while the ascending aorta and left
ventricular outflow tract underlie the centre of the chest.33 39 There are
important differences in anatomy between individuals and depend on
age, body mass index, congenital cardiac disease and pregnancy, and
thus one specific hand placement strategy might not provide optimal
compressions across a range of persons.34,38,40
These findings led ILCOR to retain their current recommendation
and continue to suggest performing chest compressions on the lower
half of the sternum in adults in cardiac arrest (weak recommendation,
very-low-certainty evidence). Consistent with the ILCOR treatment
recommendations, the ERC recommends teaching that chest
compressions should be delivered ‘in the centre of the chest’, whilst
demonstrating hand position on the lower half of the sternum.
 RESUSCITATION 161 (2021) 98
Chest compression depth, rate and recoil
This guideline is based on ILCOR recommendations,1 informed by an
ILCOR scoping review41 and the previous 2015 ERC BLS Guide-
lines.42 The ILCOR BLS Task Force scoping review related to chest
compression rate, chest compression depth, and chest wall recoil. It
aimed to identify any recently published evidence on these chest
compression components as discrete entities and to assess whether
studies have reported interactions among these chest compression
components.
In addition to the 14 studies identified in the 2015 ERC BLS
guidelines,42 8 other studies43 50 published after 2015 were identified
so that a total of 22 studies evaluated compression depth rate and
recoil. Five observational studies examined both chest compression
rate and chest compression depth.48,49,51,52 One RCT,44 one
crossover trial,53 and 6 observational studies45,50,54 57 examined
chest compression rate only. One RCT58 and 6 observational studies
examined chest compression depth only,59 64 and 2 observational
studies examined chest wall recoil.43,46 No studies were identified that
examined different measures of leaning.
While this scoping review highlighted significant gaps in the
research evidence related to interactions between chest compression
components, it did not identify sufficient new evidence that would
justify conducting a new systematic review or reconsideration of
current resuscitation treatment recommendations.
ILCOR's treatment recommendations for chest compression
depth, rate and recoil are therefore unchanged from 2015.42 ILCOR
recommends a manual chest compression rate of 100 to 120 min 1
(strong recommendation, very-low-certainty evidence), a chest
compression depth of approximately 5 cm (2 in) (strong recommen-
dation, low-certainty evidence) while avoiding excessive chest
compression depths (greater than 6 cm [greater than 2.4 in] in an
average adult) during manual CPR (weak recommendation, low-
certainty evidence) and suggest that people performing manual CPR
avoid leaning on the chest between compressions to allow full chest
wall recoil (weak recommendation, very-low-certainty evidence).
Consistent with the ILCOR Treatment Recommendations, the
ERC recommends a chest compression rate of 100 to 120 min 1 and a
compression depth of 5 6 cm while avoiding leaning on the chest
between compressions. The recommendation to compress 5 6 cm is
a compromise between observations of poor outcomes with shallow
compressions and increased incidence of harm with deeper
compressions.42
Firm surface
ILCOR updated the Consensus on Science and Treatment Recom-
mendation for performing CPR on a firm surface in 2020.1,65 When
CPR is performed on a soft surface (e.g. a mattress), both the chest
wall and the support surface are compressed.66 This has the potential
to diminish effective chest compression depth. However, effective
compression depths can be achieved even on a soft surface, providing
the CPR provider increases overall compression depth to compensate
for mattress compression.67 73
The ILCOR systematic review identified twelve manikin studies
evaluating the importance of a firm surface during CPR.65 These
studies were further grouped into evaluations of mattress type,70,74 76
floor compared with bed,75 78 and backboard.69,70,79 83 No human
studies were identified. Three RCTs evaluating mattress type did not
identify a difference in chest compression depth between various
114 105
mattress types.70,74 76 Four RCTs evaluating floor compared with bed
found no effect on chest compression depth.75 78 Of the seven RCTs
evaluating use of backboard, six could be meta-analysed and showed
increased compression depth using a backboard with a mean
difference of 3 mm (95% CI, 1 to 4).69,70,79 82 The clinical relevance of
this difference was debated, although statistically significant the
actual increase in compression depth was small.
These findings led ILCOR to suggest performing manual chest
compressions on a firm surface when possible (weak recommenda-
tion, very low certainty evidence). ILCOR also suggested that when a
bed has a CPR mode that increases mattress stiffness, it should be
activated (weak recommendation, very-low-certainty evidence), but
suggested against moving a patient from a bed to the floor to improve
chest compression depth in the hospital setting (weak recommenda-
tion, very-low-certainty evidence). The confidence in effect estimates
is so low that ILCOR was unable to make a recommendation about the
use of a backboard strategy.
Consistent with the ILCOR Treatment Recommendations, the
ERC suggests performing chest compressions on a firm surface
whenever possible. For the in-hospital setting, moving a patient from
the bed to the floor is NOT recommended. The ERC does not
recommend using a backboard.
Rescue breaths
Compression-ventilation (CV) ratio
ILCOR updated the Consensus on Science and Treatment Recom-
mendations for compression-ventilation (CV) ratio in 2017.84 The
supporting systematic review found evidence from two cohort studies
(n = 4877) that a ratio of compressions to ventilation of 30:2 compared
with 15:2 improved favourable neurological outcome in adults (risk
difference 1.72% (95% CI 0.5 2.9%).85 Meta-analysis of six cohort
studies (n = 13,962) found that more patients survived with a ratio of
30:2 compared with 15:2 (risk difference 2.48% (95% CI 1.57 3.38).
A similar pattern of better outcomes was observed in a small cohort
study (n = 200, shockable rhythms) when comparing a ratio of 50:2
with 15:2 (risk difference 21.5 (95% CI 6.9 36.06).86 The ILCOR
treatment recommendation, which suggests a CV ratio of 30:2
compared with any other CV ratio in patients with cardiac arrest (weak
recommendation, very-low-quality evidence), remains valid and forms
the basis for the ERC guidelines to alternate between providing 30
compressions and 2 ventilation.
Compression-only CPR
The role of ventilation and oxygenation in the initial management of
cardiac arrest remains debated. ILCOR performed systematic
reviews of compression-only versus standard CPR in both lay rescuer
and professional or EMS settings.85,87
In the lay rescuer setting, six very-low-certainty observational
studies compared chest compression-only with standard CPR using a
CV ratio of 15:2 or 30:2.18,88 92 In a meta-analysis of two studies, there
was no significant difference in favourable neurological outcome in
patients who received compression-only CPR compared with patients
who received CPR at a CV ratio of 15:2 (RR, 1.34 [95% CI, 0.82 2.20];
RD, 0.51 percentage points [95% CI, 2.16 to 3.18]).18,90 In a meta-
analysis of three studies, there was no significant difference in
favourable neurological outcome in patients who received compres-
sion-only CPR compared with patients who received compressions
and ventilations during a period when the CV ratio changed from 15:2
to 30:2 (RR, 1.12 [95% CI, 0.71 1.77]; RD, 0.28 percentage points
106 RESUSCITATION 161 (2021) 98
[95% CI, 2.33 to 2.89]).89,91,92 In one study, patients receiving
compression-only CPR had worse survival compared with patients
who received CPR at a CV ratio of 30:2 (RR, 0.75 [95% CI, 0.73 0.78];
RD, 1.42 percentage points [95% CI, 1.58 to 1.25]).88 Lastly,
one study examined the influence of nationwide dissemination of
compression-only CPR recommendations for lay people and showed
that, although bystander CPR rates and nationwide survival improved,
patients who received compression-only CPR had lower survival
compared with patients who received chest compressions and
ventilations at a CV ratio of 30:2 (RR, 0.72 [95% CI, 0.69 0.76];
RD, 0.74 percentage points [95% CI, 0.85 to 0.63]).88 Based on
this review, ILCOR suggests that bystanders who are trained, able,
and willing to give rescue breaths and chest compressions do so for
all adult patients in cardiac arrest (weak recommendation, very-low-
certainty evidence).
In the EMS setting, a high-quality RCT included 23,711 patients.
Those randomised to bag-mask ventilation, without pausing for chest
compressions, had no demonstrable benefit for favourable neurologi-
cal outcome (RR, 0.92 [95% CI, 0.84 1.00]; RD, 0.65 percentage
points [95% CI, 1.31 to 0.02]) compared with patients randomised to
conventional CPR with a CV ratio of 30:2.93 ILCOR recommends that
EMS providers perform CPR with 30 compressions to 2 ventilations
(30:2 ratio) or continuous chest compressions with positive pressure
ventilation delivered without pausing chest compressions until a
tracheal tube or supraglottic device has been placed (strong
recommendation, high-certainty evidence).
Consistent with the ILCOR treatment recommendations, the ERC
recommends alternating between providing 30 compressions and 2
ventilations during CPR in both lay rescuer and professional settings.
Automated external defibrillator
An AED (automated external defibrillator or, less commonly termed,
automatic external defibrillator) is a portable, battery-powered device
with adhesive pads that are attached to a patient's chest to detect the
heart rhythm following suspected cardiac arrest. Occasionally it may
be necessary to shave the chest if very hairy and/or the electrodes will
not stick firmly. If the rhythm is ventricular fibrillation (or ventricular
tachycardia), an audible or audible-and-visual prompt is given to the
operator to deliver a direct current electric shock. For other heart
rhythms (including asystole and a normal rhythm), no shock is
advised. Further prompts tell the operator when to start and stop CPR.
AEDs are very accurate in their interpretation of the heart rhythm and
are safe and effective when used by laypeople.
The probability of survival after OHCA can be markedly increased
if victims receive immediate CPR and a defibrillator is used. AEDs
make it possible for laypeople to attempt defibrillation following
cardiac arrest many minutes before professional help arrives; each
minute of delay decreases the chance of successful resuscitation by
about 3 5%.94
The ILCOR Consensus on Science and Treatment Recom-
mendations (2020) made a strong recommendation in support of
the implementation of public-access defibrillation programmes for
patients with OHCA based on low-certainty evidence.1 The ILCOR
Scientific Statement on Public Access Defibrillation addresses key
interventions (early detection, optimising availability, signage,
novel delivery methods, public awareness, device registration,
mobile apps for AED retrieval and public access defibrillation)
which should be considered as part of all public access
defibrillation programmes.
114
Compressions before defibrillation
ILCOR updated the Consensus on Science and Treatment Recom-
mendation for CPR before defibrillation in 2020.1 Five RCTs were
identified comparing a shorter with a longer interval of chest
compressions before defibrillation.95 99 Outcomes assessed varied
from 1-year survival with favourable neurological outcome to ROSC.
No clear benefit from CPR before defibrillation was found in a meta-
analysis of any of the critical or important outcomes. In a meta-analysis
of four studies, there was no significant difference in favourable
neurological outcome in patients who received a shorter period of
CPR before defibrillation compared with a longer period of CPR
(RR, 1.02 [95% CI, 0.01 0.01]; 1 more patient/1000 ( 29
to 98).95,96,98,99 In a meta-analysis of five studies, there was no
significant difference in survival to discharge in patients who received
a shorter period of CPR before defibrillation compared with a longer
period of CPR (RR, 1.01 [95% CI, 0.90 1.15]; 1 more patient/1000
( 8 to 13).95 99
ILCOR suggests a short period of CPR until the defibrillator is
ready for analysis and/or defibrillation in unmonitored cardiac arrest.
Consistent with the ILCOR Treatment Recommendations, the ERC
recommends CPR be continued until an AED arrives on site, is
switched on and attached to the victim, but defibrillation should not be
delayed any longer for additional CPR.
Electrode positioning
ILCOR completed a scoping review on AED paddle size and
placement in 2020, searching for any available evidence to guide
optimal pad placement and size.1 No new evidence that directly
addressed these questions was identified, and the scoping review
from the ILCOR BLS task force is therefore limited to expert
discussion and consensus. These discussions highlighted studies
that showed that antero-posterior electrode placement is more
effective than the traditional antero-lateral or antero-apical position
in elective cardioversion of atrial fibrillation (AF), while most studies
have failed to demonstrate any clear advantage of any specific
electrode position. Transmyocardial current during defibrillation is
likely to be maximal when the electrodes are placed so that the area
of the fibrillating heart lies directly between them (i.e. ventricles in
VF/pulseless VT, atria in AF). Therefore, the optimal electrode
position may not be the same for ventricular and atrial arrhythmias.
ILCOR continues to suggest that pads be placed on the exposed
chest in an antero-lateral position. An acceptable alternative
position is antero-posterior. In large-breasted individuals, it is
reasonable to place the left electrode pad lateral to or underneath
the left breast, avoiding breast tissue. Consideration should be
given to the rapid removal of excessive chest hair before the
application of pads, but emphasis must be on minimising delay in
shock delivery. There is insufficient evidence to recommend a
specific electrode size for optimal external defibrillation in adults. It
is, however, reasonable to use a pad size greater than 8 cm.100,101
Consistent with the ILCOR Treatment Recommendations and to
avoid confusion for the person using the AED, the ERC BLS writing
group recommends attaching the electrode pads to the victim's bare
chest using the antero-lateral position as shown on the AED.
CPR feedback devices
To improve CPR quality, key CPR metrics need to be measured. CPR
quality data can be presented to the rescuer in real-time and/or
provided in a summary report at the end of a resuscitation. Measuring
 RESUSCITATION 161 (2021) 98
CPR performance to improve resuscitation systems is addressed in
the Systems Saving Lives chapter.102 Real-time feedback devices for
CPR providers will be discussed in this section.
ILCOR updated the Consensus on Science and Treatment
Recommendation for feedback for CPR quality in 2020.1 Three types
of feedback devices were identified: (1) digital audio-visual feedback
including corrective audio prompts; (2) analogue audio and tactile
‘clicker’ feedback for chest compression depth and release; and (3)
metronome guidance for chest compression rate. There is consider-
able clinical heterogeneity across studies with respect to the type of
devices used, the mechanism of CPR quality measurement, the
mode of feedback, patient types, locations (e.g. in-hospital and out-of-
hospital), and baseline (control group) CPR quality.
Digital audio-visual feedback including corrective audio
prompts
One cluster RCT103 and four observational studies47,104 106
evaluated the effects of these devices on favourable neurological
outcome. The low-certainty cluster RCT found no difference in
favourable neurological outcome (relative risk 1.02; 95% CI
0.76 1.36; p = 0.9).103 While one of the observational studies found
an association with improved favourable neurological outcome (adjusted
odds ratio 2.69; 95% CI 1.04 6.94),106 the other three did not. 47,104,105
One cluster RCT103 and six observational studies48,52,104,106,107
evaluated the effects of these devices on survival to hospital discharge
or 30-day survival. Neither the low-certainty cluster RCT (relative risk
0.91; 95% CI 0.69 1.19; p = 0.5),103 nor the observational studies
found any benefit associated with these devices.48,52,104,106 108
The potential benefit from real-time audio-visual feedback would
be their ability to improve CPR quality. While the low-certainty cluster
RCT showed improved chest compression rate (difference of 4.7 per
minute; 95% CI 6.4 3.0), chest compression depth (difference of
1.6 mm; 95% CI 0.5 2.7 mm) and chest compression fraction
(difference of 2%; 66% vs. 64%, p = 0.016), the clinical significance
of these relatively small differences in CPR metrics is debated.103
Five very-low-certainty observational studies compared various
CPR metrics.47,52,104,106,107 One observational study showed no
difference in chest compression rates with and without feedback.107
The other four observational studies47,52,104,106 showed lower
compression rates in the group with CPR feedback with differences
ranging from 23 to 11 compressions per minute. One observational
study showed no difference in chest compression depth with and
without feedback.107 Three observational studies showed significant-
ly deeper chest compressions ranging from 0.4 to 1.1 cm.47,52,106 Two
studies reported statistically significant increases in CPR fraction
associated with feedback104,107 and three studies did not observe a
statistically or clinically important difference.47,52,106 The Couper
study demonstrated an increase in compression fraction from 78%
(8%) to 82% (7%), p = 0.003.104 This increase is of questionable
clinical significance. The Bobrow study demonstrated an increase in
chest compression fraction from 66% (95% CI 64 to 68) to 84% (95%
CI 82 to 85).106 Two major caveats with this study include a concern
that the observed difference may have not been related to the
feedback device, as there were other training interventions and use of
an imputed data set. None of the studies showed any improvement in
ventilation rates.47,52,103,104,106,107
Analogue audio and tactile clicker feedback
The standalone analogue clicker device, designed to be placed on the
patient's chest under the hands of a CPR provider, involves a
114 107
mechanism that produces a clicking noise and sensation when
enough pressure is applied. It provides tactile feedback on correct
compression depth and complete release between chest
compressions.
One very-low-certainty RCT evaluated the effect of a clicker device
on survival to hospital discharge and found significantly improved
outcome in the group treated with the clicker device (relative risk 1.90;
95% CI 1.60 2.25; p < 0.001).109 Two very-low-certainty RCTs
evaluated the effect of a clicker device on ROSC, and found
significantly improved outcome in the group treated with the clicker
device (relative risk 1.59; 95% CI 1.38 1.78; p < 0.001 and relative
risk 2.07; 95% CI 1.20 3.29, p < 0.001).109,110
Metronome rate guidance
One very-low-certainty observational study evaluated the effect of a
metronome to guide chest compression rate during CPR before
ambulance arrival found no benefit in 30 day survival (relative risk
1.66; 95% CI 17.7 14.9, p = 0.8) One very-low-certainty observa-
tional study evaluated the effect of a metronome on 7-day survival and
found no difference (3/17 vs. 2/13; p = 0.9).111 Two observational
studies evaluated the effect of a metronome on ROSC, and found no
difference in outcome (adjusted relative risk 4.97; 95% CI 21.11
11.76, p = 0.6 and 7/13 vs. 8/17, p = 0.7).108,111
Taking these data together ILCOR suggested the use of real-time
audio visual feedback and prompt devices during CPR in clinical
practice as part of a comprehensive quality improvement programme
for cardiac arrest designed to ensure high-quality CPR delivery and
resuscitation care across resuscitation systems, but suggested
against the use of real-time audiovisual feedback and prompt devices
in isolation (ie, not part of a comprehensive quality improvement
programme).112
Safety
Harm to people providing CPR
This guideline is based on an ILCOR scoping review,112 the previous
2015 ERC BLS Guidelines42 and the recently published ILCOR
consensus on science, treatment recommendations and task
force insights,3 ILCOR systematic review,4 and ERC COVID-19
guidelines.2
The ILCOR BLS Task Force performed a scoping review related
to harm to people providing CPR to identify any recent published
evidence on risk to CPR providers. This scoping review was
completed before the COVID-19 pandemic. In this review, very few
reports of harm from performing CPR and defibrillation were
identified. Five experimental studies and one case report published
since 2008 were reviewed. The five experimental studies reported
perceptions in experimental settings during shock administration for
elective cardioversion. In these studies, the authors also measured
current flow and the average leakage current in different experi-
ments to assess rescuer safety. Despite limited evidence evaluating
safety, there was broad agreement within the ILCOR BLS Task
Force and ERC BLS writing group that the lack of published
evidence supports the interpretation that the use of an AED is
generally safe. Consistent with ILCOR treatment recommendations,
the ERC recommends that lay rescuers perform chest compres-
sions and use an AED as the risk of damage from accidental shock
during AED use is low.1,42,112
As the SARS CoV-2 infection rates have continued to rise
throughout the world, our perception of safety during CPR has
108 RESUSCITATION 161 (2021) 98
changed profoundly. A recent systematic review on transmission of
SARS CoV-2 during resuscitation performed by ILCOR identified
eleven studies: two cohort studies, one case control study, five case
reports, and three manikin RCTs. The review did not identify any
evidence that CPR or defibrillation generated aerosol or transmitted
infection, but the certainty of evidence was very low for all outcomes.4
Based on the findings in this systematic review, yet still erring on the
side of caution, ILCOR published Consensus on Science and
Treatment Recommendations aimed at balancing the benefits of
early resuscitation with the potential for harm to care providers during
the COVID-19 pandemic. The resulting recommendations are for lay
people to consider chest compressions and public-access defibrilla-
tion during the current COVID-19 pandemic. However, ILCOR clearly
recommends that healthcare professionals use personal protective
equipment for all aerosol-generating procedures. The following ERC
guidelines have emphasised the need to follow current advice given
by local authorities, as infection rates vary between areas. For the lay
rescuer, it is important to follow instructions given by the emergency
medical dispatcher. The ERC has published guidelines for modified
BLS in suspected or confirmed COVID-19.2 The most important
changes relate to the use of personal protection equipment, assessing
breathing without getting close to the victim's nose and mouth, and
recognising ventilation as a potential aerosol generating procedure
with greater risk of disease transmission. Details can be found in the
ERC COVID-19 guidelines. (www.erc.edu/COVID)
Harm from CPR to victims not in cardiac arrest
Lay people may be reluctant to perform CPR on an unresponsive
person with absent or abnormal breathing because of concern that
delivering chest compressions to a person who is not in cardiac arrest
could cause serious harm. The evidence for harm from CPR to victims
not in cardiac arrest was reviewed by ILCOR in 2020.1 This systematic
review identified four very-low-certainty observational studies enroll-
ing 762 patients who were not in cardiac arrest but received CPR by
lay people outside the hospital. Three of the studies reviewed the
medical records to identify harm,113 115 and one included follow-up
telephone interviews.113 Pooled data from the first three studies,
including 345 patients, found an incidence of rhabdomyolysis of 0.3%
(one case), bone fracture (ribs and clavicle) of 1.7% (95% CI, 0.4
3.1%), pain in the area of chest compression of 8.7% (95% CI, 5.7
11.7%), and no clinically relevant visceral injury. The fourth study
relied on fire department observations at the scene, and there were no
reported injuries in 417 patients.116 Case reports and case series of
serious harm to persons receiving CPR who are not in cardiac arrest
are likely to be published because they are of general interest to a
broad group of healthcare providers. The few reports of harm
published, strengthens the arguments that harm is likely very rare and
desirable effects will far outweigh undesirable effects.
Despite very-low-certainty evidence, ILCOR recommends that
laypersons initiate CPR for presumed cardiac arrest without concerns
of harm to patients not in cardiac arrest. The ERC guidelines are
consistent with the ILCOR Treatment Recommendations.
How technology can help
Technology is used for many lifestyle comforts, from our smartphones
to innovative applications in medicine. Several researchers are
working on different areas of implementation. For BLS, the main areas
of interest are applications to locate AEDs, smartphones and
smartwatches as an aid for first responder and providers to reach
114
the patients, and CPR feedback in real-time and video communication
for video dispatch. The new ‘sci-fi’ technology describes the potential
impact of drones and artificial intelligence on the chain of survival.
AED locator apps
In the case of OHCA, early defibrillation increases the chances of
survival, but retrieving an AED during an emergency can be
challenging because the rescuer needs to know where the AED is
located. Thanks to built-in global positioning systems (GPS) in
smartphones, numerous apps have been developed to locate the user
and display the nearest AEDs. Moreover, such apps enable users to
add new AEDs that become available, or to update details of existing
ones throughout communities. As a result, apps to locate AEDs may
help build and maintain an updated registry of AEDs in the community
that could be used and integrated by emergency dispatch centres.
Usually, this kind of app provides a list of nearby AEDs that can
immediately display the route to reach the location with a navigation
app. Data on location, access, availability time, photo of installation,
and contacts of owner or person in charge of the AED are commonly
provided. Users also have the possibility to report malfunctioning or
missing AEDs. The role of mobile phone technology as a tool to locate
AEDs is described in detail in the Systems Saving Lives chapter.102
Smartphones and smartwatches
There is growing interest among researchers in integrating
smartphones and smartwatches in education and training in
cardiopulmonary resuscitation and defibrillation, and for improving
the response to OHCA with dedicated apps. Initially, apps were
developed to provide educational content on resuscitation. Follow-
ing the technological evolution of the last years, smartphone apps
have been used to provide feedback on CPR quality by exploiting
the built-in accelerometer. Such systems can provide real-time
audio-visual feedback to the rescuer through the speakers and the
screen. Although current real-time feedback devices tested in
professional settings have had limited effect on patient outcomes,
new technology could improve the quality of CPR. As technology
has evolved, the same concept has been applied to smartwatches,
devices particularly suitable to be used as feedback devices thanks
to their small size and their wearability. A systematic review found
conflicting results on the role of smart devices. In one randomised
simulation study that evaluated the effectiveness of one of these
apps, the quality of CPR significantly improved by using a
smartwatch-based app with real-time audio-visual feedback in
simulated OHCA.117 Similarly, a higher proportion of chest
compressions of adequate depth was observed when using a
smartphone.118 The current body of evidence is still limited, but
smartwatch-based systems might be an important strategy to
provide CPR feedback with smart devices.
During telephone CPR, dispatchers can locate and alert first-
responder citizens who are in the immediate vicinity of an OHCA
through a text message system or a smartphone app and guide them
to the nearest AED. This strategy has been studied and been shown to
increase the proportion of patients receiving CPR before ambulance
arrival and improve survival.119 122 The role of mobile phone
technology as a tool to activate first responders is also described in
the Systems Saving Lives chapter.102
Video communication
Smartphone and video communication play an important role in
modern society. Traditionally, dispatchers give audio-only CPR
 RESUSCITATION 161 (2021) 98
instructions; newly developed technology enables dispatchers to
provide video CPR instructions through the caller's mobile phone. A
recent systematic review and meta-analysis identified nine papers
evaluating video instructions for simulated OHCA. Compression
rates were better with video-instructions, and there was a trend
towards better hand-placement. No difference was observed in
compression depth or time to first ventilation, and there was a slight
increase in the time it took to start CPR with video instructions.123 In
a more recent retrospective study of adult OHCA a total of 1720
eligible OHCA patients (1489 and 231 in the audio and video
groups, respectively) were evaluated. The median instruction time
interval (ITI) was 136 s in the audio group and 122 s in the video
group (p = 0.12). The survival to discharge rates were 8.9% in the
audio group and 14.3% in the video groups (p < 0.01). Good
neurological outcome occurred in 5.8% and 10.4% in the audio and
video groups, respectively (p < 0.01).124 In a prospective clinical
study of OHCAs in nursing homes the application of video
communication to guide advanced cardiac life support by para-
medics was evaluated in 616 consecutive cases. Survival among
the third that received video-instructed ALS was 4.0% compared to
1.9% without video instructions (p = 0.078), and survival with good
neurological outcome was 0.5% vs. 1.0%, respectively.125
Artificial intelligence
Artificial intelligence (AI) is intelligence demonstrated by machines, in
contrast to the natural intelligence displayed by humans. The term AI is
often used to describe machines (or computers) that mimic cognitive
functions associated with the human mind, such as learning and
problem solving.
Artificial intelligence (AI) has been applied to health conditions
demonstrating that a computer can help with clinical decision-
making.126,127 The use of AI as a tool to improve the key components
of the chain of survival is under evaluation. Recently, a machine-
learning approach was used to recognise OHCA from unedited
recordings of emergency calls to an emergency medical dispatch
centre, and the performance of the machine-learning framework was
subsequently assessed.128 The study included 108,607 emergency
calls, of which 918 (0.8%) were out-of-hospital cardiac arrest calls
eligible for analysis. Compared with medical dispatchers, the
machine-learning framework had a significantly higher sensitivity
(72.5% vs. 84.1%, p < 0.001) with a slightly lower specificity (98.8%
vs. 97.3%, p < 0.001). The machine-learning framework had a lower
positive predictive value compared with dispatchers (20.9% vs.
33.0%, p < 0.001). Time to recognition was significantly shorter for the
machine-learning framework compared with the dispatchers (median
44 s vs. 54 s, p < 0.001). Another application of AI in terms of
recognition of OHCA is integrated software home assistant devices.
Widespread adoption of smartphones and smart speakers presents a
unique opportunity to identify this audible biomarker (agonal
breathing) and link unwitnessed cardiac arrest victims to EMS or
lay people. A recent study hypothesised that existing commodity
devices (e.g., smartphones and smart speakers) could be used to
identify OHCA-associated agonal breathing in a domestic setting. The
researchers developed a specific algorithm that recognises agonal
breathing through a dataset from EMS. Using real-world labelled EMS
audio of cardiac arrests, the research team trained AI software to
classify agonal breathing. The results obtained an overall sensitivity
and specificity of 97.24% (95% CI: 96.86 97.61%) and 99.51% (95%
CI: 99.35 99.67%). The false positive rate was between 0 and 0.14%
over 82 h (117,985 audio segments) of polysomnographic sleep lab
114 109
data that includes snoring, hypopnea, and central, and obstructive
sleep apnoea events.129
The last example of the potential use of AI is as a tool to predict
survival. Two studies reported the use of AI as a deep-learning-based
prognostic system and a machine-learning algorithm to discover
potential factor influencing outcomes and predict neurological
recovery and discharge alive from hospital.130,131 Further research
is needed to understand the potential of this new AI technology as a
tool to support human clinical decisions.
Drones
Despite the increasing number of AEDs in communities, an AED is still
rarely available on site during OHCA. Increasing access to AEDs and
reducing time to first defibrillation are critical for improving survival
after an OHCA. Drones or unmanned aerial vehicles have the
potential to speed up the delivery of an AED, and mathematical
modelling can be used to optimise the location of drones to improve
the emergency response in OHCA.
In the last years, several studies have investigated the feasibility of
delivering AEDs with drones to a simulated OHCA scene. Studies have
demonstrated how delivering AEDs through a drone is feasible without
issues during drone activation, take-off, landing, or bystander retrieval
of the AED from the drone, and confirmed that they could be expected to
arrive earlier by drone than by ambulance.132,133 A study conducted in
Toronto (Canada) estimated that the AED arrival time could be reduced
by almost 7 min in an urban area and by more than 10 min in a rural
area.133 Such reduction in time of AED arrival could translate to shorter
time to first defibrillation, which may ultimately improve survival. Drones
for AED delivery might also play a more important role in areas with a low
density of population and AEDs, and in mountain and rural areas.134 A
study that investigated the bystander experience in retrieving an AED
from a drone found that interacting with a drone in simulated OHCA was
perceived to be safe and feasible by laypeople.135
The effect of the impact of technologies on recognition and
performance during cardiac arrests or on patient outcomes is
unknown. Further research is needed to understand how different
technologies could affect the recognition of cardiac arrest (e.g.
artificial intelligence and video communication), the rate of bystander
CPR (e.g. AED locator apps, smartphones and smartwatches) and
survival (e.g. drones). Measuring the implementation and conse-
quences of these technologies into resuscitation programmes would
be useful to inform future practices.
Foreign body airway obstruction
Foreign body airway obstruction (FBAO) is a common problem, with
many cases being relieved easily without the need to involve
healthcare providers. Foreign body airway obstruction, however, is
an important cause of accidental death.136 It can affect all ages but is
most common in young children and older adults.136a,136b
As most choking events are associated with eating, they are
commonly witnessed and potentially treatable. Victims are initially
conscious and responsive, so there are often opportunities for early
intervention, which can be lifesaving. For every case leading to
hospitalisation or death there are many more that are treated
effectively by first aid in the community.
Recognition
Recognition of airway obstruction is the key to successful outcome. It
is important not to confuse this emergency with fainting, myocardial
110 RESUSCITATION 161 (2021) 98
infarction, seizure or other conditions that may cause sudden
respiratory distress, cyanosis or loss of consciousness. Factors
which place individuals at risk of FBAO include psychotropic
medication, alcohol intoxication, neurological conditions producing
reduced swallowing and cough reflexes, mental impairment, devel-
opmental disability, dementia, poor dentition and older age.138,139
Foreign bodies most commonly associated with airway obstruction
are solids such as nuts, grapes, seeds, vegetables, meat and
bread.137,138 Children, in particular, may put all sorts of objects in their
mouths.137
A foreign body can lodge in the upper airway, trachea or lower
airway (bronchi and bronchioles).140 Airway obstruction may be partial
or complete. In partial airway obstruction, air may still pass around the
obstruction, allowing some ventilation and the ability to cough.
Complete airway obstruction occurs when no air can pass around the
obstruction. Left untreated, complete airway obstruction will rapidly
cause hypoxia, loss of consciousness and cardiac arrest within a few
minutes. Prompt treatment is critical.
It is important to ask the conscious victim “Are you choking?” A
victim who is able to speak, cough and breathe has mild obstruction;
one who is unable to speak, has a weakening cough, is struggling or
unable to breathe, has severe airway obstruction.
Treatment of foreign body airway obstruction
The guidelines for the treatment of FBAO, informed by the ILCOR
systematic review and CoSTR,112,141 highlight the importance of early
bystander intervention.142,143
Conscious patient with foreign body airway obstruction
A person who is conscious and able to cough, should be encouraged to
do so as coughing generates high and sustained airway pressures and
may expel the foreign body.142,144,145 Aggressive treatment with back
blows, abdominal thrusts and chest compressions carry the risk of injury
and can even worsen the obstruction. These procedures, particularly
abdominal thrusts, are reserved for victims who have signs of severe
airway obstruction, such as inability to cough or fatigue. If coughing fails
to clear the obstruction or the victim starts to show signs of fatigue, give
up to 5 back blows. If these are ineffective, give up to 5 abdominal
thrusts. If both of these interventions are unsuccessful, further series of
5 back blows followed by 5 abdominal thrusts are continued.
Unconscious victim with foreign body airway obstruction
If at any point, the victim becomes unconscious with absent or abnormal
breathing, chest compressions are started in accordance with the
standard BLS resuscitation algorithm and continued until the victim
recovers and starts to breathe normally, or emergency services arrive.
The rationale for this is that chest compressions generate higher airway
pressures than abdominal thrusts and may potentially alleviate the
obstruction, whilst also providing some cardiac output.146 148
Approximately 50% of episodes of FBAO are not relieved by a
single technique.144 The likelihood of success is increased when
combinations of back blows and abdominal thrusts and, if necessary,
chest thrusts are used.
A blind finger sweep as a means of removing unseen solid material
may worsen airway obstruction or cause soft tissue injury.1 Attempt a
finger sweep only when an obstruction can be clearly seen in the mouth.
The use of a Magill's forceps by trained healthcare professionals
falls outside the scope of the intended audience for the ERC BLS
guidelines and is therefore not included in these guidelines.
114
Alternative techniques
In recent years, manual suction airway clearance devices to remove
foreign bodies have become commercially available. The ERC adopts
a similar approach to ILCOR in suggesting that further evidence is
needed in relation to the safety, efficacy and training requirements of
such devices before any recommendations for or against their use can
be made.1 Similarly, interventions such as the Table149 and chair
manoeuvres,150 lack sufficient evidence for their introduction into the
guidelines at the present time.
Aftercare and referral for medical review
Following successful treatment of FBAO, foreign material may
nevertheless remain in the upper or lower airways and cause
complications later. Victims with a persistent cough, difficulty
swallowing, or the sensation of an object being still stuck in the
throat should, therefore, be referred for a medical opinion. Abdominal
thrusts and chest compressions can potentially cause serious internal
injuries and all victims successfully treated with these measures
should be examined by a qualified practitioner.
Conflict of interest
TO declares research funding from Laerdal Foundation and Zoll
Foundation. JS declares his role as an editor of Resuscitation; he
declares institutional research funding for the Audit-7 project. MS
reports unspecified institutional research funding. GR declares his
role of consultant for Zoll; he reports research grant from Zoll for the
AMSA trial and other Institutional grants: EU Horizon 2020 support
for ESCAPE-NET, Fondazione Sestini support for the project
“CPArtrial”, EU Horizon 2020 and Coordination and support for the
action “iProcureSecurity”.GDP reports funding from Elsevier for his
role as an editor of the journal Resuscitation. He reports research
funding from the National Institute for Health Research in relation to
the PARAMEDIC2 trial and the RESPECT project and from the
Resuscitation Council UK and British Heart Foundation for the
OHCAO Registry. AH declared his role of Medical advisor British
Airways and Medical Director of Places for People.
Acknowledgement
The Writing Group acknowledges the contributions by Tommaso
Scquizzato in drafting the “How technology can help” section. GDP is
supported by the by the National Institute for Health Research (NIHR)
Applied Research Collaboration (ARC) West Midlands. The views
expressed are those of the author(s) and not necessarily those of the
NIHR or the Department of Health and Social Care.
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 RESUSCITATION 161 (2021) 115 151

Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Adult advanced life support

Jasmeet Soar a, *, Bernd W. Böttiger b , Pierre Carli c , Keith Couper d,

Charles D. Deakin e , Therese Djärv f , Carsten Lott g , Theresa Olasveengen h ,
Peter Paal i , Tommaso Pellis j , Gavin D. Perkins k , Claudio Sandroni l,m , Jerry P. Nolan n
a
Southmead Hospital, North Bristol NHS Trust, Bristol, UK
b
Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
c
SAMU de Paris, Centre Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris
Descartes, Paris, France
d
Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick,
Coventry,UK
e
University Hospital Southampton NHS Foundation Trust, Southampton, UK; South Central Ambulance Service NHS Foundation Trust,
Otterbourne,UK
f
Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden, Department of Medicine Solna, Karolinska Institutet,
Stockholm, Sweden
g
Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet Mainz, Germany
h
Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
i
Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
j
Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Italy
k
University of Warwick, Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, Coventry, UK
l
Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
m
Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
n
University of Warwick, Warwick Medical School, Coventry, CV4 7AL; Royal United Hospital, Bath, UK

Abstract
These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary
Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital
cardiac arrest and out-of-hospital cardiac arrest.

Introduction
Adult advanced life support (ALS) includes the advanced interven-
tions that follow basic life support (BLS) and use of an automated
external defibrillator (AED). Basic life support continues during and
overlaps with ALS interventions.
This ALS section includes the prevention and treatment of both in-
hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest cardiac
arrest (OHCA), the ALS algorithm, manual defibrillation, airway
management during cardiopulmonary resuscitation (CPR), drugs and
their delivery during CPR, and the treatment of peri-arrest arrhythmias.
These Guidelines are based on the International Liaison
Committee on Resuscitation (ILCOR) 2020 Consensus on Science
and Treatment Recommendations (CoSTR) for ALS.1 For these ERC

* Corresponding author.
E-mail address: jasmeet.soar@nbt.nhs.uk (J. Soar).
https://doi.org/10.1016/j.resuscitation.2021.02.010

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
116 RESUSCITATION 161 (2021) 115
Guidelines the ILCOR recommendations were supplemented by
focused literature reviews undertaken by the ERC ALS Writing Group
for those topics not reviewed in the 2020 ILCOR CoSTR. When
required, the guidelines were informed by the expert consensus of the
writing group membership.
The ERC has also produced guidance on cardiac arrest for patients
with coronavirus disease 2019 (COVID-19),2 which is based on an
ILCOR CoSTR and systematic review.3,4 Our understanding of the
optimal treatment of patients with COVID-19 and the risk of virus
transmission and infection of rescuers is poorly understood and
evolving. Please check ERC and national guidelines for the latest
guidance and local policies for both treatment and rescuer precautions.
Guidelines were drafted and agreed by the ALS Writing Group
members before posting for public comment between 21 October and
5 November 2020. Twenty-five individuals from 11 countries made
109 comments. Review of these comments led to 46 changes. The
Guideline was presented to and approved by the ERC General
Assembly on 10th December 2020. The methodology used for
guideline development is presented in the Executive summary.4a
Summary of key changes
 There are no major changes in the 2020 Adult ALS Guidelines.
 There is a greater recognition that patients with both in- and out-of-
hospital cardiac arrest have premonitory signs, and that many of
these arrests may be preventable.
 High quality chest compressions with minimal interruption and
early defibrillation remain priorities.
 During CPR, start with basic airway techniques and progress
stepwise according to the skills of the rescuer until effective
ventilation is achieved. If an advanced airway is required, rescuers
with a high tracheal intubation success rate should use tracheal
intubation. The expert consensus is that a high success rate is
over 95% within two attempts at intubation.
 When adrenaline is used it should be used as soon as possible
when the cardiac arrest rhythm is non-shockable cardiac arrest, and
after 3 defibrillation attempts for a shockable cardiac arrest rhythm.
 The guideline recognises the increasing role of point-of-care
ultrasound (POCUS) in peri-arrest care for diagnosis, but
emphasise that it requires a skilled operator, and the need to
minimise interruptions during chest compression.
 The guideline reflects the increasing evidence for extracorporeal
CPR (eCPR) as a rescue therapy for selected patients with cardiac
arrest when conventional ALS measures are failing or to facilitate
specific interventions (e.g. coronary angiography and percutane-
ous coronary intervention (PCI), pulmonary thrombectomy for
massive pulmonary embolism, rewarming after hypothermic
cardiac arrest) in settings in which it can be implemented.
 These ERC guidelines have followed European and international
guidelines for the treatment of peri-arrest arrhythmias.
Key messages from this section are presented in Fig. 1.
Concise guidelines for clinical practice
Prevention of in-hospital cardiac arrest
 The ERC supports shared decision making and advanced care
planning which integrates resuscitation decisions with emergency
care treatment plans to increase clarity of treatment goals and also
151
prevent inadvertent deprivation of other indicated treatments,
besides CPR. These plans should be recorded in a consistent
manner (See Ethics section).
 Hospitals should use a track and trigger early warning score
system for the early identification of patients who are critically ill or
at risk of clinical deterioration.
 Hospitals should train staff in the recognition, monitoring and
immediate care of the acutely-ill patient.
 Hospitals should empower all staff to call for help when they identify
a patient at risk of physiological deterioration. This includes calls
based on clinical concern, rather than solely on vital signs.
 Hospitals should have a clear policy for the clinical response to
abnormal vital signs and critical illness. This may include a critical
care outreach service and, or emergency team (e.g. medical
emergency team, rapid response team).
 Hospital staff should use structured communication tools to
ensure effective handover of information.
 Patients should receive care in a clinical area that has the
appropriate staffing, skills, and facilities for their severity of illness.
 Hospitals should review cardiac arrest events to identify
opportunities for system improvement and share key learning
points with hospital staff.
Prevention of out-of-hospital cardiac arrest
 Symptoms such as syncope (especially during exercise, while
sitting or supine), palpitations, dizziness and sudden shortness of
breath that are consistent with an arrhythmia should be
investigated.
 Apparently healthy young adults who suffer sudden cardiac death
(SCD) can also have signs and symptoms (e.g. syncope/pre-
syncope, chest pain and palpitations) that should alert healthcare
professionals to seek expert help to prevent cardiac arrest.
 Young adults presenting with characteristic symptoms of
arrhythmic syncope should have a specialist cardiology assess-
ment, which should include an electrocardiogram (ECG) and in
most cases echocardiography and an exercise test.
 Systematic evaluation in a clinic specialising in the care of those at
risk for SCD is recommended in family members of young victims
of SCD or those with a known cardiac disorder resulting in an
increased risk of SCD.
 Identification of individuals with inherited conditions and screening
of family members can help prevent deaths in young people with
inherited heart disorders.
 Follow current European Society of Cardiology (ESC) guidelines
for the diagnosis and management of syncope.
Treatment of in-hospital cardiac arrest
 Hospital systems should aim to recognise cardiac arrest, start
CPR immediately, and defibrillate rapidly (<3 min) when
appropriate.
 All hospital staff should be able to rapidly recognise cardiac arrest,
call for help, start CPR and defibrillate (attach an AED and follow
the AED prompts, or use a manual defibrillator).
 European hospitals should adopt a standard “Cardiac Arrest Call”
telephone number (2222).
 Hospitals should have a resuscitation team that immediately
responds to IHCAs.
 RESUSCITATION 161 (2021) 115 151 117

Fig. 1 – ALS summary

 The hospital resuscitation team should include team members
who have completed an accredited adult ALS course.
 Resuscitation team members should have the key skills and
knowledge to manage a cardiac arrest including manual
defibrillation, advanced airway management, intravenous access,
intra-osseous access, and identification and treatment of revers-
ible causes.
 The resuscitation team should meet at the beginning of each shift
for introductions and allocation of team roles.
 Hospitals should standardise resuscitation equipment.
 Start ALS as early as possible.
 Emergency medical systems (EMS) should consider implement-
ing criteria for the withholding and termination of resuscitation
(TOR) taking in to consideration specific local legal, organizational
and cultural context (see Ethics section)
 Systems should define criteria for the withholding and termination of
CPR, and ensure criteria are validated locally (see the Ethics section).
 Emergency medical systems (EMS) should monitor staff exposure
to resuscitation and low exposure should be addressed to
increase EMS team experience in resuscitation.
118 RESUSCITATION 161 (2021) 115
 Adult patients with non-traumatic OHCA should be considered for
transport to a cardiac arrest centre according to local protocols
(see Systems saving lives)
Manual defibrillation
Defibrillation strategy
 Continue CPR while a defibrillator is retrieved and pads applied.
 Give a shock as early as possible when appropriate.
 Deliver shocks with minimal interruption to chest compression, and
minimise the pre-shock and post-shock pause. This is achieved by
continuing chest compressions during defibrillator charging, deliver-
ing defibrillation with an interruption in chest compressions of less
than 5 s and then immediately resuming chest compressions.
 Immediately resume chest compressions after shock delivery. If
there is a combination of clinical and physiological signs of return
of spontaneous circulation (ROSC) such as waking, purposeful
movement, arterial waveform or a sharp rise in end-tidal carbon
dioxide (ETCO2), consider stopping chest compressions for
rhythm analysis, and if appropriate a pulse check.
Safe and effective defibrillation
 Minimise the risk of fire by taking off any oxygen mask or nasal
cannulae and place them at least 1 m away from the patient’s
chest. Ventilator circuits should remain attached.
 Antero-lateral pad position is the position of choice for initial pad
placement. Ensure that the apical (lateral) pad is positioned
correctly (mid-axillary line, level with the V6 pad position) i.e. below
the armpit.
 In patients with an implantable device, place the pad > 8 cm away
from the device, or use an alternative pad position. Also consider
an alternate pad position when the patient is in the prone position
(bi-axillary), or in a refractory shockable rhythm (see below).
 A shock can be safely delivered without interrupting mechanical
chest compression.
 During manual chest compressions, ‘hands-on’ defibrillation, even
when wearing clinical gloves, is a risk to the rescuer.
Energy levels and number of shocks
 Use single shocks where indicated, followed by a 2 min cycle of
chest compressions.
 The use of up to three-stacked shocks may be considered only
if initial ventricular fibrillation/pulseless ventricular tachycardia
(VF/pVT) occurs during a witnessed, monitored cardiac arrest with
a defibrillator immediately available e.g. during cardiac catheter-
isation or in a high dependency area.
 Defibrillation shock energy levels are unchanged from the 2015
guidelines:
For biphasic waveforms (rectilinear biphasic or biphasic
truncated exponential), deliver the first shock with an energy
of at least 150 J.
For pulsed biphasic waveforms, deliver the first shock at
120 150 J.
 If the rescuer is unaware of the recommended energy settings of
the defibrillator, for an adult use the highest energy setting for all
shocks.
Recurrent or refractory VF
 Consider escalating the shock energy, after a failed shock and for
patients where refibrillation occurs.
151
 For refractory VF, consider using an alternative defibrillation pad
position (e.g. anterior- posterior)
 Do not use dual (double) sequential defibrillation for refractory VF
outside of a research setting.
Airway and ventilation
 During CPR, start with basic airway techniques and progress
stepwise according to the skills of the rescuer until effective
ventilation is achieved.
 If an advanced airway is required, rescuers with a high tracheal
intubation success rate should use tracheal intubation. The expert
consensus is that a high success rate is over 95% within two
attempts at intubation.
 Aim for less than a 5 s interruption in chest compression for
tracheal intubation.
 Use direct or video laryngoscopy for tracheal intubation according
to local protocols and rescuer experience
 Use waveform capnography to confirm tracheal tube position.
 Give the highest feasible inspired oxygen during CPR.
 Give each breath over 1 s to achieve a visible chest rise.
 Once a tracheal tube or a supraglottic airway (SGA) has been
inserted, ventilate the lungs at a rate of 10 min 1 and continue
chest compressions without pausing during ventilations. With a
SGA, if gas leakage results in inadequate ventilation, pause
compressions for ventilation using a compression-ventilation ratio
of 30:2.
Drugs and fluids
Vascular access
 Attempt intravenous (IV) access first to enable drug delivery in
adults in cardiac arrest.
 Consider intraosseous (IO) access if attempts at IV access are
unsuccessful or IV access is not feasible
Vasopressor drugs
 Give adrenaline 1 mg IV (IO) as soon as possible for adult patients
in cardiac arrest with a non-shockable rhythm.
 Give adrenaline 1 mg IV (IO) after the 3rd shock for adult patients in
cardiac arrest with a shockable rhythm.
 Repeat adrenaline 1 mg IV (IO) every 3 5 min whilst ALS
continues.
Antiarrhythmic drugs
 Give amiodarone 300 mg IV(IO) for adult patients in cardiac arrest
who are in VF/pVT after three shocks have been administered.
 Give a further dose of amiodarone 150 mg IV (IO) for adult patients
in cardiac arrest who are in VF/pVT after five shocks have been
administered.
 Lidocaine 100 mg IV (IO) may be used as an alternative if
amiodarone is not available or a local decision has been made to
use lidocaine instead of amiodarone. An additional bolus of
lidocaine 50 mg can also be given after five defibrillation attempts.
Thrombolytic drugs
 Consider thrombolytic drug therapy when pulmonary embolus is
the suspected or confirmed cause of cardiac arrest.
 Consider CPR for 60 90 min after administration of thrombolytic
drugs.
 RESUSCITATION 161 (2021) 115
Fluids
Severe heart failure manifested by pulmonary oedema
 Give IV (IO) fluids only where the cardiac arrest is caused by or
possibly caused by hypovolaemia.
Myocardial ischaemia may present with chest pain (angina) or
Waveform capnography during advanced life support
 Use waveform capnography to confirm correct tracheal tube
placement during CPR.
 Use waveform capnography to monitor the quality of CPR.
 An increase in ETCO2 during CPR may indicate that ROSC has
occurred. However, chest compression should not be interrupted
based on this sign alone.
 Although high and increasing ETCO2 values are associated with
increased rates of ROSC and survival after CPR, do not use a low
ETCO2 value alone to decide if a resuscitation attempt should be
stopped.
Use of ultrasound imaging during advanced life support
An initial synchronised shock at maximum defibrillator output
 Only skilled operators should use intra-arrest point-of-care
ultrasound (POCUS).
 POCUS must not cause additional or prolonged interruptions in
Give an initial shock of 70 120 J.
chest compressions.
Give subsequent shocks using stepwise increases in energy.
 POCUS may be useful to diagnose treatable causes of cardiac
arrest such as cardiac tamponade and pneumothorax.
 Right ventricular dilation in isolation during cardiac arrest should
not be used to diagnose massive pulmonary embolism.
 Do not use POCUS for assessing contractility of the myocardium
as a sole indicator for terminating CPR.
Mechanical chest compression devices
 Consider mechanical chest compressions only if high-quality
manual chest compression is not practical or compromises
provider safety.
 When a mechanical chest compression device is used, minimise
interruptions to chest compression during device use by using only
trained teams familiar with the device.
Extracorporeal CPR
 Consider extracorporeal CPR (eCPR) as a rescue therapy for
selected patients with cardiac arrest when conventional ALS
measures are failing or to facilitate specific interventions (e.g.
coronary angiography and percutaneous coronary intervention
(PCI), pulmonary thrombectomy for massive pulmonary embo-
lism, rewarming after hypothermic cardiac arrest) in settings in
which it can be implemented.
Peri-arrest arrhythmias
 The assessment and treatment of all arrhythmias addresses the
condition of the patient (stable versus unstable) and the nature of
the arrhythmia. Life-threatening features in an unstable patient
include:
Shock appreciated as hypotension (e.g. systolic blood
pressure < 90 mmHg) and symptoms of increased sympathetic
activity and reduced cerebral blood flow.
Syncope as a consequence of reduced cerebral blood flow.
151 119
(failure of the left ventricle) and/or raised jugular venous
pressure (failure of the right ventricle).
may occur without pain as an isolated finding on the 12-lead
ECG (silent ischaemia).
Tachycardias
 Electrical cardioversion is the preferred treatment for tachyar-
rhythmia in the unstable patient displaying potentially life-
threatening adverse signs.
 Conscious patients require anaesthesia or sedation, before
attempting synchronised cardioversion.
 To convert atrial or ventricular tachyarrhythmias, the shock must
be synchronised to occur with the R wave of the electrocardiogram
(ECG).
 For atrial fibrillation:
rather than an escalating approach is a reasonable strategy
based on current data.
 For atrial flutter and paroxysmal supraventricular tachycardia:
 For ventricular tachycardia with a pulse:
Use energy levels of 120 150 J for the initial shock.
Consider stepwise increases if the first shock fails to achieve
sinus rhythm.
 If cardioversion fails to restore sinus rhythm and the patient
remains unstable, give amiodarone 300 mg intravenously over
10 20 min (or procainamide 10 15 mg/kg over 20 min) and re-
attempt electrical cardioversion. The loading dose of amiodarone
can be followed by an infusion of 900 mg over 24 h.
 If the patient with tachycardia is stable (no adverse signs or
symptoms) and is not deteriorating, pharmacological treatment
may be possible.
 Consider amiodarone for acute heart rate control in AF patients
with haemodynamic instability and severely reduced left ventricu-
lar ejection fraction (LVEF). For patients with LVEF < 40%
consider the smallest dose of beta-blocker to achieve a heart
rate less than 110 min-1 . Add digoxin if necessary.
Bradycardia
 If bradycardia is accompanied by adverse signs, give atropine
500 mg IV (IO) and, if necessary, repeat every 3 5 min to a total of
3 mg.
 If treatment with atropine is ineffective, consider second line drugs.
These include isoprenaline (5 mg min 1 starting dose), and
adrenaline (2 10 mg min 1).
 For bradycardia caused by inferior myocardial infarction, cardiac
transplant or spinal cord injury, consider giving aminophylline
(100 200 mg slow intravenous injection).
 Consider giving glucagon if beta-blockers or calcium channel
blockers are a potential cause of the bradycardia.
 Do not give atropine to patients with cardiac transplants it can
cause a high-degree AV block or even sinus arrest use
aminophylline.
 Consider pacing in patients who are unstable, with symptomatic
bradycardia refractory to drug therapies.
 If transthoracic pacing is ineffective, consider transvenous pacing.
120 RESUSCITATION 161 (2021) 115
 Whenever a diagnosis of asystole is made, check the ECG
carefully for the presence of P waves because unlike true asystole,
this is more likely to respond to cardiac pacing.
 If atropine is ineffective and transcutaneous pacing is not
immediately available, fist pacing can be attempted while waiting
for pacing equipment.
Uncontrolled organ donation after circulatory death
 When there is no ROSC, consider uncontrolled organ donation
after circulatory death in settings where there is an established
programme, and in accordance with local protocols and
legislation.
Debriefing
 Use data-driven, performance-focused debriefing of rescuers to
improve CPR quality and patient outcomes.
Evidence informing the guidelines
Prevention of in-hospital cardiac arrest (IHCA)
In-hospital cardiac arrest (IHCA) occurs in about 1.5 patients per 1000
admitted to hospital.5,6 There are two main strategies to prevent
cardiac arrest and the need for attempted CPR:
 Patient-focussed decision-making to determine if CPR is
appropriate.
 Identifying and treating physiological deterioration early to prevent
cardiac arrest.
Emergency care treatment and CPR decisions
Most patients who die in hospital do not have a resuscitation attempt.7 10
The ERC Ethics guidelines promote shared decision making and
advanced care planning which integrates resuscitation decisions with
emergency care treatment plans to increase clarity of treatment goals
and also prevent inadvertent deprivation of other indicated treatments,
besides CPR. Further information is provided in the Ethics section.
Physiological deterioration
In-hospital cardiac arrest is often preceded by physiological deterio-
ration.11,12 This provides an opportunity to recognise deterioration and
prevent the cardiac arrest. The 5 key steps have been conceptualised
as the in-hospital chain of survival: 'staff education', 'monitoring',
'recognition', the 'call for help' and the 'response'.13 This ERC
guidance is based on an ILCOR COSTR and systematic review of
adult rapid response systems, and UK guidance for early warning
scores and recognising and responding to deterioration of acutely-ill
adults in hospital.14 16
Staff education
Education should include measurement of vital signs, a structured
ABCDE-type approach that includes assessment and initial
treatment interventions, use of structured communication tools
such as Situation-Background-Assessment-Recommendation
(SBAR), and how to call for help and escalate care.15 Staff should
also know how to implement local policies about do-not-attempt
CPR (DNACPR) decisions, treatment escalation plans, and starting
end-of-life care.
151
Monitoring
Most cases of IHCA have an initial non-shockable rhythm and
preceding signs of respiratory depression or shock are common.5,6,17
To help detect deterioration and critical illness early, all patients
should have a documented plan for vital sign monitoring that includes
which physiological measurements should be recorded and how
frequently. This can be addressed by using a standardised early
warning score (EWS) system for all patients. The choice of system
depends on local circumstances and should align with national
guidelines. For example in the UK the National Early Warning Score 2
(NEWS2) is endorsed by the National Institute for Health and Care
Excellence (NICE) guidelines.14,15 Higher trained nurse staffing levels
are associated with lower rates of failure-to-respond to abnormal vital
signs, and the quality of patient care.18,19 There is a lack of
randomised controlled trials (RCTs) or consensus on which patients
should undergo continuous ECG monitoring. In a registry-based
study, settings where patients are closely monitored are associated
with improved survival irrespective of initial rhythm.20
Recognition
Strategies to simplify and standardise tracking of a patient's condition,
and recognising acute illness or deterioration, and triggering a
response include early warning score (EWS) systems.
These systems have a predefined graded and escalating response
according to the patient’s EWS. The EWS is used to identify ward
patients needing escalation of care, increasing vital sign monitoring,
and may improve identification of deterioration, and reduce time to
emergency team activation.21 Clinical concern from nurses and other
members of the multidisciplinary team can also indicate patient
deterioration.22,23
The call for help
All staff should be empowered to call for help and also trained to use
structured communication tools such as SBAR (situation-back-
ground-assessment-recommendation) to ensure effective communi-
cation.24 26 The response to patients who are critically ill or who are at
risk of becoming critically ill is often provided by a medical emergency
team (MET), rapid response team (RRT), or critical care outreach
team (CCOT). Any member of the health-care team can initiate a
MET/RRT/CCOT call. In some hospitals, the patient, and their family
and friends, are also encouraged to activate the team.27 29
Response
The response to patients who are or at risk of being critically ill is often
provided by a MET/RRT/CCOT. These teams usually comprise critical
care medical and nursing staff who respond to specific calling criteria.
They replace or coexist with traditional cardiac arrest teams, which
typically only respond to patients already in cardiac arrest. Systematic
reviews, meta-analyses and multicentre studies suggest that RRT/
MET/CCOT systems reduce the rate of IHCA and hospital mortali-
ty.30,31 These data led ILCOR to suggest that hospitals consider the
introduction of rapid response systems (rapid response team/medical
emergency team) to reduce the incidence of IHCA and in-hospital
mortality (weak recommendation, low-quality evidence).16 Team
interventions often involve simple tasks such as starting oxygen
therapy and intravenous fluids, as well as more complex decision-
making such as transferring the patient to the intensive care unit (ICU)
or initiating discussions regarding DNACPR, treatment escalation or
end-of-life care plans (See Ethics section). An important part of the
response is to place a patient at risk of deterioration, or an already
 RESUSCITATION 161 (2021) 115
deteriorating patient, in an appropriate setting. Patients should be
treated in a clinical area that is equipped and staffed to meet the
patient’s needs.
Prevention of out-of-hospital cardiac arrest (OHCA)
In industrialised countries, sudden cardiac death (SCD) is the third
leading cause of death. Survival following out-of-hospital cardiac
arrest (OHCA) is only 10% or less,32 34 which makes prevention of
OHCA important.35 Apparently healthy young adults who sustain SCD
can also have signs and symptoms (e.g. syncope/pre-syncope, chest
pain and palpitations) that should alert healthcare professionals to
seek expert help to prevent cardiac arrest.36 45
There is no systematic review on this topic. A search on 26
February 2020 using the terms “out-of-hospital cardiac arrest” AND
“prevention” limited to clinical trials and reviews since 1 January 2015
identified 65 articles. The references of these articles were also
reviewed. Existing guidelines of the European Society of Cardiology
(ESC), the American Heart Association (AHA) and European
Resuscitation Council (ERC) were considered.
Epidemiology and pathophysiology of sudden cardiac death
Coronary heart disease (CHD) accounts for 80% of SCD, especially in
older patients, and non-ischaemic cardiomyopathies account for
another 10 15%.46 In the young, inherited diseases, congenital heart
disease, myocarditis and substance abuse are predominant causes.
Knowledge of the causes of SCD will assist in early treatment and the
prevention of OHCA (Table 1).
Coronary heart disease (CHD)
Arrhythmias triggered by acute myocardial infarction (AMI) or
subsequent myocardial scarring can result in SCD.48 About two-
thirds of SCDs occur as the first CHD event or in individuals
considered to be at low risk.46 During the last 50 years primary
prevention and secondary revascularisation have reduced CHD age-
adjusted mortality.46 The percentage of SCDs associated with CHD
remains unchanged suggesting that there are interactions between
CHD and triggering events such as autonomic nervous system
dysfunction, electrolyte disturbances, drug toxicity and individual
genetic profiles.46 Cardiac electrophysiology studies can identify
patients with CHD at high versus low risk of SCD.49 Additional factors
such as heart failure (HF) and left ventricular hypertrophy (LVH)
predispose to ventricular arrhythmias (polymorphic ventricular
tachycardia [VT] and VF]). How to identify patients at high risk of
SCD with HF and LVH is uncertain.50 Changes in left ventricular
geometry affect the likelihood of developing VT and VF. High blood
levels of B-type natriuretic peptide (BNP) and its N-terminal fragment
(NT-proBNP) are associated with higher rates of appropriate
implantable cardioverter defibrillator (ICD) placement and mortali-
ty.51,52 The only indicator that has been identified to be consistently
associated with an increased risk of SCD in the setting of CHD and left
ventricular (LV) dysfunction is LV ejection fraction (LVEF).48 LVEF is
used to indicate the need for an implantable cardioverter defibrillator
(ICD) for the primary and secondary prevention of SCD.53 Despite
considerable progress, the ability to recognise the risk of SCD before
the event remains very limited.48
SCD in the young
SCD in the young (SCDY, 5 35 years of age) accounts for 7% of all
SCDs;47 the incidence is 1 8/100 000 fatalities per year.54 In
151 121
Table 1 – Causes of sudden cardiac arrest (SCD).
Adapted from Kandala46 and Winkel.47.
Coronary heart disease
ST-segment elevation
Other myocardial infarction
Unstable angina
Silent ischaemia
Electrical heart disease, often associated with SCD in the young
Long QT-syndrome (LQTS)
Short QT syndrome
Brugada syndrome
Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
Triadin knock-out syndrome (TKOS)
Arrhythmogenic bi-leaflet mitral valve prolapse (ABiMVPS))
Drug or medication induced
Non-atherosclerotic coronary artery anomalies
Congenital heart disease
Hypertrophic cardiomyopathy (HCM)
Dilated cardiomyopathy (DCM)
Valvular heart disease
adolescent SCD, 50% of patients had misinterpreted symptoms
before death.44 CHD is the most frequent cause of explained SCDY;
25 31% of the cases remain unexplained after post mortem
examination (Sudden Arrhythmic Death Syndrome- SADS).47 The
majority of inherited cardiac diseases can be treated if diagnosed, yet
most young SCD victims are not diagnosed.42 Premonitory signs of
SCDY were present in only 29% in one study, and thus lower than in
older patients.55 QT-prolonging and psychotropic drugs, alone or in
combination, increase the risk of SCD.56 Post mortem examination is
crucial to identify inherited cardiac disease in unexplained cases of
SCD; this should result in a cardiac investigation of first-degree
relatives. This screening resulted in a diagnosis of an inherited cardiac
disease in over half of the families.57 In a large retrospective SCDY
study, a cause was identified in 113/180 patients (62.8%), the rest
were classified as idiopathic VF.58 With improvements in diagnosis
(e.g. provocation drug testing for cardiac channelopathies and
coronary vasospasm, genetical testing), the number of unexplained
SCDs should decrease.58 (See the Epidemiology section).35
Non-atherosclerotic coronary artery anomalies
Coronary artery embolism, coronary arteritis (e.g. Kawasaki disease,
polyarteritis nodosa), spasm and myocardial bridging have all been
described with SCD.
Congenital heart disease
Congenital coronary anomalies are present in 1% of all patients. SCD
because of congenital coronary anomalies is exercise-related and
accounts for 17% of SCD in young athletes.46,55
Hypertrophic cardiomyopathy (HCM)
Hypertrophic cardiomyopathy is the most common genetic disorder of
the heart, with 1 in 200 500 cases, and it is the most frequent cause of
SCDY.59 It often remains clinically silent until SCD presents as the first
cardiac event. The incidence of SCD in families with HCM may be 2-
4% a year and 4-6% in children and adolescents.46
Premonitory signs
Approximately 50% of cardiac arrests occur in individuals with
undiagnosed CHD. 48,60 Many SCD victims have a history of cardiac
disease and warning signs before cardiac arrest, most commonly
122 RESUSCITATION 161 (2021) 115 151

chest or upper abdominal pain or dyspnoea that has not been acted on
by the patient or health care professionals.61,62 Approximately one
third of elderly patients will have symptoms in the days or hours before
cardiac arrest; primarily chest pain, dyspnoea, syncope and/or cold
sweats.62,63 In 1960 OHCA patients, 9.4% had been assessed by an
ambulance crew within the preceding 48 h.64 Emergency care in
patients with symptoms is associated with improved survival.61 Early
recognition of acute coronary syndrome (ACS) by emergency medical
system (EMS) teams with 12-lead ECG capabilities and reduction of
time to reperfusion may prevent SCD.65 The most effective approach
to prevent SCD in the general population remains the quantification of
the individual risk of developing CHD followed by control of risk
factors.65 Syncope can be an important premonitory sign of SCD.
Syncope
Syncope occurring during strenuous exercise, while sitting or in the
supine position should always raise the suspicion of a cardiac cause;
in other situations it is more likely to be vasovagal syncope or postural
hypotension.65 In patients with known cardiac disease, syncope (with
or without prodrome particularly recent or recurrent) is an independent
risk factor for increased risk of death.53,59,66 76 High-risk (suggesting
a serious condition) and low-risk features (suggesting a benign
condition) of patients with syncope at initial evaluation in the
emergency department have been published by the ESC (Table 2).53
Early EMS acquisition of a 12 lead-ECG may be helpful.
Screening programs for athletes may be helpful but vary between
countries.88,89 In one study from the United Kingdom between 1996
and 2016 11,168 athletes received cardiovascular screening and
diseases associated with SCD were identified in 0.38% (n = 42).90
Preventive measures against SCD
Prevention of SCD is focused on the associated medical conditions
that may contribute to or exacerbate arrhythmia, the risk posed by
arrhythmia and the risk-benefit of a given therapy. Interventions
include anti-arrhythmic drugs, implantable cardioverter defibrillators
(ICD), and ablation or surgery.53,91 Noninvasive telemetry or
implantable devices transmitting the ECG are currently used in
selected group of patients to detect high risk arrhythmias and prevent
SCD. More recently, connected devices with arrhythmia detection
capabilities (smartwatch, smartphone applications) have been

Table 2 – High risk features suggesting a serious condition in patients with syncope at initial evaluation in the
emergency department. Adapted from Brignole 2018.53 ECG electrocardiogram; ICD implantable cardioverter defibrillator; LVEF left
ventricular ejection fraction; SCD sudden cardiac death; VT ventricular tachycardia.

Syncopal event features

Major
New onset of chest discomfort, breathlessness, abdominal pain or headache77 79
Syncope during exertion or when supine80
Sudden onset palpitation immediately followed by syncope80
Minor
No warning symptoms or short (<10 s) prodrome 80 83
Family history of SCD at young age84
Syncope in the sitting position85
Past medical history
Major
Severe structural or coronary artery disease (heart failure, low LVEF or previous myocardial infarction)77,79
Physical examination
Major
Unexplained systolic blood pressure <90 mmHg77,79
Persistent bradycardia (<40 min 1) in awake state in absence of physical training
Undiagnosed systolic murmur
ECG
Major
ECG changes consistent with acute ischaemia
Mobitz II second- and third-degree atrioventricular (AV) block
Slow atrial fibrillation (AF) (<40 min 1)
Persistent sinus bradycardia (<40 min 1) or repetitive sinoatrial block or sinus pauses >3 s in awake state in absence of physical training
Bundle branch block, intraventricular conduction disturbance, ventricular hypertrophy or Q waves consistent with ischaemic heart disease or cardiomyopathy78,83
Sustained and non-sustained VT
Dysfunction of an implantable cardiac device (pacemaker or ICD)
Type 1 Brugada pattern
ST-segment elevation with type 1 morphology in leads V1-V3 (Brugada pattern)
QTc >460 ms in repeated 12-lead ECGs indicating long QT syndrome (LQTS)86
Minor (high-risk only if history consistent with arrhythmic syncope)
Mobitz I second-degree AV block and 1st degree AV block with markedly prolonged PR interval
Asymptomatic inappropriate mild sinus bradycardia (40 50 bpm.)83
Paroxysmal supraventricular (SVT) or atrial fibrillation87
Pre-excited QRS complex
Short QTc interval (< = 340 ms)86
Atypical Brugada patterns86
Negative T waves in right precordial leads, epsilon waves suggestive of arrhythmogenic right ventricular cardiomyopathy (ARVC)86
 RESUSCITATION 161 (2021) 115
introduced and may be helpful in detecting asymptomatic AF, however
their potential role in the general population to detect SCD arrhythmias
is unknown.92,93 Public education to report on symptoms before SCD
and to help a persons in cardiac arrest are important.61
Treatment of in-hospital cardiac arrest (IHCA)
Cardiac arrest treatment principles, such as rapid defibrillation and
delivery of high-quality CPR, are consistent across both the IHCA and
OHCA settings. In the hospital setting, the immediate availability of
trained clinical staff and equipment provides an opportunity for the
rapid identification of cardiac arrest and initiation of treatment. An
IHCA can be defined as any cardiac arrest that occurs on the hospital
premises. This can include a cardiac arrest in patients, hospital visitors
or staff, in a variety of hospital settings. For IHCA, BLS and ALS
interventions can often start and take place at the same time (see
Fig. 2). These guidelines are based on the ILCOR CoSTR,1 the 2015
ERC ALS Guidelines21 and ERC Quality Standards for CPR Practice
and Training.94
ILCOR undertook a systematic review of accredited training in
adult ALS. The review included eight observational studies and
identified benefits of ALS for ROSC and survival to hospital discharge
or 30-days.16 ILCOR also undertook a systematic review on team and
leadership training including sixteen RCTs and three observational
studies identifying a benefit for patient survival as well as skill
performance.16
First responders
The clinical skill of a first responder may range from a non-clinical
member of staff trained in BLS to an ALS provider. Irrespective of skill
level, the initial action of the first responder is to recognise cardiac
arrest, immediately start CPR, call for help and facilitate rapid
defibrillation. Delays in starting treatment reduce the likelihood of a
successful outcome.95,96
The process for calling for help may differ between hospitals or
locations within a hospital. If the responder is alone, they may need to
leave the patient to call for help. Where a telephone system is used to
activate the emergency team, the standard European number (2222)
should be used.97
Following the completion of initial actions and provided sufficient
staff are available, staff should collect ALS equipment and prepare to
handover to the resuscitation team using either the SBAR (Situation,
Background, Assessment, Recommendation) or RSVP (Reason,
Story, Vital Signs, Plan) systems.24,98,99 Each clinical area in a
hospital should consider patient acuity, risk of cardiac arrest, and
geographical location (i.e. distance for the resuscitation team to travel)
in determining the specific training needs of staff.
Resuscitation team
The resuscitation team may take the form of a traditional cardiac arrest
team that responds only to cardiac arrest events or a MET/RRT
(medical emergency team/ rapid response team) that responds to
both cardiac arrests and critically unwell patients. The ILCOR
recommends accredited ALS level training for healthcare staff (weak
recommendation based on very low certainty evidence) as ALS
training is associated with increased ROSC and patient survival.16
ILCOR also recommends team and leadership training (weak
recommendation based on very low certainty evidence) because it
is associated with improved patient and process-outcomes.16
Resuscitation teams often form on an ad hoc basis depending on
151 123
hospital work rosters and include individuals from a range of
specialities (e.g. acute medicine, cardiology, critical care). Lack of
knowledge of team member roles, including who is acting as team
leader can lead to errors during CPR for IHCA.100,101 A team meeting
at the beginning of each shift for introductions and allocation of roles
may support effective team-working during resuscitation.
Equipment
Hospitals should ensure that clinical areas should have immediate
access to resuscitation equipment and drugs to facilitate rapid
resuscitation of the patient in cardiac arrest. Missing or malfunctioning
equipment contributes to treatment delays.100,102 Equipment should
be standardised throughout the hospital and equipment checked
regularly.
Treatment of out-of-hospital cardiac arrest
This section provides an overview of specific ALS issues related to
CPR for OHCA. Further information is available in the sections Basic
life support (BLS), Cardiac Arrest in Special Circumstances, Systems
of Care, Epidemiology, Post-resuscitation care, and Ethics. The aim of
ALS for OHCA is to provide the same interventions as available in
hospital as early as possible, and to rapidly transfer the patient to
hospital for those interventions that are not feasible out-of-hospital.
Three ILCOR systematic reviews were identified.103,103a108 A
focused search on 13 March limited to clinical trials and reviews since
1 January 2015 identified 612 articles. The titles and abstracts were
screened and pertaining articles included.
Initial ALS treatment of OHCA
Several patient and CPR factors affect outcome from OHCA (Table 3).
Community programs of lay bystander CPR and AED use improve
outcome from OHCA.104 Chest compressions and early defibrillation
are the cornerstones of CPR in OHCA. The only definitive treatment
for VF remains prompt defibrillation.105
EMS personnel and interventions
ILCOR performed a systematic review of EMS exposure to and
experience of OHCA on outcome.103 The largest study in this review
linked exposure of paramedics to OHCA, defined as the number of
times a paramedic had attended an OHCA, to patient survival to
hospital discharge.106 Increasing exposure in the preceding three
years was associated with increased survival to discharge:  6
exposure (control group), >6-11 exposures (adjusted odds ratio
(aOR) 1.26, 95% CI 1.04 1.54), 11 17 exposures (aOR 1.29, 95%CI
1.04 1.59), >17 exposures (aOR 1.50, 95%CI 1.22 1.86).106
Another large observational study reported that increased exposure
of the treating paramedic was associated with increased ROSC
(<15 exposures, control group vs.  15 exposures (aOR 1.22, 95%CI
1.11 1.36).107 The ILCOR CoSTR concluded that EMS should
monitor exposure of their clinical personnel to resuscitation and
implement strategies to address low exposure or ensure that treating
teams have members with recent exposure (weak recommendation,
very-low certainty of evidence).
Termination of CPR rules
Termination of resuscitation (TOR) rules are used by many EMS. An
ILCOR systematic review on the use of TOR rules found that
implementing the currently studied TOR rules would result in some
missed survivors.103a ILCOR recommended the use of TOR rules to
124 RESUSCITATION 161 (2021) 115 151

Fig. 2 – In-hospital resuscitation algorithm. AED automated external defibrillator; ALS advanced life support; CPR cardiopulmonary
resuscitation; SBAR situation, background, assessment, recommendation.
 RESUSCITATION 161 (2021) 115
Table 3 – Patient and CPR factors affecting outcome
from OHCA. Adapted from Kandala 2017.46 AED automated
external defibrillation; CPR cardiopulmonary resuscitation.
Patient
Age
Sex
Comorbidities
Cardiac function
Pulmonary function
Renal function
Trauma
Special circumstances
Cardiopulmonary resuscitation
Location (private vs. public)
Witnessed vs. unwitnessed cardiac arrest
Bystander CPR
Type of bystander CPR (compression only vs. standard)
First cardiac arrest rhythm
Use of AED by bystander
Time to return of spontaneous circulation
assist clinicians in deciding whether to discontinue resuscitation
efforts at the scene or to transport the patient to the hospital with
ongoing CPR (weak recommendation, very-low certainty evidence).
Decisions to terminate resuscitation should also take into account the
local legal, organizational, and cultural context. EMS personnel
working in systems where TOR by non-physicians is not legal or
culturally acceptable should transport patients with ongoing CPR to
hospital. The Ethics section provides more specific guidance on the
use of termination of resuscitation rules.
Care at cardiac arrest centres
An ILCOR systematic review assessed the benefits of care at a
dedicated cardiac arrest centre (CAC).16,108 The resulting ILCOR
treatment recommendations included:
 We suggest adult non-traumatic OHCA cardiac arrest patients be
cared for in cardiac arrest centres rather than in non-cardiac arrest
centres (weak recommendation, very low certainty of evidence).
 We cannot make a recommendation for or against regional triage
of OHCA patients to a cardiac arrest centre by primary EMS
transport (bypass protocols) or secondary interfacility transfer.
For further information about cardiac arrest centres see sections
on Systems Saving Lives and Post Resuscitation Care.
ALS treatment algorithm
Cardiac arrest is associated with either shockable rhythms (ventricular
fibrillation/pulseless ventricular tachycardia (VF/pVT)) or non-shock-
able rhythms (asystole and pulseless electrical activity (PEA)). The
main difference in the treatment of shockable rhythms is the need for
attempted defibrillation. Other interventions, including high-quality
chest compressions with minimal interruption, airway management
and ventilation, venous access, administration of adrenaline and the
identification and treatment of reversible causes, are common for all
arrests. The ALS algorithm (Fig. 3) provides an overview of these key
interventions. These are based on the expert consensus of the writing
group. The ALS cardiac arrest algorithm is applicable to all cardiac
arrests. Additional interventions may be indicated for cardiac arrest
caused by special circumstances.
151 125
Manual defibrillation
Defibrillation is a vital component of CPR as it has the potential to
terminate VF/pVT and achieve ROSC. Defibrillation is indicated in
approximately 20% of cardiac arrests. As its effectiveness decreases
with time and VF duration, defibrillation attempts must be timely, whilst
remaining efficient and safe. Knowledge of how to use a defibrillator
(manual or AED) is key for rescuers performing advanced life support.
Rescuers who use a manual defibrillator should aim to take less than 5 s
to recognise a shockable cardiac arrest rhythm and make the decision
to give a shock in order to minimise interruption to chest compressions.
Since 2015, ERC defibrillation guidelines have referred solely to
biphasic energy waveforms and in these 2020 guidelines we refer only
to the use of defibrillation pads (rather than paddles).21
The evidence for this section is based on ILCOR 2020 CoSTRs,
the ERC 2015 ALS Guidelines, and expert consensus.1,21,104
Strategies for minimising the peri-shock pause
The delay between stopping chest compressions and shock delivery (the
pre-shock pause) must be kept to an absolute minimum; even a 5 10 s
delay will reduce the chances of the shock being successful.109 114 The
pre-shock pause can be reduced to less than 5 s by continuing
compressions during charging of the defibrillator and by having an
efficient team coordinated by a leader who communicates effective-
ly.115,116 The safety check to avoid rescuer contact with the patient at the
moment of defibrillation should be undertaken rapidly but efficiently. The
delay between shock delivery and recommencing chest compressions
(the post-shock pause) is minimised by immediately resuming chest
compressions after shock delivery.1 If there are clinical and physiological
signs of ROSC (e.g. arterial waveform, increase in ETCO2), chest
compressions can be paused briefly for rhythm analysis. The entire
process of manual defibrillation should be achievable with less than a 5 s
interruption to chest compressions.
CPR versus defibrillation as the initial treatment
A 2020 ILCOR systematic review addressed whether a specified period
(typically 1.5 3 min) of chest compressions before shock delivery
compared with a short period of chest compressions before shock
delivery affected resuscitation outcomes. Outcomes were no different
when CPR was provided for up to 180 s before attempted defibrillation,
compared with rhythm analysis and attempted defibrillation first.104
Therefore, the routine delivery of a pre-specified period of CPR (e.g. 2
3 min) before rhythm analysis and a shock is delivered is not
recommended. Rescuers should provide a short period of CPR until the
defibrillator is ready for rhythm analysis in unmonitored cardiac arrest
(weak recommendation, low-certainty evidence). Defibrillation should
then be delivered as indicated, without delay. Immediate defibrillation of
VF of any amplitude should be attempted at the end of each 2 min cycle.
The 2015 ERC ALS Guideline stated that if there is doubt about
whether the rhythm is asystole or extremely fine VF, do not attempt
defibrillation; instead, continue chest compressions and ventilation.21
We wish to clarify that when the rhythm is clearly judged to be VF a
shock should be given.
Anticipatory defibrillator charging
Using this method, the defibrillator is charged as the end of a
compression cycle is approached, but before the rhythm is checked.
When compressions are paused briefly to check rhythm, a shock can
be delivered immediately (if indicated) from a defibrillator that is
already charged, avoiding a period of further chest compressions
126 RESUSCITATION 161 (2021) 115 151

Fig. 3 – Advanced Life Support algorithm. ABCDE airway, breathing, circulation, disability, exposure CPR cardiopulmonary resuscitation;
ECG electrocardiogram; EMS emergency medical system; PEA pulseless electrical activity; PaCO2 arterial partial pressure of carbon dioxide;
ROSC return of spontaneous circulation; SpO2 arterial oxygen saturation; VF ventricular fibrillation; VT ventricular tachycardia.

while the defibrillator is charged. This method was reviewed by ILCOR
in 2020 as the technique is already in use as an alternative to the
conventional sequence.117 Manikin studies show anticipatory charg-
ing is feasible, can reduce the overall interruption to chest
compression, but increases pre- post, and peri-shock pause duration.
This technique may be a reasonable alternative for use by well-drilled
teams that can minimise pre- post, and peri-shock pause duration.
Clinical studies are required to determine the best technique for
manual defibrillation.
Safe use of oxygen during defibrillation
In an oxygen-enriched atmosphere, sparking from poorly applied
defibrillator paddles can cause a fire and significant burns to the
patient.118 123 Although defibrillation pads may be safer than paddles
with regards to arcing and spark generation, recommendations for the
safe use of oxygen during defibrillation remain unchanged in these
guidelines. The risk of fire during attempted defibrillation can be
minimised by taking the following precautions:
 Take off any oxygen mask or nasal cannulae and place them at
least 1 m away from the patient’s chest.
 Leave the ventilation bag or ventilation circuit connected to the
tracheal tube or supraglottic airway, any oxygen exhaust is
directed away from the chest.
 If the patient is connected to a ventilator, for example in the
operating room or critical care unit, leave the ventilator tubing
(breathing circuit) connected to the tracheal tube.
Pad contact with the chest and anatomical position
There is no new evidence since the 2015 guidelines regarding optimal
defibrillation pad position.21 The techniques described below aim to
place external defibrillation pads (self-adhesive pads) in an optimal
position to maximise transmyocardial current density and minimise
transthoracic impedance. No human studies have evaluated the pad
position as a determinant of ROSC or survival from VF/pVT.104
Transmyocardial current during defibrillation is likely to be maximal
when pads are placed so that the area of the heart that is fibrillating lies
directly between them (i.e. ventricles in VF/pVT, atria in AF).
Therefore, the optimal pad position may not be the same for
ventricular and atrial arrhythmias.
Pad placement for ventricular arrhythmias and cardiac arrest
Place pads in the conventional antero-lateral (sternal-apical) position.
The right (sternal) pad is placed to the right of the sternum, below the
clavicle. The apical pad is placed in the left mid-axillary line,
approximately level with the V6 ECG electrode. This position should
be clear of any breast tissue.124 It is important that this pad is placed
 RESUSCITATION 161 (2021) 115
sufficiently laterally (Fig. 4) and in practical terms, the pad should be
placed just below the armpit.125 Other acceptable pad positions
include:
 Placement of each pad on the lateral chest walls, one on the right
and the other on the left side (bi-axillary).
 One pad in the standard apical position and the other on the right
upper back.
 One pad anteriorly, over the left precordium, and the other pad
posteriorly to the heart just inferior to the left scapula.
Either pad can be placed in either position (apex or sternal). An
observational study in patients undergoing elective cardioversion with
external defibrillator paddles showed that transthoracic impedance
was lower when the paddle was orientated in a cranio-caudal
direction.126 Consider shaving the chest if it is very hairy and the
electrodes will not stick firmly. Do not delay shock delivery, and
consider alternative pad positions if necessary.
Pad placement for atrial arrhythmias
Atrial fibrillation is usually maintained by functional re-entry circuits in
the left atrium. As the left atrium is located posteriorly in the thorax, pad
positions that result in a more posterior current pathway may
theoretically be more effective for atrial arrhythmias. Although some
studies have shown that antero-posterior pad placement is more
effective than the traditional antero-apical position in elective
cardioversion of atrial fibrillation,127,128 the majority have failed to
show any clear advantage of any specific pad position.129 132 Efficacy
of cardioversion may be less dependent on pad position when using
biphasic impedance-compensated waveforms.131 133 The following
pad positions are safe and effective for cardioversion of atrial
arrhythmias:
Fig. 4 – Correct pad placement for defibrillation (© Charles Deakin).
151 127
 Traditional sternal-apical position.
 Antero-posterior position (one pad anteriorly, over the left
precordium, and the other pad posteriorly to the heart just inferior
to the left scapula).
Pad placement to avoid implantable medical devices
More patients are presenting with implantable medical devices (e.g.
permanent pacemaker, implantable cardioverter defibrillator (ICD)).
Medic Alert bracelets are recommended for these patients. These
devices may be damaged during defibrillation if current is discharged
through pads placed directly over the device.134,135 Place the pad
away from the device (at least 8 cm) or use an alternative pad position
(anterior-lateral, anterior-posterior).134,136
Hands-on defibrillation
By allowing continuous chest compressions during the delivery of the
defibrillation shock, hands-on defibrillation can minimise peri-shock
pause and allow continuation of chest compressions during
defibrillation. The benefits of this approach are unproven and further
studies are required to assess the safety and efficacy of this technique.
A post-hoc analysis of a multi-centre trial did not observe any benefit
when shocks were delivered without pausing manual or mechanical
chest compressions.137 Only Class 1 electrical safety gloves, but not
standard clinical examination gloves (or bare hands) provide a safe
level of electrical insulation for hands-on defibrillation.138 There have
been no new studies since the 2015 guidelines and the recommen-
dation therefore remain unchanged.21
Respiratory phase
Positive end expiratory pressure (PEEP) increases transthoracic
impedance and should be minimised where possible during
128 RESUSCITATION 161 (2021) 115
defibrillation. Auto-PEEP (gas trapping) may be particularly high in
patients with asthma and may necessitate higher than usual energy
values for defibrillation.139
One shock versus three stacked shock sequence
In 2010, it was recommended that when defibrillation was required, a
single shock should be provided with immediate resumption of chest
compressions after the shock.140,141 This recommendation was made
for two reasons. Firstly, to minimise peri-shock interruptions to chest
compressions and secondly, given the greater efficacy of biphasic
shocks, if a biphasic shock failed to defibrillate, a further period of chest
compressions could be beneficial. Studies have not shown that any
specific shock strategy is of benefit for any survival end-point.142,143
There is no conclusive evidence that a single-shock strategy is of benefit
for ROSC or recurrence of VF compared with three stacked shocks, but
in view of the evidence suggesting that outcome is improved by
minimising interruptions to chest compressions, we continue in 2020 to
recommend single shocks for most situations (see below).
When defibrillation is warranted, give a single shock and resume
chest compressions immediately following the shock.104 Do not delay
CPR for rhythm reanalysis or a pulse check immediately after a shock.
Continue CPR for 2 min until rhythm reanalysis is undertaken and
another shock given (if indicated). Even if the defibrillation attempt is
successful, it takes time until the post shock circulation is established
and it is very rare for a pulse to be palpable immediately after
defibrillation.144,145 Patients can remain pulseless for over 2 min and
the duration of asystole before ROSC can be longer than 2 min in as
many as 25% of successful shocks.146 In patients where defibrillation
achieves a perfusing rhythm, the effect of chest compressions on re-
inducing VF is not clear.147
If a patient has a monitored and witnessed cardiac arrest (e.g. in
the catheter laboratory, coronary care unit, or other monitored critical
care setting in or out-of-hospital) and a manual defibrillator is rapidly
available:
 Confirm cardiac arrest and shout for help.
 If the initial rhythm is VF/pVT, give up to three quick successive
(stacked) shocks.
 Rapidly check for a rhythm change and, if appropriate, ROSC after
each defibrillation attempt.
 Start chest compressions and continue CPR for 2 min if the third
shock is unsuccessful.
This three-shock strategy may also be considered for an initial,
witnessed VF/pVT cardiac arrest if the patient is already connected to
a manual defibrillator. Although there are no data supporting a three-
shock strategy in any of these circumstances, it is unlikely that chest
compressions will improve the already very high chance of ROSC
when defibrillation occurs early in the electrical phase, immediately
after onset of VF/pVT (expert opinion).
Fibrillation waveform analysis
It is possible to predict, with varying reliability, the success of
defibrillation from the fibrillation waveform.148 170 If optimal defibrilla-
tion waveforms and the optimal timing of shock delivery can be
determined in prospective studies, it should be possible to prevent the
delivery of unsuccessful high energy shocks and minimise myocardial
injury. This technology is under active development and investigation,
but current sensitivity and specificity are insufficient to enable
introduction of VF waveform analysis into clinical practice. Although
one large RCT,171 and 20 observational studies172 191 published
151
since the 2010 guidelines review 140,141 have shown promise and
some improvements in this technology, there remains insufficient
evidence to support routine use of VF waveform analysis to guide the
optimal timing for a shock attempt.1,104
Waveforms
Biphasic waveforms are now well established as a safe and effective
waveform for defibrillation. Biphasic defibrillators compensate for the
wide variations in transthoracic impedance by electronically adjusting
the waveform magnitude and duration to ensure optimal current
delivery to the myocardium, irrespective of the patient’s size
(impedance compensation). There are two main types of biphasic
waveform: the biphasic truncated exponential (BTE) and rectilinear
biphasic (RLB). A pulsed biphasic waveform is also in clinical use, in
which the current rapidly oscillates between baseline and a positive
value before inverting in a negative pattern.21
Energy levels
Defibrillation requires the delivery of sufficient electrical energy to
defibrillate a critical mass of myocardium, abolish the wavefronts of VF
and enable restoration of spontaneous synchronised electrical activity
in the form of an organised rhythm. The optimal energy for defibrillation
is that which achieves defibrillation whilst causing the minimum of
myocardial damage.192 Selection of an appropriate energy level also
reduces the number of repetitive shocks, which in turn limits
myocardial damage.193
Optimal energy levels for defibrillation are unknown. The
recommendations for energy levels are based on a consensus
following careful review of the current literature. Although delivered
energy levels are selected for defibrillation, it is the transmyocardial
current flow that achieves defibrillation; the electrical current
correlates well with successful defibrillation and cardioversion.194
Defibrillation shock energy levels are unchanged from the 2015
guidelines.21
First shock
Relatively few studies have been published with which to refine the
current defibrillation energy levels set in the 2010 guidelines.195
There is no evidence that one biphasic waveform or device is more
effective than another. First shock efficacy of the BTE waveform
using 150 200 J has been reported as 86-98%.196 200 First shock
efficacy of the RLB waveform using 120 J has been reported as
85%.201 Four studies have suggested equivalence with lower and
higher starting energy biphasic defibrillation.202 205 although one
has suggested that initial low energy (150 J) defibrillation is
associated with better survival.206 Although human studies have
not shown harm (raised biomarkers, ECG changes, ejection
fraction) from any biphasic waveform up to 360 J,202,207 several
animal studies have suggested the potential for harm with higher
energy levels.208 211
The initial biphasic shock should be no lower than 120 J for RLB
waveforms and at least 150 J for BTE waveforms. For pulsed biphasic
waveforms, begin at 120 150 J. Ideally, the initial biphasic shock
energy should be at least 150 J for all biphasic waveforms in order to
simplify energy levels across all defibrillators, particularly because the
type of waveform delivered by a defibrillator is not marked.
Manufacturers should display the effective waveform dose range
on the face of the biphasic defibrillator. If the rescuer is unaware of the
recommended energy settings of the defibrillator, for an adult use the
highest energy setting for all shocks (expert opinion).
 RESUSCITATION 161 (2021) 115
Second and subsequent shocks
The 2010 guidelines recommended either a fixed or escalating energy
strategy for defibrillation. Several studies show that although an
escalating strategy reduces the number of shocks required to restore
an organised rhythm compared with fixed-dose biphasic defibrillation,
and may be needed for successful defibrillation,212,213 rates of ROSC
or survival to hospital discharge are not significantly different between
strategies.202 204 Conversely, a biphasic protocol using a fixed
energy level showed high cardioversion rates (>90%) but significantly
lower ROSC rate for recurrent VF could not be excluded.214 Several
in-hospital studies using an escalating shock energy strategy have
shown improvement in cardioversion rates (compared with fixed dose
protocols) in non-arrest rhythms.215 220
In 2020, there remains no evidence to support either a fixed or
escalating energy protocol. Both strategies are acceptable; however,
if the first shock is not successful and the defibrillator is capable of
delivering shocks of higher energy it is reasonable to increase the
energy for subsequent shocks.
Recurrent ventricular fibrillation (refibrillation)
Recurrence of fibrillation is usually defined as ‘recurrence of VF during
a documented cardiac arrest episode, occurring after initial termina-
tion of VF while the patient remains under the care of the same
providers (usually out-of-hospital).’ Refibrillation is common and
occurs in >50% of patients following initial first-shock termination of
VF.212 Two studies showed termination rates of subsequent
refibrillation were unchanged when using fixed 120 J or 150 J shock
protocols respectively,214,221 but a larger study showed termination
rates of refibrillation declined when using repeated 200 J shocks,
unless an increased energy level (360 J) was selected.212 In a
retrospective analysis, conversion of VF to an organised rhythm was
higher if the VF had first appeared after a perfusing rhythm, than after
PEA or asystole.222
In view of the larger study suggesting benefit from higher
subsequent energy levels for refibrillation,212 we recommend that if
a shockable rhythm recurs after successful defibrillation with ROSC,
and the defibrillator is capable of delivering shocks of higher energy, it
is reasonable to increase the energy for subsequent shocks.
Refractory ventricular fibrillation
Refractory VF is defined as fibrillation that persists after three or more
shocks and occurs in approximately 20% of patients who present in
VF.212 Duration of VF correlates negatively with good outcome.
Actively search for and correct any reversible causes (Fig. 3 ALS
algorithm). Ensure that the defibrillation energy output is on the
maximum setting an escalating protocol may be more effective in
treating refractory VF. Check that the defibrillation pads are placed
correctly (particularly the apical pad, when using the antero-lateral pad
position). Consider using an alternative defibrillation pad orientation
(e.g. antero-posterior).
Dual/double sequential defibrillation
Patients in refractory VF have significantly lower rates of survival
than patients who respond to standard resuscitation treatments.
Double sequential defibrillation is the use of two defibrillators to
deliver two overlapping shocks or two rapid sequential shocks, one
with standard pad placement and the other with either anterior-
posterior or additional antero-lateral pad placement. The tech-
nique has been suggested as a possible means of increasing VF
termination rates. With numerous case reports and some
151 129
observational studies,223 230 ILCOR reviewed the efficacy of
this technique and based on very low certainty evidence made a
weak recommendation against the routine use of a double
sequential defibrillation strategy in comparison with standard
defibrillation strategy for cardiac arrest with a refractory shockable
rhythm.1,231
Analysis of rhythm during chest compression
New software technology in some defibrillators enables removal of
ECG motion artefact generated during chest compressions in order
to show the real-time underlying waveform during CPR. An ILCOR
systematic review found no studies in humans evaluating this
technology leading to a weak recommendation based on very low
certainty evidence to suggest against the routine use of artifact-
filtering algorithms for analysis of electrocardiographic rhythm
during CPR.104 In making its recommendation, ILCOR placed a
priority on avoiding the costs of a new technology where
effectiveness remains to be determined. The ILCOR task force
acknowledged that some EMS already use artifact-filtering algo-
rithms for rhythm analysis during CPR, and strongly encouraged
EMS to report their experience to build the evidence base regarding
these technologies in clinical practice.
Implantable cardioverter defibrillators
Implantable cardioverter defibrillators (ICDs) are becoming increas-
ingly common as they are implanted more frequently in an aging
population. They are implanted because a patient is at risk from, or has
had, a life-threatening shockable arrhythmia. They are usually
embedded under the pectoral muscle below the left clavicle (in a
similar position to pacemakers, from which they cannot be
immediately distinguished). More recently, extravascular devices
can be implanted subcutaneously in the left chest wall, with a lead
running parallel to the left of the sternum.232 In a recent randomised
controlled trial the subcutaneous ICD was non-inferior to the
transvenous ICD with respect to device-related complications and
inappropriate shocks.233
On sensing a shockable rhythm, an ICD will discharge approxi-
mately 40 J (approximately 80 J for subcutaneous devices) through an
internal pacing wire embedded in the right ventricle. On detecting VF/
pVT, ICD devices will discharge no more than eight times, but may
reset if they detect a new period of VF/pVT. Patients with fractured ICD
leads may suffer repeated internal defibrillation as the electrical noise
is mistaken for a shockable rhythm. In these circumstances, the
patient is likely to be conscious, with the ECG showing a relatively
normal rate. A magnet placed over the ICD will disable the defibrillation
function in these circumstances.136
Discharge of an ICD may cause pectoral muscle contraction in the
patient, and shocks to the rescuer have been documented.234 In view
of the low energy values discharged by conventional ICDs, it is unlikely
that any harm will come to the rescuer, but minimising contact with the
patient whilst the device is discharging is prudent. Surface current
from subcutaneous ICDs is significant and may cause a perceptible
shock to the rescuer.235,236 Cardioverter and pacing function should
always be re-evaluated following external defibrillation, both to check
the device itself and to check pacing/defibrillation thresholds of the
device leads.
Pacemaker spikes generated by devices programmed to unipolar
pacing may confuse AED software and emergency personnel, and
may prevent the detection of VF.237 The diagnostic algorithms of
modern AEDs can be insensitive to such spikes.
130 RESUSCITATION 161 (2021) 115
Airway and ventilation
In 2015 the ERC recommended a stepwise approach to airway
management during CPR.21 Three large RCTs of airway manage-
ment for OHCA have been published since 2015.238 240 Check the
latest ERC guidelines for COVID-19 precautions required during
airway management.
An ILCOR systematic review addressed whether a specific
advanced airway management strategy improved outcome from
cardiac arrest (CA) in comparison with an alternative airway
management strategy.241,242 Seventy-eight observational studies
were included; nine of these addressed the question of timing of
advanced airway management. Eleven controlled trials were
included but only three of these were RCTs.238 240 The first of
these RCTs compared early tracheal intubation (TI) with bag-mask
ventilation (TI delayed until after ROSC) in a physician-staffed EMS
system.239 The result of this non-inferiority trial that recruited over
2000 patients was inconclusive (4.3% versus 4.2% for 28-day
survival with favourable functional outcome (CPC 1 2), no
significant difference). Notably, the TI success rate was 98% and
146 patients in the bag-mask ventilation group underwent ‘rescue
intubation’ (i.e. crossed over); 100 of these were because of
regurgitation. In a comparison of initial laryngeal tube (LT) insertion
with TI in 3000 OHCAs by paramedics in the United States, 72-h
survival (primary outcome) was higher in the LT group (18.2%
versus 15.3%; p = 0.04).240 However, the overall TI success rate
was just 51% making it possible that the lower survival rate in the TI
group was a reflection of the poor TI success rate. The third of these
RCTs was a comparison of the initial insertion of an i-gel supraglottic
airway (SGA) with TI in OHCA treated by paramedics in the United
Kingdom (UK).238 Among the more than 9000 patients enrolled,
there was no difference in the primary outcome of favourable
functional survival (mRS  3; 6.4% versus 6.8%; P = 0.33).
A large observational cohort study of IHCA from the American
Heart Association (AHA) Get with the Guidelines-Resuscitation
(GWTG-R) registry matched patients intubated at any given minute
within the first 15 min after cardiac arrest onset, with patients still
receiving CPR at risk of being intubated within the same minute.243
The matching was based on a time-dependent propensity score and
matched 43,314 intubated patients with patients with same propensity
for intubation but who were not intubated in the same minute.
Compared with not intubating, TI was associated with a lower rate of
ROSC (risk ratio [RR] = 0.97; 95% CI 0.96 0.99; p < 0.001), lower
survival to hospital discharge (RR = 0.84; 95% CI 0.81 0.87;
p < 0.001), and worse neurological outcome (RR = 0.78; 95% CI
0.75 0.81; p < 0.001).
After reviewing the evidence for airway management during
cardiac arrest, the ILCOR ALS Task Force made the following
treatment recommendations:244
 We suggest using bag-mask ventilation or an advanced airway
strategy during CPR for adult cardiac arrest in any setting (weak
recommendation, low to moderate certainty of evidence).
 If an advanced airway is used, we suggest a SGA for adults with
OHCA in settings with a low TI success rate (weak recommenda-
tion, low certainty of evidence).
 If an advanced airway is used, we suggest an SGA or TI for adults
with OHCA in settings with a high TI success rate (weak
recommendation, very low certainty of evidence).
 If an advanced airway is used, we suggest an SGA or TI for adults
with IHCA (weak recommendation, very low certainty of evidence).
151
Patients often have more than one type of airway intervention,
typically starting with basic and advancing to more complex
techniques that are inevitably applied later during cardiac arrest
the stepwise approach.238,245 The best airway, or combination of
airway techniques will vary according to patient factors, the phase of
the resuscitation attempt (during CPR, after ROSC), and the skills of
rescuers. If basic airway techniques enable effective ventilation, there
may be no need to progress to advanced techniques until after ROSC.
One potential advantage of inserting an advanced airway is that it
enables chest compressions to be delivered continuously without
pausing during ventilation. Most patients with ROSC remain comatose
and will need tracheal intubation (TI) and mechanical ventilation (See
Post-resuscitation Care).246
Airway obstruction
Patients requiring resuscitation often have an obstructed airway,
usually secondary to loss of consciousness, but occasionally it may be
the primary cause of cardiorespiratory arrest. Prompt assessment,
with control of the airway and ventilation of the lungs, is essential. This
will help to prevent secondary hypoxic damage to the brain and other
vital organs. Without adequate oxygenation it may be impossible to
achieve ROSC. These principles may not apply to the witnessed
primary cardiac arrest in the vicinity of a defibrillator; in this case, the
priority is immediate defibrillation.
Basic airway management and adjuncts
There are three manoeuvres that may improve the patency of an
airway obstructed by the tongue or other upper airway structures:
head tilt, chin lift, and jaw thrust. Despite a total lack of published data
on the use of nasopharyngeal and oropharyngeal airways during
CPR, they are often helpful, and sometimes essential, to maintain an
open airway, particularly when CPR is prolonged.
Oxygen during CPR
During cardiac arrest the blood flow and oxygen reaching the brain is
low even with effective CPR. Based on the physiological rationale and
expert opinion, ILCOR recommends giving the highest feasible
inspired oxygen concentration during cardiac arrest to maximise
oxygen delivery to the brain thereby minimising hypoxic-ischaemic
injury.1 Immediately after ROSC, as soon as arterial blood oxygen
saturation can be monitored reliably (by pulse oximetry or arterial
blood gas analysis), titrate the inspired oxygen concentration to
maintain the arterial blood oxygen saturation between 94 98% or
arterial partial pressure of oxygen (PaO2) of 10 13 kPa or
75 100 mmHg. (See Post Resuscitation Care).246
Choking
The initial management of foreign body airway obstruction (choking) is
addressed in the BLS section.247,248 In an unconscious patient with
suspected foreign body airway obstruction if initial basic measures are
unsuccessful use laryngoscopy and forceps to remove the foreign
body under direct vision. To do this effectively requires training.104
Ventilation
Advanced life support providers should give artificial ventilation as
soon as possible for any patient in whom spontaneous ventilation is
inadequate or absent. This is usually achieved with a self-inflating bag
attached to a facemask or an advanced airway. Deliver each breath
over approximately 1 s, giving a volume that corresponds to normal
chest movement (expert opinion). The chest should visibly rise; this
 RESUSCITATION 161 (2021) 115
represents a compromise between giving an adequate volume,
minimizing the risk of gastric inflation, and allowing adequate time for
chest compressions. Although the delivery of continuous chest
compressions during face-mask ventilation was previously thought to
increase the risk of regurgitation, a trial of continuous versus
interrupted chest compressions during CPR (CCC Trial) that enrolled
more than 23,000 patients showed no statistically significant
difference in survival to discharge.249 ILCOR has subsequently
recommended that when using bag mask, EMS providers perform
CPR either using a 30:2 compression-ventilation ratio (pausing chest
compressions for ventilation) or continuous chest compressions
without pausing while delivering positive pressure ventilation (strong
recommendation, high-quality evidence).250 In Europe, the most
common approach during CPR with an unprotected airway is to give
two ventilations after each sequence of 30 chest compressions.
Once a tracheal tube (TT) or an SGA has been inserted, ventilate
the lungs at a rate of 10 min 1 and continue chest compressions
without pausing during ventilations (expert opinion).251 The laryngeal
seal achieved with an SGA may not be good enough to prevent at least
some gas leaking when inspiration coincides with chest compres-
sions. Moderate gas leakage is acceptable (unless there is a
significant risk of infection, e.g. see ERC COVID-19 Guidelines),
particularly as most of this gas will pass up through the patient’s
mouth. If excessive gas leakage results in inadequate ventilation of
the patient’s lungs, chest compressions will have to be interrupted to
enable ventilation, using a compression ventilation ratio of 30:2.
Passive oxygen delivery
In the presence of a patent airway, chest compressions alone may
result in some ventilation of the lungs.252 Oxygen can be delivered
passively, either via an adapted TT (Boussignac tube),253,254 or with
the combination of an oropharyngeal airway and standard oxygen
mask with non-rebreather reservoir.255 In theory, an SGA can also be
used to deliver oxygen passively but this has yet to be studied. One
study has shown higher neurologically favourable survival with
passive oxygen delivery (oral airway and oxygen mask) compared
with bag-mask ventilation after VF OHCA, but this was a retrospective
analysis and is subject to numerous confounders.255 The CCC Trial
included a subgroup of patients who were treated with passive
oxygenation but until further data are available, passive oxygen
delivery without ventilation is not recommended for routine use during
CPR.249
Choice of airway devices
Disadvantages of TI over bag-mask ventilation include:
 The risk of an unrecognised misplaced TT; in patients with OHCA
the reliably documented incidence ranges from 0.5% to 17%:
emergency physicians 0.5%;256 paramedics - 2.4%,257
258,259 260 261
6%, 9%, 17%.
 A prolonged period without chest compressions while TI is
attempted. In a study of prehospital TI by paramedics during 100
CA the total duration of the interruptions in CPR associated with TI
attempts was 110 s (IQR 54 - 198 s; range 13 446 s) and in 25%
the interruptions were more than 3 min.262 Tracheal intubation
attempts accounted for almost 25% of all CPR interruptions.
 A comparatively high failure rate. Intubation success rates
correlate with the TI experience attained by individual para-
medics.263 The high failure rate of 51% documented in the PART
trial240 is similar to those documented in some prehospital
systems more than 20 years ago.264,265
151 131
 Tracheal intubation is a difficult skill to acquire and maintain. In one
study, anaesthesia residents required about 125 intubations in the
operating room setting before they were able to achieve a TI
success rate of 95% under such optimal conditions.266
Healthcare personnel who undertake prehospital TI should do so
only within a structured, monitored program, which should include
comprehensive competency-based training and regular opportunities
to refresh skills (expert opinion).
The ILCOR recommendation is that only systems that achieve high
tracheal intubation success rates should use this technique.242 ILCOR
did not recommend a particular success rate but suggested it should
be similar to that achieved in the RCT comparing early tracheal
intubation with bag-mask ventilation (TI delayed until after ROSC) in a
physician-staffed EMS system.239 The TI success rate in this study
was 98%. The expert consensus of this writing group is that a high
success rate is greater than 95% with up to 2 intubation attempts.
Rescuers must weigh the risks and benefits of intubation against the
need to provide effective chest compressions. To avoid any interruptions
in chest compressions, unless alternative airway management techni-
ques are ineffective, it is reasonable to defer TI until after ROSC. In
settings with personnel skilled in advanced airway management
laryngoscopy should be undertaken without stopping chest compres-
sions; a brief pause in chest compressions will be required only as the
tube is passed through the vocal cords. The TI attempt should interrupt
chest compressions for less than 5 s (expert opinion); if intubation is not
achievable within these constraints, recommence bag-mask ventilation.
After TI, tube placement must be confirmed immediately (see below) and
the tube must be secured adequately.
Videolaryngoscopy
Videolaryngoscopy is being used increasingly in anaesthetic and
critical care practice.267,268 Preliminary studies indicate that com-
pared with direct laryngoscopy, videolaryngoscopy during CPR
improves laryngeal view and TI success rates,269,270 reduces the
risk of oesophageal intubation271 and reduces interruptions to chest
compressions.272 One systematic review concluded that in the
prehospital setting, videolaryngoscopy decreased the first-attempt TI
success rate (RR, 0.57; P < 0.01; high-quality evidence) and overall
success rate (RR, 0.58; 95% CI, 0.48 0.69; moderate-quality
evidence) by experienced operators.273 Several different video-
laryngoscopy systems are available and they do not all perform in the
same way. The expert consensus of the writing group is that the
rescuer’s choice of direct laryngoscopy or videolaryngoscopy should
be guided by local protocols and rescuer experience.
Confirmation of correct placement of the tracheal tube
Unrecognised oesophageal intubation is the most serious complica-
tion of attempted tracheal intubation. The evidence supporting the
guideline is summarised in longstanding ILCOR recommenda-
tions.1,274,275 Routine use of clinical assessment and immediate
capnography reduces this risk significantly.275,276 Initial assessment
includes observation of bilateral chest expansion, bilateral lung
auscultation in the axillae (breath sounds should be equal and
adequate) and over the epigastrium (breath sounds should be
absent). Clinical signs of correct TT placement (condensation in the
tube, chest rise, breath sounds on auscultation of lungs, and inability to
hear gas entering the stomach) are not reliable. The reported
sensitivity (proportion of TI correctly identified) and specificity
(proportion of oesophageal intubations correctly identified) of
132 RESUSCITATION 161 (2021) 115
clinical assessment varies: sensitivity 74 100%; specificity
66 100%.256,277 279
The ILCOR ALS Task Force recommends using waveform
capnography to immediately confirm and continuously monitor the
position of a TT during CPR in addition to clinical assessment (strong
recommendation, low quality evidence).275 Waveform capnography is
given a strong recommendation because it has other potential uses
during CPR (see below). The persistence of exhaled CO2 after six
ventilations indicates placement of the TT in the trachea or a main
bronchus.256 The ‘No Trace = Wrong Place’ campaign by the UK
Royal College of Anaesthetists emphasises that immediately after TI
(even during CA) the absence of exhaled CO2 strongly suggests
oesophageal intubation.280
Waveform capnography is the most sensitive and specific way to
confirm and continuously monitor the position of a TT in victims of
cardiac arrest and must supplement clinical assessment (visualization
of TT through cords and auscultation). Existing portable monitors
make capnographic initial confirmation and continuous monitoring of
TT position feasible in all out- and in-of-hospital settings where TI is
performed.
Ultrasonography of the neck or visualisation with a fibreoptic scope
by skilled operators can also be used to identify the presence of a
tracheal tube in the trachea. This requires additional equipment and
skills. These techniques were not formally reviewed for this guideline.
Cricoid pressure
The use of cricoid pressure in CA is not recommended (expert
consensus). Cricoid pressure can impair ventilation, laryngoscopy, TT
and SGA insertion, and may even cause complete airway obstruction.281
Securing the tracheal tube and supraglottic device
Accidental dislodgement of a TT can occur at any time but may be
more likely during CPR and during transport. An SGA is more prone to
being dislodged than a TT.238 The most effective method for securing
the TT or a SGA has yet to be determined. Use either conventional
tapes or ties, or purpose-made holders (Expert opinion).
Cricothyroidotomy
Occasionally it will be impossible to ventilate an apnoeic patient with a
bag-mask, or to pass a TT or SGA. This may occur in patients with
extensive facial trauma or laryngeal obstruction caused by oedema,
tumour or foreign material. In these circumstances, delivery of oxygen
through a surgical cricothyroidotomy may be lifesaving.282 A
tracheostomy is contraindicated in an emergency because it is time
consuming, hazardous and requires considerable surgical skill and
equipment.
Surgical cricothyroidotomy provides a definitive airway that can be
used to ventilate the patient’s lungs until semi-elective intubation or
tracheostomy is performed. Needle cricothyroidotomy is a much more
temporary procedure providing only short-term oxygenation and
minimal if any pulmonary CO2 removal.
Drugs and fluids
Vascular access
ILCOR suggests the intravenous route as opposed to the intra-
osseous route is used as the first attempt for drug administration
during adult cardiac arrest.1,283 This weak recommendation is based
on very low-certainty evidence drawn from three retrospective
observational studies which included 34,686 adult out-of-hospital
151
cardiac arrests which suggests worse outcomes when the IO route
was used.284 286 Since the ILCOR review, secondary analyses of the
PARAMEDIC2.287 and ALPS randomised trials288 suggested no
significant effect modification by drug administration route although
the studies were underpowered to assess for differences between the
IV and IO routes.
Consistent with ILCOR, the ERC suggests attempting IV access
first to enable drug delivery in adults in cardiac arrest. IO access may
be considered if unable to obtain IV access in adults in cardiac arrest.
Vasopressors
ILCOR reviewed the use of vasopressors in cardiac arrest
following the publication of the PARAMEDIC2 trial.242,289 System-
atic reviews and meta-analyses examined standard dose adrena-
line (1 mg) versus placebo, high dose (5 10 mg) versus standard
dose (1 mg) adrenaline, adrenaline versus vasopressin and
adrenaline and vasopressin versus adrenaline alone.290,291 The
reviews reported evidence that adrenaline (1 mg) improved the
rate of survival to hospital admission and long-term survival (to 3
months) but did not improve favourable neurological outcome. By
contrast, the use of high-dose adrenaline or vasopressin (with or
without adrenaline) did not improve long term survival or
favourable neurological outcome.
These data led to ILCOR upgrading the strength of recommenda-
tion to strong recommendation in favour of the use of adrenaline during
CPR (strong recommendation, low to moderate certainty of
evidence).242 The justification and evidence to decision framework
highlights that the Task Force placed a very high value on the apparent
life-preserving benefit of adrenaline, even if the absolute effect size is
likely to be small and the effect on survival with favourable neurological
outcome is uncertain.
The PARAMEDIC2 trial followed the ERC ALS 2015 Guidelines,
which recommended that adrenaline was given as soon as vascular
access is obtained for non-shockable rhythms and for shockable
rhythms, refractory to 3 attempts at defibrillation.21 Meta-analysis of
the two placebo-controlled trials (PACA and PARAMEDIC2) found
that the effects of adrenaline on ROSC relative to placebo were
greater for patients with an initially non-shockable rhythm than those
with a shockable rhythms.292 Similar patterns were observed for
longer term survival and favourable neurological outcomes, although
the differences in effects were less pronounced.292 A secondary
analysis which examined the time to drug administration in the
PARAMEDIC2 trial found that whilst the relative treatment effects of
adrenaline did not change over time, survival rates and favourable
neurological outcomes decreased over time, suggesting early
intervention would lead to the best outcomes.293
These findings led ILCOR to recommend that adrenaline is
administered as soon as feasible for non-shockable rhythms (PEA/
asystole) (strong recommendation, very low-certainty evidence). For
shockable rhythms (VF/pVT), ILCOR suggests administration of
adrenaline after initial defibrillation attempts are unsuccessful during
CPR (weak recommendation, very low-certainty evidence).
Consistent with the ILCOR Treatment Recommendations, the
ERC recommends adrenaline 1 mg IV (IO) is administered as soon as
possible for adult patients in cardiac arrest with a non-shockable
rhythm. For patients with a shockable rhythm persisting after 3 initial
shocks, give adrenaline 1 mg IV (IO). Repeat adrenaline 1 mg IV (IO)
every 3 5 min whilst ALS continues.
If 3 stacked shocks have been given for a witnessed and monitored
shockable cardiac arrest, these initial 3 stacked shocks should be
 RESUSCITATION 161 (2021) 115
considered as the first shock with regards to timing of the first dose of
adrenaline.
Consistent with the ILCOR treatment recommendation, the ERC
does not support the use of vasopressin during cardiac arrest.
Antiarrhythmic drugs
ILCOR updated the Consensus on Science and Treatment Recom-
mendation for antiarrhythmic drugs in 2018.294 No further relevant
studies were identified upon searching the literature to 10 February
2020.
The ILCOR systematic review identified evidence from 14
randomised controlled trials and 17 observational studies which
evaluated lidocaine, amiodarone, magnesium, bretylium, nifekalant
and procainamide.295 Meta-analysis of randomised trials in adults,
found that none of the anti-arrhythmic drugs improved survival or
favourable neurological outcome compared to placebo. Meta-
analysis showed that lidocaine compared to placebo improved ROSC
(RR = 1.16; 95% CI, 1.03 1.29, p = 0.01).
The largest and most recent randomised trial compared
amiodarone, lidocaine or placebo in patients with VF/pVT refractory
after at least one defibrillation attempt. Compared with placebo,
amiodarone and lidocaine increased survival to hospital admission.
However, there was no difference in survival to discharge or
favourable neurological survival at discharge between groups.296 In
the pre-defined sub-group of bystander witnessed cardiac arrests,
amiodarone and lidocaine increased survival to hospital discharge
compared with placebo. Survival was also higher with amiodarone
than with placebo after EMS-witnessed arrest.
These data led ILCOR to suggest that amiodarone or lidocaine
could be used in adults with shock refractory VF/pVT (weak
recommendation, low quality evidence).294 The values and prefer-
ences analysis indicates that the Task Force prioritised the pre-
defined and reported sub-group analysis from the ALPS study, which
showed greater survival with amiodarone and lidocaine in patients
with a witnessed cardiac arrest. ILCOR did not support the use of
magnesium, bretylium, nifekalant or procainamide.
The ERC updated its guidelines in 2018 to recommend that
amiodarone should be given after three defibrillation attempts,
irrespective of whether they are consecutive shocks, or interrupted
by CPR, or for recurrent VF/pVT during cardiac arrest.297 The initial
recommended dose is amiodarone 300 mg; a further dose of 150 mg
may be given after five defibrillation attempts. The recommendation in
favour of amiodarone was based on 21 of 24 National Resuscitation
Councils of Europe reporting that amiodarone was the main drug used
during CPR.297 Lidocaine 100 mg may be used as an alternative if
amiodarone is not available, or a local decision has been made to use
lidocaine instead of amiodarone. An additional bolus of lidocaine
50 mg can also be given after five defibrillation attempts.297
Thrombolytic therapy
The 2020 ILCOR Consensus on Science with Treatment Recom-
mendations pooled evidence from a sub-group analysis of the
TROICA trial298 and 4 observational studies299 302 which examined
the use of thrombolytic drugs in cardiac arrest caused by suspected or
confirmed pulmonary embolus (PE). The studies did not find evidence
that thrombolytic drugs improved neurological outcome.298,301 By
contrast, in one study, 30-day survival was higher in the intervention
group (16% vs 6%; P = 0.005)302 but not in 3 other studies which
examined survival to discharge.299 301 ROSC also improved in one
study300 but not two others.299,301 In making a weak recommendation
151 133
for the use of thrombolytic drugs for suspected or confirmed PE and
cardiac arrest based on very low certainty evidence, the ILCOR Task
Force considered the potential benefits outweighed the potential harm
from bleeding.1
The ERC endorses the recommendation from ILCOR, which aligns
with the ERC guidelines in 2015.21 The ERC does not support the
routine use of thrombolytic drugs in cardiac arrest, unless the cause is
suspected or confirmed PE. When thrombolytic drugs have been
administered, consider continuing CPR attempts for at least 60
90 min before termination of resuscitation attempts.303 305
Fluid therapy
No randomised controlled trials have evaluated the routine adminis-
tration of fluids versus no fluids as a treatment strategy for cardiac
arrest. Two large randomised trials provide indirect evidence from
treatment strategies designed to induce hypothermia which included
administration of up to 2 L ice cold intravenous fluids during OHCA306
or immediately after ROSC.307 The studies found no improvement in
short306,307 or long-term outcomes.308 The studies reported evidence
of reduced ROSC in patients with VF,306 increased rate of re-arrest,307
and higher rates of pulmonary oedema.306,307 It is not possible to
determine from these studies whether the harmful effects were related
to fluid volume per se or the temperature of the infused fluids.309
Nevertheless, based on expert consensus, the ERC maintains its
recommendation to avoid the routine infusion of large volume fluids in
the absence of evidence of suspicion of a hypovolaemic cause of the
cardiac arrest.
Waveform capnography during advanced life support
This guideline is based on an ILCOR evidence update and scoping
review,1 a recent systematic review,276 a narrative review310 and the
previous 2015 ERC ALS Guidelines.21 End-tidal carbon dioxide is the
partial pressure of carbon dioxide (PCO2) measured at the end of
expiration. It reflects cardiac output, tissue perfusion and pulmonary
blood flow, as well as the ventilation minute volume. Carbon dioxide is
produced in perfused tissues by aerobic metabolism, transported by
the venous system to the right side of the heart and pumped to the
lungs by the right ventricle, where it is removed by alveolar ventilation.
Waveform capnography enables a continuous, non-invasive
measurement of PCO2 in the exhaled air during CPR. In the typical
capnogram, the ETCO2 recorded at the end of the plateau phase best
reflects the alveolar PCO2. End-tidal CO2 is most reliable when the
patient’s trachea is intubated, but it can also be used with a SGA or bag
mask.311
The aims of monitoring waveform capnography during CPR
include:21,310
 Confirming correct tracheal tube placement (see airway
section).
 Monitoring the quality of CPR (ventilation rate and chest
compressions). Monitoring ventilation rate helps avoiding hyper-
ventilation during CPR. In a paediatric resuscitation model a
greater depth of chest compression was associated with higher
end-tidal CO2 values.312 Whether this can be used to guide care
and improve outcome requires further study.313
 Detecting ROSC during CPR. When ROSC occurs, end-tidal
CO2 may increase up to three times above the values during
CPR.314 Capnography may therefore help detect ROSC during
resuscitation and avoid unnecessary chest compression or
adrenaline in a patient with ROSC. However, no specific threshold
134 RESUSCITATION 161 (2021) 115
for the increase in end-tidal CO2 has been identified for reliable
diagnosis of ROSC. The increase in ETCO2 can start several
minutes before a palpable pulse is detected.315 317
 Prognostication during CPR. Failure to achieve an ETCO2
value >1.33 kPa (10 mmHg) during CPR is associated with a
poor outcome in observational studies276,318,319 This threshold
has also been suggested as a criterion to withhold e-CPR in
refractory cardiac arrest.320 However values of ETCO2 during
CPR depend on several factors including the timing of
measurement (initial vs. final,321,322 cause of cardiac arrest,
323,324
chest compression quality,312 ventilation rate and
325
volume, presence of airway closure during CPR326 and the
use of adrenaline.327,328 In general, ETCO2 tends to decrease
during CPR in patients in whom resuscitation is unsuccessful
and tends to increase in those who go on to achieve
ROSC.318,329 For this reason, ETCO2 trends might be more
appropriate than point values for predicting ROSC during
CPR.276 However, evidence on this is still limited.329 Studies
assessing the prognostic value of ETCO2 have not been blinded,
which may have caused a self-fulfilling prophecy. For this
reason, although an ETCO2 > 1.33 kPa (10 mmHg) measured
after tracheal intubation or after 20 min of CPR may be a
predictor of ROSC or survival to discharge, using ETCO2
threshold values alone as a mortality predictor or for the
decision to stop a resuscitation attempt is not recommended.1 In
selected patients, continue CPR to facilitate the implementation
of other technologies such as E-CPR, that buy time for
treatments that address a reversible cause of the cardiac arrest
(e.g. re-warming following accidental hypothermia, intra-arrest
primary percutaneous coronary intervention for acute myocar-
dial ischaemia).
Use of ultrasound imaging during advanced life support
Point-of-care ultrasound (POCUS) imaging is already commonly used
in emergency care settings. Its use during CPR is also increasing.
Previous and current guidance emphasises the need for skilled
POCUS operators.21
An ILCOR systematic review assessed the role of POCUS during
cardiac arrest as a prognostic tool.330 The review identified several
limitations such as inconsistent definitions and terminology around
sonographic evidence of cardiac motion, low inter-rater reliability of
findings, low sensitivity and specificity for outcomes, confounding from
self-fulfilling prophecy when terminating resuscitation in unblinded
settings as well as unspecified timing of POCUS.330 The review
concluded that no sonographic finding had sufficiently or consistently
high sensitivity to support its use as a sole criterion to terminate CPR.
The authors of the ILCOR systematic review advised that clinicians
should be cautious about introducing additional interruptions in chest
compressions with a transthoracic approach to POCUS during cardiac
arrest.1,331,332
POCUS can be used to diagnose treatable causes of cardiac
arrest such as cardiac tamponade or pneumothorax. The ERC ALS
2015 guidelines recommended a sub-xiphoid probe position placed
just before chest compressions are paused for a planned rhythm
assessment.21 [Soar 2015 100] These applications were not covered
in the ILCOR systematic review; however, the review stressed the
issue of over-interpreting the finding of right ventricular dilation in
isolation as a diagnostic indicator of massive pulmonary embolism.
Right ventricular dilation begins a few minutes after onset of cardiac
151
arrest as blood shifts from the systemic circulation to the right heart
along its pressure gradient.333 335 Right ventricular dilation was
consistently observed in a porcine model of cardiac arrest caused by
hypovolaemia, hyperkalaemia, and primary arrhythmia,336 and is a
common finding regardless of the cause of OHCA during trans-
oesophageal echocardiography performed in the emergency depart-
ment.337 At present, there is limited knowledge about the use POCUS
during CPR to assess deep vein thrombosis to help diagnose
pulmonary embolism, to assess for pleural effusion and FAST
(Focussed Assessment with Sonography for Trauma) assessment of
the abdomen and aorta.
Mechanical chest compression devices
Informed by evidence from 8 RCTs338 345 the ILCOR 2015 CoSTR
and ERC Guidelines did not recommend the routine use of automated
mechanical chest compression devices but did suggest that they are a
reasonable alternative when sustained high-quality manual chest
compressions are impractical or compromise provider safety.21,275
This evidence update focused on randomised controlled trials and
systematic reviews.
Two new randomised trials were identified.346,347 One study
examined the use of the Autopulse applied in the emergency
department following OHCA (n = 133). The trial found the rate of
survival to hospital discharge was higher in the Autopulse group
(18.8% versus 6.3%, p = 0.03) but no difference in favourable
neurological outcome (16.2% versus 13.4%). A randomized non-
inferiority safety study, involving 374 patients, reported that LUCAS
device did not cause significantly more serious or life-threatening
visceral damage than manual chest compressions. For the Autopulse
device, significantly more serious or life-threatening visceral damage
than manual compressions cannot be excluded.346
Six systematic reviews and meta-analyses were published since
the ILCOR review, including a Cochrane review.348 353 Significant
methodological errors in one systematic review and meta-analysis led
to its exclusion.354 Four reviews drew conclusions similar to the
ILCOR 2015 review, that mechanical CPR did not improve critical or
important outcomes.348 351 A review focusing solely on mechanical
CPR in the in-hospital setting, reported very low-certainty evidence
that mechanical chest compressions improved patient outcomes in
that setting.352 A Bayesian network meta-analysis reported that
manual CPR was more effective than Autopulse mechanical chest
compression device and comparable to LUCAS mechanical chest
compression device.353
The writing group considered that the new data did not materially
alter the previous ERC guidelines on the use of mechanical chest
compression devices in cardiac arrest.21
Circumstances to consider mechanical chest compression
devices
A review identified several specific circumstances where it is difficult to
deliver high-quality manual CPR where mechanical CPR can be
considered as an alternative.355 Examples include transporting to
hospital in an ambulance or helicopter, during percutaneous coronary
intervention, diagnostic imaging such as a CT scan, as a bridge to
establishing extra-corporeal CPR or maintaining circulation prior to
organ retrieval when resuscitation is unsuccessful. The expert
consensus is that mechanical devices should be considered when
high-quality manual compressions are not practical or pose a risk to
rescuer safety.
 RESUSCITATION 161 (2021) 115
Device deployment
Observational studies show that interruptions in chest compressions,
particularly immediately before or around the time of attempted
defibrillation are harmful.111,356 Some studies report long pauses in
chest compressions associated with mechanical chest compression
device deployment.357 359 Training those responsible for mechanical
device deployment can reduce interruptions to less than 15 s.358,360
The expert consensus is that mechanical devices should be used only
in settings where teams are trained in their deployment.
Extracorporeal CPR
Extracorporeal CPR (eCPR) is defined by the ELSO (Extracorporeal
Life Support Organization) as the application of rapid-deployment
veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to
provide circulatory support in patients in whom conventional CPR is
unsuccessful in achieving sustained ROSC.361 The use of eCPR has
increased for both IHCA and OHCA in recent years.362 365
The 2019 ILCOR CoSTR informed by a systematic review made
the following recommendation:242,244,366
 We suggest that eCPR may be considered as a rescue therapy for
selected patients with cardiac arrest when conventional CPR is
failing in settings in which it can be implemented (weak
recommendation, very low certainty of evidence).
There is one recent small randomised controlled trial of eCPR for
OHCA refractory VF cardiac arrest,367 and several others in progress.
There are no universally agreed indications for eCPR regarding which
patients and the optimum time-point during conventional ALS. There
are guidelines on when to start eCPR.320,363,368 370 Inclusion criteria
have not been used consistently or prospectively tested in trials.365
Commonly used criteria include:
 Witnessed cardiac arrest with bystander CPR.
 Time to establishing eCPR is less than 60 min from starting CPR.
 Younger patients (e.g. less than 65 70 years) and no major
comorbidities precluding a return to independent life.
 Known or suspected treatable underlying cause of cardiac arrest.
The role of eCPR for specific causes of cardiac arrest is addressed.
Cardiac Arrest in Special Circumstances. Establishing an eCPR
programme requires a whole system approach (in- and out-of
hospital) and considerable resources to implement effectively, and
not all healthcare systems will have sufficient resources.371 373
Peri-arrest arrhythmias
Prompt identification and treatment of life-threatening arrhythmias
may prevent cardiac arrest or its recurrence. This section offers
guidance and treatment algorithms for the non-specialist ALS
provider. The scope is to focus on peri-arrest arrhythmias that cause
life-threatening instability. If patients are stable there is time to seek
advice from a specialist or more experienced physician. Other
international organisations have produced comprehensive evidence-
based arrhythmia guidelines.86,91,374 377 Electrical cardioversion is
required in the peri-arrest patient with a clinical unstable arrhythmia
while pacing is used in refractory bradycardia. The key interventions
are summarised in Fig. 5 and 6.
These guidelines follow recommendations published by interna-
tional cardiology societies including the European Society of
Cardiology (ESC), the American Heart Association (AHA), the
151 135
American College of Cardiology (ACC) and the Heart Rhythm Society
(HRS).86,91,374 377 Table 4 summarises the supporting evidence for
vagal manoeuvres and some of the more commonly used drugs for the
treatment of arrhythmias.
Pharmacological cardioversion restores sinus rhythm in approx-
imately 50% of patients with recent-onset AF. Among the several
drugs for pharmacological conversion suggested by the ESC,378
beta-blockers and diltiazem/verapamil are preferred over digoxin
because of their rapid onset of action and effectiveness at high
sympathetic tone. For patients with LVEF < 40%, consider the
smallest dose of beta-blocker to achieve a heart rate less than 110
min 1 and add digoxin if necessary. Amiodarone is the drug most
likely to be familiar to non-specialists and can be considered for
acute heart rate control in atrial fibrillation (AF) patients with
haemodynamic instability and severely reduced left ventricular
ejection fraction (LVEF).
The ESC has published recent guidelines for the acute manage-
ment of regular tachycardias in the absence of an established
diagnosis.91 The guidelines for treating regular narrow QRS (
120 ms) and wide QRS (> 120 ms) tachycardias have been
incorporated into the tachycardia algorithm. The ESC Guidelines
provide more detailed recommendations and evidence for treating
rhythms once a specific diagnosis of the rhythm has been made.
In a randomised trial involving haemodynamically stable patients
with wide QRS-complex tachycardia of unknown aetiology, procai-
namide was associated with fewer major adverse cardiac events and
a higher proportion of tachycardia termination within 40 min compared
with amiodarone.379 However, in many countries procainamide is
either unavailable and/or unlicensed.
Evidence for the treatment of patients with bradycardia was
included in ACC/AHA/HRS guidelines published in 2019 (Fig. 6
Bradycardia algorithm).377 If bradycardia is accompanied by adverse
signs, atropine remains the first choice drug.21 When atropine is
ineffective, second line drugs include isoprenaline (5 mg min starting
dose) and adrenaline (2 10 mg min). For bradycardia caused by
inferior myocardial infarction, heart transplant or spinal cord injury,
consider giving aminophylline (100 200 mg slow intravenous injec-
tion). Atropine can cause a high-degree atrioventricular (AV) block or
even sinus arrest in heart transplant patients.380 Consider giving
intravenous glucagon if beta-blockers or calcium channel blockers are
a potential cause of the bradycardia. Consider pacing in patients who
are unstable, with symptomatic bradycardia refractory to drug therapy
(see below).
Cardioversion
Electrical cardioversion is the preferred treatment for tachycardia in
the unstable patient displaying potentially life-threatening adverse
signs (Fig. 5. Tachycardia algorithm).381 383 The shock must be
synchronised to occur with the R wave of the electrocardiogram rather
than with the T wave: VF can be induced if a shock is delivered during
the relative refractory portion of the cardiac cycle.384 Synchronisation
can be difficult in VT because of the wide-complex and variable forms
of ventricular arrhythmia. Inspect the synchronisation marker carefully
for consistent recognition of the R wave. If needed, choose another
lead and/or adjust the amplitude. If synchronisation fails, give
unsynchronised shocks to the unstable patient in VT to avoid
prolonged delay in restoring sinus rhythm. Ventricular fibrillation or
pulseless VT require unsynchronised shocks. Conscious patients
require anaesthesia or sedation, before attempting synchronised
cardioversion.
136 RESUSCITATION 161 (2021) 115 151

Fig. 5 – Tachycardia algorithm. ABCDE airway, breathing, circulation, disability, exposure BP blood pressure; DC direct current; ECG
electrocardiogram; IV intravenous; SpO2 arterial oxygen saturation; VT ventricular tachycardia.

Cardioversion for atrial fibrillation Cardioversion for pulsatile ventricular tachycardia

Some studies,127,128 but not all,130,133 have suggested that antero-
posterior pad position is more effective than antero-lateral pad
position, but both are acceptable positions.131 More data are needed
before specific recommendations can be made for optimal biphasic
energy levels and different biphasic waveforms. Biphasic rectilinear
and biphasic truncated exponential (BTE) waveform show similar high
efficacy in the elective cardioversion of atrial fibrillation.385 A recent
RCT showed that maximum fixed energy electrical cardioversion
(360 J BTE in this study) was more effective in achieving sinus rhythm
one minute after cardioversion than an energy-escalating strategy.386
There was no increase in adverse events. An initial synchronised
shock at maximum defibrillator output rather than an escalating
approach is a reasonable strategy based on current data. In stable
patients, follow appropriate guidelines on the need for anticoagulation
before cardioversion to minimise stroke risk.378
Cardioversion for atrial flutter and paroxysmal supraventric-
ular tachycardia
Atrial flutter and paroxysmal supraventricular tachycardia (SVT)
generally require less energy than atrial fibrillation for cardiover-
sion.387 Give an initial shock of 70 120 J. Give subsequent shocks
using stepwise increases in energy.194
The energy required for cardioversion of VT depends on the
morphological characteristics and rate of the arrhythmia.388 Ventricu-
lar tachycardia with a pulse responds well using energy levels of
120 150 J for the initial shock. Consider stepwise increases if the first
shock fails to achieve sinus rhythm.388
Pacing
Consider pacing in patients who are unstable, with symptomatic
bradycardia refractory to drug therapy. Immediate pacing is indicated
especially when the block is at or below the His-Purkinje level. If
transthoracic (transcutaneous) pacing is ineffective, consider trans-
venous pacing. Whenever a diagnosis of asystole is made, check the
ECG carefully for the presence of P waves because this will likely
respond to cardiac pacing. The use of epicardial wires to pace the
myocardium following cardiac surgery is effective and discussed
elsewhere. Do not attempt pacing for asystole unless P waves are
present; it does not increase short or long-term survival in- or out-of-
hospital.389 397 For haemodynamically unstable, conscious patients
with bradyarrhythmia, percussion pacing as a bridge to electrical
pacing may be attempted, although its effectiveness has not been
established.104,398,399 Give serial rhythmic blows with the closed fist
over the left lower edge of the sternum to pace the heart at a
 RESUSCITATION 161 (2021) 115 151 137

Fig. 6 – Bradycardia algorithm. ABCDE airway, breathing, circulation, disability, exposure BP blood pressure; ECG electrocardiogram; IV
intravenous; SpO2 arterial oxygen saturation.
138 RESUSCITATION 161 (2021) 115 151

Table 4 – Recommendations for the acute management of narrow and wide QRS tachycardia (Drugs may be
administered via peripheral IV in an emergency. HF heart failure; LV left ventricular).

Drug /procedure Indication Timing Dose/delivery Notes

Vagal Manoeuvre Narrow QRS tachycardia Blow into a 10 mL syringe with Preferably in the supine posi-
Wide QRS tachycardia sufficient force to move the plunger tion with leg elevation400 403

Adenosine Narrow QRS tachycardia
Wide QRS tachycardia
Recommended if vagal Incremental, starting at 6 mg, fol- If no evidence of pre-excitation
manoeuvres fail lowed by 12 mg IV. on resting ECG404 406
An 18 mg dose should then be When using an 18 mg dose,
considered take into account the tolerabili-
ty/side effects in the individual
patient.

Verapamil or diltiazem Narrow QRS tachycardia Consider if vagal ma- Verapamil (0.075 0.15 mg/kg IV Should be avoided in patients
noeuvres and adeno- [average 5 10 mg] over 2 min) with haemodynamic instability,
sine fail Diltiazem [0.25 mg/kg IV(average HF with reduced LV ejection
20 mg) over 2 min]. fraction (<40%).404,406 411

Beta-blockers Narrow QRS tachycardia Consider if vagal ma- Esmolol (0.5 mg/kg IV bolus or More effective in reducing the
(IV esmolol or metoprolol) noeuvres and adeno- 0.05 0.3 mg/kg/min infusion) heart rate than in terminating
sine fail Metoprolol (2.5 15 mg given IV in tachycardia.410,412 414
2.5 mg boluses),

379,415
Procainamide Wide QRS tachycardia Consider if vagal ma- 10 15 mg/kg IV over 20 min
noeuvres and adeno-
sine fail

416,417
Amiodarone Narrow and wide Consider if vagal ma- 300 mg IV over 10 60 min ac-
QRS tachycardia noeuvres and adeno- cording to circumstances fol-
sine fail lowed by infusion of 900 mg in 24h

Magnesium Polymorphic wide 2 g IV over 10 min. Can be repeated Magnesium can suppress epi-
QRS tachycardia once if necessary. sodes of TdP without neces-
(torsades de pointes -TdP) sarily shortening QT, even
when serum magnesium con-
centration is normal361,418

physiological rate of 50 70 min 1. Transthoracic and percussion
pacing can cause discomfort Consider giving analgesic or sedative
drugs in conscious patients
Uncontrolled organ donation after circulatory death
Following cardiac arrest, less than a half of patients achieve
ROSC.17,34 When standard ALS fails to achieve ROSC, there are
three broad treatment strategies:419
 Stop resuscitation and declare death.
 In selected patients, continue CPR to facilitate the implementation
of other technologies such as E-CPR, that buy time for treatments
that address a reversible cause of the cardiac arrest (e.g. re-
warming following accidental hypothermia, intra-arrest primary
percutaneous coronary intervention for acute myocardial
ischaemia).
 Continue CPR to maintain organ perfusion and transfer to a
hospital with an uncontrolled donation after circulatory death
(uDCD) pathway.
This guideline focuses on uDCD (Maastricht category I/II
donors).420 The post-resuscitation care guidelines includes guidance
for organ donation pathways following brain death or controlled
donation after circulatory death (Maastricht category III donors) in
patients who achieve ROSC or are treated with eCPR.246,420 We
acknowledge the ethical, cultural and legislative issues that lead to
variation in the use of uDCD.
Across Europe, demand for transplanted organs continues to
outstrip supply. Uncontrolled donation after circulatory death (uDCD)
provides an opportunity for cardiac arrest victims in whom ROSC
cannot be achieved, to donate their organs. In Europe, uDCD is
currently undertaken in regions of Spain, France, The Netherlands,
Belgium, and Italy.421 430 Organs that can be recovered include
kidneys, liver, pancreas and lungs. Observational data show that long-
term uDCD graft success is comparable to other organ recovery
approaches.428,430 432
There is no universal consensus on selection criteria for uDCD,
and the identification of a potential donor currently follows regional/
national protocols. These generally include: age above 18 year (for
adults) and not over 55 or 65 years, a no-flow time (the interval
between cardiac arrest and CPR start) within 15 30 min, and a total
warm ischaemia time (the interval between cardiac arrest and the start
of organ preservation) not longer than 150 min.433 Exclusion criteria
generally include trauma, homicide, or suicide as a cause of arrest,
and comorbidities such as cancer, sepsis, and, according to local
programme and the targeted organ to transplant, kidney and liver
disease.433
Uncontrolled donation after circulatory death is a time-critical,
resource-intensive, complex and ethically challenging process.434,435
Following completion of aggressive resuscitation efforts and
 RESUSCITATION 161 (2021) 115
confirmation of death, a ‘no-touch’ period is observed to rule-out the
possibility of auto-resuscitation.436 Organ preservation procedures
are then immediately started and continued whilst family consent for
organ recovery is sought, and organs are assessed for suitability for
donation. 437 439 For abdominal organs, organ preservation typically
uses an extracorporeal circulation with membrane oxygenation via a
femoro-femoral bypass.434 Catheters with balloons are used to limit
circulation to the abdominal cavity.440 Following consent and
completion of practical arrangements, the patient is transferred to
the operating theatre for organ recovery.
Consent to organ donation is obtained as soon as possible during
the process from a surrogate decision maker (e.g., a family member)
or by retrieving previous consent registered on a donor card or in a
public registry, if available. The urgency and nature of the process
creates several ethical challenges that are unique to uDCD,
highlighting the importance of clear local protocols, and legislative
and societal acceptance of the process.434 These issues are
discussed in the ethics section of the guidelines.441
Debriefing
ILCOR undertook a systematic review of debriefing following cardiac
arrest in 2020.16 The review included four observational studies and
identified that debriefing was associated with improvements in
hospital survival, ROSC and CPR quality.442 445 These studies all
described use of a cold debrief that incorporated data on CPR quality
downloaded from defibrillators.446 Based on these data, ILCOR
continues to make a weak recommendation based on very low
certainty evidence supporting the use of data-driven performance-
focused debriefing. The justification and evidence to decision
framework noted the substantial heterogeneity in debriefing interven-
tion between studies. ILCOR also noted that the intervention is highly
likely to be acceptable to stakeholders and cost of implementation
may be modest. A potential harm of debriefing is the psychological
effect on rescuers of discussing challenging clinical events. The
ILCOR summary recorded no evidence of harm from included studies
but highlighted the need to consider this effect when implementing
debriefing interventions.
Conflict of interest
JS declares his role of Co-editor Resuscitation; he declares
institutional research funding for the NAP7 project from the Royal
College of Anaesthetists.
GDP reports funding from Elsevier for his role as an editor of the
journal Resuscitation. He reports research funding from the National
Institute for Health Research in relation to the PARAMEDIC2 trial and
the RESPECT project.
JN reports funding from Elsevier for his role as Editor in Chief of the
journals Resuscitation and Resuscitation Plus. He reports research
funding from the National Institute for Health Research in relation to
the PARAMEDIC2 trial and the AIRWAYS2 trial.
CD declares research grants from RCUK and funding from the
National Institute for Health Research in relation to the PARAMEDIC2
trial and the AIRWAYS2 trial.
TO declares research grants from Swedish Heart and Lung
Foundation, Laerdal Foundation and Lof -Swedish patient insurance
and Swedish state under the agreement between the Swedish
government and the county councils, the ALF-agreement.
151 139
BB declared speakers honorarium from Baxalta, ZOLL, FomF,
Bard, Stemple, Novartis Pharma, Philips Market DACH, Bioscience
Valuation BSV.
TP declares Speakers honorarium from BARD.
Acknowledgements
The authors acknowledge the following individuals who contributed to
the 2015 version of this guideline:, Markus B. Skrifvars, Gary B. Smith,
Kjetil Sunde, Rudolph W. Koster, Koenraad G. Monsieurs, Nikolaos I.
Nikolaou. GDP is supported by the National Institute for Health
Research (NIHR) Applied Research Collaboration (ARC) West
Midlands. The views expressed are those of the author(s) and not
necessarily those of the NIHR or the Department of Health and Social
Care.
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Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Cardiac arrest in special circumstances

Carsten Lott a, * , Anatolij Truhlár b,c, Annette Alfonzo d , Alessandro Barelli e ,

Violeta González-Salvado f , Jochen Hinkelbein g , Jerry P. Nolan h,i ,
Peter Paal j , Gavin D. Perkins k,l , Karl-Christian Thies m, Joyce Yeung k,l ,
David A. Zideman n , Jasmeet Soar o , the ERC Special Circumstances
Writing Group Collaborators 1
a
Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany
b
Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic
c
Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové,
Czech Republic
d
Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
e
Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES
118, Rome, Italy
f
Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS),
Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
g
Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
h
Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK
i
Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
j
Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
k
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
l
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
m
Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University,
Germany
n
Thames Valley Air Ambulance, Stokenchurch, UK
o
Southmead Hospital, North Bristol NHS Trust, Bristol, UK

Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on
Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and
advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma,
anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia,
pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac
surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special
patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

* Corresponding author.
1
ERC Special Circumstances Writing Group Collaborators are listed in Appendix A.
https://doi.org/10.1016/j.resuscitation.2021.02.011

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
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Introduction
Irrespective of the cause of cardiac arrest, the most important
interventions are universal and according to the chain of survival.1
These include early recognition and calling for help, management of
the deteriorating patient to prevent cardiac arrest, prompt defibrillation
and high-quality cardiopulmonary resuscitation (CPR) with minimal
interruption of chest compressions, treatment of reversible causes,
and post-resuscitation care. In certain conditions, however, basic and
advanced life support interventions may require modification. This
guideline for resuscitation in special circumstances is divided into
three parts: special causes, special settings and special patients. The
first part covers treatment of potentially reversible causes of cardiac
arrest, for which specific treatment exists, and which must be identified
or excluded during advanced life support (ALS). For improving recall
during ALS, these are divided into two groups of four, based upon their
initial letter
either H or T
and are called the ‘4Hs and 4Ts’:
Hypoxia; Hypovolaemia; Hypo-/hyperkalaemia and other electrolyte
disorders; Hypo-/hyperthermia; Thrombosis (coronary and pulmo-
nary); Tamponade (cardiac); Tension pneumothorax; Toxic agents
(poisoning). The second part covers cardiac arrest in special settings,
where universal guidelines have to be modified due to specific
locations or location-specific causes of cardiac arrest. The third part is
focused on patients with specific conditions, and those with certain
long-term comorbidities where a modified approach and different
treatment decisions may be necessary.
Many of the chosen topics were not part of the ILCOR reviews.
ILCOR has published reviews on pulmonary embolism,2 extracorpo-
real CPR (ECPR),2 drowning3 and evidence updates on pregnancy2
and opioid toxicity.2 Most of the evidence is derived from individual
systematic reviews, scoping reviews and evidence updates, recom-
mendations are provided as expert consensus following discussion in
the writing group. Whenever an ILCOR systematic review or a GRADE
like systematic review informs the recommendation, the level of
recommendation is provided.
There are no major changes in the 2021 adult Special Circum-
stances guidelines. There is greater emphasis on the priorisation of
recognition and management for reversible causes in cardiac arrest
due to special circumstances. The guidelines reflect the increasing
evidence for extracorporeal CPR (eCPR) as management strategy for
selected patients with cardiac arrest in settings in which it can be
implemented. This ERC guideline follows European and international
guidelines for treatment recommendations (electrolyte disorders,
sepsis, coronary thrombosis, accidental hypothermia and avalanche
rescue). The trauma section has been revised with additional
measures for haemorrhage control, the toxic agents section comes
with an extensive supplement, focusing on management of specific
toxic agents. Prognostication of successful rewarming in hypothermic
patients follows more differentiated scoring systems (HOPE score;
ICE score). In avalanche rescue priority is given to ventilations as
hypoxia is the most likely reason of cardiac arrest. Caused by the
increasing number of patients from that special settings, recommen-
dations for cardiac arrest in the catheterisation laboratory and in the
dialysis unit have been added.
These guidelines were drafted and agreed by the Resuscitation in
Special Circumstances Writing Group members. The methodology
used for guideline development is presented in the Executive
summary.4 The guidelines were posted for public comment in October
2020. The feedback was reviewed by the writing group and the
153
guidelines was updated where relevant. The Guideline was presented
to and approved by the ERC General Assembly on 10th December
2020.
Key guideline highlights are summarised in Fig. 1.
Concise guidelines for clinical practice
Special causes
Hypoxia
 Follow the standard ALS algorithm when resuscitating patients
with asphyxial cardiac arrest.
 Treat the cause of the asphyxia/hypoxaemia as the highest priority
because this is a potentially reversible cause of the cardiac arrest.
 Effective ventilation with the highest feasible inspired oxygen is a
priority in patients with asphyxial cardiac arrest.
Hypovolaemia
Traumatic cardiac arrest (TCA)
 Resuscitation in TCA should focus on the immediate, simulta-
neous treatment of reversible causes.
 The response to TCA is time critical and success depends on a
well-established chain of survival, including focused pre-hospital
and specialised trauma centre care.
 TCA (hypovolemic shock, obstructive shock, neurogenic shock) is
different from cardiac arrest due to medical causes; this is
reflected in the treatment algorithm (Fig. 2).
 Use ultrasound to identify the underlying cause of cardiac arrest
and target resuscitative interventions.
 Treating reversible causes simultaneously takes priority over
chest compressions. Chest compression must not delay treatment
of reversible causes in TCA.
 Control haemorrhage with external pressure, haemostatic gauze,
tourniquets and pelvic binder.
 ‘Don’t pump an empty heart’.
 Resuscitative thoracotomy (RT) has a role in TCA and traumatic
peri-arrest.
Anaphylaxis
 Recognise anaphylaxis by the presence of airway (swelling),
breathing (wheeze or persistent coughing), or circulation (hypo-
tension) problems with or without skin and mucosal changes. This
can be in the context of a known trigger in a patient with an allergy,
or suspected anaphylaxis in a patient with no previous history of
allergy.
 Call for help early.
 Remove or stop the trigger if feasible.
 Give intramuscular (IM) adrenaline (0.5 mg (which is 0.5 ml of a
1 mg in 1 ml ampoule of adrenaline)) into the anterolateral thigh as
soon as anaphylaxis is suspected. Repeat the IM adrenaline if
there is no improvement in the patient’s condition after about
5 min.
 Ensure the patient is lying and do not suddenly sit or stand the
patient up.
 Use an ABCDE approach and treat problems early (oxygen, fluids,
monitoring).
 Give an IV crystalloid fluid bolus early and monitor the response

large volumes of fluids may be needed.
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Fig. 1 – Special circumstances summary infographic.

 
Consider IV adrenaline as a bolus (20
50 mcg) or infusion for
refractory anaphylaxis or in specialist care settings where the skills
are available.
 Consider alternative vasopressors (vasopressin, noradrenaline,
metaraminol, phenylephrine) in refractory anaphylaxis.
 Consider IV glucagon in patients taking beta-blockers.
 Start chest compressions and ALS as soon as cardiac arrest is
suspected and follow standard guidelines.
 Consider ECLS or ECPR for patients who are peri-arrest or in
cardiac arrest as a rescue therapy in those settings where it is
feasible.
Follow existing guidelines for the investigation and follow-up care of
patients with suspected anaphylaxis and confirmed anaphylaxis.
Sepsis
Cardiac arrest prevention in sepsis
 Follow the Surviving Sepsis Guidelines Hour-1 bundle for the
initial resuscitation of sepsis and septic shock (Fig. 3).
Specifically:
 Measure lactate level.
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Fig. 2 – Traumatic cardiac arrest algorithm.

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Fig. 3 – Initial Resuscitation for Sepsis and Septic Shock Hour-1 Bundle (published with permission of the Society of
Critical Care Medicine, 500 Midway Drive, Mount Prospect, IL 60056-5811 USA, www.sccm.org).

 Cardiac arrest treatment due to sepsis

Obtain blood cultures prior to administration of antibiotics.
 Administer broad-spectrum antibiotics.
 Begin rapid administration of 30 ml kg
1 crystalloid for hypoten-
sion or a lactate 4 mmol l
1.
 Apply vasopressors if the patient is hypotensive during or
after fluid resuscitation to maintain mean arterial pressure
65 mmHg.

Follow standard ALS guidelines including giving the maximal
inspired oxygen concentration.
 Intubate the trachea if able to do so safely.
 Intravenous (IV) crystalloid fluid resuscitation with a 500 ml initial
bolus. Consider administering further boluses.
 Venepuncture for venous blood gas/lactate/electrolytes.
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 Control the source of sepsis, if feasible, and give antibiotics early.
Hypo-/hyperkalaemia and other electrolyte disorders
 Consider hyperkalaemia or hypokalaemia in all patients with an
arrhythmia or cardiac arrest.
 Check for hyperkalaemia using point-of-care testing if available.
 The ECG may be the most readily available diagnostic tool.
Treatment of hyperkalaemia
 Protect the heart (Fig. 4).
 Shift potassium into cells.
 Remove potassium from the body.
 Consider dialysis initiation during CPR for refractory hyper-
kalaemic cardiac arrest.
 Consider ECPR.
 Monitor serum potassium and glucose levels.
 Prevent the recurrence of hyperkalaemia.
Patient not in cardiac arrest
Assess patient:
 Use the ABCDE approach and correct any abnormalities, obtain IV
access.
 Check serum K+ level
use blood gas analyser if available and
send a sample to the laboratory.
 Perform an ECG
look for signs of hyperkalaemia.
 Cardiac monitoring
if the serum K+  6.5 mmol/l or if the patient
is acutely unwell.
Follow hyperkalaemia algorithm guided by the severity of hyper-
kalaemia and ECG changes.
Moderate hyperkalaemia (serum K+ 6.0
6.4 mmol/l)
 Shift K+ into cells: Give 10 units short-acting insulin and 25 g glucose
(250 ml glucose 10%) IV over 15
30 min (onset in 15
30 min;
maximal effect 30
60 min; duration of action 4
6 h; monitor blood
glucose). Follow up with 10% glucose infusion at 50 ml/h for 5 h in
patients with a pre-treatment blood glucose <7 mmol/l.
 Remove K+ from the body: Consider oral administration of a
potassium binder, e.g. Sodium Zirconium Cyclosilicate (SZC), or a
cation exchange resin e.g., Patiromer or calcium resonium
according to local practice.
Severe hyperkalaemia (serum K+  6.5 mmol/l) without ECG
changes
 Seek expert help early.
 Shift K+ into cells: Give insulin/glucose infusion (as above).
 Shift K+ into cells: Give salbutamol 10
20 mg nebulised (onset 15

30 min; duration of action 4
6 h).
 Remove K+ from the body: Give SZC (onset in 60 min) or Patiromer
(onset in 4
7 h) and consider dialysis.
Severe hyperkalaemia (serum K+  6.5 mmol/l) with toxic ECG
changes
 Seek expert help early.
 Protect the heart: Give 10 ml calcium chloride 10% IV over
2
5 min (onset 1
3 min, repeat ECG, further dose if toxic ECG
changes persist).
 Shift K+ into cells: Give insulin/glucose infusion (as above).
 Shift K+ into cells: Give salbutamol 10
20 mg nebulised (as
above).
157
 Remove K+ from the body: Give SZC or Patiromer (see above) and
consider dialysis at outset or if refractory to medical treatment.
Patient in cardiac arrest
 Confirm hyperkalaemia using blood gas analyser if available.
 Protect the heart: Give 10 ml calcium chloride 10% IV by rapid
bolus injection. Consider repeating dose if cardiac arrest is
refractory or prolonged.
 Shift K+ into cells: Give 10 units soluble insulin and 25 g glucose IV
by rapid injection. Monitor blood glucose. Administer 10% glucose
infusion guided by blood glucose to avoid hypoglycaemia.
 Shift K+ into cells: Give 50 mmol sodium bicarbonate (50 ml 8.4%
solution) IV by rapid injection.
 Remove K+ from the body: Consider dialysis for refractory
hyperkalaemic cardiac arrest.
 Consider the use of a mechanical chest compression device if
prolonged CPR is needed.
 Consider ECLS or ECPR for patients who are peri-arrest or in
cardiac arrest as a rescue therapy in those settings where it is
feasible.
Treatment of hypokalaemia
 Restore potassium level (rate and route of replacement guided by
clinical urgency).
 Check for any potential exacerbating factors (e.g. digoxin toxicity,
hypomagnesaemia).
 Monitor serum K+ (adjust replacement as needed depending on
level).
 Prevent recurrence (assess and remove cause).
Hypothermia
Accidental hypothermia
 Assess core temperature with a low reading thermometer,
tympanic in spontaneously breathing, oesophageal in patients
with a tracheal tube or a supraglottic device with an oesophageal
channel in place (Fig. 5).
 Check for the presence of vital signs for up to one minute.
 Prehospital insulation, triage, fast transfer to a hospital and
rewarming are key interventions.
 Hypothermic patients with risk factors for imminent cardiac arrest
(i.e., core temperature <30  C, ventricular arrhythmia, systolic
blood pressure <90 mmHg) and those in cardiac arrest should
ideally be directly transferred to an extracorporeal life support
(ECLS) centre for rewarming.
 Hypothermic cardiac arrest patients should receive continuous
CPR during transfer.
 Chest compression and ventilation rate should not be different to
CPR in normothermic patients.
 If ventricular fibrillation (VF) persists after three shocks, delay
further attempts until the core temperature is >30  C.
 Withhold adrenaline if the core temperature is <30  C.
 Increase administration intervals for adrenaline to 6
10 min if the
core temperature is >30  C.
 If prolonged transport is required or the terrain is difficult, use of a
mechanical CPR device is recommended.
 In hypothermic arrested patients <28  C delayed CPR may be
used when CPR on site is too dangerous or not feasible,
intermittent CPR can be used when continuous CPR is not
possible (Fig. 6).
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Fig. 4 – Treatment algorithm for management of hyperkalaemia in adults (adapted from the UK Renal
Association Hyperkalaemia guideline 2020 https://renal.org/treatment-acute-hyperkalaemia-adults-updated-guide-
line-released/).
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Fig. 5 – Management in accidental hypothermia.4,5 (1) Decapitation; truncal transection; whole body decomposed or
whole body frozen solid (chest wall not compressible).6,7 (2) SBP < 90 mmHg is a reasonable prehospital estimate of
cardiocirculatory instability but for in-hospital decisions, the minimum sufficient circulation for a deeply hypothermic
patient (e.g., <28  C) has not been defined. (3) Swiss staging of accidental hypothermia. (4) Direct transport to an ECMO
centre is recommended in an arrested hypothermic patient. In remote areas, transport decisions should balance the
risk of increased transport time with the potential benefit of treatment in an ECLS centre (e.g. 6 h). (5) Warm
environment, chemical, electrical, or forced air heating packs or blankets, and warm IV fluids (38
42  C). In case of
cardiac instability refractory to medical management, consider rewarming with ECLS. (6) If the decision is made to
stop at an intermediate hospital to measure serum potassium, a hospital en route to an ECLS centre should be chosen.
HOPE and ICE scores should not be used in children, instead consider expert consultation.
CPR denotes cardiopulmonary resuscitation, DNR do-not- resuscitate, ECLS extracorporeal life support, HT
hypothermia, MD medical doctor, ROSC return of spontaneous circulation, SBP systolic blood pressure.

 In-hospital prognostication of successful rewarming should be
based on the HOPE or ICE score. The traditional in-hospital serum
potassium prognostication is less reliable.
 In hypothermic cardiac arrest rewarming should be performed with
ECLS, preferably with extra-corporeal membrane oxygenation
(ECMO) over cardiopulmonary bypass (CPB).
 Non-ECLS rewarming should be initiated in a peripheral hospital if
an ECLS centre cannot be reached within hours (e.g. 6 h).
 Consider CPR to be futile in cardiac arrest with a burial time
>60 min and additional evidence of an obstructed airway.
 In-hospital prognostication of successful rewarming should be
based on the HOPE score. The traditional triage with serum
potassium and core temperature (cut-offs 7 mmol/l and 30  C,
respectively) are less reliable.
Hyperthermia and malignant hyperthermia

Avalanche rescue Hyperthermia

 Start with five ventilations in cardiac arrest, as hypoxia is the most
likely cause of cardiac arrest (Fig. 7).
 Perform standard ALS if burial time is <60 min.
 Provide full resuscitative measures, including ECLS rewarming, for
avalanche victims with duration of burial >60 min without evidence
of an obstructed airway or additional un-survivable injuries.
 Measurement of core temperature should be available to guide
treatment (Fig. 8).
 Heat syncope
remove patient to a cool environment, cool
passively and provide oral isotonic or hypertonic fluids.
 Heat exhaustion
remove patient to a cool environment, lie them
flat, administer IV isotonic or hypertonic fluids, consider additional
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Fig. 6 – Delayed and intermittent CPR in hypothermic patients when continuous CPR is not possible during dangerous
or difficult rescue.8,190 .

electrolyte replacement therapy with isotonic fluids. Replacement
of 1
2 l crystalloids at 500 ml/h is often adequate.
 Simple external cooling measures are usually not required but
may involve conductive, convective and evaporative measures
(see section 10 First Aid).
 Heat stroke
a ‘cool and run’ approach is recommended:
 Remove patient to a cool environment.
 Lie them flat.
 Immediately active cool using whole body (from neck down) water
immersion technique (1
26  C) until core temperature <39  C.
 Where water immersion is not available use immediately any active
or passive technique that provides the most rapid rate of cooling.
 Administer IV isotonic or hypertonic fluids (with blood sodium Thrombosis
130 mmol/l up to 3  100 ml NaCl 3%).
 Consider additional electrolyte replacement with isotonic fluids. Pulmonary embolism
Substantial amounts of fluids may be required.
 In exertional heat stroke a cooling rate faster than 0.10  C/min is
safe and desirable.
 Follow the ABCDE approach in any patient with deteriorating
vital signs.
Malignant hyperthermia
 Stop triggering agents immediately.
 Provide oxygen.
 Aim for normocapnia using hyperventilation.
 Consider correction of severe acidosis with bicarbonate
(1
2 mmol kg
1).
 Treat hyperkalaemia (calcium, glucose/insulin, hyperventilation)
(see hyperkalaemia guideline).
 Give dantrolene (2.5 mg/kg initially, and 10 mg/kg as required).
 Start active cooling.
 Follow the ALS algorithm in cardiac arrest and continue cooling.
 After return of spontaneous circulation (ROSC) monitor the patient
closely for 48
72 h, as 25% of patients experience relapse.
 Contact an expert malignant hyperthermia centre for advice and
follow-up.
Cardiac arrest prevention
 Follow the ABCDE approach.
Airway
 Treat life-threatening hypoxia with high-flow oxygen.
Breathing
 Consider pulmonary embolism (PE) in all patients with sudden
onset of progressive dyspnoea and absence of known
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Fig. 7 – Avalanche accident algorithm. Management of completely buried victims.

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Fig. 8 – Treatment of hyperthermia (figure adapted from Racinais S, et al. www.ephysiol.com/toolbox/).
pulmonary disease (always exclude pneumothorax and
anaphylaxis).
Circulation
 Obtain 12-lead ECG (exclude acute coronary syndrome, look for
right ventricle strain).
 Identify haemodynamic instability and high-risk PE.
 Perform bedside echocardiography.
 Initiate anticoagulation therapy (heparin 80 IU/kg IV) during diagnos-
tic process, unless signs of bleeding or absolute contraindications.
 Confirm diagnosis with computed tomographic pulmonary angi-
ography (CTPA).
 Set-up a multidisciplinary team for making decisions on manage-
ment of high-risk PE (depending on local resources).
 Give rescue thrombolytic therapy in rapidly deteriorating patients.
 Consider surgical embolectomy or catheter-directed treatment as
alternative to rescue thrombolytic therapy in rapidly deteriorating
patients.
Exposure
 Request information about past medical history, predisposing
factors, and medication that may support diagnosis of pulmonary
embolism:
 Previous pulmonary embolism or deep venous thrombosis (DVT).

Surgery or immobilisation within the past four weeks.
 Active cancer.
 Clinical signs of DVT.
 Oral contraceptive use or hormone replacement therapy.
 Long-distance flights.
Cardiac arrest management
 Cardiac arrest commonly presents as PEA.
 Low ETCO2 readings (below 1.7 kPa/13 mmHg) while performing
high-quality chest compressions may support a diagnosis of
pulmonary embolism, although it is a non-specific sign.
 Consider emergency echocardiography performed by a qualified
sonographer as an additional diagnostic tool.
 Administer thrombolytic drugs for cardiac arrest when PE is the
suspected cause of cardiac arrest.
 When thrombolytic drugs have been administered, consider
continuing CPR attempts for at least 60
90 min before termination
of resuscitation attempts.
 Use thrombolytic drugs or surgical embolectomy or percutaneous
mechanical thrombectomy for cardiac arrest when PE is the
known cause of cardiac arrest.
 Consider ECPR as a rescue therapy for selected patients with
cardiac arrest when conventional CPR is failing in settings in which
it can be implemented.
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Coronary thrombosis
Prevent and be prepared (Fig. 9 and Supplementary Fig. S1):
 Encourage cardiovascular prevention to reduce the risk of acute
events.
 Endorse health education to reduce delay to first medical contact.
 Promote layperson basic life support to increase the chances of
bystander CPR.
 Ensure adequate resources for better management.
 Improve quality management systems and indicators for better
quality monitoring.
Detect parameters suggesting coronary thrombosis and activate
the ST-elevation myocardial infarction (STEMI) network (Supplemen-
tary Fig. S2):
 Chest pain prior to arrest.
 Known coronary artery disease.
 Initial rhythm: VF, pulseless ventricular tachycardia (pVT).
 Post-resuscitation 12-lead ECG showing ST-elevation.
Resuscitate and treat possible causes (establish reperfusion
strategy):
 Patients with sustained ROSC
 STEMI patients:
➢ Primary percutaneous coronary intervention (PCI) strategy
120 min from diagnosis: activate catheterisation laborato-
ry and transfer patient for immediate PCI.
➢ Primary PCI not possible in 120 min: perform pre-
hospital thrombolysis and transfer patient to PCI centre
(Fig. 9).
 Non STEMI patients: individualise decisions considering patient
characteristics, OHCA setting and ECG findings.
➢ Consider quick diagnostic work-up (discard non-coronary
causes and check patient condition).
➢ Perform urgent coronary angiography (120 min) if ongoing
myocardial ischaemia is suspected or the patient is
hemodynamically/electrically instable.
➢ Consider delayed coronary angiography if there is no
suspected ongoing ischaemia and the patient is stable
 Patients with no sustained ROSC: Assess setting and patient
conditions and available resources
 Futile: Stop CPR.
 Not-futile: Consider patient transfer to a percutaneous coronary
intervention (PCI) centre with on-going CPR (Fig. 9).
➢ Consider mechanical compression and ECPR.
➢ Consider coronary angiography.
Cardiac tamponade
 Decompress the pericardium immediately.
 Point of care echocardiography supports the diagnosis.
 Perform resuscitative thoracotomy or ultrasound guided
pericardiocentesis.
Tension pneumothorax
 Diagnosis of tension pneumothorax in a patient with cardiac arrest
or haemodynamic instability must be based on clinical examina-
tion or point of care ultrasound (POCUS).
 Decompress chest immediately by open thoracostomy when a
tension pneumothorax is suspected in the presence of cardiac
arrest or severe hypotension.
163
 Needle chest decompression serves as rapid treatment, it should
be carried out with specific needles (longer, non-kinking).
 Any attempt at needle decompression under CPR should be
followed by an open thoracostomy or a chest tube if the expertise is
available.
 Chest decompression effectively treats tension pneumothorax
and takes priority over other measures.
Toxic agents
Prevention
 Poisoning rarely causes cardiac arrest.
 Manage hypertensive emergencies with benzodiazepines, vaso-
dilators and pure alpha-antagonists.
 Drug induced hypotension usually responds to IV fluids.
 Use specific treatments where available in addition to the ALS
management of arrhythmias.
 Provide early advanced airway management.
 Administer antidotes, where available, as soon as possible.
Cardiac arrest treatment
 Have a low threshold to ensure your personal safety (Fig. 10).
 Consider using specific treatment measures as antidotes,
decontamination and enhanced elimination.
 Do not use mouth-to-mouth ventilation in the presence of
chemicals such as cyanide, hydrogen sulphide, corrosives and
organophosphates.
 Exclude all reversible causes of cardiac arrest, including
electrolyte abnormalities which can be indirectly caused by a
toxic agent.
 Measure the patient’s temperature because hypo- or hyperther-
mia may occur during drug overdose.
 Be prepared to continue resuscitation for a prolonged period of
time. The toxin concentration may fall as it is metabolised or
excreted during extended resuscitation measures.
 Consult regional or national poison centres for information on
treatment of the poisoned patient.
 Consider ECPR as a rescue therapy for selected patients with
cardiac arrest when conventional CPR is failing in settings in which
it can be implemented.
Special settings
Healthcare facilities
Cardiac arrest in the operating room (OR)
 Recognise cardiac arrest by continuous monitoring.
 Inform the surgeon and the theatre team. Call for help and the
defibrillator.
 Initiate high-quality chest compressions and effective ventilation.
 Follow the ALS algorithm with a strong focus on reversible causes,
especially hypovolaemia (anaphylaxis, bleeding), hypoxia, ten-
sion-pneumothorax, thrombosis (pulmonary embolism).
 Use ultrasound to guide resuscitation.
 Adjust the height of the OR table to enable high-quality CPR.
 Check the airway and review the EtCO2 tracing.
 Administer oxygen with a FiO2 1.0.
 Open cardiac compression should be considered as an effective
alternative to closed chest compression.
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Fig. 9 – Management of out-of-hospital cardiac arrest in the setting of suspected coronary thrombosis. *Note that
prolonged or traumatic resuscitation is a relative contraindication for fibrinolysis. **Individualised decision based on
careful evaluation of the benefit/futility ratio, available resources and team expertise.
Abbreviations: OHCA, out-of-hospital cardiac arrest; STEMI, ST-elevation myocardial infarction; ROSC, return of
spontaneous circulation; PCI, percutaneous coronary intervention; CPR: cardiopulmonary resuscitation.
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Fig. 10 – Toxic exposure algorithm. PPE—personal protective equipment.
 Consider ECPR as a rescue therapy for selected patients with
cardiac arrest when conventional CPR is failing.
Cardiac surgery
Prevent and be prepared
 Ensure adequate training of the staff in resuscitation technical
skills and ALS (Fig. 11).
 Ensure equipment for emergency re-sternotomy is available in the
ICU.
 Use safety checklists.
Detect cardiac arrest and activate cardiac arrest protocol:
 Identify and manage deterioration in the postoperative cardiac
patient.
 Consider echocardiography.
 Confirm cardiac arrest by clinical signs and pulseless pressure
waveforms.
 Shout for help and activate cardiac arrest protocol.
Resuscitate and treat possible causes:
 Resuscitate according to ALS MODIFIED algorithm:
➢ VF/ pVT ! Defibrillate: apply up to 3 consecutive shocks (<1 min).
➢ Asystole/extreme bradycardia ! Apply early pacing (<1 min).
➢ PEA ! Correct potentially reversible causes. If paced rhythm,
turn off pacing to exclude VF.
165
! No ROSC:
o Initiate chest compression and ventilation.
o Perform early resternotomy (< 5 min).
o Consider circulatory support devices and ECPR (Fig. 11).
Catheterisation laboratory
Prevent and be prepared (Fig. 12):
 Ensure adequate training of the staff in resuscitation technical
skills and ALS.
 Use safety checklists.
Detect cardiac arrest and activate cardiac arrest protocol:
 Check patient’s status and monitored vital signs periodically.
 Consider cardiac echocardiography in case of haemodynamic
instability or suspected complication.
 Shout for help and activate cardiac arrest protocol.
Resuscitate and treat possible causes:
 Resuscitate according to the MODIFIED ALS algorithm:
 VF/pVT cardiac arrest ! Defibrillate (apply up to 3 consecutive
shocks) ! no ROSC ! resuscitate according to ALS algorithm.
 Asystole/ PEA ! resuscitate according to ALS algorithm.
 Check and correct potentially reversible causes, including the use
of echocardiography and angiography.
 Consider mechanical chest compression and circulatory support
devices (including ECPR).
166 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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Fig. 11 – Advanced life support (ALS) algorithm for postoperative cardiac arrest following cardiac surgery. ALS,
advanced life support, VF, ventricular fibrillation; PVT: pulseless ventricular tachycardia; CPR, cardiopulmonary
resuscitation; ROSC, return of spontaneous circulation; PEA: pulseless electrical activity. ** Consider IABP to support
CPR or extracorporeal life support as an alternative if resternotomy is not feasible or fails to revert cardiac arrest.
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
2 1 9 167

Fig. 12 – Management of cardiac arrest in the catheterisation laboratory. ALS, advanced life support, VF, ventricular
fibrillation; PVT: pulseless ventricular tachycardia; CPR, cardiopulmonary resuscitation; ROSC, return of spontaneous
circulation; PEA: pulseless electrical activity.
168 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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Dialysis unit
 Follow the universal ALS algorithm.
 Assign a trained dialysis nurse to operate the haemodialysis (HD)
machine.
 Stop dialysis and return the patient’s blood volume with a fluid
bolus.
 Disconnect from the dialysis machine (unless defibrillation-proof)
in accordance with the International Electrotechnical Committee
(IEC) standards.
 Leave dialysis access open to use for drug administration.
 Dialysis may be required in the early post resuscitation period.
 Provide prompt management of hyperkalaemia.
 Avoid excessive potassium and volume shifts during dialysis.
Dentistry
 Causes of cardiac arrest usually relate to pre-existing comorbid-
ities, complications of the procedure or allergic reactions.
 All dental care professionals should undergo annual practical
training in the recognition and management of medical emergen-
cies, including the delivery of CPR, incl. basic airway management
and the use of an AED.
 Check patient’s mouth and remove all solid materials from the oral
cavity (e.g. retractor, suction tube, tampons). Prevention of foreign
body airway obstruction should precede positioning.
 Recline the dental chair into a fully horizontal position. If reduced
venous return or vasodilation has caused loss of consciousness
(e.g. vasovagal syncope, orthostatic hypotension), cardiac output
can be restored.
 Place a stool under the backrest for stabilisation.
 Start chest compressions immediately while patient lying flat on
the chair.
 Consider the over-the-head technique of CPR if access to either
side of chest is limited.
 Basic equipment for a standard CPR including a bag-valve-mask
device should be available immediately.
Transportation
Inflight cardiac arrest
 Medical professional help should be sought (in-flight
announcement).
 The rescuer should kneel in the leg-space in front of the aisle seats
to perform chest compressions if the patient cannot be transferred
within a few seconds to an area with adequate floor space (galley).
 Overhead-CPR is a possible option in limited space environments.
 Airway management should be based on the equipment available
and the expertise of the rescuer.
 If the flight plan is over open-water with high possibility of ROSC
during an ongoing resuscitation consider an early diversion.
 Consider risks of diversion if ROSC is unlikely and give
appropriate recommendations to the flight crew.
 If CPR is terminated (no ROSC) a flight diversion should not
usually be performed.
Helicopter emergency medical services (HEMS) and air
ambulances
 Proper pre-flight-evaluation of the patient, early recognition and
communication within the team, early defibrillation, high-quality
CPR with minimal interruption of chest compressions, and
treatment of reversible causes before flight are the most important
interventions for the prevention of CPR during HEMS missions.
 Check the patient status properly before flight. Sometimes
ground-based transport might be a suitable alternative, especially
for patients with high-risk of cardiac arrest.
 Check security of the airway and ventilator connections prior to
flight. For a cardiac arrest in an unventilated patient during flight
consider a SGA for initial airway management.
 Pulse oximetry (SpO2) monitoring and oxygen supplementation
should be available immediately if not already attached.
 CPR should be performed as soon as possible, over-the-head-
CPR (OTH-CPR) might be possible depending on the type of
helicopter.
 If cabin size does not allow high-quality CPR, consider immediate
landing.
 Always consider attaching a mechanical CPR device before flight.
 Consider three stacked shocks in case of shockable rhythm during
flight.
 Defibrillation during flight is safe.
Cruise ship
 Use all medical resources immediately (personal, equipment).
 Activate HEMS if close to the coastline.
 Consider early telemedicine support.
 Have all equipment needed for ALS available on board.
 In case of insufficient number of health care professionals to treat
CA, call for further medical staff via an on-board announcement.
Cardiac arrest in sport
Planning
 All sports and exercise facilities should undertake a medical risk
assessment of the risk of sudden cardiac arrest.
 Where there is a raised risk, mitigation must include resuscitation
planning to include:
 Staff and members training in the recognition and management
of cardiac arrest.
 Direct provision of an AED or clear directions to the nearest
public access AED.
Implementation
 Recognise collapse.
 Gain immediate and safe access to the Field of Play.
 Call for help and activate EMS.
 Assess for signs of life.
 If no signs of life:
 commence CPR.
 access an AED and defibrillate if indicated.
 If ROSC occurs, carefully observe and monitor the casualty until
advanced medical care arrives.
 If there is no ROSC:
 Continue cardio-pulmonary resuscitation and defibrillation until
advanced medical care arrives.
 In a sport arena, consider moving patient to a less exposed
position and continue resuscitation. This should be accom-
plished with minimal interruption to chest compressions.
Prevention
 Do not undertake exercise, especially extreme exercise or
competitive sport, if feeling unwell.
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 Follow medical advice in relation to the levels of exercise or sport
competition.
 Consider cardiac screening for young athletes undertaking high
level competitive sport.
Drowning
Initial rescue
 Undertake a dynamic risk assessment considering feasibility,
chances of survival and risks to the rescuer:
 Submersion duration is the strongest predictor of outcome.
 Salinity has an inconsistent effect on outcome.
 Assess consciousness and breathing:
 If conscious and/or breathing normally, aim to prevent cardiac
arrest.
 If unconscious and not breathing normally, start resuscitation.
Cardiac arrest prevention
Airway
 Ensure a patent airway.
 Treat life threatening hypoxia with 100% inspired oxygen until the
arterial oxygen saturation or the partial pressure of arterial oxygen
can be measured reliably.
 Once SpO2 can be measured reliably or arterial blood gas values
are obtained, titrate the inspired oxygen to achieve an arterial
oxygen saturation of 94
98% or arterial partial pressure of oxygen
(PaO2) of 10
13 kPa (75
100 mmHg).
Breathing
 Assess respiratory rate, accessory muscle use, ability to speak in
full sentences, pulse oximetry, percussion and breath sounds;
request chest X-ray.
 Consider non-invasive ventilation if respiratory distress and safe
to do so.
 Consider invasive mechanical ventilation if respiratory distress
and unsafe or unable to initiate non-invasive ventilation.
 Consider extracorporeal membrane oxygenation if poor response
to invasive ventilation.
Circulation
 Assess heart rate and blood pressure, attach ECG.
 Obtain IV access.
 Consider IV fluids and/or vasoactive drugs to support the
circulation.
Disability
 Assess using AVPU or GCS.
Exposure
 Measure core temperature.
 Initiate hypothermia algorithm if core temperature <35  C.
Cardiac arrest
 Start resuscitation as soon as safe and practical to do so. If
trained and able this might include initiating ventilations whilst
still in the water or providing ventilations and chest compres-
sions on a boat.
169
 Start resuscitation by giving 5 rescue breaths/ventilations using
100% inspired oxygen if available.
 If the person remains unconscious, without normal breathing, start
chest compressions.
 Alternate 30 chest compressions to 2 ventilations.
 Apply an AED if available and follow instructions.
 Intubate the trachea if able to do so safely.
 Consider ECPR in accordance with local protocols if initial
resuscitation efforts are unsuccessful.
Mass casualty incidents
 Identify hazards and immediately request assistance if necessary.
 Use adequate personal protection equipment (PPE) (e.g.
bulletproof vest, respirator, long-sleeved gown, eye and face
protection) depending on specific risks on scene.
 Reduce secondary risks to other patients and providers.
 Use a locally established triage system to prioritise treatment.
 Perform life-saving interventions in patients triaged as “immedi-
ate” (highest priority) to prevent cardiac arrest.
 Consider assigning a higher triage risk level to elderly and to
survivors of high-energy trauma in order to reduce preventable
deaths.
 Healthcare professionals must be regularly trained to use the
triage protocols during simulations and live exercises.
Special patients
Asthma and COPD
Cardiac arrest prevention
Airway
 Ensure a patent airway.
 Treat life threatening hypoxia with high flow oxygen (Fig. 13).
 Titrate subsequent oxygen therapy with pulse oximetry (SpO2
94
98% for asthma; 88
92% for chronic obstructive pulmonary
disease (COPD)).
Breathing
 Assess respiratory rate, accessory muscle use, ability to speak in
full sentences, pulse oximetry, percussion and breath sounds;
request chest X-ray.
 Look for evidence of pneumothorax/tension pneumothorax.
 Provide nebulised bronchodilators (oxygen driven for asthma,
consider air driven for COPD).
 Administer steroids (Prednisolone 40
50 mg or hydrocortisone
100 mg).
 Consider IV magnesium sulphate for asthma.
 Seek senior advice before giving IV aminophylline or salbutamol.
Circulation
 Assess heart rate and blood pressure, attach ECG.
 Obtain vascular access.
 Consider IV fluids.
Cardiac arrest treatment
 Administer high concentration oxygen.
 Ventilate with respiratory rate (8
10 min
1) and sufficient tidal
volume to cause the chest to rise.
170 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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Fig. 13 – Management of acute asthma in adults in hospital. 2019. (SIGN publication no. 158). Reproduced with
permission from the Scottish Intercollegiate Guidelines Network (SIGN). Edinburgh: SIGN; available from URL: http://
www.sign.ac.uk.
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2 1 9
 Intubate the trachea if able to do so safely.
 Check for signs of tension pneumothorax and treat accordingly.
 Disconnect from positive pressure ventilation if relevant and apply
pressure to manually reduce hyper-inflation.
 Consider IV fluids.
 Consider E-CPR in accordance with local protocols if initial
resuscitation efforts are unsuccessful.
Neurological disease
 There are no modifications required in the BLS and ALS
management of cardiac arrest from a primary neurological cause.
 Following ROSC, consider clinical features such as young age,
female sex, non-shockable rhythm and neurological antecedents
such as headache, seizures, and focal neurological deficit when
suspecting a neurological cause of cardiac arrest.
 Early identification of a neurological cause can be achieved by
performing a brain CT-scan at hospital admission, before or after
coronary angiography.
 In the absence of signs or symptoms suggesting a neurological
cause (e.g. headache, seizures or neurological deficits) or if there
is clinical or ECG evidence of myocardial ischaemia, coronary
angiography is undertaken first, followed by CT scan in the
absence of causative lesions.
Obesity
 Delivery of effective CPR in obese patients may be challenging
due to a number of factors:
 patient access and transportation
 vascular access
 airway management
 quality of chest compressions
 efficacy of vasoactive drugs
 efficacy of defibrillation
 Provide chest compressions up to a maximum of 6 cm.
 Obese patients lying in a bed do not necessarily need to be moved
down onto the floor.
 Change the rescuers performing chest compression more
frequently.
 Consider escalating defibrillation energy to maximum for repeated
shocks.
 Manual ventilation with a bag-mask should be minimised and be
performed by experienced staff using a two-person technique.
 An experienced provider should intubate the trachea early so that
the period of bag-mask ventilation is minimised.
Pregnancy
Prevention of cardiac arrest in the deteriorating pregnant
patient
 Use a validated obstetric early warning scoring system when
caring for the ill-pregnant patient.
 Use a systematic ABCDE approach to assess and treat the
pregnant patient.
 Place the patient in the left lateral position or manually and gently
displace the uterus to the left to relieve aortocaval compression.
 Give oxygen guided by pulse oximetry to correct hypoxaemia.
 Give a fluid bolus if there is hypotension or evidence of
hypovolaemia.
 Immediately re-evaluate the need for any drugs being given.
171
 Seek expert help early
obstetric, anaesthetic, critical care and
neonatal specialists should be involved early in the resuscitation.
 Identify and treat the underlying cause of cardiac arrest, e.g.
control of bleeding, sepsis.
 Give intravenous tranexamic acid 1 g IV for postpartum
haemorrhage.
Modification for advanced life support in the pregnant patient
 Call for expert help early (including an obstetrician and
neonatologist).
 Start basic life support according to standard guidelines.
 Use the standard hand position for chest compressions on the
lower half of the sternum if feasible.
 If over 20 weeks pregnant or the uterus is palpable above the level
of the umbilicus:
 Manually displace the uterus to the left to remove aortocaval
compression.
 If feasible, add left lateral tilt
the chest should remain on
supported on a firm surface (e.g. in the operating room). The
optimal angle of tilt is unknown. Aim for a tilt between 15 and 30
degrees. Even a small amount of tilt may be better than no tilt.
The angle of tilt used needs to enable high-quality chest
compressions and if needed allow caesarean delivery of the
fetus.
 Prepare early for emergency hysterostomy early
the fetus will
need to be delivered if immediate (within 4 min) resuscitation
efforts fail.
 If over 20 weeks pregnant or the uterus is palpable above the level
of the umbilicus and immediate (within 4 min) resuscitation is
unsuccessful, deliver the fetus by emergency caesarean section
aiming for delivery within 5 min of collapse.
 Place defibrillator pads in the standard position as far as possible
and use standard shock energies.
 Consider early tracheal intubation by a skilled operator.
 Identify and treat reversible causes (e.g. haemorrhage). Focused
ultrasound by a skilled operator may help identify and treat
reversible causes of cardiac arrest.
 Consider extracorporeal CPR (ECPR) as a rescue therapy if ALS
measures are failing.
Preparation for cardiac arrest in pregnancy
Healthcare settings dealing with cardiac arrest in pregnancy should:
 have plans and equipment in place for resuscitation of both the
pregnant woman and the newborn.
 ensure early involvement of obstetric, anaesthetic, critical care
and neonatal teams.
 ensure regular training in obstetric emergencies.
Evidence informing the guidelines
Special causes
Hypoxia
Cardiac arrest caused by pure hypoxaemia is uncommon. It is seen
more commonly as a consequence of asphyxia, which accounts for
most of the non-cardiac causes of cardiac arrest. There are many
causes of asphyxial cardiac arrest (Table 1); although there is usually
a combination of hypoxaemia and hypercarbia, it is the hypoxaemia
that ultimately causes cardiac arrest.9 In an epidemiological study of
172 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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44,000 OHCAs in Osaka, Japan, asphyxia accounted for 6% of
cardiac arrests with a resuscitation attempt, hanging 4.6% and
drowning 2.4%.10
Evidence for the treatment of asphyxial cardiac arrest is based
mainly on observational studies. There are very few data comparing
different therapies for the treatment of asphyxial cardiac arrest
although there are data comparing standard CPR with compression-
only CPR. The Guidelines for clinical practice are based largely on
expert opinion.
Pathophysiological mechanisms
If breathing is completely prevented by airway obstruction or apnoea,
consciousness will be lost when oxygen saturation in the arterial blood
reaches about 60%. The time taken to reach this concentration is
difficult to predict, but based on mathematical modelling is likely to be
of the order 1
2 min.11 Based on animal experiments of cardiac arrest
caused by asphyxia, pulseless electrical activity (PEA) will occur in
3
11 min. Asystole will ensue several minutes later.12 In comparison
with simple apnoea, the exaggerated respiratory movements that
frequently accompany airway obstruction will increase oxygen
consumption resulting in more rapid arterial blood oxygen desatura-
tion and a shorter time to cardiac arrest. Complete airway obstruction
after breathing air will result in PEA cardiac arrest in 5
10 min.9 An
initial monitored rhythm of VF occurs rarely after asphyxial cardiac
arrest
in two of the largest series of hanging-associated out-of-
hospital cardiac arrests (OHCAs), one from Melbourne, Australia, and
the other from Osaka, Japan, just 20 (0.6%) of 3320 patients were in
VF.10,13
Compression-only versus conventional CPR
ILCOR and the ERC 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 (weak recommendation, very-low-
certainty evidence).14,15 Observational studies suggest conventional
CPR even more where there is a non-cardiac cause of cardiac
arrest.16,17
Outcome
Survival after cardiac arrest from asphyxia is rare and most survivors
sustain severe neurological injury. The Osaka study documented
respectively one-month survival and neurologically favourable
outcome after cardiac arrest following: asphyxia 14.3% and 2.7%;
hanging 4.2% and 0.9%; and drowning 1.1% and 0.4%.10
Table 1 – Causes of asphyxial cardiac arrest.
Trauma
Hanging
Chronic obstruction pulmonary disease
Asthma
Airway obstruction, soft tissues (coma), laryngospasm, aspiration
Drowning
Central hypoventilation
brain or spinal cord injury
Impaired alveolar ventilation from neuromuscular disease
Traumatic asphyxia or compression asphyxia (e.g. crowd crush), tension
pneumothorax
Pneumonia
High altitude
Avalanche burial
Anaemia
Of eight published series that included a total of 4189 patients with
cardiac arrest following hanging where CPR was attempted, the
overall survival rate was 4.3%; there were just 45 (1.1%) survivors with
a favourable neurological outcome (CPC 1 or 2); 135 other survivors
were documented to be CPC 3 or 4.10,13,18
23 When resuscitating
these patients, rescuers are frequently able to achieve ROSC but
subsequent neurologically intact survival is rare. Those who are
unconscious but have not progressed to a cardiac arrest are much
more likely to make a good neurological recovery.19,23,24
Hypovolaemia
Hypovolaemia is a potentially treatable cause of cardiac arrest that
usually results from a reduced intravascular volume (i.e. haemor-
rhage), but relative hypovolaemia may also occur in patients with
severe vasodilation (e.g. anaphylaxis, sepsis, spinal cord injury).
Hypovolaemia from mediator-activated vasodilation and increased
capillary permeability is a major factor causing cardiac arrest in severe
anaphylaxis.25 Hypovolaemia from blood loss, is a leading cause of
death in traumatic cardiac arrest.26 External blood loss is usually
obvious, e.g. trauma, haematemesis, haemoptysis, but may be more
challenging to diagnose when occult, e.g. gastrointestinal bleeding or
rupture of an aortic aneurysm. Patients undergoing major surgery are
at high-risk from hypovolaemia due to post-operative haemorrhage
and must be appropriately monitored (see perioperative cardiac
arrest). Depending on the suspected cause, initiate volume therapy
with warmed blood products and/or crystalloids, in order to rapidly
restore intravascular volume. At the same time, initiate immediate
intervention to control haemorrhage, e.g. surgery, endoscopy,
endovascular techniques,27 or treat the primary cause (e.g.
anaphylactic shock). In the initial stages of resuscitation use any
crystalloid solution that is immediately available, if haemorrhage is
likely aim for early blood transfusion and vasopressor support. If
there is a qualified sonographer able to perform ultrasound with
minimum interruption to chest compressions, it may be considered
as an additional diagnostic tool in hypovolaemic cardiac arrest.
Treatment recommendations for cardiac arrest and peri arrest
situations in trauma, anaphylaxis and sepsis are addressed in
separate sections because of the need for specific therapeutic
approaches.
Traumatic cardiac arrest (TCA)
Traumatic cardiac arrest (TCA) carries a very high mortality, but in
those where ROSC can be achieved, neurological outcome in
survivors appears to be much better than in other causes of cardiac
arrest.28,29 The response to TCA is time-critical and success depends
on a well-established chain of survival, including advanced preho-
spital and specialised trauma centre care. Immediate resuscitative
efforts in TCA focus on simultaneous treatment of reversible causes,
which takes priority over chest compressions.
This section is based on an evidence update on TCA produced by
recent systematic reviews and focused on scoping reviews address-
ing the questions:28,30
32
 Chest compressions in hypovolemic cardiac arrest/peri-arrest?
(1291 titles screened/120 abstracts screened/8 publications
selected).
 Chest compressions versus open cardiac massage (808 titles
screened/43 abstracts screened/29 publications selected).
 Needle thoracocentesis versus resuscitative thoracotomy in
pericardial tamponade (572 titles screened/29 abstracts
screened/7 publications selected).
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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 Needle decompression in traumatic tension pneumothorax? (214
titles screened/7abstracts screened/5 publications selected).
 REBOA versus aortic occlusion of the descending aorta in TCA or
peri-arrest (1056 titles screened/156 abstracts screened/11
publications selected).
Epidemiology and pathophysiology
Traumatic cardiac arrest (TCA) carries a high mortality. Registry data
for survival range from 1.6% to 32%.33
37 The considerable variation
in reported survival mainly reflects heterogeneity in entry criteria but
also in case mix and care in different systems.
In survivors, the neurological outcome appears to be much better
than in other causes of cardiac arrest.26,29,35,37 The reversible causes of
TCA are uncontrolled haemorrhage (48%); tension pneumothorax
(13%); asphyxia (13%); pericardial tamponade (10%).26 The prevalent
initial heart rhythms found in TCA are either PEA or asystole, depending
on the time interval between circulatory arrest and the first electrocar-
diogram (ECG) recording PEA (66%); asystole (30%); VF (6%).26
Diagnosis
Patients with TCA will usually present with loss of consciousness,
agonal or absent spontaneous breathing and absence of a central
pulse. A peri-arrest state is characterised by cardiovascular instability,
hypotension, loss of peripheral pulses and a deteriorating conscious
level, without obvious underlying central nervous system problems. If
untreated this state is likely to progress to cardiac arrest. The use of
ultrasound may help to verify the cause of the TCA and direct the
resuscitative efforts accordingly.38
Prognostic factors and withholding resuscitation
There are no reliable predictors of survival for TCA. Factors that are
associated with survival include the presence of reactive pupils,
respiratory activity, spontaneous movements and an organised ECG
rhythm.39,40 Short duration of CPR, short prehospital times,41
penetrating chest injury,42 witnessed arrest and the presence of a
shockable rhythm are also associated with positive outcomes.43,44
Children presenting with TCA have a better outcome than adults.28,29
The American College of Surgeons and the National Association of
EMS physicians recommend withholding resuscitation in situations
where death is inevitable or established and in trauma patients
presenting with apnoea, pulselessness and without organised ECG
activity.45 However, neurologically intact survivors initially presenting
in this state have been reported.29 We therefore recommend the
following approach:
Consider withholding resuscitation in TCA in any of the following
conditions:
 no signs of life within the preceding 15 min.
 massive trauma incompatible with survival (e.g. decapitation,
penetrating heart injury, loss of brain tissue).
We suggest termination of resuscitative efforts if there is:
 no ROSC after reversible causes have been addressed.
 no detectable ultrasonographic cardiac activity in PEA after
reversible causes have been addressed.
Initial management steps
Pre-hospital care
The key decision to be made in the prehospital environment is establish
whether the cardiac arrest is caused by trauma or by an underlying
173
medical problem. If TCA cannot be confirmed, standard ALS guidelines
apply. Short pre-hospital times are associated with increased survival
rates for major trauma and traumatic cardiac arrest.38
Hospital care
Successful treatment of TCA requires a team approach with all
measures carried out in parallel rather than sequentially. The
emphasis lies on rapid treatment of all potentially reversible causes.
Fig. 2 shows the traumatic cardiac (peri-)arrest algorithm of the
European Resuscitation Council (ERC), which is based on the
universal ALS algorithm.
Effectiveness of chest compressions
In cardiac arrest caused by hypovolaemia, cardiac tamponade or
tension pneumothorax, chest compressions are unlikely to be as
effective as in normovolaemic cardiac arrest and may reduce residual
spontaneous cardiac output.46
48 Therefore, chest compressions
take a lower priority than addressing the reversible causes. Chest
compressions must not delay immediate treatment of reversible
causes. A retrospective cohort study analysing data from the Trauma
Quality Improvement Program (TQIP) database, a nationwide trauma
registry in the USA, between 2010 and 2016 compared open cardiac
compressions to close chest compressions in IHCA patients admitted
with signs of life. Results in this specific patient group showed a
favourable outcome for the patients receiving open cardiac com-
pressions versus closed chest compressions.49
Hypovolaemia
The treatment of severe hypovolaemic shock has several elements.
The main principle is to achieve immediate haemostasis. Temporary
haemorrhage control can be lifesaving.38 In hypovolemic TCA,
immediate restoration of the circulating blood volume with blood
products is mandatory. Prehospital transfusion of fresh plasma and
packed red cells yields a significant survival benefit if the journey time
to the receiving hospital exceeds 20 min.50,51
Compressible external haemorrhage can be treated with direct or
indirect pressure, pressure dressings, tourniquets and topical
haemostatic agents.52 Non-compressible haemorrhage is more
difficult to address and splints (pelvic splint), blood products, IV fluids
and tranexamic acid can be used while transferring the patient to
surgical haemorrhage control.
 Immediate aortic occlusion is recommended as a last resort
measure in patients with exsanguinating and uncontrollable infra-
diaphragmatic torso haemorrhage. This can be achieved through
Resuscitative Thoracotomy (RT) and cross-clamping the de-
scending aorta or Resuscitative Endovascular Balloon Occlusion
of the Aorta (REBOA). There is no evidence for one technique
being superior over the other.30
 Neurogenic shock as a sequel of spinal cord injury (SCI) can
aggravate hypovolemia due to blood loss in trauma patients. Even
moderate blood loss can cause cardiac arrest in the presence of
SCI due to the limited compensatory capacity. Indicators for SCI in
severely injured patients are warm peripheries and loss of reflexes
below the injured segment, severe hypotension and a low heart
rate. The cornerstones of treatment are fluid replacement and IV
vasopressors.53
Hypoxia
In TCA, hypoxaemia can be caused by airway obstruction, traumatic
asphyxia or impact brain apnoea.54 Impact brain apnoea is an
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underestimated cause of morbidity and mortality in trauma but not
necessarily associated with an un-survivable brain injury.55 Impact
brain apnoea may aggravate the course of traumatic brain injury and
can lead to asphyxiation if left untreated. Effective airway
management and ventilation can prevent and reverse hypoxic
cardiac arrest.
However, controlled ventilation in circulatory compromised
patients is associated with major risks related to the side effect of
anaesthetics and increase in intrathoracic pressure56 which may lead
to:57 further decrease in residual cardiac output by impeding venous
return to the heart, particularly in severely hypovolaemic patients.
 reduced diastolic filling in cardiac tamponade
 conversion of pneumothorax into a tension pneumothorax
 increase in blood loss from venous bleeding sites
Low tidal volumes may help optimise cardiac preload. Ventilation
should be monitored with capnography and adjusted to achieve
normocapnia.38,58
Tension pneumothorax
To decompress the chest in TCA, perform bilateral thoracostomies in the
4th intercostal space (ICS), allowing extension to a clamshell thoracotomy
if required. Alternatively, a needle thoracocentesis can be attempted (see
corresponding guideline section). In the presence of positive pressure
ventilation, thoracostomies are likely to be more effective than needle
thoracocentesis and quicker than inserting a chest tube.59
62
Cardiac tamponade
Cardiac tamponade is a frequent cause of cardiac arrest in penetrating
chest trauma and immediate resuscitative thoracotomy (RT) via a
clamshell or left anterolateral incision, is indicated to restore
circulation.63,64 The chance of survival is about 4 times higher in
cardiac stab wounds than in gunshot wounds.65
The prerequisites for a successful RT can be summarized as “four
E rule” (4E):
 Expertise: teams that perform RT must be led by a highly trained
and competent healthcare practitioner. These teams must operate
under a robust governance framework.
 Equipment: adequate equipment to carry out RT and to deal with
the intrathoracic findings is mandatory.
 Environment: ideally RT should be carried out in an operating
theatre. RT should not be carried out if there is inadequate physical
access to the patient, or if the receiving hospital is not easy to
reach.
 Elapsed time: the time from loss of vital signs to commencing a RT
should not be longer than 15 min.
If any of the four criteria is not met, RT is futile and exposes the
team to unnecessary risks. RT is also a viable therapeutic option in the
prehospital environment.31,32,66,67
Subsequent management and treatment
The principle of ‘damage control resuscitation’ has been adopted in
trauma resuscitation for uncontrolled haemorrhage. Damage control
resuscitation combines permissive hypotension and haemostatic
resuscitation with damage control surgery. Limited evidence and
general consensus have supported a conservative approach to IV
fluid infusion, with permissive hypotension until surgical haemostasis
is achieved.68 Permissive hypotension allows IV fluid administration to
a volume sufficient to maintain a radial pulse. Caution is advised
patients with traumatic brain injury were a raised intracranial pressure
may require a higher cerebral perfusion pressure. The duration of
hypotensive resuscitation should not exceed 60 min, because the
risks of irreversible organ damage then exceed its intended benefits.69
Haemostatic resuscitation is the very early use of blood products as
primary resuscitation fluid to prevent exsanguination and trauma-
induced coagulopathy.70
72 Tranexamic acid (TXA) (loading dose 1 g
IV over 10 min followed by infusion of 1 g over 8 h) increases survival
from traumatic haemorrhage. It is most effective when administered
within the first hour and certainly within the first three hours following
trauma.73 TXA should not be started any later than four hours after the
injury as it then may increase mortality.
Diagnostics
Sonography should be used in the evaluation of the compromised
trauma patient to target lifesaving interventions if the cause of shock
cannot be diagnosed clinically. Haemoperitoneum, haemo- or pneu-
mothorax and cardiac tamponade can be diagnosed within minutes.38,74
Anaphylaxis
This guideline is specific for the initial treatment of adult patients with
anaphylaxis or suspected anaphylaxis by clinicians. A precise
definition of anaphylaxis is not important for its emergency treatment.
Anaphylaxis is a serious systemic allergic reaction that is rapid in onset
and may cause death.75 The incidence of anaphylaxis is increasing
globally, whereas the case fatality rate has remained stable or
decreased, with an overall population risk of death of about 0.5
1 per
million.76,77 Foods (especially in children), drugs and insect bites are
the commonest triggers.76
This anaphylaxis guidance is based on the most recent First Aid
ILCOR CoSTR,52 guidelines and updates from the World Allergy
Organisation Anaphylaxis Committee,78 European Academy of
Allergy and Clinical Immunology (EAACI),25 North American Practice
Parameter,79 Australasian Society of Clinical Immunology and Allergy
(ASCIA) (https://www.allergy.org.au/hp//papers/acute-management-
of-anaphylaxis-guidelines, accessed 10 August 2020), recent guid-
ance on perioperative allergic reactions,80 the findings from the UK
National Audit Project of perioperative anaphylaxis,81 and our
understanding of the pathophysiology of anaphylaxis.82 We complet-
ed a focused literature search up to July 2020 to identify any new
relevant studies. The evidence supporting specific interventions for
the treatment of anaphylaxis is limited with few RCTs. The majority of
recommendations are based on observational data, good practice
statements and expert consensus.79,83
Recognition of anaphylaxis
Anaphylaxis causes life threatening airway (swollen lips, tongue,
uvula), breathing (dyspnoea, wheeze, bronchospasm, stridor,
reduced peak flow, hypoxaemia) and circulation problems (hypoten-
sion, cardiac arrest) with or without skin or mucosal changes
(generalised urticaria, flushing or itching) as part of an allergic
reaction.25,52,75,84 Skin and mucosal changes are not always present
or obvious to the rescuer and severe bronchospasm, hypotension, or
rarely sudden cardiac arrest can be the first features.77,81 Knowledge
of the patient's allergy history and triggers can help make the
diagnosis, but this will not always be known.
Remove or stop the trigger if possible
Based on expert consensus, stop any drug suspected of causing
anaphylaxis. Remove the stinger after a bee sting
early removal is
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more important than the method of removal.85,86 Do not delay
definitive treatment if removing the trigger is not feasible.
Give intramuscular adrenaline early and repeat after 5 min if
necessary
Adrenaline is the most important drug for the treatment of
anaphylaxis and is the first line treatment according to all current
guidelines for anaphylaxis based on both its alpha- (vasoconstrictor)
and beta-(bronchodilator, inotropic, mast cell stabilisation) agonist
properties. Intramuscular (IM) adrenaline works within minutes and
adverse effects are extremely rare with the correct doses. The best
site for IM injection is the anterolateral aspect of the middle third of
the thigh. The available evidence for adrenaline and the recom-
mended doses is weak and based on observational data and expert
consensus.78,83,87 The EAACI suggests Intramuscular adrenaline
(1 mg/ml) should be given at a dose of 0.01 ml kg
1 of body weight to
a maximum total dose of 0.5 ml.25 These ERC guidelines
recommend a dose of 0.5 mg IM in adults based on expert opinion.
Adrenaline auto-injectors are also available
auto-injector devices
are manufacturer specific for preparation, mechanism of injection
and dose delivery (0.3 mg and 0.15 mg are the commonest doses).
These can be used as an alternative to a syringe, needle and
ampoule
follow the manufacturer instructions on how to use them.
This ERC guideline does not address the choice, prescription,
dosing, and instructions for self-use of adrenaline auto-injectors by
those at risk of anaphylaxis.
Based on the available evidence52,88 time to effect, the variability in
response to the first dose of adrenaline, the observed need for a
second dose reported to be in about 10
30% of cases,89,90 variable
EMS response times, and exiting international guideline recommen-
dations, we suggest repeating the IM adrenaline dose if there is no
improvement in the patient’s condition after about 5-min.
Ensure the patient is lying and do not suddenly sit or stand the
patient up
Observational data from a detailed review of 214 individual cases of
death from anaphylaxis referred to Coroner's in the UK observed
cardiovascular collapse occurred when some individuals with out-of-
hospital anaphylaxis who had clinical signs of a low blood pressure
sat- or stood-up or were sat- or stood-up by rescuers.91 Based on this
limited evidence, expert consensus and existing guidelines we
suggest:
 Patients with Airway and Breathing problems may prefer to sit up
as this will make breathing easier.
 Lying flat with or without leg elevation is helpful for patients with a
low blood pressure.
 Patients who are breathing and unconscious should be placed on
their side (recovery position).
 Pregnant patients should lie on their left side to prevent aortocaval
compression.
Give intravenous fluids
Anaphylaxis can cause hypotension due to vasodilation, redistribution of
blood between vascular compartments, and fluid extravasation and
correcting for fluid losses in addition to adrenaline is based on experience
of managing shock in other settings such as sepsis.82,92 In line with these
guidelines we suggest the use of either balanced crystalloids or 0.9%
sodium chloride bolus doses and further doses based on haemodynamic
response. The first resuscitation fluid bolus should be about 500 ml over 5

10 min.93 Expert opinion suggests patients with refractory anaphylaxis
175
may need large volumes of fluid resuscitation.80,81 Emerging observa-
tional evidence suggests that anaphylaxis can impair stroke volume and
that improves with early use of fluids.94
Give oxygen
Oxygen therapy to correct hypoxaemia is a standard part of
resuscitation. As for other emergency conditions, high flow oxygen
should be given early and once an oxygen saturation can be measured
reliably with a pulse oximeter the inspired oxygen should be titrated to
target an oxygen saturation of 94
98%.95
Intravenous (IV) adrenaline in specialist settings
Intravenous adrenaline should be used only by those experienced in
the use and titration of vasopressors in their normal clinical practice
(based on expert opinion and exiting guidelines) Patients who are
given IV adrenaline must be monitored
continuous ECG and pulse
oximetry and frequent non-invasive blood pressure measurements as
a minimum. Titrate IV adrenaline using a 20
50 mg bolus according to
response.80,84 If repeated adrenaline doses are needed, start an IV
adrenaline infusion.80,81,84
Other drugs to support the circulation
Several guidelines based on expert opinion recommend glucagon
1
2 mg IV is considered for anaphylaxis refractory to adrenaline in
patients who are taking beta-blockers.80,84 In addition based on expert
opinion when anaphylaxis is refractory other vasopressors can be
considered as a bolus dose or infusion including vasopressin, noradrena-
line, metaraminol, phenylephrine.80,81,84 (Australian guideline website -
https://www.allergy.org.au/images/ASCIA_HP_Guidelines_Acute_Man-
agement_Anaphylaxis_2020.pdf
accessed 10 August 2020).
Role of steroids and antihistamines in the immediate
management of anaphylaxis
There is no evidence that supports the routine use of either steroids or
antihistamines in the initial resuscitation of a patient with anaphylax-
is.79,83,96
98 They do not appear to alter the progress of anaphylaxis or
prevent biphasic reactions.77,99,100 Steroids should be considered if
there are ongoing asthma-like symptoms or in the setting of refractory
shock in accordance with guidelines for asthma and shock states.
Considerations for cardiac arrest in anaphylaxis
There are no specific studies of advanced life support for
anaphylaxis. Based on expert opinion follow standard ALS guide-
lines for cardiac arrest care including use of IV adrenaline and
correction of potentially reversible causes (fluids, oxygen) (see ALS
Guidelines).101 Areas of controversy is the effectiveness of chest
compressions in patients with vasodilatory cardiac arrest and when
should chest compressions start in closely monitored patients.80,102
In a case series of peri-operative cardiac arrest caused by
anaphylaxis 31 of 40 patients (77.5%) survived with ALS
interventions, and 67% of survivors required an adrenaline or
vasopressor infusion after ROSC.81 The cardiac arrest rhythm was
PEA in 34 (85%), VF in 4 (10%) and asystole in 2 (5%).
Role of extracorporeal life support and extracorporeal CPR in
anaphylaxis
The ILCOR ALS Task Force suggests that ECPR may be considered
as a rescue therapy for selected patients with cardiac arrest when
conventional CPR is failing in settings in which it can be implemented
(weak recommendation, very low-certainty evidence).2,103 Expert
176 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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opinion, case reports and clinical experience supports the use of
emergency ECLS or ECPR in the peri-arrest or refractory cardiac
arrest setting in select patients.
Follow up and further investigations
The ongoing care of patients with anaphylaxis should follow existing
guidelines from the World Allergy Organisation Anaphylaxis Commit-
tee,78 European Academy of Allergy and Clinical Immunology
(EAACI),25 North American Practice Parameter79 Australasian
Society of Clinical Immunology and Allergy (ASCIA). (https://www.
allergy.org.au/hp//papers/acute-management-of-anaphylaxis-guide-
lines, accessed 10 August 2020) Mast cell tryptase measurement can
help diagnose anaphylaxis. The consensus on optimal timing for
measurement is that ideally three timed samples should be taken:104
 First sample as soon as feasible after resuscitation has started

do not delay resuscitation to take sample.
 Second sample at 1
2 h after the start of symptoms
 Third sample either after 24 h or in convalescence. This provides
baseline tryptase levels
some individuals have an elevated
baseline level.
Sepsis
Sepsis is defined as life-threatening organ dysfunction caused by a
dysregulated host response to infection. Septic shock is a subset of
sepsis with circulatory and cellular/metabolic dysfunction associated
with a higher risk of mortality.92
This section is written on the care of the adult patient based on the
Surviving Sepsis Campaign: International Guidelines for Manage-
ment of Sepsis and Septic Shock (2016) and National Institute of
Clinical Excellence (2016).92,105 Please refer to paediatric and
neonatal guidelines on sepsis. An update to guidelines was published
by Surviving Sepsis Campaign in 2018 which combined initial
resuscitation into Hour 1 Bundle.106 This was revised in 2019, the
starting time was defined as time when sepsis is recognised (Fig. 3).
Cardiac arrest prevention in sepsis
Sepsis is defined as life-threatening organ dysfunction caused by a
dysregulated host response to infection. Septic shock is a subset of
sepsis with circulatory and cellular/metabolic dysfunction associated
with a higher risk of mortality.92
Key steps in the initial treatment and management of severe sepsis
to prevent cardiac arrest in adults are summarized in Fig. 3. The ERC
recommends assessment using the ABCDE approach while control-
ling the underlying source of infection is critical in the prevention of
shock, multi-organ failure and cardiorespiratory arrest. Once
immediate life-threatening problems have been addressed, initial
resuscitation in patients should begin immediately. High-flow oxygen
should be given to optimize oxygen delivery to tissues. Blood cultures
should be obtained followed by the administration of broad-spectrum
antibiotics. Lactate levels should be measured. Hypotension or a
lactate measurement of 4 mmol/l should be treated with the rapid
administration of 30 ml kg
1 crystalloid. Hourly urine output should be
measured to help guide IV fluid therapy. Vasopressors should be
started if the patient remains hypotensive during or after fluid
resuscitation to maintain a mean arterial pressure 65 mmHg.
Cardiac arrest treatment due to sepsis
Cardiac arrest in a person with severe sepsis can be a result of hypoxia
and cardiovascular collapse. Treat cardiac arrest in a patient with
sepsis or suspected sepsis according to standard ALS guidelines.
Hypoxia
The correction of hypoxia in cardiac arrest due to sepsis may require
high flow oxygenation, intubation and mechanical ventilation.
Correcting hypoxia and hypotension will optimise oxygen delivery
to tissues and vital organs.
Hypovolaemia
Sepsis-induced tissue hypoperfusion or septic shock requires prompt
and effective fluid resuscitation. Initial fluid resuscitation should begin
immediately following the recognition of a patient with sepsis and/or
hypotension and elevated lactate, and completed within 3 h of
recognition. A minimum of 30 ml kg
1 of IV crystalloid fluid is
recommended based on data from observational studies.107,108
Based on the lack of evidence to support the use of colloid compared
with crystalloid solutions, the guidelines make a strong recommenda-
tion for the use of crystalloid solutions in the initial resuscitation of
patients with sepsis and septic shock.
The goal of resuscitation is to restore adequate perfusion pressure
to the vital organs. If patient remains hypotensive after initial fluid
resuscitation, then vasopressors should be started within the first hour
to achieve a mean arterial pressure (MAP) of 65 mmHg.109,110
Post resuscitation care
Sources of infection should be identified and treated accordingly.
Serum lactate is a surrogate for tissue perfusion and can be used to
guide resuscitation.111,112 Careful clinical assessment is required
beyond the initial resuscitation stages to assess fluid responsiveness
and avoid potentially harmful sustained positive fluid balance.113
115
Early initiation of treatment is required to prevent organ dysfunction
and cardiac arrest. Follow standard ALS guidelines for cardiac arrest in
a patient with sepsis or suspected sepsis. Correct hypoxia and treat
hypovolaemia and look for other potentially reversible causes using the
4Hs and 4Ts approach. In post resuscitation care, avoid sustained
positive fluid balance. Serum lactate may be useful in guiding therapy.
Hypo-/hyperkalaemia and other electrolyte disorders
Electrolyte abnormalities are recognised causes of arrhythmias and
cardiac arrest. Potassium disorders, hyperkalaemia and hypokalae-
mia are the most common electrolyte disturbances associated with
life-threatening arrhythmias, whilst calcium and magnesium disorders
occur less commonly. The primary focus in this section is the
recognition, treatment and prevention of hyperkalaemia.
This section is based on the UK Renal Association Hyperkalaemia
guideline 2020 which used the GRADE approach for quality of
evidence.116 There remains sparse evidence for the drug treatments
for hyperkalaemia (i.e. intravenous calcium and insulin-glucose) in
cardiac arrest. A review did not identify any other relevant, high quality
guidelines on the management of hyperkalaemic cardiac arrest or the
initiation of dialysis during CPR. A scoping review was performed
using keywords ‘hyperkalaemia’, ‘treatment’, ‘ECG’, and ‘Cardiac
arrest’ in PubMed (1960
2020), Ovid Medline (1946
2020),
EMBASE (1974
2020) and The Cochrane Library (1995
2020).
Websites searches included National Institute for Health and Care
Excellence (NICE), Scottish Medicines Consortium (SMC), Health-
care Improvement Scotland, Medicines and Healthcare products
Regulatory Agency (MHRA) and European Medicines Agency (EMA).
Hyperkalaemia
Hyperkalaemia occurs in 1
10% of hospitalised patients, most often
in patients with pre-existing kidney disease or in the context of an
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acute kidney injury.117
119 People receiving long-term haemodialysis
(HD) are most at risk of hyperkalaemia. They are also susceptible to
cardiac disease and together with hyperkalaemia, may account for the
high risk of sudden cardiac death in patients on maintenance dialysis.
The reported incidence varies from 1% to 13% of in-hospital cardiac
arrests (IHCA).120
122
Definition
There is no universal definition. We have defined hyperkalaemia as a
serum potassium (K+) concentration greater than 5.5 mmol/l, although
in clinical practice, hyperkalaemia is a continuum. The severity of
hyperkalaemia guides response to treatment. Hyperkalaemia may be
categorised as ‘mild’ (K+ 5.5
5.9 mmol/l), ‘moderate’ (K+ 6.0
6.4
mmol/l) or ‘severe’ (K+ 6.5 mmol/l).
Causes
The main causes of hyperkalaemia are:
 Renal failure (i.e. acute kidney injury (AKI), chronic kidney disease
(CKD) or end-stage renal disease (ESRD)).
 Drugs (e.g. angiotensin converting enzyme inhibitors (ACE-I),
angiotensin II receptor antagonists (ARB), mineralocorticoid
receptor antagonists (MRA), non-steroidal anti-inflammatory drugs,
non-selective beta-blockers, trimethoprim, suxamethonium).
 Endocrine disorders (e.g. diabetic ketoacidosis, Addison’s
disease).
 Tissue breakdown (e.g. rhabdomyolysis, tumour lysis syndrome,
haemolysis).
 Diet (high potassium intake in patients with advanced CKD).
 Spurious
consider pseudo-hyperkalaemia in the presence of
normal renal function, normal ECG and/or history of haemato-
logical disorder.123 Pseudo-hyperkalaemia is detected when the
serum (clotted blood) K+ level exceeds that of the plasma (non-
clotted blood) by more than 0.4 mmol/l on simultaneous
samples.124 Difficult venepuncture, prolonged transit time and
poor storage conditions can contribute to spurious K+ levels.
The risk of hyperkalaemia increases in the presence of multiple
risk factors (e.g. the concomitant use of ACE-I and/or MRA in the
presence of CKD).
Diagnosis
Consider hyperkalaemia in all patients with an arrhythmia or cardiac
arrest, especially in the patient groups at risk (e.g. renal failure, heart
failure, diabetes mellitus, rhabdomyolysis).
Symptoms may be absent or over-shadowed by the primary illness
causing hyperkalaemia, but the presence of limb weakness, flaccid
paralysis or paraesthesia are indicators of severe hyperkalaemia.
Confirm the presence of hyperkalaemia using point-of-care testing
(i.e. blood gas analyser) if available. Formal laboratory samples will
take some time, therefore clinical decisions can be made on the results
using point-of-care testing.19,125
128 The ECG is used to assess
cardiac toxicity and risk of arrhythmias in patients with known or
suspected hyperkalaemia and may be the most readily available
diagnostic tool. When the diagnosis of hyperkalaemia can be
established based on the ECG, treatment can be initiated even
before serum biochemistry is available.
The ECG signs of hyperkalaemia are usually progressive and
include:
 First degree heart block (prolonged PR interval >0.2 s).
 Flattened or absent P waves.
177
 Tall, peaked (tented) T waves (i.e. T wave larger than R wave in
more than 1 lead).
 ST-segment depression.
 Widened QRS (>0.12 s).
 VT.
 Bradycardia.
 Cardiac arrest (PEA, VF/pVT, asystole).
The incidence of ECG changes appears to correlate with severity
of hyperkalaemia. In patients with severe hyperkalaemia (K+ 6.5
mmol/l), arrhythmias or cardiac arrest have been shown to occur in
15% of patients within 6 h of the presenting ECG prior to initiation of
treatment.129 However, it is also recognised that the ECG may be
normal even in the presence of severe hyperkalaemia and the first
ECG sign of hyperkalaemia may be an arrhythmia or cardiac arrest.116
Treatment
There are five key steps in the treatment of hyperkalaemia:116
1 Protect the heart;
2 Shift potassium into cells;
3 Remove potassium from the body;
4 Monitor serum potassium and glucose levels;
5 Prevent recurrence of hyperkalaemia.
Follow a systematic approach as outlined in the hyperkalaemia
treatment algorithm (Fig. 4). Assess the patient using the ABCDE
approach and check the severity of hyperkalaemia with urgent bloods
and an ECG. Treatment is guided by the severity of hyperkalaemia
and the presence of ECG changes. Cardiac monitoring is essential for
patients with severe hyperkalaemia. Consider the need for early
specialist or critical care referral. The treatment of mild hyperkalaemia
is out with the scope of this guideline.
Intravenous calcium salts (calcium chloride or gluconate) are
indicated in severe hyperkalaemia in the presence of ECG changes.
Although this therapy lacks a strong evidence base, it is widely
accepted that it prevents arrhythmias and cardiac arrest.130 The
main risk of this treatment is tissue necrosis secondary to
extravasation, therefore ensure secure vascular access prior to
administration.
Insulin and glucose is the most effective and reliable therapy for
lowering serum K+ by shifting K+ into cells. However, there is growing
evidence to highlight the risk of hypoglycaemia with an incidence rate of
up to 28%. Studies comparing low dose (5 units) to conventional dose
(10 units) insulin reported hypoglycaemia in 8.7
19.7% of patients.
Two studies have also reported an apparent dose-dependent effect
with 10 units insulin showing greater efficacy than 5 units insulin.131 The
risk of hypoglycaemia is reduced by the administration of 50 g
glucose.132 Continuous delivery of glucose has also been shown to
reduce hypoglycaemic events, therefore this strategy has been applied
to the patient group most at risk. A low pre-treatment blood glucose level
appears to be a consistent risk factor for development of hypoglycae-
mia.133
139 Treat moderate or severe hyperkalaemia with 10 units
insulin and 25 g, glucose followed by a continuous infusion of 10%
glucose over 5 h (25 g glucose) in patients with a baseline glucose
<7.0 mmol/l to reduce the risk of hypoglycaemia.116
Salbutamol is a beta-2 adrenoceptor agonist and promotes the
intracellular shift of K+. Its effect is dose-dependent, but a lower
dose is recommended in patients with heart disease. Salbutamol
may be ineffective in some patients including those receiving non-
selective beta-blockers and in up to 40% of patients with ESRD,
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therefore it should not be used as monotherapy. The combination of
salbutamol with insulin-glucose is more effective than either
treatment alone.140
142
The novel potassium binders SZC143 and the cation exchange
resin Patiromer144 are approved by NICE in the UK for the treatment of
life-threatening hyperkalaemia (K+ 6.5 mmol/l) (enteral application).
SZC works within 1 h145 and lowers serum K+ by 1.1 mmol/l within
48 h.146 Efficacy increases with severity of hyperkalaemia. In patients
with a serum K+ >6.0 mmol/l, SZC lowers serum K+ by 1.5 mmol/l
within 48 h.146 SZC normalises serum K+ in 66% of patients within
24 h, 75% within 48 h and in 78% of patients within 72 h.147 Patiromer
works more slowly with an onset of action within 4
7 h and lowers
serum K+ by 0.36 mmol/l within 72 h.148 Pilot studies for both drugs in
the acute setting have been inconclusive.149,150 Both drugs may be
used in patients with persistent moderate hyperkalaemia. However,
NICE has recommended restricted use for patients with CKD 3b-5 (not
on dialysis) or heart failure who are being treated with a sub-optimal
dose of an ACE-I or ARB. Resins, e.g. calcium resonium, may be
considered for patients who do not meet these criteria. Follow local
guidelines for use of potassium binders.
Serial monitoring of the serum K+ and blood glucose are essential
to assess efficacy of treatment and to detect hypoglycaemia. Insulin-
glucose and salbutamol are effective for 4
6 h, thereafter, be alert for
a rebound of hyperkalaemia.
Indications for dialysis
Dialysis is the most definitive treatment for hyperkalaemia. The main
indications for dialysis in patients with hyperkalaemia are:
 Severe life-threatening hyperkalaemia with or without ECG
changes or arrhythmia.
 Hyperkalaemia resistant to medical treatment.
 End-stage renal disease.
 Oliguric acute kidney injury (urine output <400 ml/day).
 Marked tissue breakdown (e.g. rhabdomyolysis).
Several dialysis modalities have been used safely and effectively
in cardiac arrest, but requires expert help and equipment.151
155 The
procedure for dialysis initiation during cardiac arrest is outlined in the
Renal Association (UK) Hyperkalaemia Guideline (2020).116 Follow-
ing dialysis, rebound hyperkalaemia may occur.
Hypokalaemia
Hypokalaemia is a common electrolyte disorder in clinical practice. It is
associated with a higher in-hospital mortality and an increased risk of
ventricular arrhythmias.156
158 The risk of adverse events is
increased in patients with pre-existing heart disease and in those
treated with digoxin.158
160
Definition
Hypokalaemia is defined as a serum K+ <3.5 mmol/l. Clinical manifes-
tations and treatment is guided by severity: mild (K+ 3.0
3.4 mmol/l),
moderate (K+ 2.5
2.9 mmol/l) or severe (K+ <2.5 mmol/l or
symptomatic).160
Causes
The main causes of hypokalaemia are:
 Gastrointestinal loss (e.g. diarrhoea, laxative abuse, villous
adenoma of colon);
 Drugs (e.g. diuretics, laxatives, steroids);
 Therapies for hyperkalaemia (insulin/ glucose, salbutamol);
 Renal losses (e.g. renal tubular disorders, diabetes insipidus);
 Dialysis losses (e.g. peritoneal dialysis, post haemodialysis
therapy);
 Magnesium depletion;
 Metabolic alkalosis;
 Endocrine disorders (e.g. Cushing’s syndrome, primary
hypoaldosteronism);
 Poor dietary intake.
Recognition
Consider hypokalaemia for all patients with an arrhythmia or cardiac
arrest. As serum K+ level falls, the nerves and muscles are
predominantly affected causing fatigue, weakness, leg cramps and
constipation. Mild hypokalaemia is usually asymptomatic, however, in
severe cases (K+ <2.5 mmol/l), rhabdomyolysis, ascending paralysis,
respiratory difficulties and arrhythmias may occur.160
ECG features of hypokalaemia:
 U waves;
 T wave flattening;
 Prolonged PR interval;
ST segment changes (ST depression, T-wave inversion);

 Arrhythmias (increased risk on patients taking digoxin);
 Cardiac arrest (PEA, VF/pVT, asystole).
Treatment
There are 4 key steps in treating hypokalaemia:
1. Restore potassium level (rate and route of replacement guided by
clinical urgency).
2. Check for any potential exacerbating factors (e.g. digoxin toxicity,
hypomagnesaemia).
3. Monitor serum K+ (adjust replacement as needed depending on
level).
4. Prevent recurrence (assess and remove cause).
Treatment is guided by the severity of hypokalaemia and presence
of symptoms and/or ECG abnormalities. Slow replacement of
potassium is preferable, but in an emergency, more rapid IV
replacement is required.
 The standard rate of infusion of potassium is 10 mmol/h. The
maximum rate is 20 mmol/h, but more rapid infusion (e.g. 2 mmol/
min for 10 min, followed by 10 mmol over 5
10 min) is indicated for
unstable arrhythmias when cardiac arrest is imminent.
 Continuous ECG monitoring is essential, ideally in a high
dependency area.
 Monitor potassium level closely and titrate rate of replacement
according to the level.
Magnesium is important for potassium uptake and for the maintenance
of intracellular potassium concentration, particularly in the myocardium.
Magnesium deficiency is common in patients with hypokalaemia.
Repletion of magnesium will facilitate more rapid correction of
hypokalaemia.161 If hypokalaemia occurs concurrently with hypomagne-
saemia, give 4 ml magnesium sulphate 50% (8 mmol) diluted in 10 ml
NaCl 0.9% over 20 min, followed by potassium replacement (40 mmol
KCL in 1000 ml 0.9% NaCl at a rate guided by urgency for correction as
above). Follow with further magnesium replacement.160
Calcium and magnesium disorders
The recognition and treatment of calcium and magnesium disorders is
summarised in Table 2.
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Table 2 – Calcium and magnesium disorders with associated clinical presentation, ECG manifestations and
recommended treatment.

Disorder Causes Presentation ECG Treatment

Hypercalcaemia Primary or tertiary Confusion Short QT interval Fluid replacement IV
Calcium >2.6 mmol/l hyperparathyroidism
Malignancy Weakness Prolonged QRS interval Furosemide 1 mg/kg IV
Sarcoidosis Abdominal pain Flat T waves Hydrocortisone 200
300 mg IV
Drugs Hypotension AV block
Arrhythmias Cardiac arrest Pamidronate 30
90 mg IV
Cardiac arrest Treat underlying cause

Hypocalcaemia Chronic kidney disease Paraesthesia Prolonged QT interval Calcium chloride 10% 10
40 ml IV
Calcium <2.1 mmol/l Acute pancreatitis Tetany
Calcium channel blocker Seizures T wave inversion Magnesium sulphate 50% 4
8
overdose mmol IV (if necessary)
Toxic shock syndrome AV-block
Rhabdomyolysis Cardiac arrest Heart block
Tumour lysis syndrome Cardiac arrest

Hypermagnesaemia Renal failure Iatrogenic Confusion Prolonged PR and QT intervals Consider treatment when magne-
Magnesium >1.1 mmol/l Weakness T wave peaking sium >1.75 mmol/l:
Respiratory depression AV block Calcium chloride 10% 5
10 ml IV
repeated if necessary
AV-block Cardiac arrest Saline diuresis
0.9% saline with
furosemide 1 mg/kg IV
Cardiac arrest Haemodialysis
Ventilatory support if necessary

Hypomagnesaemia GI loss Tremor Prolonged PR and QT intervals Severe or symptomatic: 2 g mag-

Magnesium <0.6 mmol/l Polyuria Ataxia ST-segment depression nesium sulphate 50% (4 ml;
8 mmol) IV over 15 min
Starvation Nystagmus T-wave inversion Torsades de pointes: 2 g magne-
Alcoholism Seizures Flattened P waves sium sulphate 50% (4 ml; 8 mmol)
IV over 1
2 min
Malabsorption Arrhythmias
Increased QRS duration Seizure: 2 g magnesium sulphate
torsade de pointes 50% (4 ml; 8 mmol) IV over 10 min
Cardiac arrest Torsades de pointes

Hypothermia persons), while secondary hypothermia is rapidly increasing among

Accidental hypothermia is the involuntary drop in core temperature
<35  C. Severe hypothermia may reduce vital functions until the
occurrence of cardiac arrest. In hypothermic patients with spontane-
ous circulation insulation, hospital triage followed by transfer and
rewarming are key interventions. In hypothermic patients with cardiac
arrest, continuous CPR and ECPR rewarming may result in good
neurological outcome even with prolonged no-flow or low-flow (i.e.
CPR) time, provided that hypothermia ensued before cardiac arrest.
These guidelines help to improve prehospital triage, transport and
treatment as well as in-hospital management of hypothermic patients.
A scoping review was performed using the PubMed search engine
on February 22nd 2020 using the keywords “avalanche” AND “rescue”
(n = 100). Four systematic reviews were identified.162
165 Relevant
articles from the systematic reviews were included and references
lists crosschecked for further articles.
Accidental hypothermia
Prevention from cardiac arrest
Accidental hypothermia is the involuntary drop in the core temperature
<35  C.5,6 Primary hypothermia is induced by exposure to cold, while
secondary hypothermia is induced by illness and other external
causes. Primary hypothermia is prominent in outdoor (athletes and
lost persons) and urban environments (homeless and intoxicated
old and multimorbid persons in the indoor environment.166,167
Assess temperature with a low reading thermometer (Fig. 5):168,169
 tympanically in spontaneously breathing patients,
 oesophageal in patients who are endotracheal intubated or
instrumented with a 2nd generation supraglottic airway,
 If the ear is not well cleaned from snow and cold water or not
insulated against the cold environment the reading could be
mistakenly low by several  C.170,171
Accidental hypothermia gradually reduces vital functions until they
finally cease completely (Table 3). Hypothermic patients should be
protected from the cold environment through minimal exposure and
insulation and be transferred as fast as possible to the next,
appropriate hospital for rewarming. Rewarming is not feasible during
short transportation times (e.g. <1 h).6,172,173 Hypothermic patients
with signs of prehospital cardiac instability (i.e. systolic blood pressure
<90 mmHg, ventricular arrhythmia, core temperature <30  C) should
be rewarmed in hospital using minimally invasive techniques. Where
possible they should be directly transferred to a hospital with stand-by
extracorporeal life support (ECLS). ECLS should only be established if
patients arrest or deteriorate (e.g. decreasing blood pressure,
increasing acidosis).6,84 Primary ECLS rewarming should also be
considered in patients with etCO2 < 10 mmHg or a systolic blood
pressure 60 mmHg.174
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Management of cardiac arrest
The lowest temperature from which successful resuscitation and
rewarming has been achieved is currently 11.8  C176 or accidental
hypothermia and 4.2  C for induced hypothermia.177 A recent
systematic review reported only five patients (28
75 years of age)
who had arrested at a core temperature >28  C, suggesting that
cardiac arrest due to primary hypothermia at >28  C is possible but
unlikely.164 Some may still have minimal vital signs at a core
temperature <24  C.175 This does not preclude resuscitation attempts
at even lower temperatures if clinical judgment suggests the possibility
of successful resuscitation.
A deeply hypothermic person may appear dead but still survive
with resuscitation. Check for signs of life for one minute
not only by
clinical examination but also by using ECG, EtCO2 and ultrasound.6,84
In hypothermic cardiac arrest information should be collected to
estimate the survival probability from hypothermic cardiac arrest with
HOPE, ICE or the traditional potassium triage:162,163,178,179
 Core temperature,
 Mechanism of hypothermia induction,
 Duration of CPR,
 Sex,
 Witnessed/unwitnessed cardiac arrest,
 First cardiac rhythm,
 Trauma (to decide whether to start ECLS rewarming with heparin),
 Serum potassium (in hospital).
This information is crucial for prognostication and to decide
whether to rewarm the patient with ECLS. For hypothermic cardiac
arrest HOPE (Hypothermia Outcome Prediction after ECLS rewarm-
ing for hypothermic arrested patients) has been best validated. The
website to calculate HOPE can be accessed via: https://www.
hypothermiascore.org.
Hypothermic patients in witnessed and unwitnessed cardiac arrest
have good chances of neurological recovery if hypothermia developed
before hypoxia and cardiac arrest and if the chain of survival is
functioning well.6,164,180
183 Hypothermia diminishes the oxygen
demand of the body (6
7% per 1  C cooling) and thereby protects
the most oxygen dependent organs of the body
brain and heart

against hypoxic damage.184 A recent systematic review on witnessed
hypothermic cardiac arrest patients (n = 214) reported a survival to
hospital-discharge rate of 73%, 89% had a favourable outcome.
Another systematic review on hypothermic patients with unwitnessed
cardiac arrest (n = 221) reported a survival rate of 27%, 83% had a
neurologically intact outcome. Of note, the first rhythm was asystole in
48% of survivors.165 Hypothermic cardiac arrest patients should
receive continuous CPR until circulation has been re-established.
Table 3 – Staging of accidental hypothermia.6 .
Stage Clinical findings
Hypothermia I (mild) Conscious, shivering a
Hypothermia II (moderate) Impaired consciousnessa ; may or may not be shivering
Hypothermia III (severe) Unconsciousa ; vital signs present
Hypothermia IV (severe) Apparent death; Vital signs absent
a
Shivering and consciousness may be impaired by comorbid illness (i.e. trauma, CNS pathology, toxic ingestion, etc.) or drugs (i.e. sedatives, muscle relaxants,
narcotics etc.) independent of core temperature.
b
The risk of cardiac arrest increases <32  C, older and sicker are at higher risk, alternative causes should be considered. Some still have vital signs <24  C.175 .
Chest compression and ventilation rate should follow the standard ALS
algorithm as for normothermic patients. Hypothermic cardiac arrest is
often refractory to defibrillation and adrenaline. Defibrillation attempts
have been successful in patients with a core temperature >24  C,
however, ROSC tends to be unstable with lower temperature.185
The hypothermic heart may be unresponsive to cardioactive
drugs, attempted electrical pacing and defibrillation. Drug metabolism
is slowed, leading to potentially toxic plasma concentrations of any
drug given.6 The evidence for the efficacy of drugs in severe
hypothermia is limited and based mainly on animal studies. For
instance, in severe hypothermic cardiac arrest, the efficacy of
amiodarone is reduced.186 Adrenaline may be effective in increasing
coronary perfusion pressure, but not survival.187,188 Vasopressors
may also increase the chances of successful defibrillation, but with a
core temperature <30  C, sinus rhythm often degrades back into VF.
Given that defibrillation and adrenaline may induce myocardial injury,
it is reasonable to withhold adrenaline, other CPR drugs and shocks
until the patient has been warmed to a core temperature 30  C. Once
30  C has been reached, the intervals between drug doses should be
doubled when compared to normothermia (i.e. adrenaline every 6

10 min). As normothermia (35  C) is approached, standard drug
protocols become effective again.5,6
Arrested hypothermic patients should, where possible, be directly
transferred to an ECLS centre for rewarming. In primary hypothermia
an unwitnessed cardiac arrest with asystole as first rhythm is not a
contraindication to ECLS rewarming.165 In hypothermic cardiac arrest
rewarming should be performed with ECLS, preferably with ECMO
rather than CPB.6,189,190 If ECLS is not available within 6 h, non-ECLS
rewarming may be used.183,191,192 If prolonged transport is required or
the terrain is difficult, mechanical CPR is suggested. In hypothermic
arrested patients with a body temperature <28  C delayed CPR may
be used when CPR is too dangerous and intermittent CPR can be
used when continuous CPR is not possible (Fig. 6).8
In-hospital prognostication of successful rewarming should be
based on the HOPE or ICE score (Table 4), the traditional in-hospital
serum potassium prognostication is less reliable.162,163,178
A post-resuscitation care bundle is recommended following
successful resuscitation. Emergency medical services (EMS) and
hospitals should install structured protocols to improve prehospital
triage, transport and treatment as well as in-hospital management of
hypothermic patients.
Avalanche rescue
Most avalanche victims die from asphyxia.193,194 Avalanche victims in
an unwitnessed cardiac arrest have a poor chance of survival.193
195
The chance of a good outcome are improved if there is a ROSC in the
Core temperature ( C) (if available)
35
32  C
<32
28  C
<28 C
Variableb
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first minutes of CPR.162,163,194 In arrested patients five ventilations
should initially be provided because hypoxia is the most likely cause of
the cardiac arrest. Avalanche victims with OHCA and duration of burial
<60 min should be managed like normothermic patients (Fig. 7).
Standard ALS should be provided for at least 20 min.84,196,197
Avalanche victims with duration of burial >60 min without evidence
of an un-survivable injury undertake full resuscitative measures,
including ECLS rewarming.6,84,197 CPR should be considered as futile
in cardiac arrest with a burial time >60 min and evidence of an
obstructed airway.84,197 In-hospital prognostication of successful
rewarming should be based on the HOPE score.162,163 The traditional
triage with based on serum potassium and the core temperature (cut-
off 7 mmol/l and 30  C, respectively) may be less reliable.178 A post-
resuscitation care bundle is recommended following successful
resuscitation.
Hyperthermia and malignant hyperthermia
Hyperthermia is a condition when the temperature of the body
increases above normothermia (36.5
37.5  C) because of failed
thermoregulation. Heat stroke is an emerging health concern due to a
soaring environmental temperature caused by increasing green-
house gas emissions.198 Heatwaves kill more people than any other
extreme weather condition.199 In 2003, an extreme heatwave killed
70,000 people in Europe.200 The lack of ability to sweat is the main risk
factor for hyperthermia. Extremes of age and multimorbidity confer
additional risks.199,201 The easiest modifiable risk factor is sufficient
hydration.202 Hyperthermia is a continuum of heat-related conditions,
ranging from heat stress progressing to heat exhaustion, finally to
exertional and non-exertional (caused by environmental heat) heat
stroke and potentially progressing to multiple organ dysfunction and
cardiac arrest (>40  C).
Malignant hyperthermia (MH) is a rare pharmacogenetic disorder
of skeletal muscle calcium homeostasis characterised by muscle
contracture and life-threatening hypermetabolic crisis following
exposure of genetically predisposed individuals to halogenated
anaesthetics and succinylcholine. 3,4-Methylenedioxymethamphet-
amine (MDMA, ‘ecstasy’) and amphetamines may also cause a
condition similar to MH. After exposure a rapid and uncontrolled influx
of calcium into the cytoplasm of the skeletal muscle cell results in a
hypermetabolic cascade involving sustained muscular contractures,
depletion of adenosine triphosphate (ATP) and muscular cell death.
The resulting clinical signs include hypercapnia, masseter muscle,
generalized muscle rigidity, acidosis, hyperkalaemia, peaked T waves
and hyperthermia.
Table 4 – Hypothermia Outcome Prediction after ECLS (HOPE) for hypothermic cardiac arrest patients, description
of parameters affecting HOPE with regard to estimation of the survival probability. CPR denotes cardiopulmonary
resuscitation, ECLS extracorporeal life support.
Age (yrs)
Sex
Core temperature ( C/ F)
Serum potassium (mmol/l)
Presence of asphyxia
Duration of CPR (min)
181
This section is based on an ILCOR systematic review, two recent
reviews and an additional scoping review (February 22nd
2020).52,199,202,203
Hyperthermia
Hyperthermia occurs when the body’s ability to thermoregulate fails
and core temperature exceeds values normally maintained by
homeostatic mechanisms.199,202 Hyperthermia may be primarily
induced by environmental conditions, or secondary due to endoge-
nous heat production.199 Environment-related hyperthermia occurs
where heat, usually in the form of radiant energy, is absorbed by the
body at a rate faster than can be lost by thermoregulatory
mechanisms. Hyperthermia is a continuum of heat-related conditions,
starting with heat syncope, progressing to heat exhaustion, then to
heat stroke with a compensable and a non-compensable state and
finally to multiple organ dysfunction and cardiac arrest. Importantly,
the heat stroke-triggered inflammatory response may resemble the
systemic inflammatory response syndrome (SIRS) and be misdiag-
nosed and a critical delay may result in providing the appropriate
treatment.199 A rectal or oesophageal temperature probe should be
available to measure core temperature and to guide treatment
(Fig. 8).168
Heat syncope is a mild form of hyperthermia.202 Treatment
includes removing patients to a cool environment, passive cooling and
administration of oral isotonic or hypertonic fluids.
Heat exhaustion is caused by mild to moderate hyperthermia due
to exposure to high environmental heat or excessive exercise.202
Symptoms include intense thirst, weakness, discomfort, anxiety,
dizziness, syncope, core temperature may be normal or >37  C.
Treatment includes removing patients to a cool environment, lying
them flat and administering IV isotonic or hypertonic fluids, consider
additional electrolyte replacement therapy with isotonic fluids. Oral
rehydration may not be effective in rapidly replacing electrolytes but
may be a more practical treatment. Replacement of 1
2 l crystalloids
at 500 ml/h is often adequate. Simple external cooling measures are
usually not required but may involve conductive (cold floor, ice sheets;
commercial ice packs to hand, feet and cheek), convective (cold water
immersion, cold shower) and evaporative measures (spraying cold
water, fanning the undressed).
Heat stroke is primarily a clinical diagnosis based on the triad of
severe hyperthermia (core temperature >40  C), neurological
symptoms and recent passive environmental exposure (classic or
passive heat stroke) or excessive exercise (exertional heat stroke or
exertional hyperthermia).204 Symptoms include central nervous
Definition of parameters and when to record them
On site or in hospital
On site or in hospital
First measurement at hospital admission
First measurement at hospital admission
Asphyxia (head fully covered by water or snow) AND in cardiac arrest at extrication.
No asphyxia: immersion, outdoor or indoor exposure.
Data recorded on site
From initiation of manual CPR until expected start of ECLS. Data recorded
prehospitally and in-hospital once establishment of ECLS can be expected.
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system dysregulation (e.g. altered mental state, seizure, coma),
tachycardia, tachypnoea and arterial hypotension.199 Mortality is
approximately 10% and when combined with hypotension it
approaches 33%.202 The outcome worsens if the body temperature
is sustained at >40.5  C.
It is essential to rapidly cool the patient to <39  C, preferably <38.5

38.0  C as quickly as possible. Treatment involves removing
patients to a cool environment, lying them flat. Cold-water immersion
(from neck down) or full body conductive cooling should be used,
cooling rates of 0.2
0.35  C/min can be achieved.205 Cold water
immersion should be continued until the symptoms have resolved or
for a reasonable amount of time, e.g. 15 min, because benefit
outweighs risk (weak recommendation, very low certainty evi-
dence).203 Alternatively, a combination of simple cooling techniques
could be used including conductive, convective and evaporative
measures, although no comparative studies exist to guide the best
option.203 One systematic review concluded that water immersion (1

17  C water) lowers body temperature more effective compared to
passive cooling.203 Misting and fanning cooling techniques are
marginally faster than passive cooling and cold showers (20.8  C) cool
faster than passive cooling.203 Isotonic or hypertonic fluids should be
administered (with blood sodium >130 mEq/l up to 3  100 ml 3%
NaCl at 10 min intervals).206 If mental state is abnormal 3% NaCl
should be administered IV, if mental state is normal it can be
administered orally.206 Additional electrolyte replacement with
isotonic fluids should be considered and substantial amounts of
fluids may be required. For exertional heatstroke, a cooling rate faster
than 0.10  C/min is safe and desirable. Follow the ABCDE approach in
any patient with deteriorating vital signs. Critically ill patients will
require aggressive and extended treatment in an intensive care
unit.199,207 There may be a requirement for advanced cooling
techniques including external or internal devices used for targeted
temperature management. There are no specific drugs lowering core
temperature.
Malignant hyperthermia
Most MH associated variants are caused by mutation of the RYR1 gene.
RYR1 encodes the skeletal muscle ryanodine receptor protein, that
regulates the movement of calcium from the sarcoplasmic reticulum into
the cytoplasm of the muscle cell.208,209 Drugs such as 3,4-methyl-
enedioxymethamphetamine (MDMA, ‘ecstasy’) and amphetamines
may also cause a condition similar to MH and the use of dantrolene may
be helpful.210 If cardiac arrest occurs, follow the universal ALS algorithm
and continue to cool the patient. Attempt defibrillation using standard
energy levels. Apply the same cooling techniques as for post-
resuscitation care targeted temperature management.
Give dantrolene (2.5 mg/kg initially, 10 mg/kg as required).
Ryanodex1 is a lyophilized nanosuspension of dantrolene sodium
with substantially improved pharmacological properties (fewer vials
1:12.5, administration time is 1 instead of 20 min). The introduction in
European countries is pending.
It is essential to contact an expert MH centre for ongoing advice
once the patient has been stabilized. Due the increased metabolic
rate, outcome is poor compared with normothermic cardiac arrest.211
Unfavourable neurological outcome increases by 2.26 odds ratio for
1  C of body temperature >37  C.212
Thrombosis
This section refers to pulmonary and to coronary thrombosis as
potential reversible causes of cardiac arrest.
Pulmonary embolism
Cardiac arrest from acute pulmonary embolism is the most serious
clinical presentation of venous thromboembolism, in most cases
originating from a DVT.213 The reported incidence of cardiac arrest
caused by pulmonary embolism is 2
7% of all OHCAs,214,215 and 5

6% of all IHCAs,120,216 but this is likely to be an underestimation.
Overall survival is low.215,217 Specific treatments for cardiac arrest
resulting from pulmonary embolism include administration of
fibrinolytics, surgical embolectomy and percutaneous mechanical
thrombectomy.
The updated 2020 ILCOR systematic review explored the
influence of specific treatments (e.g. fibrinolytics, or any other)
yielding favourable outcomes.2 The 2019 ILCOR summary statement
reviewed the use of ECPR for cardiac arrest in adults.103 Additional
evidence was identified from the updated ESC guideline on pulmonary
embolism,213 pertaining articles were included and references lists
crosschecked for further articles.
Diagnosis
Diagnosis of acute pulmonary embolism during cardiac arrest is
difficult. One study has reported correct recognition of the underlying
causes in up to 85% of all in-hospital resuscitation attempts,216 but
accurate prehospital diagnosis of acute pulmonary embolism is
particularly challenging.218
220 The 2019 European Society of
Cardiology Guidelines on the diagnosis and management of acute
pulmonary embolism define ‘confirmed pulmonary embolism’ as a
probability of pulmonary embolism high enough to indicate the need
for specific treatment.213 Clinical history and assessment, capnog-
raphy and echocardiography (if available) can all assist in the
diagnosis of acute pulmonary embolism during CPR with varying
degrees of specificity and sensitivity. Cardiac arrest commonly
presents as PEA.217 Low ETCO2 readings (about 1.7 kPa/13 mmHg)
while performing high quality chest compressions may support a
diagnosis of pulmonary embolism, although it is a non-specific
sign.219,221
Common symptoms preceding cardiac arrest are sudden onset of
dyspnoea, pleuritic or substernal chest pain, cough, haemoptysis,
syncope and signs of DVT in particular (unilateral lower extremity
swelling) Information about past medical history, predisposing factors,
and medication that may support diagnosis of pulmonary embolism
should be obtained, although none of these are specific.84,213 In as
many as 30% of the patients with pulmonary embolism, no risk factors
are apparent.222 If a 12-lead ECG can be obtained before onset of
cardiac arrest, changes indicative of right ventricular strain may be
found:213,223
 Inversion of T waves in leads V1
V4,
 QR pattern in V1,
 S1 Q3 T3 pattern (i.e. a prominent S wave in lead I, a Q wave and
inverted T wave in lead III),
 Incomplete or complete right bundle-branch block.
Acute PE can cause right ventricle (RV) pressure overload and
dysfunction and these signs can be seen on echocardiography.
Unfortunately, there is no individual echocardiographic parameter that
provides fast and reliable information on RV size or function.
Echocardiographic criteria for the diagnosis of PE differ between
studies, the negative predictive value is only 40
50%.213 Signs of
right ventricular overload or dysfunction may also be caused by other
cardiac or pulmonary disease.224
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Prevention of cardiac arrest
Airway
Low cardiac output results in desaturation of the mixed venous blood.
Although no studies were found which examined the role of oxygen
versus any other gas, the writing group considered hypoxaemia as
confounding risk factor for cardiac arrest and recommends adminis-
tration of high-flow oxygen until goal-directed therapy could be
established.
Breathing
Hypoxaemia and hypocapnia are frequently encountered in patients
with PE, but they are of moderate severity in most cases. PE should be
considered in all patients with sudden onset of progressive dyspnoea,
especially in patients without pre-existing pulmonary disease. Other
reversible causes of cardiovascular deterioration and dyspnoea have
to be excluded, e.g. (tension) pneumothorax and anaphylaxis
(anaphylactic shock). Hypoxaemia is usually reversed with adminis-
tration of oxygen.
When mechanical ventilation is required, care should be taken to
limit its adverse haemodynamic effects. In particular, the positive
intrathoracic pressure induced by mechanical ventilation may reduce
venous return and worsen RV failure.213
Circulation
The clinical classification of the severity of an episode of acute PE is
based on the estimated in-hospital or 30-day mortality. High-risk PE is
suspected or confirmed in the presence of shock or persistent arterial
hypotension. Suspected high-risk PE is an immediately life-threaten-
ing situation.
Acute right ventricle (RV) failure is the leading cause of death in
patients with high-risk PE. Aggressive volume expansion is of no
benefit and may even worsen RV function by causing mechanical
overstretch. On the other hand, modest (500 ml) fluid challenge may
help to increase cardiac index in patients with PE, low cardiac index,
and normal BP. Use of vasopressors and/or inotropes is frequently
needed.213
Reperfusion
Parenteral anticoagulation should be initiated whilst awaiting the
results of diagnostic tests. Intravenous unfractionated heparin (UFH)
is recommended for patients with shock and hypotension, and in
whom primary reperfusion is considered. Thrombolytic treatment of
acute PE restores pulmonary perfusion more rapidly than anti-
coagulation with UFH alone. A review of RCTs indicated that
thrombolysis may be associated with a reduction in mortality or
recurrent PE in high-risk patients who present with haemodynamic
instability.225 Surgical embolectomy or percutaneous catheter-
directed treatment are recommended as alternative to rescue
thrombolytic therapy in rapidly deteriorating patients if expertise
and resources are available on site. Treatment decisions should be
made by an interdisciplinary team involving a thoracic surgeon or
interventional cardiologist.213,226
Modifications to ALS for PE
Thrombolysis
When PE is the suspected cause of cardiac arrest thrombolytic
drugs should be administered (weak recommendation, very low
certainty of evidence).2 For ROSC two studies provided very-low-
183
certainty evidence of no difference with thrombolysis versus
without,227,228 one study showed benefit associated with the use of
thrombolytic drugs compared with no thrombolytic drugs in
patients with PE.217 One study showed benefit with thrombolysis
for survival at 24 h whereas another study showed no difference
with versus without thrombolysis.214,227 Three observational
studies showed no benefit for survival to discharge.217,227,228
For survival with favourable neurologic outcome at 30 days one
RCT compared thrombolytics with placebo in 37 patients with
confirmed PE, finding no difference between groups,215 another
observational study with/without thrombolysis found no differ-
ence.214 There is insufficient evidence to recommend any optimal
drug and dosing strategy for thrombolysis during CPR.2 When
thrombolytic drugs have been administered, consider continuing
CPR attempts for at least 60
90 min before termination of
resuscitation attempts.229
231
Surgical embolectomy
When PE is the known cause of cardiac arrest the use of fibrinolytic
drugs or surgical embolectomy or percutaneous mechanical throm-
bectomy is recommended (weak recommendation, very low certainty
of evidence).2 The method is reported in 2 case series without control
group in cardiac arrest patients.232,233
Percutaneous mechanical thrombectomy
This method is reported in 1 case series in cardiac arrest patients.234
Extracorporeal CPR
ECPR should be considered as a rescue therapy for selected patients
with cardiac arrest when conventional CPR is failing in settings in
which it can be implemented (weak recommendation, very low
certainty of evidence).103 ECPR is increasingly used to support
circulation in patients with cardiac arrest refractory to conventional
CPR.235 Some observational studies suggest the use of extracorpo-
real life support (ECLS) if cardiac arrest is associated with PE.236,237
ECPR maintains vital organ perfusion while potential reversible
causes of the cardiac arrest can be identified and treated. ECPR can
be considered in select patients when rapid expert deployment is
possible; however, the optimal patient selection and timing of the
therapy are not well defined. The recommendations on ECPR derive
from heterogeneous individual studies that are difficult to interpret,
mainly because of confounding. Randomised controlled trials (RCTs)
are not available. This recent weak recommendation takes the
extremely high mortality rate of patients with cardiac arrest,
particularly when the arrest is refractory to standard advanced
cardiac life support interventions (i.e., cardiac arrest when conven-
tional CPR is failing) in account. Therefore, the potential for benefit and
the value of this intervention remain despite the overall low certainty of
supporting evidence and lack of randomised trials.238
Coronary thrombosis
Obstructive coronary artery disease (CAD) is the most common
condition underlying OHCA in adults.239,240 The clinical spectrum of
CAD includes ventricular arrhythmias due to acute ischaemia, those
presenting during the acute and convalescent stages of myocardial
infarction and arrhythmias related with post-myocardial infarction scar
or ischaemic remodelling.241 Significant or acute coronary stenosis
are especially prevalent in the presence of shockable rhythms (VF/
pVT) and ST-elevation in the post-arrest ECG, although a significant
percentage of acute coronary lesions has been reported among
184 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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patients with ROSC and no ST-elevation (Table 5). Conversely, the
presence and role of CAD in non-shockable rhythms (PEA or asystole)
remains uncertain, since coronary angiography is less frequently
performed in such cases.242
Evidence based recommendations for the suspicion and
management of coronary thrombosis as the cause of OHCA derive
from the 2019 ILCOR CoSTR summary,238 the 2015 ILCOR CoSTR
on acute coronary syndromes (ACS),243 the European Society of
Cardiology Guidelines,244
246 the consensus statement from the
European Association for Percutaneous Cardiovascular Interven-
tions (EAPCI)247 and the American Heart Association (AHA)
scientific statement.242 Guidelines were assessed according to the
AGREE-II framework. Additionally, focused literature search for an
evidence update was performed and recommendations were
established by consensus within the writing group.
Prevent and be prepared
Encourage cardiovascular prevention
Tackling the onset and progression of CAD by means of primary and
secondary cardiovascular prevention, including healthy lifestyles and
adherence to evidence-based medications may be the first step to
reduce the risk of acute cardiovascular events, including OHCA.246,248
Cardiac rehabilitation for patients after acute coronary syndrome
(ACS) has proven effective at reducing the risk of subsequent
events,249 but it remains underutilised and should be
encouraged.250,251
Endorse health education
Reducing time from symptom onset to first medical contact is a well-
known area for improvement. This could be attained by educational
campaigns to increase public awareness on the importance of
recognising symptoms of myocardial infarction (chest pain) and early
alerting the EMS.245
Promote layperson basic life support (BLS)
Initiatives promoting BLS training among the general public might
improve awareness and the likelihood of bystander intervention in
OHCA, increasing the chances of good outcome. Further informa-
tion is provided in section 12 (education). Particularly, training
should involve high-risk groups such as relatives of patients with
previous ACS.252,253 A systematic review of studies addressing
BLS training for family members of high-risk cardiac patients
reported adequate disposition and capacity to learn,254 but
reaching this group may be challenging. Additional later studies
have shown positive results of implementing BLS training targeted
at patients and their relatives within cardiac rehabilitation
programs.255,256
Table 5 – Prevalence of significant coronary artery disease among patients with ventricular fibrillation/pulseless
electrical tachycardia out-of-hospital cardiac arrest.
ROSC
ST elevation
Prevalence of significant CAD 70
95%
Prevalence of acute lesions 70
80%
Ensure adequate resources
Regional STEMI networks have contributed to reduce reperfusion
times and improve patient outcomes.257
262 These initiatives should
be encouraged and provided with sufficient human and material
resources and adequate training of the staff (including ECG
interpretation and advanced life support).263
Improve quality management systems and indicators
Data concerning OHCA in the setting of ACS have irregularly been
reported or excluded from mortality analyses. Seeking quality
standards similar to those established for non-OHCA ACS might
enhance quality monitoring and lead to better outcomes.245 However,
the particular characteristics of OHCA-ACS patients may require
categorising these cases separately and pursuing appropriate and
reliable quality indicators.264
Detect parameters suggesting coronary thrombosis and
activate STEMI network
Post-arrest 12-lead ECG may present unspecific alterations that hinder
interpretation, and criteria suggesting coronary occlusion (i.e. bundle
branch block, hyperacute T-waves, diffuse ST depression with V1/aVR
ST-elevation) if symptoms of ischaemia are present 245 [Ibanez 2018,
119] may not necessarily apply to OHCA patients. Given the limitations
of a post-arrest ECG to predict coronary occlusion,265,266 all available
information should be gathered to make decisions, including specific
clinical features such as chest pain prior to arrest or known history of
CAD. Once clinical suspicion is established, the STEMI network should
be activated to facilitate early reperfusion.
Resuscitate and treat possible causes (establish reperfusion
strategy)
Patients with sustained ROSC
Although prospective randomised trials are lacking, there is general
consensus that successfully resuscitated STEMI patients should
undergo immediate reperfusion, as extrapolated from recommenda-
tions regarding non-OHCA STEMI patients.242,243,245,247 Primary
percutaneous coronary intervention (PCI) is the strategy of choice and
should be performed in 120 min from diagnosis.242,243,245,247 Pre-
hospital fibrinolysis may be administered if a greater delay is
expected, unless resuscitation efforts were prolonged or traumatic
or other contraindications are present.242,243,245,247 Resuscitated
STEMI patients who remain comatose after ROSC constitute a highly
heterogeneous subgroup with a poorer prognosis, but there is no
current evidence to discourage urgent coronary angiography.243
In patients with ROSC and no-STEMI criteria, two systematic reviews
reported benefits of performing PCI,267,268 although the timing of
coronary angiography remains controversial. The COACT trial showed
no benefit of emergent compared to delayed coronary angiography in 90-
Refractory VF/pVT
No ST elevation
25
50% 75
85%
25
35% 60
65%
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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days survival among patients with initial shockable rhythm and no STEMI
or another non-cardiac cause for OHCA who remained unconscious after
ROSC.269 However, the higher survival than expected in both groups
may have lessened the power of the trial. Until new evidence from
ongoing randomised trials is available, an individualised approach
considering patient characteristics, ECG findings and haemodynamic
condition is recommended.244 Brief evaluation in the emergency
department or intensive care unit may be considered to exclude obvious
non-coronary causes of OHCA and check patient’s status. If ongoing
myocardial ischaemia is suspected or the patient is haemodynamically or
electrically unstable, early coronary angiography (120 min) should be
performed. In resuscitated stable patients without STEMI, a delayed
angiography strategy would be considered.242
245,247,270
Patients with no sustained ROSC
Decisions regarding patients who do not achieve sustained ROSC
despite resuscitation are challenging, and should be individualised
considering patient and the setting conditions and the available
resources. Further information on termination of resuscitation decisions
is provided in the ERC Guidelines on Ethics.271 Consistent with the
principles outlined in those guidelines, routine coronary angiography
cannot be recommended in this subset of patients with refractory
OHCA, and should be individualised after careful evaluation of the
benefit/futility ratio, available resources and expertise of the team.247
Although mechanical CPR has not proven superiority to
conventional CPR, it may facilitate delivering high-quality chest
compressions during transportation of patients or during coronary
angiography. Special attention must be paid to minimising interruption
of compressions and any delay to defibrillation.272 A recent systematic
review on ECPR showed no conclusive evidence to support or
discourage its use for IHCA or OHCA for both adults and children.273
Accordingly, ILCOR considers ECPR for selected patients when
conventional CPR is failing (weak recommendation, very-low
certainty of evidence).103,238 However, a later large registry study
including 13,191 patients with OHCA found no association between
ECPR and improved outcome compared with conventional CPR,
although certain features (initial shockable rhythm, transient ROSC)
leading to better outcomes in the ECPR group were identified.274
Randomised trials of ECPR initiated out of hospital (clinicaltrials.gov
NCT02527031) and in hospital (clinicaltrials.gov NCT03101787 and
NCT01511666) will contribute to increase evidence on patient
selection, risk-benefit and cost-effectiveness.
Cardiac tamponade
Cardiac tamponade occurs when the pericardial sac is filled with fluid
under pressure, which leads to compromise of cardiac function and
ultimately cardiac arrest. The condition most commonly occurs after
penetrating trauma and cardiac surgery. Mortality is high and
immediate decompression of the pericardium is required to give
any chance of survival. Evidence base for diagnosis (ultrasound/ALS)
and treatment (trauma/Special circumstances
TCA; cardiac
surgery/Special circumstances
cardiac surgery) is given in more
detail in the respective sections of the 2020 guidelines.
The literature review for an evidence update did not result in any
new evidence compared to the ERC guidelines 2015.
Diagnosis
Echocardiographic evaluation of cardiac tamponade is important for
timely and appropriate diagnosis and management. Use of point of
care cardiac ultrasound is described in detail in the ALS chapter.
185
Treatment
Thoracotomy
The criteria and prerequisites for resuscitative thoracotomy in patients
with penetrating trauma to the chest or epigastrium are described in
the section on traumatic cardiac arrest. Treatment of cardiac
tamponade following cardiac surgery is addressed in the section on
cardiac arrest following cardiac surgery.
Pericardiocentesis
If thoracotomy is not possible, consider ultrasound guided pericar-
diocentesis to treat cardiac arrest associated with suspected
traumatic or non-traumatic cardiac tamponade. Non-image guided
pericardiocentesis is an alternative, only if ultrasound is not
available.84
Tension pneumothorax
Tension pneumothorax is a reversible cause of cardiac arrest and
must be excluded during CPR. It may lead to cardiac arrest by
obstructing venous return through mediastinal shift. Tension pneu-
mothorax may be caused by trauma, severe asthma and other
respiratory disease, but can also be iatrogenic following invasive
procedures, e.g. central line insertion. Institution of positive pressure
ventilation can convert a pneumothorax into a tension pneumotho-
rax.275 The prevalence of tension pneumothorax is approximately
0.5% in all major trauma patients treated in the prehospital setting and
13% of those developing TCA.26
Recommendations in this section are based on focused literature
search for evidence update and 1 systematic review.275
Diagnosis
Diagnosis of tension pneumothorax in a patient with cardiac arrest or
haemodynamic instability must be based on clinical examination or
POCUS. The symptoms include haemodynamic compromise (hypo-
tension or cardiac arrest) in conjunction with signs suggestive of a
pneumothorax (preceding respiratory distress, hypoxia, absent
unilateral breath sounds on auscultation, chest crepitations and
subcutaneous emphysema and mediastinal shift (tracheal deviation
and jugular venous distention).275 During CPR presentation is not
always classical, but when it is suspected in the presence of cardiac
arrest or severe hypotension, chest decompression by open
thoracostomy should be carried out immediately if the expertise is
available.276
Treatment recommendations
Needle decompression
Needle chest decompression is rapid and within the skill set of most
ambulance personnel. It is frequently carried out with standard IV
cannulas. However, a significant proportion of patients have a chest
wall thickness which makes needle decompression with a standard
length 14-gauge cannula ineffective.61 A needle length of at least 7 cm
is required to reach the pleural space at mid-clavicular position in the
2nd intercostal space in 90% of all attempts in an average population.62
Needle decompression in the 4th/5th ICS at anterior axillary line has the
lowest predicted failure rate compared to the 4th/5th ICS midaxillary
line and the 2nd ICS MCL.277
Cannulae are also prone to kinking and blockage.278 Any attempt
at needle decompression under CPR must be followed by an open
thoracostomy or a chest tube if the expertise is available.
186 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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Thoracostomy
In TCA patients, chest decompression effectively treats tension
pneumothorax and takes priority over all other measures. Open
thoracostomy is simple to perform and used routinely by several
prehospital services.279 The thoracostomy is the first stage of
standard chest tube insertion
a simple incision and rapid dissection
into the pleural space (see traumatic cardiac arrest). Chest drain
insertion can be carried out following successful resuscitation.
Toxic agents
Overall, poisoning rarely causes cardiac arrest or death,280 although
the latest reports show that, among human exposure to toxic agents,
those with more serious outcomes (moderate, major or death) have
increased 4.45% per year since 2000.281 The top 5 poisoning
substance classes in 2018 were analgesics, household cleaning
substances, cosmetics and personal care products, sedatives,
hypnotics, antipsychotics and antidepressants.281 Intentional (i.e.
suicide) and accidental poisoning from pesticides are both significant
causes of mortality.282 Poisoning is an important cause of OHCA in
younger age groups.283 Inappropriate drug dosing, drug interactions
and other medication errors can also cause harm. Accidental
poisoning is more common in children than in adults.284,285 Homicidal
poisoning is uncommon. Industrial accidents, warfare or terrorism can
also cause exposure to toxins.
Recommendations in this section are based on systematic
reviews, using a dual review approach. For opioid toxicity ILCOR
published an evidence update.2 Given the infrequent nature of most
poisonings, clinical effectiveness of many interventions often is based
on low-certainty evidence including animal studies and human case
series or case reports, with significant publication bias. The likelihood
of confirmatory RCTs to prove effectiveness of such results is poor.
Hence, most of the following updates and related recommendations
are weak and based on low level of evidence.
Cardiovascular emergencies in acute poisoning
Toxic agents can produce cardiovascular emergencies via indirect
(mediated by metabolic disorders) or direct mechanisms. In the latter
case, toxic agents can modify blood pressure, myocardial contractility
and conductivity. Hypertensive emergencies can occur during acute
poisonings with adrenergic agonists such as cocaine or amphet-
amines. The best management consists of sedation with benzodia-
zepines, vasodilators and pure alpha-antagonists.
Hypotension can be caused by many toxic agents which lead
to hypovolaemia due to acute losses (pesticides, mushrooms,
lithium, diuretics, cholinomimetics) or to vasodilation (alcohol, anti-
hypertensive medications, anticholinergics, tricyclic antidepres-
sants, calcium channel blockers, opioids). Toxic agents can also
cause tachy- or bradyarrhythmia (anticholinergics, sympathomi-
metics, anti-arrhythmic drugs, halogenated hydrocarbons, etc).
Medications with quinidine-like effects should be treated with
sodium bicarbonate (1
2 mmol kg
1) IV. It is important to keep in
mind specific treatments where available (calcium channel blocker
and beta-blocker, digoxin intoxications) on top of the ALS
management of arrythmias.101
Neurological emergencies in acute poisoning
Toxic agents can also be responsible for neurological emergencies,
such as reduced levels of consciousness, seizures and movement
disorders. Clinically, in metabolic (or toxic) comas, oculo-cephalic and
oculo-vestibular reflexes are usually preserved and motor response is
usually symmetrical. Pupillary size can guide the diagnosis (miosis
being typical of opioid overdose and mydriasis of anticholinergic
overdose). Many medications can cause seizures via direct effect
(anti-histamine, antidepressant, antipsychotics, antibiotics, lithium,
caffeine, cocaine, amphetamines, pesticides, carbon monoxide).
Treatment of such emergencies must follow the ALS algorithm
including early advanced airway management (see ALS
Guidelines).101
Prevention of cardiac arrest
Assess the patient using the systematic ABCDE approach. Airway
obstruction and respiratory arrest secondary to a decreased
conscious level is a common cause of death after self-poisoning
(benzodiazepines, alcohol, opiates, tricyclics, barbiturates).286,287
Early tracheal intubation of the unconscious patient by trained
personnel may decrease the risk of aspiration. Drug-induced
hypotension usually responds to IV fluids, but occasionally vasopres-
sor support is required. Measure serum electrolytes (particularly
potassium), blood glucose and arterial blood gases. Retain samples of
blood and urine for toxin analysis. Patients with severe poisoning
should be cared for in a critical care setting.287 If available, once the
patient has been stabilised, check for any history that can provide
information on the toxic agent involved. If an antidote is available
administer it as soon as possible in order to improve outcome. The
causative agent has been shown to be strongly associated with
outcome in poisoning-induced OHCAs.288
Modifications to resuscitation
In cardiac arrest caused by toxic agents specific treatment measures
such as antidotes, decontamination and enhanced elimination should
be considered. There are several specific precautions regarding
resuscitation of intoxicated patients. Personal safety is most
important. A careful approach to the patient must be considered in
suspicious cases, unexpected cardiac arrests or in cases with more
than one casualty. Mouth-to-mouth ventilation in the presence of
chemicals such as cyanide, hydrogen sulphide, corrosives and
organophosphates should be avoided as it might lead to poisoning of
the rescuer.
The toxin(s) need to be identified as early as possible. Relatives,
friends and ambulance crews can provide useful information.
Examination of the patient may reveal diagnostic clues such as
odours, needle marks, pupil abnormalities and signs of corrosion in
the mouth.
All reversible causes of cardiac arrest should be excluded in
cardiac arrest patients due to toxic agents. Life-threatening tachyar-
rhythmias can be caused by toxic agents directly or indirectly, e.g. due
to electrolyte abnormalities. Hypo- or hyperthermia may occur during
drug overdose as well. It might be necessary to continue resuscitation
for a prolonged time period, particularly in young patients, as the
poison may be metabolised or excreted during extended resuscitation
measures.
There are a number of alternative approaches which may be
effective in severely poisoned patients including higher doses of
medication than in standard protocols (e.g. high-dose insulin
euglycemia);289 non-standard drug therapies (e.g. IV lipid emul-
sion);290
292 ECPR;293,294 and haemodialysis.294
Regional or national poison centres for information on treatment of
the poisoned patient and On-line databases for information on
toxicology and hazardous chemicals are available for consultation.
The International Programme on Chemical Safety (IPCS) lists poison
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centres on its website: https://www.who.int/gho/phe/chemical_safety/
poisons_centres/en/.
Helpful websites:
 https://pubchem.ncbi.nlm.nih.gov/.
 https://chem.nlm.nih.gov/chemidplus/chemidlite.jsp.
Specific therapeutic measures
There are a few specific therapeutic measures for poisoning

decontamination, enhancing elimination and the use of specific
antidotes. Many of these interventions should only be used based on
expert advice. For up-to-date guidance in severe or uncommon
poisonings, seek advice from a poisons centre.
Decontamination
Decontamination is a process of removal of the toxic agent from the
body dependent on the route of exposure:
For dermal exposure clothing should be removed and copious
irrigation with water for at least 15 min should be commenced.
Neutralising chemical substances should not be used, as these might
cause further tissue damage.
For ocular lesions immediate copious irrigation with normal saline
for at least 30 min in the most severe cases should be commenced.
Topical medication should not be applied before an expert evaluation
has taken place.52
Gastric lavage should not be performed routinely, if at all, for the
treatment of poisoned patients. In the rare instances in which gastric
lavage is indicated, it should only be performed by individuals with
proper training and expertise. It is only indicated in case of assumption
of a potentially lethal amount of toxic agent and only within one hour of
ingestion. 295 Gastric lavage may be associated with life-threatening
complications, e.g. aspiration pneumonitis, aspiration pneumonia,
oesophageal or gastric perforation, fluid and electrolyte imbalances or
arrythmias. It is contraindicated if the airway is not protected and if a
hydrocarbon with a high risk of aspiration potential or a corrosive
substance has been ingested.296
The preferred method of gastrointestinal decontamination in
patients with an intact or protected airway is activated charcoal, but the
evidence that active charcoal improves outcome is limited.287 It is
most effective if given within 1 h of the time of ingestion.297 The
recommended dose is 0.5
1 g kg
1 both in paediatric and adult
patients. Activated charcoal does not bind lithium, heavy metals and
toxic alcohols. Most common side effects are vomiting and
constipation. It is contraindicated if the airway is not protected, in
case of ingestion of corrosive, irritant agents or hydrocarbons with a
high potential of aspiration.
Whole bowel irrigation (WBI) can be considered for potentially toxic
ingestions of sustained-release or enteric-coated drugs particularly for
those patients presenting later than 2 h after drug ingestion when
activated charcoal is less effective. WBI can be considered for patients
who have ingested substantial amounts of iron, lithium, or potassium as
the morbidity is high and there is a lack of other potentially effective
options for gastrointestinal decontamination. WBI can be considered for
removal of ingested packets of illicit drugs in "body packers." However,
controlled data documenting improvement in clinical outcome after WBI
are lacking. WBI is contraindicated in patients with bowel obstruction,
perforation, or ileus, and in patients with hemodynamic instability or
compromised unprotected airways. It should be used cautiously in
debilitated patients and in unstable patients. The concurrent adminis-
tration of activated charcoal and WBI might decrease the effectiveness
of the charcoal.298
187
Routine administration of laxatives (cathartics) must be avoided,
emetics should not be used as well (e.g. ipecac syrup).299
Enhanced elimination
The aim of this technique is to accelerate elimination of substances
that have already been absorbed. Non-invasive strategies include
multiple-dose activated charcoal (MDAC) and forced diuresis (with)
urine alkalisation. Invasive techniques include haemodialysis,
hemofiltration, plasmapheresis.
MDAC administered over several hours can increase elimination
for certain drugs,300,301 especially in high doses of toxic agents, drugs
that tend to form bezoars, agents that slow the GI motility, sustained
release or toxic agents with elevated biliary excretion and entero-
hepatic circulation. The initial dose is 1 g kg
1, followed by 0.25

0.5 g kg
1 every 2
4 h.
Forced diuresis is a very useful technique for drugs with
elevated renal excretion, low protein binding and low volume of
distribution. Indications are poisonings from amanita phalloides
(death cap fungus), phenobarbital, salicylates and ethylene
glycol.
Urinary alkalinisation (urine pH 7.5) involves an IV sodium
bicarbonate infusion.302 It is most commonly performed in patients
with salicylate intoxication who do not need dialysis. Consider urine
alkalinisation in addition with forced diuresis (3
6 ml kg
1 h
1) in
severe poisoning by phenobarbital and herbicides. Hypokalaemia is
the most common complication.303
Haemodialysis removes drugs or metabolites with low molecular
weight, low protein binding, small volumes of distribution and high water-
solubility. In hypotension, use continuous veno-venous hemofiltration
(CVVH) or continuous veno-venous haemodialysis (CVVHD). Indica-
tions for haemodialysis include: worsening despite standard treatment;
lethal blood levels of a toxic agents or certain history of lethal dose;
patients with alterations of normal excretion systems or kidney injury
secondary to the intoxication; poisonings with substances that produce
highly toxic metabolites. Main indications for haemodialysis are poison-
ings with ethylene glycol, methanol, lithium, barbiturates, salicylates,
paraquat.304
Antidotes
Antidotes interact with the toxic agent by means of different
mechanisms, they make it less effective and decrease or stops its
biological effects. Although basic supportive care remains the key
treatment of poisonings, antidotes can be sometimes life-saving or may
reduce morbidity as well as medical and other resources required in the
care of a patient. In areas remote from hospital or in developing countries
where facilities for supportive care are often limited and transport to
treatment centres may take a long time, the availability of antidotes is
even more essential.305,306 Nano-antidotes have shown efficacy in
proof-of-concept studies, but require clinical validation (Table 6).307
Specific toxic agents
Special settings
Healthcare facilities
Cardiac arrest in the operating room (OR)
Cardiac arrest in the operating room (OR) is a rare but a potentially life-
limiting event with a mortality rate of more than 50%.392,393 In the event
of cardiac arrest in the OR, follow the ALS algorithmwith appropriate
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Table 6 – Specific toxic agents.

Drugs First Line Consider Avoid
Cardiovascular and neurological medication
Digoxin Lidocaine
ventricular arrhythmias Digoxin-Fab 80 mg, repeated Calcium channel blockers
as required308,309 Class 1a antiarrhythmic drugs

Calcium channel blockers IV calcium 1
2 g every 10
20 min/ 0.02
0.04 g/kg/h Pacing
High-dose insulin euglycemic therapy Catecholamines VA-ECMO
Atropine289,310
323 Intravenous lipid
emulsion324,325

Beta-blockers High-dose insulin euglycemic therapy Glucagon

Catecholamines326
328 Intravenous lipid emulsion
phosphodiesterase inhibi-
tors329
332

Tricyclic antidepressants Sodium bicarbonate - broad complex Intravenous lipid emulsion290

ventricular arrhythmias: 1-2 mmol kg
1, target
pH 7.45
7.55333
339

Neuroleptics Sodium bicarbonate - broad complex ventricular Dopamine

arrhythmias: 1
2 mmol kg
1
Dantrolene, Bromocriptine - neuroleptic malignant Adrenaline
syndrome340 Dobutamine341

Anticonvulsants Sodium bicarbonate - broad complex ventricular Haemodialysis

arrhythmias: 1
2 mmol kg
1
Dantrolene ECLS
carbamazepine343,344
Carnitine, Naloxone
valproic acid342

Benzodiazepines Flumazenil345,346

Local anaesthetics Intravenous lipid emulsion: 20% lipid emulsion, 1.5 ml

kg
1 over 1 min followed by an infusion at 0.25 ml kg

1
min
1 for up to 60 min. 2 bolus repetitions, max
cumulative dose 12 ml kg
1.290,347
353

Drugs of abuse
Opioids Naloxone 0.4
2 mg, repeat every 2
3 min (strong
recommendation, very low- quality evidence)354,355

Cocaine Benzodiazepines - seizure control356,357 Alpha-blockers, calcium chan- Beta-blockers not as first line
nel blockers, nitro-glycerine
management362
364
hypertension358
361

Amphetamines Benzodiazepines - seizure control Cyproheptadine, chlorproma-

zine, ziprasidone
serotonin-
ergic syndrome365
368

Systemic asphyxiants
Cyanide Hydroxycobolamin Sodium thiosulfate371 Amyl nitrite, sodium nitrite

70 mg/kg/1
3 min369,370 avoid if smoke inhalation372,373

Carbon monoxide Oxygen Hyperbaric oxygen374
379

Hydrogen sulphide Nitrite Hydroxycobolamin380
384

Local asphyxiants (Irritant gases) N-Acetylcysteine

phosgene385

Organic solvents and halogenated Beta-blockers
arrhythmias

hydrocarbons N-Acetylcysteine
hepato-
toxicity386,387

Biotoxins
Botulinum toxin Antitoxin388,389

Viper envenomation Antivenom Polyvalent immune Fab390

Marine biotoxins Antivenom, magnesium
jellyfish391

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modifications. The incidence of perioperative cardiac arrest is higher
in children, especially newborns and infants as well as in older
patients.394
Strong predictors of Intraoperative Cardiac Arrest (IOCA) are
associated with higher American Society of Anesthesiologists (ASA)
physical status, current sepsis, urgent/emergency case, anaesthetic
technique and age.392,395 In addition, there are also several factors
such as hypoxia, acute blood loss with shock, pulmonary embolism,
myocardial infarction, arrhythmia or electrolyte disturbances, which all
can be the cause or confounding factors in an intraoperative cardiac
arrest.392,396,397 Additional risk factors for intraoperative cardiac
arrest for patients in prone position, such as major spinal surgery, can
include air embolism, wound irrigation with hydrogen peroxide and
occluded venous return.
This section is based on recent European Society of Anaesthesi-
ology and Intensive Care (ESAIC) and ERC guideline process (27
PICO questions; 28,221 titles screened/452 publications selected).
Early recognition of intraoperative cardiac arrest
In many cases of intraoperative cardiac arrest, physiological
deterioration is gradual and the cause of the cardiac arrest is known
and hence the arrest anticipated.398 In those where this is not the case,
follow the ALS algorithm and and prioritise the reversible causes. If the
patient deteriorates, call for help immediately. Inform the perioperative
team of the deterioration and a possible impending cardiac arrest.
Ensure that sufficient skilled assistance is present.
High-risk patients will often have invasive blood pressure
monitoring (IABP), which is invaluable for recognition and treatment
of cardiac arrest. If cardiac arrest is a strong possibility, a defibrillator
should be on standby. Apply self-adhesive defibrillation electrodes
before induction of anaesthesia, ensure adequate venous access,
and prepare resuscitation drugs and fluids. Use fluid warmers and
forced air warmers to limit perioperative hypothermia and monitor the
patient’s temperature.
Chest compressions and defibrillation
In adult IOCA patients with shockable rhythm, immediate
defibrillation should be performed. A high incidence of reversible
causes is to be expected. This could be hypoxemia due to airway
problems, bronchospasm or equipment failure, intoxications
caused by drug error, hypovolemia due to blood loss, anaphylactic
reactions, thromboembolism including air embolism and tension
pneumothorax or even cardiac tamponade after central line
insertion.
The majority of events is covered by standard ALS measures.
However, closed chest compressions are not very effective in
hypovolemia, cardiac tamponade or tension pneumothorax (see
corresponding section). Therefore closed chest compressions should
not delay addressing these particular reversible causes. To optimise
closed chest compressions the position and height of the operating
table or trolley should be adjusted. CPR is ideally carried out in the
supine position of the patient, but is possible in patients in prone
position as well.399,400 Open cardiac compressions should be
considered early as an effective alternative to closed chest
compressions in the operating room environment.398
Airway management
Advanced airway management (if not already undertaken) and
ventilation with 100% oxygen should be performed as soon as
possible.397
189
Reversible causes
Hypovolaemia
Depending on the suspected cause, initiate volume therapy with
warmed blood products and/or crystalloids, in order to rapidly restore
intravascular volume. At the same time, initiate immediate haemor-
rhage control, e.g. surgery, endoscopy, endovascular techniques.27
Chest compressions are only of use if the circulating volume is replaced
simultaneously. In the initial stages of resuscitation crystalloid solutions
are acceptable. In case of massive blood loss immediate transfusion of
blood products is required. A focused ultrasound examination can help
to confirm the course of cardiac arrest and target resuscitative
interventions. (see hypovolaemia section).
Anaphylaxis
The incidence of immune-mediated anaphylaxis during anaesthesia
ranges from 1 in 10,000 to 1 in 20,000. Neuromuscular blocking drugs
are the commonest cause, being associated with 60% of cases. The
associated morbidity and mortality are high, particularly if there are
delays in the diagnosis and management.401 Initial management of
anaphylaxis starts with removal of the allergen if possible and then
follows the ABCDE approach and the management principles outlined
in the chapter on anaphylaxis. Adrenaline is the most effective drug in
anaphylaxis and should be given as early as possible. In contrast to
alternative anaphylaxis scenarios it might be appropriate for
anaesthetists to give adrenaline by the IV route. Repeated doses
of adrenaline maybe necessary (see anaphylaxis section below).
Systemic toxicity of local anaesthetic
Cardiac arrest is a rare but well recognized complication of local
anaesthetic (LA) overdose, especially following inadvertent intravas-
cular injection. Direct action of the LA on cardiac myocytes causes
cardiovascular collapse, usually within 1
5 min of injection, but onset
may range from 30 s to as long as 60 min.402 Significant hypotension,
dysrhythmias, and seizures are typical manifestations, but the
diagnosis maybe one of exclusion.292 Intravenous lipid therapy has
been used as a rescue therapy to treat cardio-vascular collapse and
cardiac arrest, but its efficacy is controversial.403 In the absence of
documented harm, guidelines recommend that 20% lipid emulsion
should be available for use wherever patients receive large doses of
LA (e.g. operating rooms, labour wards and the emergency
department).404 Stop injecting the LA and call for help. Secure and
maintain the airway and, if necessary, intubate the trachea. Give
100% oxygen and ensure adequate ventilation (hyperventilation may
help by increasing plasma pH in the presence of metabolic acidosis).
Control seizures using a benzodiazepine, thiopentone or propofol.
Give an initial IV bolus injection of 20% lipid emulsion at 1.5 ml kg

1
over 1 min and then start an infusion at 15 ml kg
1 h
1. If ROSC
has not been achieved at 5 min, double the rate of lipid infusion and
give a maximum of two additional lipid boluses at 5-min intervals until
ROSC has been achieved. Do not exceed a maximum cumulative
dose of 12 ml kg
1.405,406 If the patient does not respond to treatment
ECPR should be considered.
Crew resource management
Every resuscitation event should have a designated team leader who
directs and coordinates all staff and the components of the
resuscitation, with a central focus on minimising no-flow times and
addressing the reversible causes simultaneously. Operative surgery
needs to be stopped unless it is addressing a reversible cause of the
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cardiac arrest. Patient access and resuscitation tasks may necessi-
tate covering the surgical field and withdrawing the surgical team from
the patient. Team tasks should be prioritised, good quality BLS should
be ensured, relevant reversible causes should be identified and non-
priority tasks avoided. If the patient is not responding to resuscitative
efforts (i.e. ETCO2 <2.7 kPa/20 mmHg), the quality of CPR needs to
be improved.407
Successful management of intraoperative cardiac arrest requires
not only individual technical skills and a well-organized team
response, but also an institutional safety culture embedded in
everyday practice through continuous education, training and
multidisciplinary cooperation. Corresponding institutional protocols
(e.g. massive transfusion protocols) and checklists help to optimise
the response to cardiac arrest in the operating room environment.
Post resuscitation care
There is lack of evidence to support the use of immediate hypothermia
versus no hypothermia after adult intraoperative cardiac with only one
single case report showed complete neurological recovery and data
suggest improved neurological outcome.408 Targeted temperature
management should be applied according to general post resuscita-
tion care.
Cardiac surgery
The incidence of cardiac arrest following cardiac surgery has been
reported around 2
5% in recent series, with higher survival rates
(around 50%) compared to other scenarios.409
412 This is largely
justified by the fact that many causes are reversible; Major causes of
cardiac arrest in this setting include ventricular fibrillation (VF),
accounting for up to 50% of cases, followed by cardiac tamponade and
major bleeding, which often present as PEA.
Evidence based recommendations for the management of cardiac
arrest following cardiac surgery derive from the 2019 and 2018 ILCOR
CoSTR documents,103,413 the European Association for Cardio-
Thoracic Surgery (EACTS) guidelines 414,415 and the Society of
Thoracic Surgeons (STS) expert consensus document for the
resuscitation of patients who arrest after cardiac surgery.416
Additional focused literature search was conducted for evidence
update and consensus was reached within the writing group to
establish recommendations.
Prevent and be prepared
Ensure adequate training of the staff in resuscitation technical skills
and ALS (Figs. 11 and S3).
Staff involved in the care of post-operative cardiac patients should
receive adequate training with periodic refreshers. This should
comprise resuscitation technical skills and ALS, including training
to perform an emergency resternotomy. Roles should be previously
allocated to staff in the intensive care unit (ICU) to favour coordination
in case this procedure is required.417
Ensure availability and well-functioning of emergency
equipment
All emergency equipment should be located, adequately marked and
periodically checked, including small resternotomy sets containing
only the essential elements to open the chest.415,416
Use safety checklists
First introduced in the surgical environment by the World Health
Organization, safety checklists have proven to reduce complications
and mortality of non-cardiac surgery, and should be implemented.418
Specific checklists developed for cardiothoracic surgery, including
checks on preparations for bleeding, perfusions and ICU preparations
should be considered to enhance prevention.414
Detect cardiac arrest and activate cardiac arrest protocol
Identify and manage deterioration in the postoperative cardiac
patient
Early signs of deterioration can be identified in the monitored
postoperative patient after careful examination. Hypotension is a
common observation to several different complications
(Table 7).419
421 Echocardiography should be performed in case of
haemodynamic instability, considering transoesophageal application
for more precise diagnosis.422 Continuous ECG monitoring allows
early identification of arrhythmias; supraventricular tachycardias are
the most frequent in this setting.423
Confirm cardiac arrest by clinical signs and pulseless pressure
waveforms
Cardiac arrest can be detected by checking rhythm in the ECG
monitor, identifying absent circulation by clinical examination and
monitoring of vital signs, including pulseless pressure waveforms
(arterial, central venous and pulmonary artery pressures, and pulse
oximetry) and rapid decrease in the end-tidal capnography.415,416
Shout for help and activate cardiac arrest protocol
Once recognised, immediately getting help and activating the cardiac
arrest protocol are mandatory.
Resuscitate and treat possible causes
Modifications to the standard ALS algorithm include immediate
correction of reversible causes and emergent resternotomy if this is
not successful.415,416
Restore pulsatile cardiac rhythm
In patients with VF/pVT defibrillation of up to three stacked shocks
should be prioritised and justifies delaying external chest compres-
sions for as long as one minute.424,425 If these fail, immediate
resternotomy is advised.425 In case of asystole or extreme bradycar-
dia, epicardial pacing (DDD mode at 80
100 beats min
1 and at
maximum output voltages) or transcutaneous pacing should be
attempted for one minute before initiating chest compressions. PEA
should trigger immediate external chest compressions, searching for
reversible causes and preparing for early resternotomy. In the
presence of a pulseless stimulated rhythm, pacing should be paused
to eventually unmask underlying VF and, if indicated, a defibrillation
should be provided.415,416
Compressions and ventilations
If ROSC is not achieved following defibrillation or pacing, or in case of
PEA, compressions and ventilations should be initiated while
preparing for emergency resternotomy. External compressions
should be performed at 100
120 beats min
1, aimed to reach a
systolic blood pressure >60 mmHg; failure to attain this value despite
adequate performance may indicate tamponade or severe haemor-
rhage, requiring emergency resternotomy.415,416 Compared with
external compressions, internal cardiac massage provides better
coronary and systemic perfusion pressure and this sole fact may
justify chest reopening.426,427 Airway management in this setting
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Table 7 – Common causes of patient deterioration after cardiac surgery and management.
Haemorrhage
 “Medical” bleeding: post-operative coagulopathy
 “Surgical” bleeding: operative trauma
Low cardiac output state
 Inadequate preload
 Excessive afterload
 Decreased ventricular contractility
 Diastolic dysfunction
Graft or valve failure
Arrhythmias
Vasodilation
 Rewarming
 Analgesics/sedatives
 Sepsis
 Anaphylaxis
 Adrenal insufficiency
 Vasoplegic syndrome
follows the usual indications for ALS.101 In mechanically ventilated
patients the position and patency of the tracheal tube should be
checked, inspiratory oxygen increased at 100% and positive end-
expiratory pressure removed. If a tension pneumothorax is suspected,
emergent decompression is advocated.415,416
Drugs during resuscitation
As a general principle previous infusion other than needed for
resuscitation should be stopped, with the possible exception of
sedatives. Amiodarone (300 mg) or lidocaine (100 mg) may be
administered intravenously after three failed shocks to treat VF/pVT,
although this recommendation is extrapolated from research in
OHCA (weak recommendation, low certainty evidence).413,416
Conversely, using adrenaline (1 mg) shortly after cardiac surgery
is controversial. The European Association of Cardio-Thoracic
Surgery (EACTS) and the Society of Thoracic Surgeons (STS)
discourage the routine use of adrenaline415,416 based on the
concern that intense hypertension induced by adrenaline may
cause bleeding or disruption of surgical anastomoses after
ROSC, although lower doses (50
300 mcg boluses) may be
considered in peri-arrest situations (expert consensus).416,421,428
The 2019 ILCOR CoSTR Summary included a specific section on
the role of vasopressor drugs for adult cardiac arrest, based on an
ILCOR-commissioned systematic review and meta-analy-
sis.238,429 The recommendation to administer 1 mg adrenaline
during CPR was maintained (strong recommendation, low-
moderate certainty of evidence), based on increased ROSC
and survival at hospital discharge. However, limited RCT
evidence on its use for IHCA was acknowledged, with recom-
mendations being extended from the OHCA setting. In summary,
although there is insufficient evidence to establish recommen-
dations on the use of adrenaline in the postoperative cardiac
patient, considering the potential risks of adrenaline-induced
intense hypertension in this particular setting, 1 mg adrenaline
191
 Correct hypothermia and hypertension, avoid haemodilution
 Consider blood products transfusion and use of haemostatic agents guided
by haematological tests
 Check drains to detect active bleeding and perform echocardiography to
exclude cardiac tamponade; consider early re-operation if suspected
 Perform echocardiography to assess ventricular function
 Ensure adequate ventricular filling
 Correct systemic vasoconstriction
 Maintain atrioventricular coordination
 Correct metabolic disturbances and hypocalcaemia
 Consider inotropic or mechanical circulatory support
 Check for ECG abnormalities
 Perform echocardiography
 Consider percutaneous intervention or re-operation
 Correct electrolytic disturbances
 Consider antiarrhythmic, electrical cardioversion or pacing
 Correct specific underlying causes
 Consider haemodynamic-guided IV fluid therapy
 Consider vasopressor support
should be avoided in patients who collapse shortly after cardiac
surgery, if defibrillation and early resternotomy are likely to revert
cardiac arrest. However, lower doses may be considered in peri-
arrest situations.415,416,428
Early resternotomy
Refractory cardiac arrest requires performing resternotomy within
5 min, in order to perform internal massage or defibrillation and
eventually correct underlying causes. This has shown to be a safe
procedure in the ICU,430 leading to significantly higher survival rates,
especially if performed with minimum delay and in the presence of
surgically repairable problem on reopening.431 Resternotomy should
be conceived as part of the resuscitation protocol of postoperative
cardiac patients until at least day 10 after surgery.416
Circulatory support devices
In patients supported by intra-aortic balloon pump who present
cardiac arrest, the device may contribute to improve coronary and
brain perfusion if coordinated with cardiac massage (1:1 ratio, with
maximal amplification). The ECG trigger of the balloon is not reliable
during resuscitation and should be switched to pressure trigger mode,
or to internal mode at 100 beats min
1 if massage is interrupted for a
significant interval. ECPR may be considered if resternotomy fails to
revert cardiac arrest or as an alternative for patients undergoing
minimally invasive cardiac surgery (i.e. thoracotomy) or who arrest
>10 days after initial sternotomy.416 However, there is limited data
addressing this specific scenario, since most studies have studied its
usefulness to treat cardiogenic shock or have focused on paediatric
populations. A small series of twenty-four adult patients who received
ECPR support for postoperative cardiac arrest reported overall
successful weaning from extracorporeal membrane oxygenation
(ECMO) in sixteen patients (66.7%), eight of whom survival to hospital
discharge (33.3%) with most of patients dying because of multiple
organ failure.432
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Catheterisation laboratory
The type of patients treated and procedures performed in the
catheterisation laboratory has evolved over the last years
towards greater complexity. More critically ill patients now
undergo percutaneous coronary intervention (PCI) or implant
of ventricular assist devices, and the volume of structural heart
interventions, mostly offered to high-risk patients who are unfit for
surgery, is rapidly increasing (i.e. percutaneous valve replace-
ment or repair, leaks, septal defects or left atrial appendage
closure). As a result, cardiac arrest in the catheterisation
laboratory may occur in critically ill patients (i.e. cardiogenic
shock due to extensive myocardial infarction), but also in stable
patients undergoing planned procedures, which carry inherent
potential hazards and are extremely sensitive to both technical
and human factors.
Updated robust data on the global incidence of cardiac arrest in the
catheterisation laboratory are lacking; registries mostly refer to PCI
and show incidence rates highly dependent on patient pre-procedural
risk.433,434
Evidence based recommendations derive from the ILCOR CoSTR
documents238,435,436 and ILCOR systematic reviews,273 expert
consensus statements from the European Association of Percutane-
ous Cardiovascular Interventions (EAPCI),437 the Society for
Cardiovascular Angiography and Interventions (SCAI),438 and the
International ECMO Network and The Extracorporeal Life Support
Organization (ELSO),439 plus focused literature search for evidence
update. Where insufficient quality of evidence was obtained,
recommendations were established by consensus expert within the
writing group.
Prevent and be prepared
Ensure adequate training of the staff in technical skills and ALS
Staff working in the catheterisation laboratory should be adequately
trained in resuscitation technical skills and ALS, including team and
leadership training (Figs. 12 and S1).435 Protocols for specific
emergency procedures (e.g. initiation of mechanical CPR, emergency
transcutaneous or transvenous pacing, pericardiocentesis, ventricu-
lar assist devices) should be established. On-site emergency drills
should be considered to facilitate implementation and familiarisation
of the staff.438
Ensure availability and well-functioning of emergency
equipment
Emergency equipment should be clearly identified and the staff should
be aware of its location to minimise delays if needed. Proper
functioning should be regularly tested.
Use safety checklists
The use of safety checklists to minimise human factors should be
encouraged,437,438,440 since their use has been associated with fewer
procedural complications and improved team communication.441
Detect cardiac arrest and activate cardiac arrest protocol
Check patient’s status and monitored vital signs periodically
Continuous monitoring of vital signs (invasive blood pressure,
heart rate and rhythm, pulse oximetry, capnography) facilitates
early recognition and management of complications to prevent
further deterioration and should be periodically checked. For
example, high-degree atrioventricular block can occur during PCI,
septal alcohol ablation or transaortic valve replacement (TAVR);
chest pain, haemodynamic instability and ST-elevation in the ECG
may be an alert for acute stent thrombosis during PCI or coronary
ostium occlusion during TAVR; sudden hypotension requires
ruling out pericardial tamponade (due to coronary perforation,
atrial/ ventricular wall perforation or annulus rupture during balloon
valvotomy or TAVR) or hypovolaemia in case of vascular
complications. Defibrillation pads should be attached to at least
all STEMI patients and considered in cases of complex PCI or
high-risk patients.438
Consider cardiac echocardiography in case of haemodynamic
instability or suspected complication
Cardiac echocardiography can help to detect complications and
should rapidly be performed in case of haemodynamic instability. In
procedures performed under transoesophageal echocardiography
monitoring, this may provide better quality imaging for quicker and
more precise identification of complications.422
Shout for help and activate cardiac arrest protocol
Once cardiac arrest is confirmed, the resuscitation team should be
called immediately. Even if staff in the catheterisation laboratory
should initiate resuscitation without delay, additional support may
be required to allow on-going resuscitation while specific
procedures to treat possible causes of arrest are performed (i.e.
PCI, pericardiocentesis, invasive pacing). Leadership and roles
during resuscitation should be clearly identified especially if new
rescuers take over, to ensure coordinated and effective
performance.
Resuscitate and treat possible causes
Resuscitate according to the modified ALS algorithm
Cardiac arrest in the catheterisation laboratory should be managed
according to the ALS protocol, with some modifications.101 In the
presence of monitored VF/pVT, consider immediate defibrillation with
up to three stacked shocks before starting chest compressions. In
case of asystole/PEA, CPR and drugs should be administered
according to the ALS protocol.
Check for reversible causes, including the use of echocardiogra-
phy and angiography.
Identifying reversible causes is especially critical in non-shockable
rhythms, for which cardiac echocardiography should be performed,
and angiography considered if appropriate. Point of care ultrasonog-
raphy (POCUS) can help to identify reversible causes of cardiac
arrest, although attention should be paid to minimising pauses in chest
compression.442
444 In this regard, transoesophageal echocardiog-
raphy may be helpful to enable continuous, higher-quality imaging
assessment without interfering with resuscitation efforts.445,446
Consider mechanical compressions and percutaneous circu-
latory support devices
A Cochrane review including 11 trials comparing mechanical CPR
versus manual chest compressions during CPR for adult patients
suffering IHCA or OHCA arrest failed to prove superiority of
mechanical over conventional CPR. However, the role of mechanical
CPR was recognised as a reasonable alternative in settings where
high-quality chest compressions are not possible or dangerous for the
provider.272 Delivering quality manual CPR in the catheterisation
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laboratory may be challenging due to the presence of the X-ray tube,
and may expose the rescuer harmful radiation; for this reason,
mechanical CPR should be considered.
Percutaneous ventricular assist devices such as intra-aortic balloon
pump, Impella1 447 or TandemHeart1 may provide circulatory support
while performing rescue procedures during cardiac arrest, although
their use in this setting has not been extensively evaluated. Veno-
arterial extracorporeal membrane oxygenation (VA-ECMO) offers both
circulatory and pulmonary support and may be used in cardiac arrest
(extracorporeal life support: ECPR), but there is insufficient evidence to
systematically recommend such strategy.238 A recent systematic
review comparing ECPR to manual or mechanical CPR reported
positive outcomes of ECPR in seven studies assessing their use for
adult IHCA, although these were handicapped by their observational
nature and limited internal validity.273 Other smaller series have
reported successful use of ECPR for in-hospital refractory cardiac
arrest due to acute myocardial infarction448 or complicating PCI or
TAVR.449 Should ECPR be considered, rapid initiation rather than
waiting for complete failure of conventional measures is recom-
mended,439,450 since shorter conventional CPR (low-flow) time is a key
factor for success.451 Until randomised trials provide more consistent
evidence, decisions to use ECPR or other ventricular assist devices
should be adapted to the case, availability and expertise of the team.
Dialysis unit
Patients receiving long-term HD are one of the highest risk groups for
out-of-hospital cardiac arrest (OHCA), which includes events
occurring within dialysis clinics. OHCA occurs 20 times more
frequently in dialysis patients compared with the general popula-
tion.452 Cardiac arrests occurring within a dialysis clinic are
predominantly witnessed events and may occur before, during or
after dialysis treatment. Studies investigating the timing of cardiac
arrest in relation to dialysis have reported that 70
80% of cardiac
arrests occurred during HD treatment.453
455 Several risk factors for
cardiac arrest in patients receiving long-term HD have been
postulated including hyperkalaemia, excessive volume shifts during
dialysis, the 2-day inter-dialytic interval, low potassium dialysate fluid,
cardiac disease, and non-compliance with diet and dialysis regi-
men.456
461 Although HD patients are susceptible to cardiac arrest in
the first 12 h from the start of the HD session,456 the highest risk period
is the latter end of the 2-day inter-dialytic interval (e.g. weekend break)
as potassium level rises and fluid accumulates.456,458 Historically, the
outcome of IHCA in HD patients was deemed to be poor,462 but this
may in part relate to the resuscitation strategy and perceived futility.
Previous studies have shown a lower survival after IHCA in dialysis
patients compared with the general population.463,464 However, a
recent study has shown a higher incidence of ROSC (69% compared
with 62%), similar survival to hospital discharge (23% compared with
22%), and a slightly higher frequency of favourable neurological status
(17% compared with 16%) in HD patients compared with non-dialysis
patients.458 Shortfalls in resuscitation practice have been found in
both OHCA and IHCA with respect to initiation of CPR and timely first
defibrillation for a shockable rhythm in the dialysis patient.458 There
are also some special considerations in the approach to resuscitation
in the setting of a dialysis clinic, particularly if the event occurs during
dialysis.116
Recommendations are based on a scoping review and the recently
updated the UK Renal Association Hyperkalaemia Guidelines.116 The
scoping review screened multiple databases
PubMed (1960
2019),
Ovid MEDLINE (1946
2019), EMBASE (1974
2019), Science Direct
193
(1995
2019), The Cochrane Library (1995
2019), Web of Knowledge
(2001
2019) for all human studies published in English pertaining to
the cardiac arrest and haemodialysis. Websites searches included
National Institute for Health and Care Excellence (NICE), Scottish
Medicines Consortium (SMC), Healthcare Improvement Scotland,
Medicines and Healthcare products Regulatory Agency (MHRA) and
European Medicines Agency (EMA). No randomised controlled trials
were identified. Evidence was drawn from observational studies. The
UK Renal Association Hyperkalaemia guideline (2019) utilised this
scoping review and expert consensus opinion to develop recommen-
dations for the treatment of cardiac arrest in dialysis units.
Prevention of cardiac arrest in dialysis patients
Hyperkalaemia and volume overload are common causes of cardiac
arrest in dialysis patients, but prevention largely relies on dietary and
fluid restrictions and dialysis-related factors. Although the delivery of
maintenance dialysis three times a week is difficult to overcome, careful
dialysis prescription may reduce the risk of cardiac arrest.453,457,465
Treatment of cardiac arrest
Initial steps
Resuscitation should be started following the standard ALS algorithm.
A trained dialysis nurse should be assigned to operate the HD
machine. The HD machine should be stopped and blood volume
returned to the patient with a fluid bolus. As long as the HD machine is
not defibrillation-proof it should be disconnected from the patient in
accordance with the International Electrotechnical Committee (IEC)
standards. The dialysis access should be kept open to use for drug
administration.
Modifications to cardiopulmonary resuscitation
Defibrillation
Dialysis clinics are predominantly nurse-led units. An automated
external defibrillator (AED) is the standard for delivery of defibrillation in
HD facilities but staff training and confidence may influence the rate of
nurse-led defibrillation.466 A three-fold increase in odds to hospital
discharge with favourable neurological status, has been shown when
CPR is initiated by dialysis staff rather than awaiting the arrival of
emergency services. Although nurse-led AED placement occurred in
only 52.3% of patients, this study also showed a trend towards improved
survival with staff-initiated defibrillation in patients with a shockable
rhythm.457 Given the higher chance of survival with shockable rhythm,
steps are required to avoid delay in defibrillation in dialysis units.
Vascular access
Use dialysis access in life-threatening situations and cardiac arrest.
Potential reversible causes
All of the standard reversible causes (4 Hs and 4Ts) apply to dialysis
patients. Electrolyte imbalances and fluid shifts during dialysis are
common causes. For management of hyperkalaemic cardiac arrest,
refer to the hyperkalaemia section of this chapter.
Post resuscitation care
Dialysis may be required in the early post resuscitation period guided
by fluid status and serum biochemistry. Patient transfer to an area with
dialysis facilities (i.e. intensive care unit or renal high dependency unit)
is essential.
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Dentistry
Medical emergencies in a dental office include a variety of situations
ranging from psychosomatic disorders precipitated by fear and anxiety
to life-threatening situations. The most frequent medical emergencies
include vasovagal (pre-) syncope, orthostatic hypotension, hyperten-
sive crisis, hyperventilation, seizures, moderate allergic reactions,
hypoglycaemia, and angina.467,468 Life-threatening emergencies
commonly arise from myocardial infarction, seizures or exacerbation
of asthma. Cardiac arrest in primary dental practice is a rare event with
an incidence of 0.002
0.011 cases per dentist per year.468,469
A PubMed scoping review was performed on March 27th, 2020
using the keywords “dentistry” OR “dental surgery” AND “cardiac
arrest or heart arrest” OR “resuscitation or cardiopulmonary
resuscitation” in the last 5 years (n = 271). There were neither RCTs
nor systematic reviews identified on this topic. Thus, recommenda-
tions are based on the evidence already informing the ERC guidelines
2015. Recommendation on modification to chest compression is
based on some case reports that described effectiveness of chest
compression in a patient left on a dental chair.470,471 Small simulation
studies comparing the effectiveness of CPR on a dental chair and on
the floor reported either lower or equivalent CPR quality.472
475
Recent simulation study verified the efficacy of a stool as a stabilizer in
different types of dental chairs and confirmed feasibility of ERC
guidelines 2015.84,476 Expert consensus was provided by the
Resuscitation Council UK in May 2020 as a part of Quality Standards
for primary dental care. (https://www.resus.org.uk/library/quality-
standards-cpr/quality-standards-acute-care).
Causes of cardiac arrest
Causes of cardiac arrest usually relate to pre-existing comorbidities,
complications of the procedure or allergic reactions.
Airway and breathing
Dental procedures may cause loss of airway patency related to the
primary pathology or complications of the procedure (e.g. bleeding,
secretions, tissue swelling). The occurrence of choking is low, with a
reported incidence of 0.07
0.09 cases per dentist per year.468,469 The
addition of sedation is a contributory risk in these cases, although
provision of dental treatment under both local anaesthesia and
sedation has an excellent safety record.477,478
Circulation
Although life-threatening anaphylaxis is rare, it is a documented cause
of death during dental procedures. In additional to chlorhexidine
mouthwash, other common causes may include local anaesthetic
agents and latex. True anaphylaxis occurs in only 0.004
0.013 cases
per dentist per year, while coronary symptoms (angina or myocardial
infarction) are reported more frequently: 0.15
0.18 cases per
year.468,469
Treatment of cardiac arrest
The patient’s mouth should be checked and all solid materials from the
oral cavity (e.g. retractor, suction tube, tampons etc.) removed.
Prevention of foreign body airway obstruction should precede
positioning.
The dental chair should be reclined into a fully horizontal position
with a stool placed under the backrest for its stabilization.470,473,476 If
reduced venous return or vasodilation has caused loss of conscious-
ness (e.g. vasovagal syncope, orthostatic hypotension), cardiac
output might be restored with no need for CPR.
If breathing is not normal following opening of the airway, assume a
cardiac arrest until proven otherwise. Chest compressions should be
started immediately with the patient lying flat on the chair. Moving the
patient down onto the floor should be considered once that could be
achieved with the help of sufficient personnel (injury prevention), when
space allows, and without delaying CPR.470,471 If access to either side
of chest is limited over-head CPR should be considered.479,480
Equipment and training
Specific resuscitation equipment, including suction, oropharyngeal
airway, self-inflating bag with face masks, oxygen, emergency drug
kit, should be available immediately. This equipment list should be
standardised on the national level (https://www.resus.org.uk/library/
quality-standards-cpr/quality-standards-acute-care).481 All dental
practices delivering clinical care should have immediate access to
an AED, with all staff trained in its use. The role of early defibrillation
should be emphasized to increase availability of AEDs in dental
offices, which is still unsatisfactory, ranging from a reported 1.7
2.6%
in Europe,467,482 to 11% in the US.483
Medical professionals working in a dental office have an obligation to
provide CPR in case of cardiac arrest, and to ensure that staff are
trained and updated regularly. (https://www.resus.org.uk/library/quali-
ty-standards-cpr/quality-standards-acute-care).484 There is a public
expectation that dental practitioners and all other dental care
professionals should be competent in treating cardiorespiratory arrest.
However, only 0.2
0.3% dentists have a real experience,467,468,485 and
CPR training varies significantly between countries.468,469,485,486
Maintaining knowledge and competence to deal with medical
emergencies must be an important part of training of the dentists.
Special settings
Inflight cardiac arrest
According to prognosis provided before the COVID pandemic the
number of passengers travelling by plane will rise to 9 billion in the
year 2040 (Association International Air Transport (2016) http://
www.iata.org/pressroom/facts_figures/fact_sheets/Documents/
fact-sheet-industry-facts.pdf accessed 20 Jul 20). Although air
travel is safe in general, passenger demographics, pre-existing
medical conditions as well as the number of passengers aboard
larger aircraft and flights over very long distances raise the
probability of in-flight emergencies per flight.487 Between 1 out of
14,000 and 50,000 passengers will experience acute medical
problems/emergencies during a flight with cardiac arrest accounting
for 0.3% of all in-flight medical emergencies.488
490
Early recognition and calling for help, early defibrillation, high-
quality cardiopulmonary resuscitation (CPR) with minimal interruption
of chest compressions and treatment of reversible causes, are the
most important interventions. Especially in the remote environment of
an aircraft, treatment of cardiac arrest requires adaption, modification,
and supplementation to ensure the best possible outcome for patients.
Recommendations are based on one treatment guideline from the
German society of aerospace medicine (DGLRM), a scoping review
and expert consensus within the writing group.491
Modifications of ALS
Chest compressions
Bystander CPR enhances the survival rate significantly and should be
performed as soon as possible. If a cardiac arrest is recognised, the
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cabin crew should commence resuscitation and medical professional
help should be sought immediately. The easiest and most effective
way is an on-board announcement. Ideally, CPR is performed by at
least two people according to the universal CPR guidelines. Optimally,
the rescuer should kneel in the leg-space in front of the aisle seats to
perform chest compressions. A second rescuer can sit/knee in the
aisle performing ventilation or attaching the AED.492 [Charles 2011,
582] In situations where it is not possible to perform standard CPR
according to the CPR guidelines, over-the-head (OTH) CPR may be
considered as a suitable alternative.480
Defibrillation
Every commercial passenger aircraft should be equipped with an
AED. An AED and a first-aid kit should be requested immediately from
the cabin crew, since time to defibrillation is one of the most important
factors for survival after cardiac arrest.492
Airway management
Adapted to the aircraft environment, the use of SGA may be
superior for airway management in inflight resuscitation.493 The
use of capnometry/capnography might be helpful during an in-
flight cardiac arrest. A (simple) qualitative capnometer should be
available.493
Environment
Emergency equipment location should be clearly signposted. Brief
information how to act in case of cardiac arrest should be printed on
the seat pocket safety instruction card. A standardised medical
documentation form must be available. Infrastructure and fast
access to emergency equipment can reduce the potential delay to
adequate therapeutic attempts, and substantially decrease no-flow-
time. Since all passengers and crew members on-board are
potential bystanders, all should know whom to contact in case of a
cardiac arrest. Besides some general information in the pocket
safety cards, the location of the emergency equipment should be
mentioned in the pre-flight safety announcement.494 Cabin crew
must be trained in CPR and AED defibrillation and should be re-
trained every six months.493
Diversion and post-resuscitation care
A typical scenario to perform an emergency diversion before ROSC is
when leaving land and expecting a flight over open-water during an
ongoing CPR event. Furthermore, when near an airport, an early
diversion might also be useful. However, there are reasons for avoiding
a diversion as long as ROSC is not achieved. For a patient presenting
with a non-shockable rhythms, available evidence suggests that the
time required for diversion may be futile. An aircraft diversion also
includes additional risks: emergency landings, potential need to dump
fuel, landing with overweight aircraft, altered flight patterns, landing in
poor weather, high costs, and landing in unfamiliar conditions all
increase the operational risk. If a person is found to be life extinct or CPR
has been terminated, a diversion is not recommended.493,495 If
telemedicine support is available, it should be used to receive
recommendations and to discuss the further course.
Helicopter emergency medical services (HEMS) and air
ambulances
Air ambulance services operate either a helicopter or a fixed wing
aircraft that routinely transport critically ill or injured patients directly
to specialty centers. They also perform secondary transfers
195
between hospitals. Cardiac arrest may occur during flight, both in
patients being transported from an accident site (primary missions)
and also in critically ill patients being transported between hospitals
(secondary missions).496,497 The extent of treatment available
onboard an air ambulance varies and depends on medical,
technical, and personal factors, e.g., crew competences and
configuration, cabin size, and equipment. Ideally, all interventions
should be performed before flight to avoid the need for unplanned
treatments during flight.492
This section is based on an evidence update on Cardiac arrest in
HEMS and air ambulance produced by recent (randomised) clinical
trials or systematic reviews and focused on scoping reviews
addressing the questions:
 General recommendations for Cardiac arrest in HEMS and air
ambulance (30 titles screened/28 abstracts screened/7 publica-
tions selected).
 Method of Chest compressions for Cardiac arrest in HEMS and air
ambulance (28 titles screened/17 abstracts screened/4 publica-
tions selected).
 Airway management for Cardiac arrest in HEMS and air
ambulance (28 titles screened/20 abstracts screened/7 publica-
tions selected).
Pre-flight evaluation
When preparing the transport of a critically ill or injured patient, ensure
that all necessary equipment is functioning, easily accessible, and that
all necessary drugs and technical equipment are available within an
arm-length during the flight. A standardized documentation form
should be available in order to check pre-flight medical status.493
Consider the patients fitness to fly. Long-haul flights lasting 12
14 h
can cause a more significant adverse effect on vulnerable passen-
gers. HEMS or aircraft cruising heights can vary between 100 and
13,000 m (300
41,000 ft) above sea level. The passenger cabin
pressure is maximum equivalent to an altitude of approx. 2500 m
(8000 ft).498 Arterial oxygen partial pressure (PaO2) can decrease
from 95 mmHg to as low as 60 mmHg at the lowest level of cabin
pressure.499
Due to high levels of stress (noise, movement etc.) and
environmental alteration evaluate patient’s current health status
according to following:
 Recent post-surgery of a large body cavity
 Recent or current pneumothorax
 Cerebrovascular accident
 Acute psychotic mental illness
 Neonates or prematurely born infants
 Acute Myocardial infarction or unstable angina
 Recent cardiac surgery
Diagnosis
Usually patients transported by HEMS or fixed wing airplane are
monitored, so asystole and shockable rhythms (VF/pVT) can be
immediately identified. However, noise levels and flight helmets
usually prevent acoustic alarm recognition. Recognition of PEA
may be challenging, especially under sedation or general
anaesthesia. Loss of consciousness, change in the ECG pattern,
and loss of the pulse oximeter signal should provoke a breathing/
pulse and patient check. A sudden decrease in EtCO2 values in
those being ventilated or loss of a waveform in those breathing
spontaneously with EtCO2 monitoring are excellent indicators of
cardiac arrest.
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Modifications to ALS
When a cardiac arrest is recognised, communication within the
medical and flight teams should occur immediately. In situations
where it is not possible to perform standard CPR according to the CPR
guidelines, over-the-head CPR may be considered as a suitable
alternative.480 According to cabin size, chest compressions in a
helicopter might not be possible. Consider installing a mechanical
CPR device on the patient before flight where there is a risk of cardiac
arrest.500
In the case of an unexpected cardiac arrest during flight,
immediate landing should be considered to initiate high quality
resuscitation. Use of a SGA should be considered if the patient was not
ventilated previously.493,501,502 For VT/VF during flight consider three
stacked shocks.503
Cruise ship
Outcome from cardiac arrest on cruise ships is worse compared to the
overall population, as access to healthcare facilities is more
complicated and transfers can be prolonged. Furthermore, some
environments overseas are harsher than urban oversea territories
(e.g. cold, windy, wet, ice and snow).504 Austere and isolated
environments (such as polar regions) will not provide any possibility to
return rapidly to the next harbour, so autonomous management of a
cardiac arrest patient might be necessary.505
This section is based on an evidence update on Cardiac arrest on a
cruise ship produced by recent (randomized) clinical trials or
systematic reviews and focused on scoping reviews addressing the
questions:
 General recommendations for Cardiac arrest on a cruise ship (16
titles screened/8 abstracts screened/6 publications selected).
 Recommendations for Post-resuscitation care for Cardiac arrest
Cardiac arrest on a cruise ship (5 titles screened/5 abstracts
screened/2 publications selected).
Cardiac arrest on a cruise ship
If a cardiac arrest is recognised on a cruise ship, all medical resources
should be used immediately. A medical first-responder team should
be available 24/7, all equipment necessary for ALS should be
available onboard and readily accessible. An AED should be onboard
and requested immediately, since time to defibrillation is one of the
most important factors for survival after cardiac arrest.506 Where there
are insufficient numbers of crew health care professionals, an onboard
announcement should be made to call for further medical professional
help.507 Depending on the resources available telemedicine should be
used as early as possible.508 Qualified medical air transportation is an
option to cover long distances to medical facilities.
Cardiac arrest in sport
The incidence of sudden cardiac death (SCD) associated with sport or
exercise in the general population is 0.46 per 100,000 person-
years.509 There is a wide range in the incidence of SCD in those below
35 years of age (1.0
6.4 cases per 100,000 participant-years)510
depending on the study parameters and the incidence is markedly
higher in those susceptible to cardiac arrythmias during or shortly after
participating in sport.511 In a recent study involving 18.5 million
person-years the incidence of SCA of sport related cardiac arrest was
0.76 cases per 100,000 athlete years.512 The same authors reported
the highest incidence as being in runners and in soccer players for
athletes in competition and for running and gym exercise during non-
competition. There have been many reports of higher risks associated
with strenuous sports such as racquet sports513 downhill skiing514
marathon running,515 triathlon participation516 and high-intensity
sports activities such as basketball.517
It is important to recognise that the absolute risk of experiencing a
cardiac event or SCD during physical exercise is small.518 It is
estimated that the absolute risk in male athletes during vigorous
exercise is 1 SCD in 1.51 million episodes.519 In population-based
studies the incidence of SCD is reported as 0.46 per 100 ,000 person-
years in France520 and 0.31 per 100,000 person-years in Japan.521 In
a Dutch study, with a reported incidence of 2.1 per 100,000 person-
years, there was a higher survival after exercise or sport related
incidents than after non-exercise related incidents (42.1% compared
with 17.2%).522 However, in the United States it has been estimated
that in younger age groups there is an approximately 4.5-fold higher
risk of sudden cardiac arrest (SCA) or SCD in competing athletes
when compared with recreational athletes of a similar age.509
Recommendations in this section are based on a literature review
for an evidence update, including one recent AHA scientific
statement,518 hand searching of specific topics and expert opinions
from sports medicine and pre-hospital emergency medicine
practitioners.
Management
SCA during sport or exercise requires rapid recognition and effective
treatment if the individual is to survive. Reports of improved survival for
SCA during sport with survival rates improving from 8.0% in the
general population to 22.8% in sport related events509 and even
reaching as high as 71% in US High schools523 are attributed to the
majority of the events being witnessed, the implementation of prompt
resuscitation and the availability of a defibrillator. In marathon running
it has been reported that 50% of SCDs occurred in the last mile with the
highest prediction of survival being early bystander resuscitation and
the use of an AED.518
Therefore, there is strong evidence in favour of planning, adhering
and implementing standard resuscitation procedures that include
basic life support and the use of an AED in sport related cardiac
events.
Prevention
Historically, cardiac screening has been the recommended strategy
for the prevention of cardiac events in sport. However there remains
differences between the European Society of Cardiology who
recommend the use of a 12-lead ECG as a screening tool for all
young athletes524 and the AHA/American College of Cardiology who
found insufficient evidence to support this screening tool.525 Currently
the International Olympic Committee and many International Sport
Federations recommend cardiac screening for athletes.526
For older participants in sports and exercise, a medical evaluation
should include the individual’s current level of physical activity, their
known cardiovascular, metabolic, or renal disease, the presence of
the signs or symptoms suggestive of cardiovascular disease and the
desired or anticipated exercise intensity.527
Commotio cordis
Whereas most cardiac events in sport are not associated with contact
or trauma, commotio cordis is the exception. Commotio cordis, the
disruption of cardiac rhythm by a blow to the precordium, has a quoted
incidence of 3%.528 The striking object must strike the chest within the
cardiac silhouette within a 20 ms window of the upstroke of the T-
wave.529 The overall survival rate from commotio cordis is reported to
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have improved with survival rates of up to 58% reported in recent
years.530 This has been attributed to rapid recognition of the collapse,
early basic life support and the availability of AEDs resulting in prompt
defibrillation.
Drowning
Drowning is the third leading cause of unintentional injury death
worldwide, accounting for over 360,000 deaths annually [https://www.
who.int/news-room/fact-sheets/detail/drowning]. Care of a submer-
sion victim in high-resource countries often involves a multiagency
approach, with several different organizations being independently
responsible for different phases of the patient’s care, beginning with
the initial aquatic rescue, through on-scene resuscitation and transfer
to hospital and in-hospital and rehabilitative care. Attempting to rescue
a submerged patient has substantial resource implications and may
place rescuers at risk themselves. The major sequalae of drowning is
hypoxia caused by respiratory impairment secondary to the aspiration
of fluid into the lungs. If severe or prolonged, this can cause cardiac
arrest. Early effective intervention is critical to improve survival and
reduce morbidity.
Recommendations in this section follow the updated 2020 ILCOR
systematic review and ILCOR scoping review.3,14
Initial rescue
The updated 2020 ILCOR systematic review explored the influence of
key prognostic factors on the likelihood of search and rescue
operations yielding favourable outcomes. The review found moderate
certainty evidence that submersion duration was the strongest
predictor of outcome and recommended its use when making
decisions surrounding search and rescue resource management/
operations.14 The CoSTR suggested against the use of age, EMS
response time, water type (fresh or salt), water temperature, and
witness status when making prognostic decisions (very low certainty
evidence). Feedback during the public consultation on the guidelines
highlighted a potential role for drones to reduce submersion duration
or provide flotation aids.531
533
Cardiac arrest prevention
Insights from a scoping review identified limited evidence from
observational studies and manikin studies to inform the treatment of
the drowning victim.3 A summary of the key findings of the review is
presented in Table 8. The ERC recommendations for the treatment of
drowning are therefore based on expert consensus from the writing
group, informed by evidence from the scoping review.
Cardiac arrest
Similar to the cardiac arrest prevention section, limited evidence to
inform practice guidelines was identified during the scoping review.3
Key findings are summarised in Table 9. The ERC recommendations
for the treatment of cardiac arrest related to drowning are therefore
based on expert consensus from the writing group, informed by
evidence from the scoping review. Given that the duration of
submersion and duration of cardiac arrest are key prognostic
indicators, initiating resuscitation as early as it is safe and practical
to do so is strongly supported by the writing group.
Mass casualty incidents
Mass casualty incidents (MCIs), characterized by greater demand for
medical care than available resources, are rare events. Among the
19.8 million yearly EMS activations in the United States, only 0.3% had
197
an MCI dispatch code of which less than a half were confirmed on
scene.535 The MCI can be caused by variety of chemical, biological,
radiological or nuclear (CBRN) incidents, but traumatic incidents (e.g.
traffic accidents, acts of crime, or natural and industrial disasters) play
a leading role in developed countries.536 Key themes were identified
recently to improve future practice of prehospital providers: tactical
emergency medical support may harmonise inner cordon interven-
tions, a need for inter-service education on effective haemorrhage
control (trauma specific), the value of senior triage operators and the
need for regular mass casualty incident simulation.537
A PubMed scoping review was performed on March 27th, 2020
using the keywords “mass-casualty incident” AND “cardiac arrest or
heart arrest” OR “resuscitation or cardiopulmonary resuscitation” in
the last 5 years (n = 47). There were no systematic reviews and
RCTs identified on this topic related to CPR. There are few RCTs
exploring different educational and managerial strategies during
MCIs including use of modern technologies, e.g. unmanned aerial
vehicle (UAV) or Smart Glasses providing telemedical connection
from the scene.538 Available resources did not provide any evidence
for change of resuscitation practice when compared to the ERC
guidelines 2015.84
Modifications to CPR during pandemics of highly contagious
infectious disease have been addressed in the separately published
ERC COVID-19 guidelines (April 2020).539 Although pandemics did
not fulfil MCI definition ‘per se’, some healthcare systems were facing
shortages of personnel and equipment limiting capacity of critical care.
Decisions on allocation of resources, including provision of CPR,
during pandemics had to be made locally on the level of individual
healthcare systems. However, the COVID-19 guidelines have
emphasised importance of generally applicable safety precautions.
Safety
Potential hazards should be identified and assistance should be
requested immediately. The presence of multiple victims should
always alert rescuers to the possibility of a CBRN incident. Never
approach the victims unless the area is safe. High risks are present at
crime scenes (e.g. shootings, bomb attacks), or places polluted by
noxious substances (e.g. carbon monoxide, industrial cyanides or
other chemicals).
Adequate personal protection equipment (PPE) (e.g. bulletproof
vest, respirator, long-sleeved gown, eye and face protection) should
be used depending on specific risks on scene. Healthcare providers
are required to don (put-on) PPE before approaching casualties even
if time-critical interventions are required. It is acknowledged that this
could cause delay to treatment.539 Wearing PPE may also adversely
affect performance of interventions and limit the standards of care.
Simulation studies have shown reduced success rate of advanced
airway techniques, prolonged time for securing IV and intraosseous
access, and difficulties with drug preparation.540
542
Secondary risks to patients and providers should be avoided.
During sarin attacks in Japan, 10% of 1363 EMS technicians
developed poisoning, mostly from primary victims in poorly ventilated
ambulances.543
Triage
Initial triage of casualties enables identification of patient care
priorities. Unlike normal circumstances, CPR is not usually initiated in
MCI, in order to avoid delay potentially effective treatment for
salvageable victims. This critical decision depends on available
resources in relation to the number of casualties.
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Table 8 – Cardiac arrest prevention in drowning.
Topic Evidence identified
Oxygen administration No studies identified which directly addressed
this question.
4 observational studies, indirectly address this
question.
Airway management No studies identified which directly addressed
this question.
Indirect evidence from 15 observational studies.
Ventilation strategies 4 observational studies
ECMO 13 observational studies
Locally established triage systems to prioritise treatment should be
used.544
546 There is not sufficient evidence to declare one of the
triage protocols superior in all aspects to the others.547 Advanced
prehospital teams involved in the initial scene triage must avoid over
triage. Repeated triage (re-triage) is needed at hospital admission and
responsible personnel at all stages of emergency care must be
familiar with the triage system used.
Life-saving interventions should be performed in patients triaged
as “immediate” (highest priority) to prevent cardiac arrest:545
 open airway using basic techniques
 control bleeding
 decompress chest for tension pneumothorax
 use antidotes in auto-injectors
 consider initial rescue breaths in a non-breathing child.
Assigning a higher triage risk level to elderly and to survivors of
high-energy trauma should be considered to reduce the number of
preventable deaths. In the National Trauma Database (NTDB),
patients in all triage levels were compared to mortality outcomes.
There were 322,162 subjects assigned to the ‘green’ triage level of
which 2046 died before hospital discharge. Age was the primary
predictor of under triage.544
In children, special triage tapes or a paediatric-specific MCI triage
system (e.g. JumpSTART) should be used.548 If this is not available,
any adult triage system can be used.
Decision to use an MCI triage sieve and withhold care to those with
imminent death, (including victims without signs of life), is responsi-
bility of a medical commander who is usually the most experienced
EMS clinician on scene. Individual role allocations usually depend on
local protocols. Modern technologies (e.g. UAVs or Smart Glasses)
allow real-time video transmission from the triage site to the remote
incident commanders or personnel at receiving hospitals.549 Triage
inaccuracy may have fatal consequences in patients with survivable
injuries. Healthcare professionals must be regularly trained to use the
Key findings
Insufficient evidence to guide the pre-hospital use of oxygen therapy in drowning.
Pragmatically, consider treating the hypoxic patient with high flow oxygen prior to
arrival in hospital where direct measurement of arterial oxygenation can be
performed to enable controlled oxygen therapy. Further research to guide on the
optimal mode for delivery and optimising pre-hospital monitoring is required.
The studies reviewed show that that intubation is a feasible intervention following a
submersion incident. The association between intubation and poor outcomes is
almost certainly confounded by the need for intubation being an intervention limited
to more severe drowning.
In the absence of data supporting an alternative strategy, adoption of the ALS Task
Force recommendations for airway management is reasonable.2
NIV appears feasible as a treatment for moderate to severe lung injury caused by
drowning. The published experience involves mostly patients with higher GCS, who
are haemodynamically stable. Patients appear to respond within 12
24 h. The
indications for the optimal time to transition to invasive ventilation if NIV is
unsuccessful requires further research.
Given the absence of direct evidence for any particular invasive ventilation strategy
in drowning, the writing group advocates the adoption of evidence based strategies
for the management of acute respiratory distress syndrome.534
The evidence identified for severe respiratory failure, is consistent with guidelines
suggesting the use of ECMO in selected patients with severe ARDS (weak
recommendation, very low certainty of evidence).534
triage protocols during simulations and live exercises.550 Educational
video games enhance learning and improve subsequent performance
when compared to traditional educational methods.551 Training allows
fast and correct recognition of those requesting lifesaving procedures
and reduces the risk of inappropriate care given to futile cases.
Special patients
Asthma and COPD
Evidence based recommendations for the management of acute life
threatening asthma are provided by the British Thoracic Society,
Scottish Intercollegiate Guidelines Network (Fig. 13) [https://www.
sign.ac.uk/sign-158-british-guideline-on-the-management-of-asth-
ma.html] and for chronic obstructive lung disease by the Global
initiative for chronic obstructive lung disease (GOLD) (https://gold-
copd.org/). The guidelines were assessed according to the AGREE-II
framework and rated as high quality and consequently recommend
the use of this guideline in practice.
The BTS/SIGN and GOLD guidelines do not contain specific
information on the management of cardiac arrest. Our review did not
identify any other relevant, high quality guidelines. Therefore, we
undertook a scoping review and formed our guidelines based on
expert consensus amongst the writing group.
The scoping review identified 352 papers of which 19 were
relevant. No RCTs were identified. Evidence is therefore drawn from
these observational studies, supplemented by studies identified in the
2015 guidelines. The recommendations are based on the expert
consensus of the writing group.
Cardiac arrest prevention
A stepwise approach to the initial assessment and treatment, based
on the ABCDE approach is recommended for patients at risk of cardiac
arrest due to an exacerbation of obstructive lung disease (asthma/
COPD).
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Table 9 – Cardiac arrest management in drowning.

Topic Evidence identified Key findings
In-water resuscitation 1 observational study and 4 manikin In-water resuscitation by highly trained rescue teams with water rescue equipment is
studies feasible. If trained and capable rescue teams are available, initiate in-water
resuscitation for the unconscious and not-breathing patient by performing up to
1 min of ventilations (10 ventilations) before attempting transfer to land. If breathing
is not restored, patient should be towed to the shore/boat without more attempts of
ventilations during water rescue.
Outside of the setting of a highly trained rescue team, who are familiar with in-water
resuscitation, transfer directly to land/boat before initiating resuscitation. One
rescuer, although well trained in in-water resuscitation, without rescue equipment
should also bring the patient directly to the shore.

CPR on a boat 2 observational studies and 4 manikin Resuscitation in a boat seems feasible. Those providing resuscitation should focus
studies on high quality CPR and be alert to the development of fatigue and consider
switching CPR provider regularly.

Bystander CPR 18 observational studies Bystander CPR in drowning is feasible and appears effective. The apparent
superiority of conventional CPR which includes ventilation, has biological plausibility
as cardiac arrest association with drowning is primarily due to hypoxia. The findings
of this review are consistent with the ILCOR CoSTR which recommends that chest
compressions be performed for all patients in cardiac arrest. ILCOR suggests that
those who are trained, able and willing to give rescue breaths as well as chest
compressions do so for all adult patients in cardiac arrest.3

AED use No studies identified which directly AED use in cardiac arrest due to drowning appears feasible and safe. The chances
addressed this question. of a shockable rhythm is lower than for a primary cardiac cause. Given this, the
Indirect evidence from 15 observational writing group considered initiating rescue breaths and chest compressions should
studies. be prioritised. This is consistent with the ILCOR treatment recommendation which
advises a short period of CPR while the defibrillator is prepared for analysis, which is
likely to be particularly important where the cardiac arrest was caused by drowning.3

Airway management No studies identified which directly In the absence of data supporting an alternative strategy, adoption of the ALS Task
addressed this question. Force recommendations for airway management is reasonable.2
Indirect evidence from 15 observational Start with basic airway techniques and progress stepwise according to the skills of
studies. the rescuer until effective ventilation is achieved.
If an advanced airway is required, only rescuers with a high tracheal intubation
success rate should use tracheal intubation.

ECPR 13 observational studies Extracorporeal oxygenation to treat cardiac arrest or severe respiratory failure
caused by drowning is feasible. The evidence identified supports the ILCOR
treatment recommendation that suggests “extracorporeal cardiopulmonary resus-
citation (ECPR) may be considered as a rescue therapy for selected patients with
cardiac arrest when conventional cardiopulmonary resuscitation is failing in settings
where this can be implemented (weak recommendation, very-low certainty of
evidence)”.

Further steps in the treatment of acute severe asthma are
summarized in Fig. 13.
For COPD, the GOLD guidelines recommend that supplemental
oxygen is titrated to achieve a target saturation of 88
92%, with
frequent monitoring of blood gases to ensure adequate oxygenation
without carbon dioxide retention. Pharmacological therapy comprises
short acting beta-2 agonists with or without short-acting anticholiner-
gics, systemic corticosteroids and antibiotics if a bacterial infection is
suspected. Non-invasive ventilation (NIV) is recommended in the
presence of respiratory acidosis (PaCO2 < 6 kPa/35 mmHg and
arterial pH <7.35); severe dyspnoea with clinical signs of fatigue
and/or increased work of breathing. Escalation to invasive ventilation
may be required in the event of NIV failure, the patient is intolerant to
NIV, agitation or reduced conscious level, risk of aspiration,
cardiovascular instability or life-threatening hypoxia. Be alert to the
higher risk of life-threatening hypotension after emergency intubation
and mechanical ventilation in patients with raised arterial CO2 and
obstructive lung disease.552
Treatment of cardiac arrest caused by obstructive lung
disease
Cardiac arrest in patients with obstructive lung disease may arise as
a consequence of hypoxia, hypovolaemia, toxins (arrhythmias
caused by stimulant drugs e.g. beta-adrenergic agonists, aminoph-
ylline), electrolyte disturbance, tension pneumothorax and/or the
effects of gas trapping leading to reducing venous return and blood
pressure.553
557 Cardiac arrest in obstructive lung disease is
usually associated with a non-shockable rhythm and therefore poor
survival rates.558,559
Airway
Oxygen: Although no definitive studies were found which
examined the role of oxygen versus any other gas in cardiac
arrest due to obstructive lung disease, the writing group
considered hypoxia, as the main cause of cardiac arrest, a high
priority and recommend high concentration oxygen when providing
assisted ventilation.
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Advanced airway management: An observational study involving
12 patients recorded peak airway pressures in acute severe asthma
(mean 67.8 + 11 cm H2O) which are significantly higher than the
normal lower oesophageal sphincter pressure.560 There is a
significant risk of gastric inflation and hypoventilation of the lungs
when attempting to ventilate a severe asthmatic without a tracheal
tube. During cardiac arrest this risk is even higher, because the lower
oesophageal sphincter pressure is substantially lower than normal.
The writing groups therefore suggest that the trachea is intubated as
soon as possible during cardiac arrest caused by asthma. Consistent
with the ALS airway management guidelines, intubation should only
be performed by someone who is trained and competent to do so.101
Breathing
Check for signs of tension pneumothorax and treat accordingly:
Patients with obstructive lung disease may develop tension
pneumothorax, which, if left untreated, may cause cardiac ar-
rest.561
565 Check for signs of tension pneumothorax and treat
accordingly, noting that needle decompression alone may be
insufficient to relieve a tension pneumothorax.561,566
Disconnect from positive pressure ventilation if air-trapping and
hyperinflation occurs and apply pressure to manually reduce the
hyperinflation: Some case reports have reported ROSC in patients
with air trapping when the tracheal tube was disconnected.567
573 If
dynamic hyperinflation of the lungs is suspected during CPR,
compression of the chest while disconnecting the tracheal tube
may relieve air trapping.572,574 Although this procedure is supported
by limited evidence, it is unlikely to be harmful in an otherwise
desperate situation.574,575
Ventilate with respiratory rate (8
10 min) and sufficient tidal
volume to cause the chest to rise. Respiratory rates of 8
10 breaths
per minute and a tidal volume required for a normal chest rise during
CPR should minimize dynamic hyperinflation of the lungs (air
trapping).576 Tidal volume depends on inspiratory time and inspiratory
flow. Lung emptying depends on expiratory time and expiratory flow.
In mechanically ventilated severe asthmatics, increasing the expira-
tory time (achieved by reducing the respiratory rate) provides only
moderate gains in terms of reduced gas trapping when a minute
volume of less than 10 l min
1 is used.560
Circulation
Consider IV fluids: No studies evaluating the use of IV fluids for cardiac
arrest due to obstructive lung disease were identified. Expert
consensus from the writing group suggests that IV fluids should be
considered due to the risk of patients with obstructive lung disease
becoming dehydrated due to reduced oral intake and/or increased
insensible losses.
Consider standard dose IV adrenaline: In alignment with the
ILCOR CoSTR on vasopressors in cardiac arrest, the ALS guidelines
recommend that 1 mg adrenaline is given every 3
5 min during
cardiac arrest based on moderate quality evidence.2,101 The main trial
informing these recommendations however excluded patients with
asthma.577 Some small observational studies, predominantly in
younger patients suggest it may be administered in life threatening
asthma without adverse sequalae.578,579
Consider ECPR: ECMO has been used successfully in patients
with life threatening asthma.580,581 Consistent with ALS guidelines E-
CPR may be considered if conventional therapies fail and the health
system has immediate access to this treatment.2
Neurological disease
Cardiac arrest associated with acute neurological disease is relatively
uncommon and can occur with subarachnoid haemorrhage, intrace-
rebral haemorrhage, epileptic seizures, and ischaemic stroke.582 In a
US post mortem study of 335 sudden cardiac deaths, 18 (5.4%) were
sudden neurological deaths (intracranial haemorrhage, sudden
unexpected death in epilepsy, aneurysmal subarachnoid haemor-
rhage, acute stroke, aspiration from Huntington Disease).583 These
deaths made up 14.9% of the 121 non-cardiac deaths in the study.
The evidence supporting this guideline is based on observational
data and expert opinion, and guidelines for the care of common
neurological conditions that may cause cardiac arrest. A focused
literature search was carried out up to 10 August 2020 and identified
observational 9 studies and a Cochrane review since the since the
2015 guideline.84
Prodromal signs
Certain features such as a younger age, female gender, non-
shockable initial rhythm and neurological antecedents (e.g. head-
ache, seizures, neurological deficits) suggest a neurological cause of
cardiac arrest.584 Other non-specific signs include syncope, short-
ness of breath and chest pain.585
Early brain imaging
Identifying a neurological cause of cardiac arrest after ROSC is part of
the ERC post resuscitation care guideline.270 The expert opinion
based on observational data is that early identification of a
neurological cause can be achieved by performing a brain CT-scan
at hospital admission, before or after coronary angiography. In the
absence of signs or symptoms suggesting a neurological cause (e.g.
headache, seizures or neurological deficits) or if there is clinical or
ECG evidence of myocardial ischaemia, coronary angiography is
undertaken first, followed by CT scan in the absence of causative
lesions on coronary angiography. A systematic review of the
diagnostic yield of non-invasive imaging in patients following non-
traumatic OHCA identified 9 observational studies of brain imaging.586
The most common diagnoses were brain haemorrhage (16.9%,
including intraparenchymal, intracranial or extra-axial haemorrhage)
and acute stroke (11.8%). The indication for the scans was not entirely
clear so the true rate of identifying neurological causes is uncertain.
Subarachnoid haemorrhage
Cardiac or respiratory arrest occurs in between 3
11% of patents with
subarachnoid haemorrhage (SAH).587 There is considerable regional
variation in the incidence of SAH as a cause of cardiac arrest among
those with sustained ROSC at hospital admission. Published case
series report 16.2% in Japan,588 11.4% in Korea589 and 7% in
France.590 In a Japanese study of patients with ROSC, SAH was most
often associated with an initial non-shockable rhythm (95.7%), a
prodromal headache before cardiac arrest (47.8%), and a negative
cardiac troponin-T (94.7%).588 Patients with SAH may have ECG
changes that suggest an acute coronary syndrome.585,591
593
This can pose challenges after ROSC in terms of whether they
should have an early brain scan or go directly for coronary
angiography. The order of brain scanning versus early coronary
angiography should be based on clinical suspicion (See Section X
Post resuscitation care).270 Prognosis is poor even in those with
ROSC after a SAH.585,591,594 This is probably because cardiac arrest
tends to occur with larger more severe bleeds following a SAH.595
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Sudden unexpected death in epilepsy
Sudden unexpected death in epilepsy (SUDEP) effects about 1 in every
100 people with epilepsy.596 Data from the North American SUDEP
registry showed cases of SUDEP had a median age of 26 years at
death, 38% were female, 40% had generalized and 60% had focal
epilepsy, most (93%) were unwitnessed, 70% occurred during apparent
sleep, 69% of patients were prone, and only 37% of cases of SUDEP
took their last dose of antiseizure medications. A Cochrane review
found very low certainty evidence for interventions to prevent SUDEP
addition to improving seizure control such as having a supervising
person share a bedroom and use of monitoring devices.597
Stroke
Data from the Ontario stroke registry found that 3.9% of acute
ischaemic stroke patients also had a cardiac arrest.598 The risk of
arrest was increased in older patients with increased stroke severity,
diabetes, myocardial infarction, heart failure and atrial fibrillation.
Mortality at 30 days was 82.1% in cardiac arrest stroke patients versus
9.3% in non-cardiac arrest stroke patients. Data from the all Japan
Utstein registry reported that 7.7% of OHCA cases had a stroke
related cardiac arrest.599 This group had worse outcomes that
patients who had a primary cardiac arrest.
Outcomes
Survival from sudden neurological death depends on the underlying
cause and the Chain of survival (i.e., witnessed, early bystander CPR,
ALS, and post resuscitation care). Survival is generally worse than for
primary cardiac arrest.1,582 Individuals who achieve ROSC after a
primary neurological cause of cardiac arrest may not recover and have
withdrawal of life sustaining treatments, or fulfil the criteria for death by
neurological criteria. These patients should be considered for organ
donation according to local legal and clinical criteria [see section X
post-resuscitation care].270
Obesity
Overweight and obesity are defined as abnormal or excessive fat
accumulation that presents a risk to health. A crude population
measure of obesity is the body mass index (BMI), a person’s weight (in
kg) divided by the square of his or her height (in metres). A person with
a BMI of 30 kg m
2 or more is generally considered obese. In 2016,
more than 1.9 billion (39%) adults were overweight, and of these over
600 million (13%) were obese. In the United States, the age-adjusted
prevalence of obesity in 2013
2014 was 35.0% among men and
40.4% among women.600
Clinical and epidemiological evidence has linked obesity to a broad
spectrum of cardiovascular diseases including coronary heart
disease, heart failure, hypertension, stroke, atrial fibrillation and
sudden cardiac death. Obesity can increase cardiovascular morbidity
and mortality directly and indirectly. Direct effects are mediated by
obesity-induced structural and functional adaptations of the cardio-
vascular system to accommodate excess body weight, as well as by
adipokine effects on inflammation and vascular homeostasis. Indirect
effects are mediated by co-existing risk factors such as insulin
resistance, hyperglycaemia, hypertension and dyslipidaemia.601
603
A scoping review using the PubMed search engine was performed
on March 27th, 2020 using the keywords “obesity” AND “cardiac arrest
or heart arrest” OR “resuscitation or cardiopulmonary resuscitation” in
the last 5 years (n = 122). There were two meta-analysis published on
association between BMI and outcome after cardiac arrest.604,605
Modification to chest compressions is based on 1 retrospective study
201
evaluating chest compression depth in obese patients using
computed tomography (CT).606
Treatment of cardiac arrest
No changes to the sequence of actions are recommended in
resuscitation of obese patients, but delivery of effective CPR may
be challenging. Physical and physiological factors related to obesity
may adversely affect the delivery of CPR, including patient access and
transportation, patient assessment, difficult IV access, airway
management, quality of chest compressions, the efficacy of vasoac-
tive drugs, and the efficacy of defibrillation because none of these
measures are standardized to a patient's BMI or weight.607
Chest compressions
Healthcare providers should consider deeper chest compression in
obese patients with a maximum depth of 6 cm using a feedback
device, if available. Obese patients lying in a bed do not necessarily
need to be moved onto the floor. Their heavy torso sinks into the
mattress and leaves less potential for mattress displacement during
chest compression.608,609 Repositioning of obese patients may delay
initiation of CPR, but also cause injuries to the patient and rescuers.
Rescuer providing chest compression should be changed more
frequent compared to the standard two-minute interval to maintain
sufficient compression depth (6 cm).84
The use of mechanical chest compression devices might be
considered although body dimensions and slope of the anterior chest
wall limit usability of most devices in obesity permagna patients. The
upper limits include sternum height of 303 or 340 mm and chest width
of 449 or 480 mm for piston devices; chest circumference of 130 cm,
chest width of 380 mm and body weight of 136 kg for devices equipped
with a load-distributing band.
Defibrillation
Defibrillation protocols for obese patients should follow those
recommended for patients with a normal BMI with escalation of
energies up to the maximum feasible for subsequent shocks if initial
defibrillation attempts fail (expert opinion). Optimal defibrillation
energy levels in obese patients are unknown. Modern biphasic
defibrillators adjust their output according to the patient’s impedance.
Two small retrospective studies have demonstrated no apparent
weight-based influence on defibrillation efficacy with a biphasic
waveform of 150 J achieving high shock success rates without need
for energy escalation.610,611 An RCT evaluating cardioversion of atrial
fibrillation in obese patients however reported lower success rate
when using adhesive pads with standard energies. Use of paddles or
manual pressure augmentation technique further improved success
of the electrical therapy.612
Airway management and ventilation
Manual ventilation, using a bag-mask technique, should be
performed by experienced staff using a two-person technique.
The increased in abdominal size of obese individuals raises intra-
abdominal pressure and repositions the diaphragm in cranial
direction.613 This requires higher inspiratory pressures for controlled
ventilation increasing the risk of gastric insufflation and aspiration of
gastric contents.
Experienced providers should intubate the trachea early so that
the period of bag-mask ventilation is kept to a minimum. In all patients
with morbid obesity, difficult intubation must be anticipated.614
616 If
intubation is not possible, use of a supraglottic airway device (SGA)
202 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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with sufficient pressure seal and oesophageal drainage tube should
be considered as suitable option.617,618
Logistical considerations
Obesity must be considered when organizing pre-hospital resuscita-
tion, especially concerning technical support and number of EMS
staff.619 Special vehicles modified to transport extremely obese
patients, equipped with reinforced stretchers and specialized lifting
gear, should be used if possible. Weight limits of both stretchers and
hospital beds must be known prior to use.620 Underestimation of the
technical aspects of rescue operations may cause secondary trauma,
or even make transportation to the hospital impossible.619
Cardiac arrest in pregnancy
Maternal mortality remains high with an estimated 295,000 deaths in
2017, the majority (94%) occurring in low and lower middle income
countries. (WHO
https://www.who.int/news-room/fact-sheets/de-
tail/maternal-mortality accessed 20 July 2020) A maternal cardiac
arrest is a cardiac arrest that occurs at any stage in pregnancy and up
to 6 weeks after birth. In a UK study the incidence of cardiac arrest was
1 in 36,000 maternities.621 This section focuses on specific additional
interventions for resuscitation during pregnancy and delivery.
This guideline has been informed by an ILCOR Evidence Update.2
The majority of the guidance is unchanged from the ERC 2015 Special
Circumstances.84 In addition, this guidance has been informed by
guidelines from the AHA,622 UK Royal College of Obstetricians and
Gynaecologists,623 European Society of Cardiology Guidelines for
management of cardiovascular disease during pregnancy.624 Most
guidance is based on expert opinion, our knowledge of the physiology
of pregnancy, and observational data.
Causes of cardiac arrest associated with pregnancy
In 2015
17, 9.2 women per 100,000 died during pregnancy or up to
six weeks after childbirth or the end of pregnancy.625 The most
common causes were heart disease (23%), thromboembolism (16%),
epilepsy and stroke (13%), sepsis (10%), mental health conditions
(10%), bleeding (8%), cancer (4%) and pre-eclampsia (2%). The risk
increased with age, social deprivation and for ethnic minorities. A
study of cardiac arrests in pregnancy between 2011 and 2014
identified 66 cardiac arrests of whom 28 died (42%).621 Of these about
25% (16) of arrest were associated with anaesthesia (12 were obese)
and all survived. Survival was poor for OHCA and if there was a delay
in perimortem caesarean section. Most babies (46) survived, 32 to
woman who survived and 14 to those that died.
Prevention and treatment of cardiac arrest in the pregnant
patient
This should follow the standard ABCDE format identifying and treating
problems as they are identified. Involving specialists in the care of the
sick obstetric patient and neonate early is important in order to deliver
specialist interventions. Expert consensus is that the use of validated
obstetric specific early warning scores improve earlier recognition
of deterioration and enable risk stratification of ill pregnant
patients.622,623
Aortocaval compression
After 20 weeks’ gestation, the pregnant woman’s uterus can press
down against the inferior vena cava and the aorta and reduces venous
return and cardiac output by 3
40%.626 This can cause pre-arrest
hypotension or shock and, in the critically ill patient, may precipitate
arrest.627,628 After cardiac arrest, the compromise in venous return
and cardiac output may limit the effectiveness of chest compressions.
Manual left uterine displacement is the easiest way to reduce
aortocaval compression and may be more effective than left lateral
tilt.629,630 This can be achieved by lifting the uterus up and leftward off
the aortocaval vessels.622 This maintains a supine position, allowing
for continuous effective cardiac compressions if necessary.
Non-arrest studies show that left lateral tilt improves maternal
blood pressure, cardiac output and stroke volume and improves fetal
oxygenation and heart rate.631
633 Non-cardiac arrest data show that
the gravid uterus can be shifted away from the cava in most cases by
placing the patient in 15 degrees of left lateral decubitus position.634
Unless the pregnant victim is on a tilting operating table, left lateral
tilt is not easy to perform whilst maintaining high-quality chest
compressions. A variety of methods to achieve a left lateral tilt have
been described including placing the victim on the rescuer’s knees. In
a manikin study, the ability to provide effective chest compressions
decreased as the angle of left lateral tilt increased and that at an angle
of greater than 30 the manikin tended to roll.635
Chest compressions
Chest compressions should be according to BLS guidelines at a rate of
100
120 min
1 and depth of 5
6 cm on the lower half of the
sternum.15 The evidence for optimal hand position is conflicting. An
MRI study showed no change in heart position636 whereas a recent
echocardiographic study suggested the enlarged uterus can push the
diaphragm and heart upwards.637 The current guideline based on
expert opinion is to use the standard manual chest compression
technique if feasible. The use of mechanical chest compression
devices is not recommended in pregnancy.
Peri-mortem delivery of the fetus
Consider the need for an emergency hysterotomy or caesarean
section as soon as a pregnant woman goes into cardiac arrest. In
some circumstances immediate resuscitation attempts will restore a
perfusing rhythm; in early pregnancy this may enable the pregnancy to
proceed to term. Delivery will relieve aortocaval compression and may
improve chances of maternal and fetal resuscitation.638 The majority
of evidence for early delivery comes from case reports and small
observational studies.84,639 A UK study of cardiac arrests in
pregnancy between 2011 and 2014 identified 66 cardiac arrests of
whom 49 (74%) had a perimortem caesarean section (PMCS).621 In
61% this was within 5 min of collapse. The time from collapse to
delivery in survivors was 7 min [interquartile range (IQR) 2.5
17.5]
and 16 min (IQR 6.5
43.5) in non-survivors (P = 0.04). When PMCS
was formed within 5 min 24 of 25 babies survived (96%). Seven of 10
babies (70%) survived when PMCS occurred after more than 5 min
(P = 0.06).
Based on the available evidence and expert consensus the ERC
guidelines remain unchanged
If over 20 weeks pregnant or the
uterus is palpable above the level of the umbilicus and immediate
(within 4 min) resuscitation is unsuccessful, deliver the fetus by
emergency caesarean section aiming for delivery within 5 min of
collapse. This requires that PMCS decision making occurs early and
ideally takes place at the location of the cardiac arrest.
Extracorporeal life support
Starting ECLS before cardiac arrest or ECPR when traditional ALS
measures are failing should be considered in pregnant patients in
those settings where it is available. A retrospective analysis of
 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
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peripartum patients who needed extracorporeal membrane oxygen-
ation between 1997 and 2017 in the International Registry of
Extracorporeal Life Support Organization identified 280 patients.640
Overall survival was 70% that improved over the data collection
period. Survival was better if ECLS was started prior to cardiac arrest.
Forty-two patients had ECPR and 19/42 (45.2%) died in hospital.
Other modifications to advanced life support
Defibrillation
For cardiac arrest with a shockable rhythm attempt defibrillation as
soon as possible. There is no change in transthoracic impedance
during pregnancy, suggesting that standard shock energies for
defibrillation attempts should be used in pregnant patients.641 There is
no evidence that shocks have adverse effects on the fetal heart. Left
lateral tilt and large breasts will make it difficult to place an apical
defibrillator pad.
Airway management
Pregnant patients have an increased risk of gastric regurgitation and
aspiration, and have an increased risk of failed intubation.642
644 The
airway should be managed according to current ALS guidelines using
a stepwise approach (bag-mask, supraglottic airway, tracheal tube,
according to rescuer skills. Early intubation will make oxygenation and
ventilation easier and protect against aspiration but this requires an
expert intubator and be carried out according to current obstetric
guidelines.643
Reversible causes
Rescuers should attempt to identify common and reversible causes of
cardiac arrest in pregnancy during resuscitation attempts. The 4 Hs
and 4Ts approach helps identify all the common causes of cardiac
arrest in pregnancy.623 Pregnant patients are at risk of all the other
causes of cardiac arrest for their age group (e.g., anaphylaxis, drug
overdose, trauma). Consider the use of abdominal ultrasound by a
skilled operator to detect pregnancy and possible causes during
cardiac arrest in pregnancy; however, do not delay other treatments
and minimise interruptions to chest compressions.
Haemorrhage
Life-threatening haemorrhage can occur both antenatally and postna-
tally.645 Associations include ectopic pregnancy, placental abruption,
placenta praevia, placenta accreta, and uterine rupture.646 A massive
haemorrhage protocol must be available in all units and should be
updated and rehearsed regularly in conjunction with the blood bank.
Women at high risk of bleeding should be delivered in centres with
facilities for blood transfusion, intensive care and other interventions,
and plans should be made in advance for their management. Treatment
is based on an ABCDE approach. Follow existing guidelines for
management of massive haemorrhage obstetrics.647,648 A large RCT
showed that 1 g IV tranexamic acid reduced death from postpartum
haemorrhage, especially if given within 3 h.649
Cardiovascular disease
Myocardial infarction and aneurysm or dissection of the aorta or its
branches, and peripartum cardiomyopathy cause most deaths from
acquired cardiac disease Patients with known cardiac disease need to
be managed in a specialist unit. Pregnant women may develop an
acute coronary syndrome, typically in association with risk factors
such as obesity, older age, higher parity, smoking, diabetes, pre-
203
existing hypertension and a family history of ischaemic heart
disease.84 Pregnant patients can have atypical features such as
epigastric pain and vomiting. Percutaneous coronary intervention
(PCI) is the reperfusion strategy of choice for ST-elevation myocardial
infarction in pregnancy.624 Thrombolysis should be considered if
urgent PCI is unavailable. A review of 200 cases of thrombolysis for
massive pulmonary embolism in pregnancy reported a maternal death
rate of 1% and concluded that thrombolytic therapy is reasonably safe
in pregnancy.650
Pre-eclampsia and eclampsia
Eclampsia is defined as the development of convulsions and/or
unexplained coma during pregnancy or postpartum in patients with
signs and symptoms of pre-eclampsia. The ERC recommends that
existing guidance for pre-eclampsia and eclampsia is followed (e.g.
Hypertension in pregnancy: diagnosis and management NICE
guideline Published: 25 June 2019.651
Amniotic fluid embolism
Amniotic fluid embolism (AFE) usually presents around the time of
delivery with sudden cardiovascular collapse, breathlessness,
cyanosis, arrhythmias, hypotension and haemorrhage associated
with disseminated intravascular coagulopathy.652 Patients may have
warning signs preceding collapse including breathlessness, chest
pain, feeling cold, light-headedness, distress, panic, a feeling of pins
and needles in the fingers, nausea, and vomiting. The UK Obstetric
Surveillance System (UKOSS identified 120 cases of AFE between
2005 and 2014 with a total and fatal incidence estimated as 1.7 and 0.3
per 100 000, respectively, and association with older maternal age,
multiple pregnancy, placenta praevia and induction of labour,
instrumental vaginal and caesarean delivery.653 Treatment is
supportive, as there is no specific therapy based on an ABCDE
approach and correction of coagulopathy.
Post resuscitation care
Post resuscitation care should follow standard guidelines. Targeted
temperature management has been used safely and effectively in
early pregnancy with fetal heart monitoring and resulted in favourable
maternal and fetal outcome after a term delivery.654,655
Preparation for cardiac arrest in pregnancy
Advanced life support in pregnancy requires coordination of maternal
resuscitation, Caesarean delivery of the fetus and newborn
resuscitation ideally within 5 min. The evidence supporting this is
largely based on observational data to achieve this, units likely to deal
with cardiac arrest in pregnancy should:
 have plans and equipment in place for resuscitation of both the
pregnant woman and newborn.
 ensure early involvement of obstetric, anaesthetic, critical care
and neonatal teams.
 ensure regular training in obstetric emergencies.
The evidence to support this is largely based on expert opinion and
observational data.656
659
Conflict of interest
JN reports funding from Elsevier for his role as Editor in Chief of the
journals Resuscitation and Resuscitation Plus. He reports research
204 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 1 5 2
2 1 9
funding from the National Institute for Health Research in relation to
the PARAMEDIC2 trial and the AIRWAYS2 trial.
JS declares his role as an editor of Resuscitation; he declares
institutional research funding for the Audit-7 project.
JH reports travel funding from Behring and Ambu
GDP reports funding from Elsevier for his role as an editor of the
journal Resuscitation. He reports research funding from the National
Institute for Health Research in relation to the PARAMEDIC2 trial.
JY declares research grants from National Institute for Health
Research and Resuscitation Council UK.
KT reports Federal research funding for drone AED research.
Acknowledgements
GDP is supported by the National Institute for Health Research (NIHR)
Applied Research Collaboration (ARC) West Midlands. The views
expressed are those of the author(s) and not necessarily those of the
NIHR or the Department of Health and Social Care.
Appendix A. ERC Special Circumstances
Writing Group Collaborators
Gamal Eldin Abbas Khalifa1, Efrén Álvarez4, Roberta Barelli2, Joost J.
L.M. Bierens1, Bernd Boettiger1, Guttorm Brattebø1, Douglas
Browne3, Hermann Brugger1,3, Tomasz Darocha3, Charles D.
Deakin1, Joel Dunning1, Silvija Hunyadi-Anticevic1, Rudolph W.
Koster1, David J. Lockey1, Mathieu Pasquier3, Jan Schmitz5.
1 Resuscitation 2021;161.
Substantial contribution to guidelines 2015
2
Substantial contribution to Toxic agents section
3
Substantial contribution to Hypothermia section
4
Substantial contribution to Coronary thrombosis, catheterisation
laboratory and cardiac surgery sections
5
Substantial contribution to cardiac arrest in the operating room,
Inflight cardiac arrest, Helicopter emergency medical services
(HEMS) and air ambulances and Cruise ship sections
Appendix B. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.resuscitation.2021.02.
011.
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 RESUSCITATION 161 (2021) 220 269

Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council and European

Society of Intensive Care Medicine Guidelines 2021:
$
Post-resuscitation care

Jerry P. Nolan a,b,1, * , Claudio Sandroni c,d,1 , Bernd W. Böttiger e, Alain Cariou f ,
Tobias Cronberg g , Hans Friberg h , Cornelia Genbrugge i,j , Kirstie Haywood k ,
Gisela Lilja l , Véronique R.M. Moulaert m, Nikolaos Nikolaou n ,
Theresa Mariero Olasveengen o , Markus B. Skrifvars p , Fabio Taccone q, Jasmeet Soar r
a
University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK
b
Royal United Hospital, Bath, BA1 3NG, UK
c
Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
d
Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
e
University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
f
Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
g
Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
h
Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
i
Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium
j
Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
k
Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
l
Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
m
University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
n
Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
o
Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
p
Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
q
Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
r
Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK

Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-
resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with
Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of
oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general
intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

$
This article is co-published in the journals Intensive Care Medicine and Resuscitation.
* Corresponding author at: University of Warwick, Warwick Medical School, Coventry, CV4 7AL.
E-mail address: jerry.nolan@nhs.net (J.P. Nolan).
1
Joint first authors.
https://doi.org/10.1016/j.resuscitation.2021.02.012

0300-9572/© 2021 European Resuscitation Council and European Society of Intensive Care Medicine. Published by Elsevier B.V. All rights reserved
 RESUSCITATION 161 (2021) 220
Introduction and scope
In 2015 the European Resuscitation Council (ERC) and the European
Society of Intensive Care Medicine (ESICM) collaborated to produce
their first combined post-resuscitation care guidelines, which were co-
published in Resuscitation and Intensive Care Medicine.1,2 These
post-resuscitation care guidelines have been extensively updated for
2020 and incorporate the science that has been published since 2015.
The topics covered include the post-cardiac arrest syndrome, control
of oxygenation and ventilation, haemodynamic targets, coronary
reperfusion, targeted temperature management, control of seizures,
prognostication, rehabilitation, and long-term outcome.
Methods
A comprehensive description of the guideline development process is
provided in an electronic supplement.
The international consensus on cardiopulmonary
resuscitation science evidence review process
The International Liaison Committee on Resuscitation (ILCOR, www.
ilcor.org) includes representatives from the American Heart Associa-
tion (AHA), the European Resuscitation Council (ERC), the Heart and
Stroke Foundation of Canada (HSFC), the Australian and New
Zealand Committee on Resuscitation (ANZCOR), the Resuscitation
Council of Southern Africa (RCSA), the Inter-American Heart
Foundation (IAHF), and the Resuscitation Council of Asia (RCA).
From 2000 to 2015 researchers from the ILCOR member councils
evaluated resuscitation science in 5-yearly cycles. After publication of
the 2015 International Consensus on CPR and ECC Science with
Treatment Recommendations (2015 CoSTR),3 ILCOR committed to a
continuous evidence-evaluation process, with topics prioritised for
review by the task forces and with CoSTR updates published annually.
4 6
For the 2020 CoSTR, the six ILCOR task forces performed three
types of evidence evaluation: the systematic review, the scoping
review, and the evidence update, which covered 184 topics in total.7 It
was agreed that only systematic reviews (these used Grading of
Recommendations Assessment, Development, and Evaluation
(GRADE) methodology) could result in new or modified treatment
recommendations.8 The data analysis from each systematic review
was presented to the task force, and the task force drafted the
summary consensus on science and the treatment recommendations.
Each treatment recommendation indicated the strength of the
recommendation (recommends = strong, suggests = weak) and the
certainty of the evidence. Draft 2020 CoSTRs were posted on the
ILCOR website (ilcor.org) for a 2-week comment period after which
final wording of science statements and treatment recommendations
were completed by the task forces and published in Resuscitation and
Circulation as the 2020 Consensus on Science and Treatment
Recommendations (CoSTR).
The European Resuscitation Council and European Society
for intensive care medicine process for developing post-
resuscitation care guidelines
Fifteen individuals were selected for the ERC-ESICM Post-Resusci-
tation Care Writing Group based on their expertise, ERC and ESICM
269 221
representation and diversity (gender, physician and non-physician,
and geography (Northern and Southern Europe).
These ERC-ESICM guidelines on post-resuscitation care for
adults are based mainly on the Advanced Life Support section of the
2020 CoSTR document and represent consensus among the writing
group, which included representatives of the ERC and the ESICM.9
Where treatment recommendations are provided by ILCOR, these
have been adopted by the ERC and ESICM. In the absence of an
ILCOR recommendation, ERC-ESICM guidance was based on
review and discussion of the evidence by the working group until
consensus was achieved. The writing group chairs ensured that
everyone on the working group had the opportunity to present and
debate their views and ensured that discussions were open and
constructive. All discussions took place during eight 2-h Zoom
videoconferences that were held between January 2020 and
November 2020. Consensus was achieved by all 15 writing group
members on all the treatment recommendations using an open
process.
These guidelines were drafted and agreed by the Post-
Resuscitation Care Writing Group members before posting on the
ERC website for public comment between 21 October and 5 Novem-
ber 2020. The opportunity to comment on the guidelines was
advertised through social media (Facebook, Twitter) and the ERC
network of 33 national resuscitation councils. Nine individuals from
four countries made 25 comments. One of these individuals was a lay
person. Review of these comments led to eight changes.
Summary of the key changes
A summary of the main changes from the 2015 ERC-ESICM Post-
resuscitation care guidelines is set out in Table 1.
Key messages from the section are presented in Fig. 1.
Concise guidelines for clinical practice
This section includes only a summary of the main recommendations.
The evidence underpinning each recommendation is detailed in the
section on ‘evidence informing the guidelines’.
Immediate post-resuscitation care
 Post-resuscitation care is started immediately after sustained
ROSC, regardless of location (Fig. 2).
 For out-of-hospital cardiac arrest consider transport to a cardiac
arrest centre.
Diagnosis of cause of cardiac arrest
 If there is clinical (e.g. haemodynamic instability) or ECG evidence
of myocardial ischaemia, undertake coronary angiography first.
This is followed by CT brain and/or CT pulmonary angiography if
coronary angiography fails to identify causative lesions.
 Early identification of a respiratory or neurological cause can be
achieved by performing a brain and chest CT-scan at hospital
admission, before or after coronary angiography (see coronary
reperfusion).
 If there are signs or symptoms pre-arrest suggesting a
neurological or respiratory cause (e.g. headache, seizures or
222 RESUSCITATION 161 (2021) 220
Table 1 – Summary
neurological deficits, shortness of breath
of changes sinceor the
documented hypo-
2015 Guidelines
xaemia in patients with known respiratory disease), perform a CT
2015 Guidelines
brain and/or a CT pulmonary angiogram.
Coronary angiography
It is reasonable to discuss and consider emergent cardiac
catheterisation laboratory evaluation after ROSC in
patients with the highest risk of a coronary cause for their
cardiac arrest
Blood pressure target
Target the mean arterial blood pressure to achieve an
adequate urine output (1 mL kg 1 h 1) and normal or
decreasing plasma lactate values, taking into
consideration the patient’s normal blood pressure, the
cause of the arrest and the severity of any myocardial
dysfunction.
Treatment of seizures
Treat [seizures] with sodium valproate, levetiracetam,
phenytoin, benzodiazepines, propofol, or a barbiturate.
Temperature control
 Maintain a constant, target temperature between
32  C and 36  C for those patients in whom tempera-
ture control is used (strong recommendation, moder-
ate-quality evidence).
 Whether certain subpopulations of cardiac arrest
patients may benefit from lower (32 34  C) or higher
(36  C) temperatures remains unknown, and further
research may help elucidate this.
 TTM is recommended for adults after OHCA with an
initial shockable rhythm who remain unresponsive
after ROSC (strong recommendation, low-quality
evidence).
 TTM is suggested for adults after OHCA with an initial
non-shockable rhythm who remain unresponsive after
ROSC (weak recommendation, very low-quality
evidence).
 TTM is suggested for adults after IHCA with any initial
rhythm who remain unresponsive after ROSC (weak
recommendation, very low-quality evidence).
 If targeted temperature management is used, it is
suggested that the duration is at least 24 h (weak
recommendation, very low-quality evidence).
General intensive care management
Short-acting drugs (e.g., propofol, alfentanil, remifentanil)
will enable more reliable and earlier neurological
assessment and prognostication
Following ROSC maintain the blood glucose at
10 mmol L 1 (180 mg dL 1) and avoid hypoglycaemia.
269
on Post-resuscitation care.
2021 Guidelines Rationale for change
In patients with ROSC after OHCA without ST- A randomised controlled trial showed no
elevation on the ECG, emergent cardiac catheter- difference in 90-day survival following out of
isation laboratory evaluation should be considered if hospital VF cardiac arrest among patients
there is an estimated high probability of acute without ST-elevation on the ECG allocated to
coronary occlusion (e.g. patients with haemody- immediate coronary angiography versus de-
namic and/or electrical instability). layed angiography.10 Recent ESC guidelines
state that ‘Delayed as opposed to immediate
angiography should be considered in haemo-
dynamically stable patients without ST-seg-
ment elevation successfully resuscitated after
an out-of-hospital cardiac arrest’.11
Avoid hypotension (<65 mmHg). Target MAP to Several studies show that hypotension
achieve adequate urine output (>0.5 mL kg 1 h 1) (<65 mmHg) is consistently associated with
and normal or decreasing lactate. poor outcome. Although we have stated a
threshold value for blood pressure, optimal
MAP targets are likely to need to be
individualised.
To treat seizures after cardiac arrest, we suggest In a recently reported trial, valproate, levetir-
levetiracetam or sodium valproate as first-line acetam and fosphenytoin were equally effective
antiepileptic drugs in addition to sedative drugs. in terminating convulsive status epilepticus but
fosphenytoin caused more episodes of
hypotension.12
 We recommend TTM for adults after either A recent randomised controlled trial of both
OHCA or IHCA (with any initial rhythm) who IHCA and OHCA patients with initial non-
remain unresponsive after ROSC. shockable rhythms showed a higher percent-
 Maintain a target temperature at a constant age of patients survived with a favourable
value between 32  C and 36  C for at least 24 h. neurological outcome when treated with TTM at
 Avoid fever (>37.7  C) for at least 72 h after 33  C versus 37  C.13 This has enabled the
ROSC in patients who remain in coma. recommendation to be extended to all rhythms
and locations.
The definition of fever (>37.7  C) is consistent
with that used in the TTM2 trial.14
 Use short acting sedatives and opioids. The 2015 guidelines included very few state-
 Avoid using a neuromuscular blocking drug ments on general intensive care management.
routinely in patients undergoing TTM, but it may For 2020 we have several best practice state-
be considered in case of severe shivering ments based mainly on data extrapolated from
during TTM. other critically ill patient groups.
 Provide stress ulcer prophylaxis routinely in
cardiac arrest patients.
 Provide deep venous thrombosis prophylaxis.
 Target a blood glucose of 7.8 10 mmol L 1
(140 180 mg dL 1) using an infusion of insulin if
required; avoid hypoglycaemia (<4.0 mmol L 1
(<70 mg dL 1).
 RESUSCITATION 161 (2021) 220 269 223

Table 1 (continued)
2015 Guidelines 2021 Guidelines Rationale for change
 Start enteral feeding at low rates (trophic
feeding) during TTM and increase after re-
warming if indicated. If TTM of 36  C is used as
the target temperature, trophic gastric feeding
rates may be increased early during TTM.
 We do not recommend using prophylactic
antibiotics routinely.

Prognostication
The prognostication strategy algorithm is applicable to all
patients who remain comatose with an absent or extensor
motor response to pain at 72 h from ROSC. Results of
earlier prognostic tests are also considered at this time
point.
One or both of the following indicate that a poor outcome is
very likely (FPR < 5%, narrow 95% CIs):
 No pupillary and corneal reflexes
 Bilaterally absent N20 SSEP wave
Two or more of the following indicate that a poor outcome
is likely:
 Status myoclonus 48 h after ROSC
 High NSE levels
 Unreactive burst-suppression or status epilepticus on
EEG
 Diffuse anoxic injury on brain CT/MRI
In a comatose patient with M  3 at 72 h from
ROSC, in the absence of confounders, poor
outcome is likely when two or more of the following
predictors are present:
 no pupillary and corneal reflexes at 72 h,
 bilaterally absent N20 SSEP wave at 24 h,
 highly malignant EEG (suppressed background
or burst-suppression) at >24 h,
 NSE >60 mg L 1 at 48 h and/or 72 h,
 status myoclonus 72 h,
 or a diffuse and extensive anoxic injury on brain
CT/MRI.
There has a very large amount of data published
on prognostication since the 2015 guidelines. A
recent systematic review identified 94 studies
that included over 30,000 patients, all published
since January 2013.15
The two-stage prognostication algorithm in the
2015 guidelines has been simplified so that a
poor outcome is considered likely when two or
more of the listed predictors are present. The
algorithm is valid for comatose patients with a
Glasgow Motor Score 3 (compared with 2 in
the 2015 version). A threshold value for NSE is
now stated. The EEG patterns suppression and
burst-suppression are the most consistent
predictors of poor neurological outcome. Con-
versely, absence of EEG reactivity has been
only inconsistently associated with poor neu-
rological outcome in recent studies.
We suggest using the 2021 ACNS terminology
when assessing these patterns for prognosti-
cation, to ensure an unequivocal identification.

Rehabilitation
Follow-up care should be organised systematically and  Perform functional assessments of physical
can be provided by a physician or specialised nurse. It and non-physical impairments before dis-
includes at least the following aspects: charge from the hospital to identify early
 Screening for cognitive impairments rehabilitation needs and refer to rehabilitation
 Screening for emotional problems if necessary.
 Provision of information  Organise follow-up for all cardiac arrest survi-
vors within 3 months after hospital discharge,
including:
1. Screening for cognitive problems.
2. Screening for emotional problems and fatigue.
3. Providing information and support for survivors
and family members.
The authorship of the 2021 guidelines now
includes 3 individuals with expertise on long-
term outcomes and rehabilitation after cardiac
arrest compared with one author in 2015. The
2021 guidelines include greater emphasis on
functional assessments of physical and non-
physical impairments before discharge and
long-term follow up and rehabilitation. There is
greater recognition of the importance of survi-
vorship after cardiac arrest. The recommen-
dations in this section are all best practice
statements

Cardiac arrest centres

No specific recommendation Adult patients with non-traumatic OHCA should be An expert consensus paper published by
considered for transport to a cardiac arrest centre several European organisations including the
according to local protocol. Association of Acute Cardiovascular Care
(ACVA) of the European Society of Cardiology
(ESC), the ERC and the ESICM, states that the
minimum requirements for a cardiac arrest
centre are 24/7 availability of an on-site
coronary angiography laboratory, an emer-
gency department, an ICU, imaging facilities,
such as echocardiography, CT, and MRI.16
Based on evidence from a systematic review,
ILCOR suggests that wherever possible, adult
patients with non-traumatic OHCA cardiac
arrest should be cared for in cardiac arrest
centres.17

ACNS American Clinical Neurophysiology Society; CT computed tomography; ESC European Society of Cariology; EEG electroencephalogram; FPR false
positive rate; ILCOR International Liaison Committee on Resuscitation; IHCA in-hospital cardiac arrest; MAP mean arterial pressure; MRI magnetic resonance
imaging; NSE neuron specific enolase; OHCA out-of-hospital cardiac arrest; ROSC return of spontaneous circulation; SSEP somatosensory evoked potential;
TTM targeted temperature management; VF ventricular fibrillation.
224 RESUSCITATION 161 (2021) 220 269

Fig. 1 – Post-resuscitation care infographic summary.

Airway and breathing 


Airway management after return of spontaneous circulation
 Airway and ventilation support should continue after return of
spontaneous circulation (ROSC) is achieved.
 Patients who have had a brief period of cardiac arrest and an
immediate return of normal cerebral function and are breathing
normally may not require tracheal intubation but should be given
oxygen via a facemask if their arterial blood oxygen saturation is
less than 94%.
Patients who remain comatose following ROSC, or who have
another clinical indication for sedation and mechanical ventilation,
should have their trachea intubated if this has not been done
already during CPR.
 Tracheal intubation should be performed only by experienced
operators who have a high success rate.
 Correct placement of the tracheal tube must be confirmed with
waveform capnography.
 In the absence of personnel experienced in tracheal intubation,
it is reasonable to insert a supraglottic airway (SGA) or
 RESUSCITATION 161 (2021) 220 269 225

Fig. 2 – Post resuscitation care algorithm.

SBP Systolic blood pressure; PCI Percutaneous coronary intervention; CTPA Computed tomography pulmonary angiogram; ICU Intensive care
unit; EEG electroencephalography; ICD implanted cardioverter defibrillator.
226 RESUSCITATION 161 (2021) 220
maintain the airway with basic techniques until skilled
intubators are available.
Control of oxygenation
 After ROSC, use 100% (or maximum available) inspired oxygen
until the arterial oxygen saturation or the partial pressure of arterial
oxygen can be measured reliably.
 After ROSC, once SpO2 can be measured reliably or arterial blood
gas values are obtained, titrate the inspired oxygen to achieve an
arterial oxygen saturation of 94 98% or arterial partial pressure of
oxygen (PaO2) of 10 13 kPa or 75 100 mmHg (Fig. 3).
 Avoid hypoxaemia (PaO2 < 8 kPa or 60 mmHg) following ROSC.
 Avoid hyperoxaemia following ROSC.
Control of ventilation
 Obtain an arterial blood gas and use end tidal CO2 in mechanically
ventilated patients.
 In patients requiring mechanical ventilation after ROSC, adjust
ventilation to target a normal arterial partial pressure of carbon
dioxide (PaCO2) i.e. 4.5 6.0 kPa or 35 45 mmHg.
 In patients treated with targeted temperature management (TTM)
monitor PaCO2 frequently as hypocapnia may occur.
 During TTM and lower temperatures use consistently either a
temperature or non-temperature corrected approach for measur-
ing blood gas values.
 Use a lung protective ventilation strategy aiming for a tidal volume
of 6 8 mL kg 1 ideal body weight.
Circulation
Coronary reperfusion
 Emergent cardiac catheterisation laboratory evaluation (and
immediate PCI if required) should be performed in adult patients
with ROSC after cardiac arrest of suspected cardiac origin with
ST-elevation on the ECG.
 In patients with ROSC after out-of-hospital cardiac arrest (OHCA)
without ST-elevation on the ECG, emergent cardiac catheter-
isation laboratory evaluation should be considered if there is an
estimated high probability of acute coronary occlusion (e.g.
patients with haemodynamic and/or electrical instability).
Haemodynamic monitoring and management
 All patients should be monitored with an arterial line for continuous
blood pressure measurements, and it is reasonable to monitor
cardiac output in haemodynamically unstable patients.
 Perform early (as soon as possible) echocardiography in all
patients to detect any underlying cardiac pathology and quantify
the degree of myocardial dysfunction.
 Avoid hypotension (<65 mmHg). Target mean arterial pressure
(MAP) to achieve adequate urine output (>0.5 mL kg 1 h 1) and
normal or decreasing lactate (Fig. 3).
 During TTM at 33  C, bradycardia may be left untreated if blood
pressure, lactate, ScvO2 or SvO2 is adequate. If not, consider
increasing the target temperature, but to no higher than 36  C.
 Maintain perfusion with fluids, noradrenaline and/or dobutamine,
depending on individual patient need for intravascular volume,
vasoconstriction or inotropy.
 Do not give steroids routinely after cardiac arrest.
 Avoid hypokalaemia, which is associated with ventricular
arrhythmias.
269
 Consider mechanical circulatory support (such as intra-aortic
balloon pump, left-ventricular assist device or arterio-venous
extra corporal membrane oxygenation) for persisting cardio-
genic shock from left ventricular failure if treatment with fluid
resuscitation, inotropes, and vasoactive drugs is insufficient.
Left-ventricular assist devices or arterio-venous extra corporal
membrane oxygenation should also be considered in haemo-
dynamically unstable patients with acute coronary syndromes
(ACS) and recurrent ventricular tachycardia (VT) or ventricular
fibrillation (VF) despite optimal therapy.
Disability (optimising neurological recovery)
Control of seizures
 We recommend using electroencephalography (EEG) to diag-
nose electrographic seizures in patients with clinical convulsions
and to monitor treatment effects.
 To treat seizures after cardiac arrest, we suggest levetiracetam or
sodium valproate as first-line antiepileptic drugs in addition to
sedative drugs.
 We suggest that routine seizure prophylaxis is not used in post-
cardiac arrest patients.
Temperature control
 We recommend targeted temperature management (TTM)
for adults after either OHCA or in-hospital cardiac arrest
(IHCA) (with any initial rhythm) who remain unresponsive after
ROSC.
 Maintain a target temperature at a constant value between 32  C
and 36  C for at least 24 h.
 Avoid fever (>37.7  C) for at least 72 h after ROSC in patients who
remain in coma.
 Do not use pre-hospital intravenous cold fluids to initiate
hypothermia.
General intensive care management
 Use short acting sedatives and opioids.
 Avoid using a neuromuscular blocking drug routinely in patients
undergoing TTM, but it may be considered in case of severe
shivering during TTM.
 Provide stress ulcer prophylaxis routinely in cardiac arrest
patients.
 Provide deep venous thrombosis prophylaxis.
 Target a blood glucose of 7.8 10 mmol L 1 (140 180 mg dL 1)
using an infusion of insulin if required; avoid hypoglycaemia
(<4.0 mmol L 1 (<70 mg dL 1).
 Start enteral feeding at low rates (trophic feeding) during TTM and
increase after rewarming if indicated. If TTM of 36  C is used as the
target temperature, gastric feeding rates may be increased early
during TTM.
 We do not recommend using prophylactic antibiotics routinely.
Prognostication
General guidelines
 In patients who are comatose after resuscitation from cardiac
arrest, neurological prognostication should be performed using
clinical examination, electrophysiology, biomarkers, and imaging,
to both inform patient's relatives and to help clinicians to target
 RESUSCITATION 161 (2021) 220
Fig. 3 – Haemodynamic, oxygenation and ventilation targets.
treatments based on the patient's chances of achieving a
neurologically meaningful recovery (Fig. 4).
 No single predictor is 100% accurate. Therefore, a multimodal
neuroprognostication strategy is recommended.
 When predicting poor neurological outcome, a high
specificity and precision are desirable, to avoid falsely pessimistic
predictions.
 The clinical neurological examination is central to prognostication.
To avoid falsely pessimistic predictions, clinicians should avoid
potential confounding from sedatives and other drugs that may
confound the results of the tests.
 When patients are treated with TTM, daily clinical examination is
advocated but final prognostic assessment should be undertaken
only after rewarming.
 Clinicians must be aware of the risk of a self-fulfilling prophecy
bias, occurring when the results of an index test predicting poor
outcome is used for treatment decisions, especially regarding life-
sustaining therapies.
269 227

Index tests for neurological prognostication are aimed at
assessing the severity of hypoxic-ischaemic brain injury. The
neurological prognosis is one of several aspects to consider in
discussions around an individual's potential for recovery.
Multimodal prognostication
 Start the prognostication assessment with an accurate clinical
examination, to be performed only after major confounders
(e.g. residual sedation, hypothermia) have been excluded
(Fig. 5).
 In a comatose patient with M  3 at 72 h from ROSC, in the
absence of confounders, poor outcome is likely when two or more
of the following predictors are present: no pupillary and corneal
reflexes at 72 h, bilaterally absent N20 SSEP wave at 24 h,
highly malignant EEG at >24 h, neuron specific enolase (NSE)
>60 mg L 1 at 48 h and/or 72 h, status myoclonus 72 h, or a
diffuse and extensive anoxic injury on brain CT/MRI. Most of these
signs can be recorded before 72 h from ROSC, however their
228 RESUSCITATION 161 (2021) 220
Fig. 4 – Prognostication modes. EEG electroencephalography; NSE neuron specific enolase; SSEP somatosensory
evoked potential.
results will be evaluated only at the time of clinical prognostic
assessment.
Clinical examination
 Clinical examination is prone to interference from sedatives,
opioids or muscle relaxants. A potential confounding from residual
sedation should always be considered and excluded.
 A Glasgow Motor Score of 3 (abnormal flexion or worse in
response to pain) at 72 h or later after ROSC may identify patients
in whom neurological prognostication may be needed.
 In patients who remain comatose at 72 h or later after ROSC the
following tests may predict a poor neurological outcome:
The bilateral absence of the standard pupillary light reflex.
Quantitative pupillometry
The bilateral absence of corneal reflex
The presence of myoclonus within 96 h and, in particular, status
myoclonus within 72 h
 We also suggest recording the EEG in the presence of myoclonic
jerks to enable detection of any associated epileptiform activity or
EEG signs, such as background reactivity or continuity, suggest-
ing a potential for neurological recovery.
Neurophysiology
 Perform an EEG in patients who are unconscious after the arrest.
 Highly malignant EEG-patterns include suppressed background
with or without periodic discharges and burst-suppression. We
suggest using these EEG-patterns after the end of TTM and after
sedation has been cleared as indicators of a poor prognosis.
269
 The presence of unequivocal seizures on EEG during the first 72 h
after ROSC is an indicator of a poor prognosis.
 Absence of background reactivity on EEG is an indicator of poor
prognosis after cardiac arrest.
 Bilateral absence of somatosensory evoked cortical N20-
potentials is an indicator of poor prognosis after cardiac arrest.
 Always consider the results of EEG and somatosensory evoked
potentials (SSEP) in the context of clinical examination findings
and other tests. Always consider using a neuromuscular
blocking drug when performing SSEP.
Biomarkers
 Use serial measurements of NSE in combination with other
methods to predict outcome after cardiac arrest. Increasing values
between 24 and 48 h or 72 h in combination with high values at 48
and 72 h indicate a poor prognosis.
Imaging
 Use brain imaging studies for predicting poor neurological
outcome after cardiac arrest in combination with other
predictors, in centres where specific experience in these studies
is available.
 Use presence of generalised brain oedema, manifested by a
marked reduction of the grey matter/white matter ratio on brain CT,
or extensive diffusion restriction on brain MRI to predict poor
neurological outcome after cardiac arrest.
 Always consider findings from imaging in combination with other
methods for neurological prognostication.
 RESUSCITATION 161 (2021) 220 269 229

Fig. 5 – Prognostication strategy algorithm.

EEG electroencephalography; NSE neuron specific enolase; SSEP somatosensory evoked potential; ROSC return of spontaneous circulation.
230 RESUSCITATION 161 (2021) 220
Fig. 6 – Recommendations for in-hospital functional assessments, follow-up and rehabilitation after cardiac arrest.
Withdrawal of life-sustaining therapy
 Separate discussions around withdrawal of life-sustaining therapy
(WLST) and the assessment of prognosis for neurological
recovery; WLST decisions should consider aspects other than
brain injury such as age, co-morbidity, general organ function and
the patients’ preferences.
 Allocate sufficient time for communication around the level-of-
treatment decision within the team and with the relatives.
Long-term outcome after cardiac arrest
 Perform functional assessments of physical and non-physical
impairments before discharge from the hospital to identify early
rehabilitation needs and refer to rehabilitation if necessary (Fig. 6).
Organise follow-up for all cardiac arrest survivors within 3 months

after hospital discharge, including:
269
1. Screening for cognitive problems.
2. Screening for emotional problems and fatigue.
3. Providing information and support for survivors and family
members.
Organ donation
 All decisions concerning organ donation must follow local legal
and ethical requirements.
 Organ donation should be considered in those who have achieved
ROSC and who fulfil neurological criteria for death (Fig. 7).
 In comatose ventilated patients who do not fulfil neurological
criteria for death, if a decision to start end-of-life care and
withdrawal of life support is made, organ donation should be
considered for when circulatory arrest occurs.
 RESUSCITATION 161 (2021) 220
Fig. 7 – Organ donation after cardiac arrest algorithm.
Cardiac arrest centres
 Adult patients with non-traumatic OHCA should be considered for
transport to a cardiac arrest centre according to local protocol.
Evidence informing the guidelines
Post-cardiac arrest syndrome
The post-cardiac arrest syndrome comprises post-cardiac arrest
hypoxic-ischaemic brain injury, post-cardiac arrest myocardial
dysfunction, the systemic ischaemia/reperfusion response, and the
persistent precipitating pathology.18 21 The severity of this syndrome
will vary with the duration and cause of cardiac arrest. It may not occur
at all if the cardiac arrest is brief. Among patients surviving to intensive
care unit (ICU) admission but subsequently dying in-hospital,
withdrawal of treatment following prognostication of poor neurological
outcome is the cause of death in approximately two-thirds after
OHCA and approximately 25% after in-hospital cardiac arrest.22 26
Cardiovascular failure accounts for most deaths in the first three days,
while, in many countries, WLST based on a prognostication of severe
hypoxic-ischaemic brain injury accounts for most of the later
269 231
deaths.23,26,27 Post-cardiac arrest hypoxic-ischaemic brain injury is
associated with hypotension, hypoxaemia, hyperoxaemia, pyrexia,
hypoglycaemia, hyperglycaemia and seizures. Significant myocardial
dysfunction is common after cardiac arrest but typically starts to
recover by 2 3 days, although full recovery may take significantly
longer.28 33 The whole-body ischaemia/reperfusion of cardiac arrest,
CPR and ROSC activates immune and coagulation pathways
contributing to multiple organ failure and increasing the risk of
infection.34 43 Thus, the post-cardiac arrest syndrome has many
features in common with sepsis, including intravascular volume
depletion, vasodilation, endothelial injury and abnormalities of the
microcirculation.44 53
Diagnosis of cause of cardiac arrest
These guidelines are informed by expert consensus.
Cardiac causes of OHCA have been studied extensively in the last
few decades; conversely, little is known about non-cardiac causes.
Early identification of a respiratory or neurological cause would enable
transfer of the patient to a specialised ICU for optimal care. Improved
knowledge of prognosis also enables discussion about the appropri-
ateness of specific therapies, including TTM. Several case series
showed that this strategy enables diagnosis of non-cardiac causes of
232 RESUSCITATION 161 (2021) 220
arrest in a substantial proportion of patients.54,55 There is consider-
able regional variation in the incidence of sub-arachnoid haemorrhage
as a cause of cardiac arrest among those with sustained ROSC at
hospital admission. Published case series report 16.2% in Japan,56
11.4% in Korea57 and 7% in France.58 In those with cardiac arrest
associated with trauma or haemorrhage a whole-body CT scan is
likely indicated.9,59,60
Airway and breathing
Airway management after return of spontaneous circulation
These guidelines are informed by expert consensus.
Patients can have their trachea intubated before, during or following
cardiac arrest depending on the setting or particular circumstances.61
Following most cardiac arrests tracheal intubation will occur during CPR
or if the patient remains comatose after ROSC.62
Tracheal intubation following ROSC in comatose patients will
facilitate post-resuscitation care that includes controlled oxygen-
ation and ventilation, protection of the lungs from aspiration of
stomach contents, control of seizures, and TTM see below for
further details.
Post ROSC patients are haemodynamically unstable and,
depending on their level of consciousness, may require drug assisted
tracheal intubation. The same level of care should be provided as for
any other critically ill patient in terms of skills of the provider,
monitoring, and choice of drugs.63,64 There are no recommendations
for a specific drug combination,65 but use of a low dose of a sedative,
an analgesic and a rapid onset neuromuscular blocking drug is
probably optimal.
Control of oxygenation
These guidelines are informed by the ILCOR systematic review on
oxygenation and ventilation targets after cardiac arrest, which
identified seven RCTs and 36 observational studies.66 and CoSTR.9
The ILCOR treatment recommendations in relation to oxygenation
are:
 We suggest the use of 100% inspired oxygen until the arterial
oxygen saturation or the partial pressure of arterial oxygen can be
measured reliably in adults with ROSC after cardiac arrest in any
setting (weak recommendation, very low-certainty evidence).
 We recommend avoiding hypoxaemia in adults with ROSC after
cardiac arrest in any setting (strong recommendation, very low-
certainty evidence).
 We suggest avoiding hyperoxaemia in adults with ROSC after
cardiac arrest in any setting (weak recommendation, low-certainty
evidence).
From a pathophysiological perspective, post cardiac arrest
patients are at risk of developing hypoxic-ischaemic brain injury
and accompanying organ dysfunction.9,21,67,68 The role of blood
oxygen values in the disease process is poorly understood.69 Studies
show that cerebral ischaemia in post cardiac arrest patients is
associated with poor outcome.70 Administering more oxygen can
increase brain oxygenation.71 On the other hand, higher oxygen
values would logically cause an increase in harmful oxygen free
radicals.72 It is also likely that the effect of oxygen values varies
between different organs such as the heart and brain.
Numerous experimental studies have assessed the impact of
hyperoxaemia on neurological injury with mixed findings.73 Six
randomised controlled trials (RCTs) have compared different
269
oxygenation targets for varying durations immediately and up to
48 h after ROSC.74 79 A sub-group analysis of a large RCT targeting
an arterial blood oxygen saturation of 90 97% compared with 90
100% showed that in patients at risk of hypoxic-ischaemic brain
injury 180-day mortality was lower in the lower oxygen target group74 ;
however, this difference was no longer statistically significant when
adjusted for baseline differences.80 A pilot RCT targeting a PaO2 of
10 15 kPa compared with 20 25 kPa showed no difference in the
values of biomarkers of neurological injury.75 Overall, the evidence is
mixed but suggests targeting normal oxygenation rather than
hyperoxaemia. Observational data suggests avoiding hypoxaemia
but there are no RCTs on this topic.
In most post-cardiac arrest patients, controlled oxygenation will
require tracheal intubation and mechanical ventilation for at least
24 72 h. The exception being the completely conscious patient with a
patent airway who should be treated with an oxygen mask or non-
invasive ventilation targeting a peripheral oxygen saturation (SpO2) of
94 98%. During cardiac arrest, patients’ lungs are ventilated with the
maximum feasible inspired oxygen, which is usually 100% during
advanced resuscitation.9 After ROSC the goal should be to monitor
oxygenation either with a pulse oximeter or preferably with an early
arterial blood gas sample. Oxygenation measured early after ROSC is
highly variable, varying from hypoxaemia to extreme hyperoxaemia.81
Thus, it is appropriate to titrate the inspired oxygen by adjusting either
the oxygen flow if using bag-mask ventilation or the fraction inspired
oxygen (FiO2) if using a mechanical ventilator.82 Prolonged use of
100% inspired oxygen, for example during transport, will lead
commonly to extreme hyperoxaemia.83 Another method for monitor-
ing is using cerebral oxygen monitoring with near infrared spectros-
copy, but its role during post resuscitation care is uncertain.84,85
Control of ventilation
These guidelines are informed by the same ILCOR systematic review
noted in the section on oxygenation.9,66 The ILCOR treatment
recommendations in relation to ventilation are:
 There is insufficient evidence to suggest for or against targeting
mild hypercapnia compared with normocapnia in adults with
ROSC after cardiac arrest.
 We suggest against routinely targeting hypocapnia in adults with
ROSC after cardiac arrest. (weak recommendation, low-certainty
evidence).
After ROSC, blood carbon dioxide values (PaCO2) are commonly
increased because of intra-arrest hypoventilation and poor tissue
perfusion,86 causing a mixed respiratory acidosis and metabolic
acidosis.87 Carbon dioxide is a well-known regulator of blood vessel
tone and cerebral blood flow.88 Increased PaCO2 (hypercapnia)
increases cerebral blood flow, cerebral blood volume and intracere-
bral pressure. Hypocapnia causes vasoconstriction that may
decrease blood flow and cause cerebral ischaemia.89
The main method for controlling PaCO2 in a mechanically
ventilated patient is adjusting the minute volume by changing the
ventilation frequency and or tidal volume. In general, limiting the tidal
volume and using a lung protective ventilation strategy is the standard
of care, especially in patients with acute respiratory distress syndrome
(ARDS).9,90,91 Acute respiratory distress syndrome is not uncommon
in cardiac arrest patients and is associated with worse out-
comes.9,92,93 Low lung compliance predicts poor functional outcome
in OHCA patients94 ; however, ventilation with lower tidal volumes is
not standard practice in neurointensive care.95
 RESUSCITATION 161 (2021) 220
Two pilot studies have compared different carbon dioxide targets
during post resuscitation care.75,96 One study found targeting mild
hypercapnia (50 55 mmHg) compared with normocapnia (35 45
mmHg) resulted in lower neuron specific enolase (NSE) values, a
marker of the magnitude of neurological injury.96 Another pilot study
compared the lower and higher end of the range for normocapnia (33
45 mmHg) for the first 36 h of post resuscitation care and found no
difference in markers of neurological injury.75 Both of these studies
showed that a higher PaCO2 was associated with higher cerebral
oxygenation measured with near infrared spectroscopy (NIRS), but the
clinical implications of this are uncertain.85 Several large observational
studies have aimed to define the optimal CO2 during post-cardiac arrest
care.97 102 The results are mixed, with some studies indicating harm
from both hypo- and hypercapnia and some suggesting better outcome
with mild hypercapnia. Recent UK observational data suggest a
relationship between arterial oxygen and carbon dioxide. Data from the
first 24 h of post resuscitation care observed a combination of hypoxia
and hypocapnia was associated with a worse outcome and did not
report harm from hyperoxia.103 Previous observational data from
Finnish ICUs reported similar findings.97
Observational data suggest that patients undergoing TTM are prone
to hypocapnia.104 This may be avoided by frequent measurement of
carbon dioxide with arterial blood gas analysis and use of end tidal CO2
monitoring. In patients undergoing TTM with lower temperature targets,
PaCO2 management including measurement is particularly challeng-
ing.105 There is limited evidence to support a particular method for
measuring PaCO2 during hypothermia, therefore the guidance to use
either a temperature or non-temperature corrected approach for
measuring blood gases is based on expert opinion.106
The recommendation for tidal volume is based on current guidance
for lung protective ventilation in the ICU107 and limited observational
data from post cardiac arrest patients.108 One observational study
suggests that using a tidal volume of 6 8 mL kg 1 to ventilate the
lungs of post-cardiac arrest patients may be associated with improved
outcome.108 This study also showed that by using higher ventilation
frequency normocapnia may be achieved.108
Circulation
Coronary reperfusion
Percutaneous coronary intervention following ROSC with
ST-elevation
[4_TD$IF]Arrhythmia caused by myocardial ischaemia is the commonest cause of
sudden cardiac death (SCD) in adults.109,110 Immediate reperfusion
using percutaneous coronary intervention (PCI) of the culprit coronary
lesion has been used for more than 20 years. This strategy is supported
by many observational studies that reported a significant association
between early PCI with survival and favourable neurological outcome
after OHCA. Whilst the benefit of early PCI in OHCA caused by a recent
coronary occlusion is universally acknowledged, the main challenge is
to identify the best candidates for coronary angiography (CAG) among
all resuscitated patients. In patients with ST segment elevation (STE) or
left bundle branch block (LBBB) on the post-ROSC electrocardiogram
(ECG) more than 80% will have an acute coronary lesion.111 A
systematic review completed for the 2015 ILCOR CoSTR identified
15 observational studies enrolling 3800 patients showing a mortality
benefit for emergent versus delayed or no cardiac catheterisation
among patients with ROSC after cardiac arrest with evidence of STE on
their ECG.112 The treatment recommendation from 2015 was to
269 233
recommend emergency cardiac catheterisation laboratory evaluation
in comparison with cardiac catheterisation later in the hospital stay or no
catheterization in select adult patients with ROSC after OHCA of
suspected cardiac origin with ST elevation on ECG (strong recommen-
dation, low-quality evidence). The 2017 European Society of
Cardiology Guidelines for the management of acute myocardial
infarction with ST-segment elevation state that ‘a primary PCI strategy
is recommended in patients with resuscitated cardiac arrest and an
ECG consistent with STEMI’.113
[5_TD$IF]Percutaneous coronary intervention following ROSC without
ST-elevation
[6_TD$IF]In OHCA patients without ST segment elevation, several large
observational series showed that absence of ST segment elevation
does not completely exclude the presence of a recent coronary
occlusion.114 Therefore, the decision for early CAG should be based
on meticulous patient assessment for the presence of haemodynamic
or electrical instability and ongoing myocardial ischaemia taking into
account multiple factors including previous medical history, warning
symptoms before arrest, initial cardiac rhythm for CA,115 ECG pattern
post ROSC, and echocardiography, as well as comorbidities. When
an ischaemic cause is considered likely, a similar approach as for
patients with STEMI should be followed. In patients with a low
probability of an ischaemic cause of cardiac arrest, delaying CAG for
few hours or days may buy time for initial management in ICU,
enabling early initiation of post-resuscitation care (haemodynamic
optimisation, protective ventilation, TTM) and prognostication. This
‘wait and see’ management may also avoid performing CAG in
patients with the lowest probability of an acute coronary lesion. These
two strategies (early versus delayed CAG) were evaluated in patients
with VF arrest and without shock in an RCT that showed no difference
in 90-day survival, the primary outcome (odds ratio 0.89; 95%
confidence interval [CI], 0.62 to 1.27; P = 0.51),10 In this study, the
median time to target temperature was 5.4 h in the immediate
angiography group and 4.7 h in the delayed angiography group (ratio
of geometric means, 1.19; 95% CI, 1.04 to 1.36). Another recently
published pilot RCT comparing early with delayed CAG also showed
no difference in the primary outcome, which was a composite of
efficacy and safety measures.116 Further trials testing the same
hypothesis are ongoing (DISCO NCT02309151, COUPe
NCT02641626, TOMAHAWK NCT02750462, EMERGE
NCT02876458). The 2020 European Society of Cardiology Guide-
lines for the management of acute coronary syndromes in patients
without persistent ST-segment elevation state that ‘delayed as
opposed to immediate angiography should be considered in
haemodynamically stable patients without ST-segment elevation
successfully resuscitated after an out-of-hospital cardiac arrest’.11
Ideally, coronary interventions would be undertaken only in those
patients without permanent severe neurological injury. Patients with
irreversible hypoxic-ischaemic brain injury are unlikely to benefit from
PCI, even if a culprit coronary lesion is successfully treated.117
However, the absence of a universally acceptable prognostic tool in
the first hours after ROSC makes it impossible to identify such patients
with high sensitivity and specificity at the time of hospital admission.
[7_TD$IF]Haemodynamic monitoring and management
Haemodynamic monitoring
[8_TD$IF]Post-resuscitation myocardial dysfunction and low cardiac index may
occur in up to 60% of post-cardiac arrest patients30,118 and may be
234 RESUSCITATION 161 (2021) 220
even more common in patients with an acute myocardial infarction
(AMI) as the cause of the arrest.119 Early echocardiography can
identify underlying cardiac pathology, quantify the degree of
myocardial dysfunction and help guide haemodynamic management.
Serial echocardiography or invasive monitoring with a pulmonary
artery catheter quantifies myocardial dysfunction and indicates
trends.28,29,120 Impaired cardiac function is most common during
the first 24 48 h after which it gradually resolves.30,118 Whether low
cardiac output (or index) is associated with poor outcome is currently
unclear. A sub-study of the TTM trial showed that low cardiac index
may not be associated with outcome if lactate clearance is
maintained.121 These findings were independent of target tempera-
ture. Both non-invasive and invasive monitoring with echocardiogra-
phy, arterial lines and measurement of cardiac output are commonly
used in intensive care and it is reasonable to use these to guide
treatment in cardiac arrest patients (best practice statement).
[9_TD$IF]Haemodynamic management
[10_TD$IF]Mean arterial pressure and cerebral perfusion
[1_TD$IF]A systematic review completed for the 2015 ILCOR CoSTR searched
for studies that compared titration of therapy to achieve a specific
haemodynamic goal with no haemodynamic goal.122 At that time, only
observational studies were identified.123 127 That systematic review
also identified observational studies that compared a bundle of
therapies with a specific blood pressure target with no bundle.128 130
The 2015 CoSTR treatment recommendations were:
 We suggest haemodynamic goals (e.g., MAP, systolic blood
pressure) be considered during post-resuscitation care and as
part of any bundle of post-resuscitation interventions (weak
recommendation, low-quality evidence).
 There is insufficient evidence to recommend specific haemody-
namic goals; such goals should be considered on an individual
patient basis and are likely to be influenced by post-cardiac arrest
status and pre-existing comorbidities (weak recommendation,
low-quality evidence).
An evidence update for this topic was included in the 2020 ILCOR
CoSTR and included two RCTs9,131,132 and 11 observational
studies121,133 142 published since the 2015 systematic review.122
Two RCTs (including 232 patients) compared a blood pressure target
of 65 75 mmHg to 80 100 mmHg with131 and without132 goal-
directed optimisation of cardiac function. These studies were not
powered for clinical outcomes but used surrogate markers of
neurological injury such as MRI131 and NSE.132 Whilst these studies
showed that higher MAP targets with vasopressors are safe, and do
not, for example, lead to cardiac arrhythmias, they failed to show any
clear improvement in surrogate markers of brain injury with a higher
MAP target.
Nine observational studies found hypotension was associated with
poor outcome.134 139,141,142 One study found time spent below
optimal MAP (assessed by correlation between near-infrared
spectroscopy and blood pressure) was associated with poor
outcome;133 one study did not find low cardiac output to be associated
with poor outcome,121 while the last study documented better
outcomes among patients given fluids compared with vasopressors
to increase MAP.140 These observations are similar to the five
observational studies included in the 2015 ILCOR Guidelines.122
While hypotension (<65 mmHg) is consistently associated with poor
269
outcome, we do not have high certainty evidence to guide an optimal
MAP target.
Mean arterial pressure (MAP) is one of the main determinants of
cerebral blood flow (CBF).143 Although a high MAP is generally
required in non-anoxic brain injured patients because of cerebral
swelling and increased intracranial pressure (ICP),144 few data on ICP
values are available in cardiac arrest survivors. In many post-cardiac
arrest patients, CBF autoregulation is impaired or the lower limit is
right-shifted.133,145 This means that at lower MAP values, in some
patients CBF may be MAP-dependent with an increased risk of
cerebral hypoperfusion (i.e. hypotension) or hyperaemia and
intracranial hypertension (i.e. hypertension).
The use of cerebral oxygen saturation or ICP monitoring to
determine the presence of autoregulation and to determine an optimal
MAP may enable a more individualised approach.146 In a retrospec-
tive study, the estimated optimal MAP (i.e. MAP target at which the
autoregulation is more effective) was 85 mmHg in post-cardiac arrest
patients with preserved autoregulation and 100 mmHg when the
autoregulation was impaired.133 Another small observational study
calculated a median optimal MAP of 89 mmHg in the same setting.147
However, there are no prospective studies evaluating whether an
autoregulation-driven MAP target may influence neurological injury
and/or outcome. A more recent study has shown that after cardiac
arrest, in particular in cases of non-cardiac origin, episodes of
elevated ICP and/or brain hypoxia are frequent and a higher MAP is
necessary to improve brain oxygenation.147 Preliminary evidence
based on measurement of brain tissue oxygenation (PbtO2) has
shown that in resuscitated comatose patients impairment of oxygen
diffusion to the brain may cause persisting brain hypoxia despite
optimisation of oxygen delivery to the brain.148 The implementation
and the safety of these invasive monitoring tools in cardiac arrest
patients need to be further evaluated. While these are all
observational findings, they indicate optimal MAP targets may need
to be individualised and support further research into identification of
optimal MAP targets for individual cardiac arrest survivors receiving
intensive care. In the post cardiac arrest patient, transcranial Doppler
(TCD) can give information about cerebral haemodynamics and, in the
future, may have a role in optimising haemodynamics in these
patients.149 Changes in cerebral blood flow can be seen using TCD
and this may be a target to for treatment.150 152 However, the
technique and interpretations of the images is operator dependent and
requires an acoustic window in the patient. Moreover, cerebral
haemodynamics are continuously changing and serial measurements
are possible only intermittently and the monitoring is labour-intensive.
Based on the evidence summarised by ILCOR9 we suggest avoiding
hypotension (MAP < 65 mmHg) and targeting MAP to achieve
adequate urine output (>0.5 mL 1 kg h 1) and normal or decreasing
lactate values (best practice statement).
[12_TD$IF]Heart rate
Tachycardia was associated with poor outcome in one retrospective
study.153 During mild induced hypothermia the normal physiological
response is bradycardia. In animal models this has been shown to
reduce the diastolic dysfunction that is usually present early after
cardiac arrest.154 Bradycardia was previously considered to be a side
effect, especially below a rate of 40 min 1; however, bradycardia has
been shown to be associated with a good outcome.155,156 Similar
association between bradycardia and improved long-term outcome
has been shown in patients not treated with TTM.157
 RESUSCITATION 161 (2021) 220
Sedation, controlled ventilation and a temperature between 32
36  C lowers oxygen consumption in cardiac arrest patients.
Although bradycardia generally reduces cardiac output, this is well
tolerated in this post-arrest setting. We suggest bradycardia (heart
rate < 30 40 min 1) be left untreated as long as there are no signs of
hypoperfusion (i.e. increasing lactate, reduced urinary output etc.)
(best practice statement).
[13_TD$IF]Fluid resuscitation, vasoactive and inotropic drugs
[14_TD$IF]There is limited evidence to guide optimal fluid therapy for post-
cardiac arrest patients. One study during which invasive monitoring
and filling pressures were used observed that up to 5 7 L of fluid were
given during the first 24 h.30 One retrospective study indicated that
with a treatment algorithm involving the pulse contour continuous
cardiac output (PiCCO) system larger fluid volumes (range 4 5 L
during the first 24 h) were associated with a lower incidence of acute
kidney injury.158
There is little direct evidence comparing various vasoactive drugs
for post-cardiac arrest patients, therefore this recommendation is
based on indirect evidence from critically ill patients in general. The
most recent Cochrane review on vasopressors for hypotensive shock
included 28 RCTs (n = 3497 patients) and did not find any mortality
benefit from any of the six vasopressors assessed. Acknowledging
noradrenaline as the most commonly used vasopressor, their
suggestion was that major changes in clinical practice were not
needed.159 As noradrenaline is the most widely used vasoactive agent
for post-cardiac arrest patients, we suggest using noradrenaline as
the first-line vasoactive agent in hypotensive post-cardiac arrest
patients. A recent RCT comparing noradrenaline with adrenaline in
57 patients with acute myocardial infarction and cardiogenic shock
was terminated early because of significantly more refractory shock in
patients treated with adrenaline.160 The COMACARE and NEURO-
PROTECT pilot trials also used noradrenaline as the drug of choice to
achieve higher MAP targets.131,132 None of the studies showed any
evidence of relevant tachycardia, arrhythmias or recurrent shock in
the higher MAP group, despite the use of significantly higher doses of
noradrenaline compared with the lower MAP group. This suggests
that noradrenaline is well tolerated in post-cardiac arrest patients.131
Post-resuscitation myocardial dysfunction often requires inotropic
support. Based on experimental data, dobutamine is the most
established treatment in this setting,161,162 but the systemic
inflammatory response that occurs frequently in post-cardiac arrest
patients also causes vasoplegia and severe vasodilation.30 The
NEUROPROTECT trial used dobutamine to increase cardiac index in
the higher MAP group. Although this did not decrease neurological
injury it also did not increase myocardial injury.131
[15_TD$IF]Steroids
ILCOR performed an evidence update on use of steroids for post-
cardiac arrest patients for the 2020 guidelines.9 Three small RCTs and
a large observational study have addressed the use of steroids in post-
cardiac arrest patients.163 166 Two of the RCTs used steroids both
during CPR for IHCA and after ROSC.163,164 The first of these RCTs
showed improved survival to discharge with a combination of
methylprednisolone, vasopressin, and adrenaline during cardiac
arrest and hydrocortisone after ROSC for those with shock, compared
with the use of only adrenaline and placebo (9/48 [19%] versus 2/52
[4%];RR, 4.87; 95% CI, 1.17 13.79).164 The second RCT showed
improved survival to discharge with favourable neurological outcome
with methylprednisolone, vasopressin, and adrenaline during cardiac
269 235
arrest, and hydrocortisone in those with post-ROSC shock compared
with only adrenaline and placebo (18/130 [13.9%] versus 7/138
[5.1%]; RR, 2.94; 95% CI, 1.16 6.50) 163 Only the third RCT confined
the use of steroids to the post-resuscitation phase; it did not show any
benefit for steroid post-ROSC but included only 50 patients.166
One trial has recently been completed but is not yet published
(NCT02790788). ILCOR recommended a systematic review be
undertaken once the recently completed trial is published, and
therefore left the treatment recommendation unchanged from
2010:167
 There is insufficient evidence to support or refute the use of
corticosteroids for patients with ROSC following cardiac arrest.
Until there is higher-certainty evidence supportive of their use, we
suggest that steroids are not given routinely to post-cardiac arrest
patients (weak recommendation, low-certainty evidence).
[16_TD$IF]Potassium
Hyperkalaemia is common immediately after cardiac arrest. Subse-
quent endogenous catecholamine release and correction of metabolic
and respiratory acidosis promotes intracellular transportation of
potassium, causing hypokalaemia. Hyperkalaemia in the post-cardiac
arrest period is associated with worse outcome.168 Hypokalaemia, on
the other hand may predispose to ventricular arrhythmias. Based on
these observational studies we suggest that potassium be given to
maintain the serum potassium concentration between 4.0 and
4.5 mmol L 1 (best practice statement).
[17_TD$IF]Mechanical circulatory support
[18_TD$IF]If treatment with fluid resuscitation, inotropes and vasoactive drugs is
insufficient to support the circulation, consider insertion of a
mechanical circulatory assistance device (e.g. IMPELLA, Abiomed,
USA).126,169,170 One study indicated that 10 15% of patients with
OHCA and ongoing cardiogenic shock eventually require mechanical
circulatory support.171 In patients with cardiogenic shock without
cardiac arrest some centres still advocate use of an intra-aortic
balloon pump (IABP), although the IABP-SHOCK II Trial failed to show
that use of the IABP improved 30-day mortality in patients with
myocardial infarction and cardiogenic shock.172,173 One recent small
RCT found no difference in outcome in patients with acute myocardial
infarction and cardiogenic shock treated with an IMPELLA device
compared with an IABP.174 Another retrospective study including only
post-cardiac arrest patients found no difference in clinical outcome but
higher incidence of bleeding with the use of IMPELLA compared with
IABP.169 Thus far, the evidence about which type of mechanical
device is superior appears inconclusive and thus their use should be
decided on a case-by-case basis.
The 2015 ESC Guidelines for the management of patients with
ventricular arrhythmias and the prevention of sudden cardiac death
include the following recommendation for the use of mechanical
circulatory support: left-ventricular assist devices or arterio-venous
extra corporal membrane oxygenation should also be considered in
haemodynamically unstable patients with acute coronary syndromes
(ACS) and recurrent ventricular tachycardia (VT) or ventricular
fibrillation (VF) despite optimal therapy.175
[19_TD$IF]Implantable cardioverter defibrillators
An implantable cardioverter defibrillator (ICD) is a device used for
the treatment of certain life-threatening arrhythmias. The Europe-
an Society of Cardiology has published guidelines on the
236 RESUSCITATION 161 (2021) 220
indications for ICD therapy.175 An ICD may be implanted for
primary or secondary prevention. The former applies to those who
have not experienced a dangerous arrhythmia but who are
considered at high risk of one. This group includes patients with
cardiomyopathies, inherited primary arrhythmic syndromes, con-
genital heart disease but also individuals with primary arrhythmias
in structurally normal hearts.176,177 Secondary prevention refers to
patients who have already survived a dangerous arrhythmic event
and are still considered at risk of further events. Careful selection
of patients is needed to identify those who may benefit from ICD
implantation and whose lives can be prolonged by preventing
arrhythmic SCD.
Disability (optimising neurological recovery)
Control of seizures
Seizures are reported in 20 30% of cardiac arrest patients in the
ICU and are usually a sign of a severe hypoxic-ischaemic brain
injury. Seizures may be observed as clinical convulsions (clinical
seizure) and/or as typical activity in the EEG (electrographic
seizure).
Myoclonus are sudden, brief, shock-like involuntary muscle
contractions and by far the most common type of clinical seizure in
post-arrest patients.178,179 It is often generalised but may be focal
(periodic eye-opening, swallowing, diaphragmic contractions etc.) or
multi-focal.180 It typically develops during the first 1 2 days after the
arrest and is often transient during the first days-week. It is associated
with a poor prognosis but some patients survive with a good
outcome.181,182 Most post-hypoxic myoclonus has a cortical origin183
and the EEG shows synchronous time-locked discharges or burst-
suppression in a substantial proportion of patients.181
Focal and generalised tonic-clonic seizures also occur after
cardiac arrest, and it is not uncommon that an individual patient has
several seizure sub-types.178
Lance-Adams syndrome is a less frequent form of myoclonus
usually developing in a patient who has regained conscious-
ness.184,185 It is more common after hypoxic cardiac arrest and
mainly affects the limbs where it is induced by purposeful actions or
sensory stimulation. It may be disabling and often becomes
chronic.182
Some of the evidence informing this guideline is set out in a
systematic review that informed the ILCOR 2015 CoSTR122 and
updated in 2020.9 The 2020 updated treatment recommendations are:
 We suggest against seizure prophylaxis in adult post-cardiac
arrest survivors (weak recommendation, very low certainty
evidence).
 We suggest treatment of seizures in adult post-cardiac arrest
survivors (weak recommendation, very low certainty evidence).
Studies using continuous EEG-monitoring reveal that electro-
graphic epileptiform activity and clinical convulsions are equally
common and that there is a substantial overlap.186 The evaluation
of electrographic seizures is often confounded by the concomitant
effects of brain injury, metabolic factors and sedation, making
possible clinical correlates and effects of treatment harder to
evaluate. New definitions of electrographic status epilepticus
have been published recently by the American Clinical Neuro-
physiology Society (ACNS).187 The ACNS uses strict and
conservative criteria which are typically not fulfilled by post-arrest
patients.186 Instead, most of these patients have EEG-patterns
269
that may or may not be defined as electrographic ‘seizures’ or, if
prolonged as ‘status epilepticus’, and depend on the local EEG-
interpreter.
Sedative drugs have potent seizure-suppressing effects and
are recommended as third-line treatment of status epilepticus.
Propofol and benzodiazepines are used routinely during the first
days after cardiac arrest while the patient is mechanically
ventilated and treated with TTM. Depending on the dosing, these
drugs will suppress clinical myoclonus and epileptiform activity in
the EEG.188,189 The seizures may be unmasked during sedation
holds. There is limited evidence that conventional antiepileptic
drugs (mainly valproate and levetiracetam) suppress epileptic
activity on the EEG of post cardiac arrest patients.190 These drugs
are known to supress myoclonus of other origins.191 Phenytoin
and the pro-drug fosphenytoin are still used widely for the
treatment of status epilepticus. In post-cardiac arrest patients
however, their negative inotropic and vasodilating effects makes
them less suitable.192 In a recently reported trial, valproate,
levetiracetam and fosphenytoin were equally effective in terminat-
ing convulsive status epilepticus but fosphenytoin caused more
episodes of hypotension.12
There is currently no evidence supporting prophylactic treat-
ment with antiepileptic drugs in the post-arrest setting. Previous
studies on the effects of bolus-doses of thiopental193 and
diazepam/magnesium194 after resuscitation showed no benefit in
terms of survival or neurologic function but these studies were
designed to investigate neuroprotection, not seizure suppression.
Whether treatment of detected clinical and electrographic seizures
alters patient outcome has not previously been studied in a
randomised fashion but a multicentre trial of aggressive treatment
of post-anoxic status epilepticus is currently ongoing.195 In case
series, 4 44% of patients with post-anoxic status epilepticus had a
good outcome.196 199 These patients were usually treated with
multiple anti-epileptic drugs and had a delayed awakening, often
beyond two weeks.
The EEG is an important tool to detect corresponding electro-
graphic seizure activity in a patient with observed clinical convulsions
and to monitor treatment effects. Shivering is a common seizure mimic
during TTM. Active treatment of status epilepticus usually neces-
sitates repeated routine EEGs or continuous EEG-monitoring. The
relative benefit of continuous EEG compared with routine EEG has not
been shown. Continuous EEG monitoring is labour intensive and likely
to add significant cost to patient care. The net cost-effectiveness of this
approach is controversial and may depend substantially on the
setting.200,201
Since post-anoxic seizures and status epilepticus are manifes-
tations of hypoxic-ischaemic brain injury, an assessment of the
prognosis and potential for an eventual good outcome are central
components of a treatment strategy. The EEG-background pattern is
important but may sometimes be difficult to assess if there are
concomitant abundant discharges. A continuous, normal voltage and
reactive EEG background are benign features whereas a burst-
suppression pattern or a suppressed background without reactivity
are features related to worse prognosis.181,199 Early onset (<24 h) of
electrographic seizures, before the recovery of a continuous
background is associated with worse prognosis.197,202,203 In these
patients, the EEG is often affected by the ongoing treatment. It is
therefore suggested that additional information is obtained on the
severity of brain injury from methods not significantly affected by
sedative and anti-epileptic drugs such as somatosensory evoked
 RESUSCITATION 161 (2021) 220
potentials, serum NSE and neuroradiological investigations (prefera-
bly MRI).
Seizures may increase the cerebral metabolic rate and have the
potential to exacerbate brain injury caused by cardiac arrest: treat
seizures with levetiracetam and/or sodium valproate. Consider
possible drug interactions. After the first event, start maintenance
therapy. Additional treatment options include perampanel, zonisa-
mide or topiramate. Consider increased dose of propofol or
benzodiazepines to suppress myoclonus and electrographic seiz-
ures. Thiopental or phenobarbital may be considered in selected
patients.
Treatment with sedatives and conventional antiepileptic drugs in
high doses may delay awakening, prolong the need for mechanical
ventilation, and increase critical care length of stay.204 Consider that
generalised myoclonus in combination with epileptiform discharges
may be early signs of Lance-Adams syndrome which is compatible
with awakening and a good outcome.181,184 In such cases, aggressive
treatment may confound the clinical examination and lead to overly
pessimistic prognostication.
Temperature control
A comprehensive systematic review of TTM was conducted for the
2015 COSTR.122,205 207 Following an evidence review for the
2020 CoSTR, these ILCOR treatment recommendations remained
unchanged from 2015.9
 We recommend selecting and maintaining a constant target
temperature between 32  C and 36  C for those patients in whom
temperature control is used (strong recommendation, moderate-
quality evidence). Whether certain subpopulations of cardiac
arrest patients may benefit from lower (32 34  C) or higher
(36  C) temperatures remains unknown, and further research may
help elucidate this.
 We recommend targeted temperature management as opposed
to no targeted temperature management for adults with OHCA
with an initial shockable rhythm who remain unresponsive after
ROSC (strong recommendation, low-quality evidence).
 We suggest targeted temperature management as opposed to no
targeted temperature management for adults with OHCA with an
initial non-shockable rhythm who remain unresponsive after
ROSC (weak recommendation, very low-quality evidence).
 We suggest targeted temperature management as opposed to no
targeted temperature management for adults with IHCA with any
initial rhythm who remain unresponsive after ROSC (weak
recommendation, very low-quality evidence).
 We suggest that if TTM is used, duration should be at least 24 h
(weak recommendation, very-low-quality evidence).
 We recommend against routine use of prehospital cooling with
rapid infusion of large volumes of cold IV fluid immediately after
ROSC (strong recommendation, moderate-quality evidence).
 We suggest prevention and treatment of fever in persistently
comatose adults after completion of TTM between 32  C and 36  C
(weak recommendation, very-low-quality evidence).
Treatment of fever
[20_TD$IF]The definition of fever varies in different studies and no specific
evaluation of the cause (i.e. ischaemia-reperfusion, neurogenic
fever, infection) is generally reported. A large observational study
investigating serial measurements in more than 35,000 individuals
concluded that mean body temperature measured in the oral cavity
was 36.6  C (99% ranges: 35.3 37.7  C) in healthy adults.208 A
269 237
reasonable definition of fever is therefore body temperature above
37.7  C, as recently used in a large randomised cardiac arrest
trial.14 However, this definition in critically ill patients usually relies
on measurement of ‘core’ temperature (i.e. blood, bladder,
oesophagus) and is only an estimation of brain temperature, which
could exceed it by 0.4  C to 2.0  C.209
Fever is common during the first 2 3 days after cardiac arrest and
is associated with worse outcomes in observational studies.210 Fever
following TTM (i.e. induction of hypothermia at 32 36  C) is also
called rebound hyperthermia and is associated with worse outcomes,
in particular with high temperatures.211,212 Whether fever contributes
to poor neurological outcome or is just a marker of severe brain injury
remains unknown. To date, no randomised trial has compared
controlled normothermia (i.e. keeping target temperature below
37.8  C) with no fever control.
[21_TD$IF]Targeted temperature management
[10_TD$IF]Cooling versus normothermia
[1_TD$IF]A meta-analysis shows that mild induced hypothermia is neuro-
protective and improves outcomes in animal models of cardiac
arrest.213 The authors conclude that there may be translational gaps
because research on large (gyrencephalic) and comorbid animals is
uncommon. The theoretical background that lowering core tempera-
ture suppresses several detrimental pathways leading to neuronal
death is well established, but the specific mechanisms of hypothermic
neuroprotection remain unclear.214 Hypothermia decreases the
cerebral metabolic rate for oxygen (CMRO2) by about 6% for each
1  C reduction in core temperature and this reduces the release of
excitatory amino acids and the production of free radicals.215,216 In the
temperature range of 33  C to 36  C, however, there is no difference in
the inflammatory cytokine response in adult patients.217
All studies evaluating post-cardiac arrest patients and mild
induced hypothermia included only patients with altered conscious-
ness (i.e. Glasgow Coma Scale < 9). One randomised trial and a
quasi-randomised trial demonstrated improved neurological outcome
at hospital discharge or at 6 months in comatose patients after out-of-
hospital witnessed cardiac arrest with an initial shockable
rhythm.218,219 Cooling was initiated within minutes to hours after
ROSC and a target temperature of 32 34  C was maintained for 12
24 h. These two trials represented the beginning of modern post-
cardiac arrest care. More recently, a French multicentre trial
randomised 581 adult patients who were comatose after resuscitation
of either an IHCA or OHCA with an initial non-shockable rhythm (i.e.
asystole or pulseless electrical activity) to either TTM with a target
temperature of 33  C or a target temperature of 37  C, for 24 h.13 The
use of TTM at 33  C led to a higher percentage of patients who
survived with a favourable neurological outcome at day 90, assessed
as a cerebral performance category score (CPC) of 1 2, (10.2%
versus 5.7%, difference 4.5%; 95% CI 0.1 8.9; P = 0.04), while
mortality did not differ (81.3% versus 83.2%, difference 1.9; 95% CI
8.0 4.3). The benefit of a lower target temperature was more
evident in patients with shorter time to ROSC (<15 min) and among in-
hospital cardiac arrest patients. These results differ from a previous
retrospective registry study of 1830 patients with non-shockable
OHCA where poor neurological outcome was more common among
those receiving mild induced hypothermia (adjusted OR 1.44 [95% CI,
1.04 2.01].220 The ongoing targeted hypothermia versus targeted
normothermia after OHCA (TTM2) trial will compare a target
temperature of 33  C with strict normothermia (<37.8  C) during a
238 RESUSCITATION 161 (2021) 220
40-h intervention period in 1900 patients and will address the
effectiveness of cooling procedures in cardiac arrest patients in
comparison with fever management.14
[2_TD$IF]Timing to initiate hypothermia
[23_TD$IF]Animal data suggest that TTM should be initiated as soon as
possible,221 although delays of several hours seem to be neuro-
protective in several species.213 Early cooling, i.e. initiated in the pre-
hospital field after ROSC, has been tested in some RCTs222,223;
although target temperature could be achieved faster than with
standard in-hospital cooling, no significant effect on patient outcomes
was reported. Moreover, in one study pre-hospital use of cold fluids to
induce early hypothermia was associated with more re-arrests in the
field and more frequent pulmonary oedema on admission than the
control group.224
Intra-arrest hypothermia (i.e. initiated during CPR) has been
proposed as an effective method to provide TTM; however, use of cold
fluids during CPR in a large RCT including OHCA patients showed no
improvement in outcome from this strategy and even a decreased
ROSC rate in patients with an initial shockable rhythm.224 One small
feasibility trial225 and one RCT226 have tested the use of trans-nasal
evaporative cooling, which could induce rapid cooling in OHCA
patients. Both trials reported no significant benefits on patient
outcomes, although in the latter trial a post hoc analysis of the
subgroup of patients with an initial shockable rhythm and in whom
cooling was initiated < 20 min from collapse showed improved
neurological outcome at 90 days.226,227
[24_TD$IF]Optimal target temperature during hypothermia
[20_TD$IF]The Targeted Temperature Management after Cardiac Arrest trial
(TTM-trial) randomised 950 OHCA patients with both initial shockable
and non-shockable rhythms to a strategy including 36 h of tempera-
ture control (i.e. 28 h at target temperature followed by slow
rewarming) and fever control up to 72 h after randomisation; the
two target temperatures during the intervention phase were 33  C or
36  C.27 Strict protocols were followed for assessing prognosis and for
withdrawal of life-sustaining treatment (WLST). There was no
difference in the primary outcome (i.e. all-cause mortality; hazard
ratio 1.06 [95% CI 0.89 1.28]) or in neurological outcome at 6 months
(relative risk 1.02 [0.88 1.16]). Neurological outcome and cognitive
function were also similar,228,229 as were brain injury biomarker
values.230,231 TTM at 33  C was associated with decreased heart rate,
elevated lactate, the need for increased vasopressor support, and a
higher extended cardiovascular SOFA score compared with TTM at
36  C.136,232 A small three-armed randomised trial compared 32  C
with 33  C and 34  C and found no difference in good neurological
outcome, assessed as a modified Rankin Score (mRS) of 0 3 at day
90 (62.3% (95% CI 48.3 76.6) vs. 68.2% 95% CI 52.4 81.4) vs.
65.1% (95% CI 49.0 79.0)).233
Since the publication of previous guidelines, many sites have
changed to a target temperature of 36  C in routine practice.234,235
There have been reports that a change to 36  C has led to worse
temperature control and more early fever,236 but there are other
reports showing good compliance with a 36  C-protocol and a possible
clinical advantage, such as earlier awakening and less sedative
use.237 Results from two large registry analyses, one from the cardiac
arrest registry to enhance survival (CARES) surveillance group in the
US238 and one from the Australian and New Zealand Intensive Care
Society Centre for Outcome and Resource Evaluation (ANZICS-
CORE)239 indicate that a widespread change in TTM-use has
269
occurred after publication of the TTM-trial, with a rising average lowest
temperature in the ICU and reduced use of TTM. Furthermore,
survival decreased, but was not statistically associated with a
decreased use of TTM.238 In this setting, the optimal temperature
during mild induced hypothermia is therefore unknown and more high-
quality large trials are needed.240
[25_TD$IF]Duration of hypothermia
[20_TD$IF]The optimal duration for mild induced hypothermia and TTM is
unknown although the period of hypothermia is most commonly 24 h.
Previous trials treated patients with 12 to 28 h of TTM.27,218,219 Two
observational trials found no difference in outcomes with 24 h
compared with 72 h of TTM.241,242 A recent randomised trial
(n = 351) investigated TTM at 33  C during 48 h or 24 h in unconscious
patients after OHCA.243 There was no significant difference in poor
neurological outcome between groups (absolute difference 4.9%;
relative risk (RR) for a cerebral performance category 1 2 at 6 months
1.08, 95% CI 0.93 1.25). Adverse events were more common in the
prolonged cooling group (RR 1.06, 95% CI 1.01 1.12).
[26_TD$IF]Contraindications to targeted temperature management
[ ithin the recommended TTM range of 32 36  C there are few, if any,
27_TD$IF]W
recognised contraindications. Results from a post hoc analysis of the
TTM-trial suggest that if there is severe cardiovascular impairment at
33  C a higher temperature might be targeted.232
[28_TD$IF]Other therapies to improve neurological outcome
In contrast to a number of positive results from studies in experimental
settings,18 several neuroprotective drugs failed to demonstrate a
positive clinical effect.164,193,194,244 247 More recently, erythropoie-
tin,248 cyclosporine,249 and exenatide,250 used alone, or as an adjunct
to mild induced hypothermia, have also not been shown to increase
neurologically intact survival when included in the post arrest
treatment of cardiac arrest patients. The combination of xenon and
mild induced hypothermia, which is beneficial and superior to mild
induced hypothermia alone in experimental settings,18,251 has been
studied in several trials with no convincing effects252 254 and is
undergoing further clinical evaluation (XePOHCAS, EudraCT Number
2017-00251432). Moreover, volatile anaesthetic drugs have demon-
strated positive effects on cardiac and cerebral recovery in
experimental settings,255 and clinical feasibility studies,256 258 but
outcome data are lacking. Most recently, it has been shown that pig
brain cells can survive and show electrical activity for more than 4 6 h
after decapitation, when reperfusion of the brain was performed in
highly artificial experimental settings.259 Very specific extracorporeal
life support concepts (i.e. controlled reperfusion of the whole body)
have also demonstrated good neurological survival following 15
20 min of experimental cardiac arrest and in humans.260,261 These
concepts are currently also undergoing further clinical evaluation.262
General intensive care management
There has been a recent systematic review and an ILCOR CoSTR on
the subject of prophylactic antibiotics.9,263 The ILCOR recommenda-
tion states:
 We suggest against the use of prophylactic antibiotics in patients
following ROSC (weak recommendation, low certainty of evidence).
The remaining guidelines for the general ICU management of post-
cardiac arrest patients are based on expert opinion. Most aspects of
 RESUSCITATION 161 (2021) 220
post cardiac arrest care follow general ICU practices. Some differences
and nuances are inherent. Few aspects of general intensive care have
been studied separately in the cardiac arrest population, but cardiac
arrest patients have been included in trials on general intensive care
practices. Specific features of the post cardiac arrest patients include
the risk of brain injury and need to apply neurointensive care principles,
the high occurrence of myocardial dysfunction, the use of anti-
coagulants and anti-platelet drugs and the high risk of aspiration
pneumonitis among others. The typical length of stay in cardiac arrest
patients will vary from three days to several weeks because of
differences in time to awakening. This will influence certain aspects of
care such as the initiation of and management of nutrition.
Many post cardiac arrest patients will require appropriate sedation
and pain management, particularly those who are treated with TTM.
During TTM, shivering is common this can be managed with opioids
and sedation. TTM influences the metabolism of several drugs and
effects are in general prolonged. One RCT has compared the use of
propofol and fentanyl with midazolam and fentanyl.264 In a trial of
59 patients, the use of propofol and remifentanil resulted in shorter
time to awakening but was associated with more frequent need of
noradrenaline.264 Similar findings have been shown in observational
studies.265 Sedation breaks are best initiated after TTM and
rewarming has been completed.
Routine use of neuromuscular blocking drugs has been shown to
be beneficial in observational studies,266,267 but one small random-
ised pilot trial failed to show any such benefit.268 In patients with ARDS
and critical hypoxaemia, a meta-analysis has shown beneficial effects
on outcome with the use of neuromuscular blockers.269 Thus, in
patients with critical hypoxaemia and ARDS following cardiac arrest,
the use of a neuromuscular blocker may be considered, given the
evidence for their use in ARDS. Patients should be nursed 30 head-
up. This may decrease intracranial pressure (ICP) and decrease the
risk of aspiration pneumonia. Many patients are at high risk of
developing aspiration and ventilator-associated pneumonia.270 A
recent RCT examined the prophylactic use of antibiotics in OHCA
patients.271 Whilst the study showed a decrease in ventilator
associated pneumonia it did not find any other differences in other
clinical outcomes; therefore, prophylactic antibiotics are not recom-
mended. However, antibiotics can be considered in cases with clear
suspicious infiltrates on the chest X-rays.
Patients require a nasogastric tube to decompress any abdominal
distension. One small observational study has indicated that low-dose
enteral feeding is tolerated during TTM after OHCA.272 Gastric feeding
may be initiated at low rates (trophic feeding) during TTM and increased
after rewarming if indicated. If TTM of 36  C is used as the target
temperature, gastric feeding rates may be increased early during TTM.
Routine use of ulcer prophylaxis in intensive care patients does not
decrease mortality.273,274 However, a recent meta-analysis showed
that in high-risk patients, the use of ulcer prophylaxis decreased
gastrointestinal bleeding.275 Post-cardiac arrest patients are likely to
be at higher risk than general ICU patients given the use of
anticoagulant and antiplatelet agents both pre and post arrest.276
Therefore, it appears reasonable to administer stress ulcer prophy-
laxis in post-cardiac arrest patients, especially in those with
coagulopathy.35
Unless patients receive anticoagulation because of a myocardial
infarction or ischaemia, deep venous thrombosis prophylaxis is
recommended in critically ill patients.277,278 The use of antiplatelet
drugs do not prevent DVTs.279 Out-of-hospital cardiac arrest patients
are at risk for developing DVTs especially if treated with TTM.280
269 239
These appear more common in those treated with an invasive TTM
device, likely related to catheter placement in the femoral vein.281 No
specific evidence exists on DVT prophylaxis in cardiac arrest patients.
Thus, treatment should be individualised and be based on general ICU
recommendations.277
Hyperglycaemia is common after OHCA.168 Hyperglycaemia is
best managed with continuous infusion of insulin. The 2019 Guidelines
of the American Diabetes Association recommend a target glucose
range of 7.8 10.0 mmol L 1 (140 180 mg dL 1) for the majority of
critically ill patients.282 Tight glucose control does not appear to
convey benefit and may be associated with hypoglycaemia (<4.0
mmol L 1 (<70 mg dL 1),283 which is harmful in critically ill patients.284
In general, glucose containing solutions are not recommended in
patients with brain injury,285 but they may be needed to treat
hypoglycaemia.284
Prognostication
About two-thirds of in-hospital deaths in patients who are admitted
to an intensive care unit in a coma following resuscitation from
OHCA are caused by hypoxic-ischaemic brain injury.23,24 In a
minority of cases these deaths occur as a direct consequence of
hypoxic-ischaemic brain injury which results in an irreversible loss of
all brain function, i.e., brain death.286 However, most of these
neurological deaths result from active withdrawal of life-sustaining
treatment (WLST) in patients where the severity of hypoxic-
ischaemic brain injury indicates that survival with a poor neurologi-
cal outcome is very likely.26,287 Accurate prognostication is
therefore essential in order to avoid an inappropriate WLST in
patients who still have a chance of a neurologically meaningful
recovery and to avoid futile treatment in patients with a severe and
irreversible neurological injury.
Outcome measures in neuroprognostication studies
Neurological outcome after cardiac arrest is most commonly reported
using Cerebral Performance Categories (CPC).288 The CPC is
expressed as a five-point scale: CPC 1 (no or minimal neurological
disability); CPC 2 (minor neurological disability); CPC 3 (severe
neurological disability); CPC 4 (persistent vegetative state); and CPC
5 (death). Another commonly used outcome measure is the modified
Rankin Score (mRS),289 which includes 7 scores, from 0 (no
symptoms) to 6 (dead). In 2018, a statement from ILCOR290
suggested using mRS rather than CPC for measuring functional
recovery after cardiac arrest, because mRS is more suitable than CPC
for discriminating between mild and moderate disability291,292 and has
a substantial interrater reliability.293 However, most studies on
neurological prognosis after cardiac arrest still use CPC.
For both clarity and statistical purposes in studies on neuro-
prognostication after cardiac arrest the outcome is dichotomised as
‘good’ or ‘poor’. However, there is no universal consensus on what
represents a poor neurological outcome. Up to 2006, most
neuroprognostication studies reported CPC 4 or 5 (vegetative state
or death) as a poor outcome, and CPC from 1 to 3 (from absent to
severe neurological disability) as a good outcome, while after that
date an increasing number of studies included CPC 3 (severe
neurological disability) among poor neurological outcomes.294 In a
recent systematic review,15 among 94 total studies on neurological
prognostication after cardiac arrest, 90 (96%) defined poor
neurological outcome as CPC 3 5 and only four defined poor
outcome as CPC 4 5.
240 RESUSCITATION 161 (2021) 220
In prognostic accuracy studies, a predictor (index test) is assessed
for its ability to predict an outcome. This design is like that of diagnostic
accuracy studies. However, while in diagnostic accuracy studies the
index test is evaluated against another test which represents the
reference standard, or gold standard, prognostic accuracy studies
evaluate the index test against the occurrence of the predicted event
(target condition) after test recording.295 When test results are
expressed in binary format (i.e., positive vs. negative) the accuracy is
expressed using sensitivity and specificity, which measure the ability
of the test to identify those who will develop or not develop the target
condition, respectively. Since most neuroprognostic tests predict poor
neurological outcome, having a high specificity (i.e., a very low rate of
falsely pessimistic predictions potentially leading to an inappropriate
WLST) is desirable. Ideally, an index test should be 100% specific, i.e.,
its false positive rate (FPR) should be zero, but this is difficult to
achieve in practice. There is no universal consensus on how specific
an index test should be for neuroprognostication after cardiac arrest.
In a recent survey of 640 healthcare providers, the majority (56%) felt
an acceptable FPR for WLST from patients who might otherwise have
recovered was 0.1%.296 Along with the absolute value of specificity,
precision of its estimate is important. A very specific test predicting
poor outcome is of little clinical use when its precision is low, (i.e., when
the confidence intervals [CIs] around the point estimate of its
specificity are wide), because this indicates a high degree of
uncertainty around the estimated specificity. In the 2014 ERC-ESICM
Advisory Statement on neuroprognostication after cardiac arrest,297
the most robust predictors were identified as those in which the upper
boundary of the 95% CI of the FPR was below 5%.
For some neuroprognostic tests used after cardiac arrest, such as
the blood values of biomarkers of neurological injury or the grey matter
to white matter density ratio on brain CT, the results are expressed as
a continuous variable. In this case, sensitivity and specificity will
depend on the value of the variable that is chosen as a threshold to
separate positive from negative test results, and the values of
sensitivity and specificity that are obtained by varying the positivity
threshold across all its possible values are expressed by a receiver
operating characteristic (ROC) curve. The problem with dichotomising
continuous predictive variables to obtain a binary test result is that
finding a consistent threshold for 100% specificity is difficult. Very high
values of test results can be caused by outliers, which cause distortion
and reduce test sensitivity.
Main sources of bias in neuroprognostication
One of the major biases in neuroprognostication after cardiac arrest is
self-fulfilling prophecy. This occurs when the treating team is aware of
the result of the prognostic test and uses it for decisions that affect
patient's outcome, e.g., WLST. This leads to an overestimation of the
test performance, and - potentially - to an inappropriate WLST. In a
systematic review on neuroprognostication after cardiac arrest
published in 2013,298,299 64/73 (88%) studies were at risk of self-
fulfilling prophecy bias.
Ideally, to avoid self-fulfilling prophecy bias, the index tests should
be investigated blindly. However, this is difficult to achieve in practice.
Concealing results of clinical examination from the treating team is
almost impossible, while concealing results of EEG or brain imaging
would be unethical, since they may reveal the presence of potentially
treatable complications (e.g., seizures or intracranial hypertension,
respectively). Nevertheless, some predictors such as biomarkers
have been evaluated blindly.230 A special condition limiting the risk of
self-fulfilling prophecy bias is the absence of an active WLST policy.
269
This has been described in some studies conducted in countries or
communities where treatment limitations are not accepted due to
cultural, legal or religious reasons.300,301
Other strategies to reduce the risk of falsely pessimistic predictions
include avoiding confounding from treatments (e.g., sedatives or other
drugs) affecting the results of some predictors, such as clinical
examination or EEG; avoiding basing decisions on life-sustaining
treatments on the results of a single index test, but rather using a
multimodal approach (Fig. 5); and always interpreting the results of the
index tests within the clinical context.
A specific source of bias in neuroprognostic studies after cardiac
arrest is the presence of a time lag between the recording of the index
test, which is usually done very early after the arrest, and the
assessment of the target condition, i.e., neurological outcome. Since
recovery from hypoxic-ischaemic brain injury following cardiac arrest
requires time, the minimum recommended timing for its assessment is
30 days or later from the event or neurological discharge.290 However,
further neurological recovery can occur later. Consequently, an early
prediction of outcome which is confirmed by CPC or mRS measured at
hospital discharge may occasionally prove false when the outcome is
reassessed later.302 For that reason, guidelines suggest reassessing
neurological outcome at three or six months after the event.295 The
majority of studies included in the systematic review informing the
present guidelines reports neurological outcome at least six months
after cardiac arrest.15
Another bias which is partly related to the time delay between index
test assessment and outcome is the interference from extracerebral
causes of death after cardiac arrest. These include cardiovascular
instability, which is the second most common cause of in-hospital
death after cardiac arrest,23 and multiple organ failure due to global
ischaemia-reperfusion injury.303,304 Although the incidence of these
complications is maximal early after arrest, death from extracerebral
organ failure may occur after neurological recovery.305 The preva-
lence of death after awakening was 16% in ICU in a single-centre
study,306 and 4.2% during hospital stay in a recent multicentre
European study including 4646 patients.307 In that study, death
occurred at a median time of 9 (3 18) days after awakening, and it
was more common after IHCA than after OHCA.
Clinical examination
These guidelines are supported by evidence derived from a
systematic review on prognostication and 2020 ILCOR CoSTRs.9,15
The relevant treatment recommendations in the 2020 ILCOR CoSTR
are:
 We suggest using pupillary light reflex at 72 h or later after ROSC
for predicting neurological outcome of adults who are comatose
after cardiac arrest (weak recommendation, very-low-certainty
evidence).
 We suggest using quantitative pupillometry at 72 h or later after
ROSC for predicting neurological outcome of adults who are
comatose after cardiac arrest (weak recommendation, low-
certainty evidence).
 We suggest using bilateral absence of corneal reflex at 72 h or
later after ROSC for predicting poor neurological outcome in adults
who are comatose after cardiac arrest (weak recommendation,
very low-certainty evidence).
 We suggest using presence of myoclonus or status myoclonus
within 96 h after ROSC, in combination with other tests, for
predicting poor neurological outcome in adults who are comatose
after cardiac arrest (weak recommendation, very low-certainty
 RESUSCITATION 161 (2021) 220
evidence). We also suggest recording EEG in presence of
myoclonic jerks in order to characterise the phenotype of the
myoclonus.
Ocular reflexes. Ocular reflexes currently used for neurological
prognostication after cardiac arrest include pupillary reflex and
corneal reflex. The pupillary light reflex (PLR) comprises a
temporary reduction of pupil size induced by a light stimulus.
Standard PLR (s-PLR) is evaluated visually and elicited generally
using a penlight. In recent years, a quantitative evaluation of PLR
using portable pupillometers has become available in the ICU. A
bilaterally absent s-PLR has low specificity for predicting poor
outcome in the first hours after ROSC, but its accuracy
progressively increases, and it achieves 100% specificity after
96 h from ROSC with 20 25% sensitivity.15 This is presumably
due to the process of brain recovery after anoxic-ischaemic injury,
but it may be due partly to interference from sedatives used in the
early post-resuscitation phase to maintain TTM. Standard PLR is
inexpensive and easy to use, but it is subjective and prone to
interrater variability.308
Quantitative evaluation of PLR (automated pupillometry) provides
an objective and quantifiable measurement of the pupillary response.
The most common pupillometry measures are the percentage
reduction of pupillary size, generally indicated as qPLR309 and the
neurological pupil index (NPi).310 NPi is calculated from several
dynamic parameters of the pupillary response (including constriction
and dilation velocity, size, and percentage size reduction after
stimulation) using a proprietary algorithm. A NPi value 3 is considered
normal. Limited evidence showed that, unlike s-PLR, NPi can predict
unfavourable outcome with no false positive results from 24 h or less to
72 h from ROSC.15 In one study this was because of the ability of
pupillometer to detect a response even when the pupil size was very
small, presumably from sedation.310 Results of pupillometry are
expressed as a continuous measure, and threshold for 100% specificity
varied among studies. In three studies included in a recent review this
threshold for NPi was <2.4 before 24 h and 2.0 at 24 72 h.15 Another
limitation of automated pupillometry is its additional cost.
The corneal reflex (CR) is elicited by touching the outer margin
(limbus) of the cornea with a cotton wisp. Alternatively, in order to
minimise the risk of corneal abrasion, an air or water squirt can be
used.311 The corresponding response is represented by an eye blink.
In patients who are comatose after cardiac arrest, an absent CR
predicts poor neurological outcome after 72 h from ROSC with 100%
specificity and 25- 40% sensitivity.15 Like PLR, CR is prone to
interference from sedation. In addition, it may be affected by muscle
relaxants. A recent survey showed that the modalities with which CR is
assessed in comatose patients are inconsistent.312
Motor response
[29_TD$IF]An absent or extensor motor response to pain (motor component [M]
1 or 2 of the Glasgow Coma Score) is associated with poor
neurological outcome after cardiac arrest.15 However, its specificity
is low, almost never achieving 100%, even when it is assessed after
96 h from ROSC. Like CR, motor response is based on striate muscle
contraction and, as such, it can be affected by muscle relaxants.
Because of its high sensitivity (>60% at 72 h or later from ROSC) a
M = 1 2 can be used as a criterion for identifying patients needing
prognostication after cardiac arrest. However, recent evidence
showed that using M  3 as an entry point increases the sensitivity
for prediction of poor outcome without reducing specificity.313
269 241
[30_TD$IF]Myoclonus and status myoclonus
[31_TD$IF]Myoclonus consists of sudden, brief, involuntary jerks caused by
muscular contractions or inhibitions. Their distribution can be focal,
multifocal, or generalised.314 Presence of myoclonus within 96 h
from ROSC in patients who are comatose after cardiac arrest is
associated with poor neurological outcome in most cases.15
However, a false positive rate of up to 22% has been described.315
Most prognostication studies did not provide a definition or
description of myoclonus. In some patients with favourable
outcome, myoclonus may persist after recovery of consciousness
in a chronic form of action myoclonus (i.e., triggered by spontaneous
movements) known as Lance-Adams syndrome.182,316
Clinical myoclonus can inconsistently be associated with electrical
seizures, therefore recording an EEG can be useful. Some studies
have identified specific EEG features associated with benign
myoclonus, such as a reactive179,184 and/or continuous EEG
background.179,181 The presence of diffuse and continuous myoclonic
jerks is usually described as status myoclonus. However, a consensus
definition of status myoclonus is lacking. The 2014 ERC-ESICM
Advisory Statement on neurologic prognostication after cardiac arrest
suggested that in comatose survivors of cardiac arrest status
myoclonus should be defined as a continuous and generalised
myoclonus persisting for 30 min or more.297 Evidence from two
studies that did not distinguish electrographic features of status
myoclonus15 showed that status myoclonus within 24 h317 or within
seven days from ROSC178,317 is almost invariably associated with
poor neurological outcome (specificity 99 100%).
The advantages of predictors based on clinical examination include
minimal equipment and costs (except pupillometry) and availability at
the bedside. Their major limitations include interference from sedatives,
opioids, and except for the PLR from muscle relaxants. In addition,
their assessment is prone to subjectivity. Use of automated assess-
ment, like pupillometry for PLR, may at least address these limitations.
Finally, results of clinical examination cannot be concealed from the
treating team, potentially causing a self-fulfilling prophecy bias.
[32_TD$IF]Neurophysiology
These guidelines are supported by evidence derived from a
systematic review on prognostication and 2020 ILCOR CoSTRs.9,15
The relevant treatment recommendations in the 2020 ILCOR CoSTR
are:
 We recommend that neuroprognostication always be undertaken
using a multi-modal approach because no single test has sufficient
specificity to eliminate false positives (strong recommendation,
very-low-certainty evidence).
 We suggest using a bilaterally absent N20 wave of somatosensory
evoked potential (SSEP) at 24 h from ROSC in combination with
other indices to predict poor outcome in adult patients who are
comatose after cardiac arrest (weak recommendation, very low-
certainty evidence).
 We suggest against using the absence of EEG background
reactivity alone to predict poor outcome in adult patients who are
comatose after cardiac arrest (weak recommendation, very low-
certainty evidence).
 We suggest using the presence of seizure activity on EEG in
combination with other indices to predict poor outcome in adult
patients who are comatose after cardiac arrest (weak recommen-
dation, very low-certainty evidence).
 We suggest using burst-suppression on EEG at 24 h from ROSC
in combination with other indices to predict poor outcome in adult
242 RESUSCITATION 161 (2021) 220
patients who are comatose and who are off sedation after cardiac
arrest (weak recommendation, very low-certainty evidence).
Electroencephalography (EEG)
[3_TD$IF]Electroencephalography (EEG) is one of the most widely used and
studied methods to assess brain function and prognosis after
cardiac arrest.318 EEG is also important for diagnosing and treating
seizures.
The main aspects when assessing EEG are the background
activity, superimposed discharges and reactivity. The EEG back-
ground continuity is most important for the prognosis and is commonly
categorised as continuous, discontinuous, burst suppression (50
99% suppression periods) or suppression (>99% activity <10 mV
amplitude).319 A standardised terminology for critical care EEG has
been proposed by the ACNS.187
Immediately after a cardiac arrest, the EEG is suppressed in many
patients, but it returns to a continuous normal voltage EEG within the
first 24 h in most patients who ultimately achieve a good out-
come.320,321 The time for this restitution is correlated with
outcome.319,322 The EEG-background is often discontinuous and of
low frequency on its first appearance.320,323 Sedative drugs affect
background continuity and have the potential to induce discontinuous
or burst-suppression background in a dose-dependent manner.324,325
[34_TD$IF]Background patterns
Suppression
A suppressed (<10 mV) or low-voltage (<20 mV) background is
relatively common during the first day after a cardiac arrest in patients
who later recover.300,320,321 However, 24 h after ROSC, a suppressed
EEG-background <10 mV is a reliable sign of a poor prognosis,326 331
although two false positive predictions by this pattern 48 72 h after
cardiac arrest were reported in one study.328 There was moderate
interrater agreement for suppressed background among senior
neurophysiologists.328,332
[35_TD$IF]Burst suppression
According to the ACNS-terminology, burst suppression (BS) is
defined as 50 99% of the recording consisting of suppression
alternating with bursts. The terminology does not have any
amplitude criteria for the bursts but these may be defined further
as ‘highly epileptiform bursts’, based on appearance 187 ‘Presence
of ‘identical bursts’ (either the first 0.5 s of each burst or each
stereotyped cluster of 2 bursts appears visually similar in >90%
of bursts in each channel) portend a poor prognosis in post-anoxic
coma.333 One research group also proposed a separation of BS-
patterns into ‘synchronous’ (with highly epileptiform or identical
bursts) and ‘heterogenous’ (not ‘synchronous’).331 The criteria
used for burst amplitude and appearance varies considerably
between studies. A substantial portion of patients with BS during
the first 24 h and occasional patients with BS-pattern after 24 h still
have a good outcome, which is possibly related to sedation
use.302,320,326 328,334 336 There was substantial interrater agree-
ment among experienced neurophysiologists for BS.328
[36_TD$IF]Discontinuous
A discontinuous background with suppression periods >10% of
the recording has low prognostic performance during the first
24 h after cardiac arrest337,338 and an inconsistent performance
after 24 h.326 328,338
269
[37_TD$IF]Reactivity
EEG-reactivity is a measurable change in amplitude or frequency
upon external stimulation (auditory and pain). There is no generally
acknowledged standard for reactivity testing and the prognostic
performance of this feature varied substantially between studies.15,339
Absence of EEG-reactivity during the first 24 h after cardiac arrest is
an indicator of a poor outcome with high sensitivity but low
specificity (41.7 87.5%).336,340 342 After 24 h, the sensitivity of
absent reactivity remains high but the specificity varied from 50 to
100%.326,328,334,336,341 345 Interrater agreement for the assessment
of EEG-reactivity varied from slight-almost perfect.328,346 Stimulus-
evoked rhythmic, periodic or ictal discharges (SIRPIDS) are not a
manifestation of normal background reactivity their prognostic
significance is still undefined.203,347
[38_TD$IF]Superimposed patterns
[39_TD$IF]Periodic discharges
A ‘periodic’ pattern is a waveform that occurs repeatedly, with a
quantifiable interval between discharges. If no such interval exists,
the pattern is termed ‘rhythmic’.187 Periodic discharges (PDs) may
be superimposed on various backgrounds and are related to a
worse prognosis. Generalised periodic discharges (GPDs) are a
sign of a poor prognosis with limited specificity.326,327,330,334 In
general, the background on which PDs appear is more related to the
neurological outcome.319 PDs on a continuous and reactive EEG-
background should not be considered as an indicator of a poor
outcome.181
[40_TD$IF]Sporadic epileptiform discharges
[41_TD$IF]‘Sporadic epileptiform discharges’ describes sharp waves or spikes
resembling those seen in patients with epilepsy, but without the
regularity of a periodic pattern. The frequency by which they appear
may vary extensively from ‘rare’ (<1 h 1) to ‘abundant’ (1/10 s),
bordering on periodic discharges. While their appearance is related to
a worse outcome, their specificity to predict poor outcome ranges from
66.7 to 100%15 and reports on the potentially important frequency or
number of discharges was lacking in studies.300,328,330,331 Presence
of sporadic epileptiform discharges is NOT a reliable indicator of a
poor neurological prognosis.
[42_TD$IF]Electrographic seizures and electrographic status epilepticus
[20_TD$IF]The ACNS defines ‘unequivocal seizures’ as generalised rhythmic
spike-and-wave discharges with a frequency 3 Hz or clearly evolving
discharges of any type >4 Hz.187 This definition was inconsistently
used in studies. Seizures had a low sensitivity but high specificity for a
poor outcome regardless of timing.326,328,330,334,348
The term ‘electrographic status epilepticus’ (ESE) is defined as an
electrographic seizure for 10 continuous minutes or for a total
duration of 20% of any 60-min period of recording. This definition has
been included for the first time in the 2021 update of the ACNS
terminology and none of the currently available prognostic studies has
incorporated it yet. Some studies based their definition of ESE on the
ACNS classification of unequivocal seizures extending 30 min but
also included epileptiform discharges 1 Hz,197,322 and in one study
0.5 Hz as ESE.349 Other studies had an unclear definition of
ESE.302,334,335,341 The proportion of patients classified with ESE
varied considerably between studies, possibly reflecting differences in
definitions. One study showed that ESE evolves from high frequency
discharges early after onset to progressively slower frequencies
 RESUSCITATION 161 (2021) 220
during the following days and weeks.186 Regardless of the
classification used, ESE is associated with a worse prognosis after
cardiac arrest, but some patients have a good outcome.196,197,199 As
with periodic discharges, it is important to consider if the EEG-
background is continuous and reactivity is present, which are both
favourable features.197,199 Because of the lack of a standardised
classification, we recommend avoiding the term ‘status epilepticus’ for
assessments of prognosis but instead to classify the EEG-background
and superimposed discharges and unequivocal seizures according to
the standardised ACNS terminology.187
[43_TD$IF]Categories of patterns
[6_TD$IF]In several studies, the most unfavourable patterns were grouped as
‘malignant’ or ‘highly malignant’. The most common grouping included
suppressed background with or without periodic discharges and burst-
suppression as ‘highly malignant patterns’.326 There was substantial
interrater agreement for these ‘highly malignant patterns’,346 and the
specificity for poor outcome was 90.6 100%.326,327,329,336,338,340,350
An alternative categorisation of ‘unfavourable patterns’ using a stricter
definition of burst-suppression has been suggested.331
[4_TD$IF]Quantitative EEG-indices
[45_TD$IF]Automated assessment of quantitative EEG-features such as the burst-
suppression amplitude ratio and reactivity has been tested in individual
studies.351,352 Combinations of quantitative EEG-features include the
Bi-spectral index (BIS) and the Cerebral Recovery Index.353 The
threshold value and specificity for BIS to predict poor outcome varied
widely between studies.354 356 Automated assessments may decrease
subjectivity in EEG assessments. Prospective multi-centre studies are
needed to assess the prognostic performance after cardiac arrest.
[46_TD$IF]Evoked potentials
Somatosensory evoked potentials (SSEPs)
When performing SSEPs the median nerve is electrically stimulated and
the ascending signals are recorded from the peripheral plexus brachialis,
cervical level, subcortical level and the sensory cortex (N20-potential).
SSEPs may be depressed by barbiturate coma but are preserved with
other sedative drugs such as propofol and midazolam.357 A bilateral
absence of the short-latency N20-potentials over the sensory cortex is a
reliable sign of a poor prognosis after cardiac arrest with high specificity
and limited sensitivity both early and late after cardiac ar-
rest.201,202,302,310,331,335,337,338,340,342,343,350,352,358 366 Occasional false
positive predictions were reported.367 The interrater reliability for
interpretation of SSEPs was moderate to good.368,369 The quality of
the recording is very important and noise from muscle activity is an
important limiting factor which may be eliminated by neuromuscular
blocking drugs.357,368
[48_TD$IF]Visual evoked potentials (VEP) and auditory evoked potentials
(AEP)
[14_TD$IF]There are few data supporting the use of visual evoked potentials
(VEPs)358 and auditory evoked potentials (AEPs)361,364 to prognosti-
cate outcome after cardiac arrest. These results need validation
before VEPs or AEPs can be recommended in this context.
[49_TD$IF]Biomarkers
These guidelines are supported by evidence derived from a systematic
review on prognostication and 2020 ILCOR CoSTRs.9,15 The relevant
treatment recommendations in the 2020 ILCOR CoSTR are:
269 243
 We recommend that neuroprognostication always be undertaken
using a multi-modal approach because no single test has sufficient
specificity to eliminate false positives (strong recommendation,
very-low-certainty evidence).
 We suggest using neuron specific enolase (NSE) within 72 h after
ROSC, in combination with other tests, for predicting neurological
outcome of adults who are comatose after cardiac arrest (weak
recommendation, very-low-certainty evidence). There is no
consensus on a threshold value.
 We suggest against using S-100B protein for predicting
neurological outcome of adults who are comatose after cardiac
arrest (weak recommendation, low-certainty evidence).
 We suggest against using serum levels of glial fibrillary acidic
protein (GFAP), serum tau protein, or neurofilament light chain
(Nfl) for predicting poor neurological outcome of adults who are
comatose after cardiac arrest (weak recommendation, very low-
certainty evidence).
Protein biomarkers that are released following injury to neurons and
glial cells may be measured in blood and are likely to correlate with the
extent of brain injury and with neurological outcome. Neuron-specific
biomarkers include NSE, Nfl and tau protein, while S100B and GFAP
originate from astrocytes. Neuron specific enolase has been recom-
mended for assessment of brain injury and to help prognosticate
outcome after cardiac arrest since the last revision in 2015.2 Their actual
use in clinical practice, however, is not known. Several reports on novel
biomarker candidates have been published since 2015.231,370 372
Importantly, a multimodal approach should be used for assess-
ment of comatose survivors after cardiac arrest. Advantages of
biomarkers include quantitative results, the relative ease of sampling
and interpretation and their independence from the effects of
sedatives. Limitations include availability, lack of robust laboratory
references, insufficiently large study populations, and lack of external
validation for some. Most of the available evidence is limited to a time
span of up to 72 h after cardiac arrest which is relevant for most
patients. However, it necessitates a strategy for prospective sampling
before the assessment of prognosis >72 h post-arrest. Very limited
evidence supports the use of biomarkers after 72 h in patients who fail
to awaken. Large studies investigating and validating promising novel
biomarkers are needed to confirm their predictive value, to assess
their reproducibility, and to identify consistent thresholds for a
specificity that should be close to 100%. The rationale for accepting
a specificity of less than 100% would be that using blood biomarkers,
there will always be outliers that must be taken into consideration, e.g.
due to poor calibration or issues with laboratory standards,
haemolysis or due to poor technique in handling of samples.
Demanding 100% specificity from a blood biomarker will lower the
sensitivity to levels where their clinical use can be questioned, while
allowing an FPR of 1% or 2% will increase their clinical relevance. With
a multimodal approach, every prognostic method used for assess-
ment of an individual patient must point in the same direction in order to
be trusted. This may be particularly true for biomarkers because of
their continuous nature; normal or mildly elevated levels (at correct
sampling time) should always alert the clinician of potential error in
other methods indicating poor prognosis.
Neuron-specific enolase (NSE)
[50_TD$IF]Neuron specific enolase has been studied extensively; since the last
systematic reviews,298,299 at least 13 observational studies have been
published with threshold values ranging from 33 120 mg L 1 within 72 h
244 RESUSCITATION 161 (2021) 220
predicting poor neurological outcome from hospital discharge to 6 months
with specificity ranging from 75 100% and sensitivity ranging from 7.8%
to 83.6%. In the largest study to date, outliers were described.373 Patients
with high NSE (>90 mg L 1) and good outcome had confounders for NSE
elevation and most patients with low NSE (<17 mg L 1) who died had a
cause of death other than hypoxic/ischaemic encephalopathy. The study
was excluded from the recent systematic review because the primary
outcome was CPC at ICU discharge.15 A large substudy of the TTM-trial
identified a threshold of 48 mg L 1 at 48 h and a threshold of 38 mg L 1 at
72 h with a specificity of 98% (FPR 2%) for poor neurological outcome at 6
months.230 In another study, NSE with a threshold of 50.2 mg L 1 at day
4 predicted poor neurological outcome at one month with 100% specificity
and 42.1% sensitivity.374
NSE decreases after 24 h in patients with good outcome and typically
increases in patients with a poor outcome to peak at 48 96 h. NSE
performs poorly at 24 h and best at 48 or 72 h. High NSE at 48 or 72 h after
cardiac arrest is a robust predictor of a poor outcome.230,365,373 378
Increasing NSE from 24 48 or 48 72 h is a reliable indicator of a poor
prognosis with similar performance as the absolute value.379 One small
study found that a 48:24 h NSE ratio 1.7 had a 100% specificity for poor
outcome.375 In a recent study, the prognostic performance of NSE was
clearly dependent on age and severity of the insult (time to ROSC).380 It
performed best in the youngest quartile and in patients with longer time to
ROSC. Several different analytical assays were used in the included
studies but the methodology for routine clinical use provided by Roche
and Brahms were most frequent. NSE has been used as a surrogate
marker for brain injury in two recent trials.75,96
Thresholds for high NSE values must be established in
collaboration with the local laboratory considering the analytical
method. Red blood cells contain NSE so haemolysis (free haemo-
globin) must be measured and samples discarded if the haemolysis
index threshold is exceeded because this may generate a falsely high
NSE value.381 The half-life of free haemoglobin is approximately 2
4 h compared with the 30-h half-life of NSE. Thus, the NSE value
may be inappropriately increased (by NSE from red blood cells) at a
time when free haemoglobin is no longer detectable, which is a
concern when using NSE for prognostication after cardiac arrest.381
[51_TD$IF]S100B
Three observational studies have been published since
2013,376,377,382 two of them investigated S100B immediately after
ROSC and identified threshold values ranging from 3.56 to 16.6 with
100% specificity of poor outcome but with low sensitivities of 2.8% to
26.9%. In the largest study, S100B discriminated best at 24 h with a
threshold value of 2.59 mg L 1 for 100% specificity but with a low
sensitivity of 10%, the corresponding sensitivity for 98% specificity
(2% FPR) was 32% (threshold value 0.36 mg L 1).382 The authors
concluded that S100B did not add any real value to present
prognostication models with or without NSE. S100B is also very
rarely used in clinical practice and for these reasons is not included in
our recommendations.
[52_TD$IF]Glial fibrillary acidic protein (GFAP)
[6_TD$IF]In one observational study with 100 patients, GFAP with a threshold
value of 0.08 mg L 1 at 48 h  12 h predicted poor neurological
outcome at one month with 100% specificity and 21.3% sensitivity.370
[53_TD$IF]Serum Tau
In one study, serum tau protein with a threshold value ranging from
72.7 to 875.6 ng L 1 predicted poor neurological outcome at 6 months
269
with 100% specificity and a sensitivity of 4% to 42% (very low certainty
of evidence).371 An ultra-sensitive single molecule assay (SIMoA) was
used, with a detection limit at the single molecular level.383
[54_TD$IF]Serum neurofilament light chain (Nfl)
[6_TD$IF]In one large study, serum Nfl with a threshold value ranging from 1539
to 12,317 pg mL 1 at 24 72 h predicted poor neurological outcome
(CPC 3 5) at 6 months with 100% specificity and sensitivity ranging
from 53.1% to 65% (moderate certainty of evidence).231 The same
ultra-sensitive SIMoA technique was used for detection of Nfl as was
used for tau protein (see above). In a post hoc analysis of the
COMACARE trial, which used the same SIMoA technique for analysis,
thresholds for serum Nfl that achieved 99% specificity for a poor
outcome were 127, 262, and 344 pg mL 1 at 24 h, 48 h and 72 h
respectively; sensitivities ranged from 78% to 85%.384 In another
study that did not use the SIMoA technique, serum Nfl with a threshold
value ranging from 252 to 405 pg mL 1 from day 1 to day 7 predicted
poor neurological outcome (CPC 4 5) at 6 months with 100%
specificity and sensitivity ranging from 55.6% to 94.4%.372
[5_TD$IF]Imaging
These guidelines are supported by evidence derived from a
systematic review on prognostication and 2020 ILCOR CoSTRs.9,15
The relevant treatment recommendations in the 2020 ILCOR CoSTR
are:
 We suggest using brain imaging studies for prognostication only in
centres where specific experience is available (weak recommen-
dation, very-low-quality evidence).
 We suggest using the presence of a marked reduction of the grey
matter/white matter (GM/WM) ratio on brain CT within 72 h after
ROSC or the presence of extensive diffusion restriction on brain
MRI at 2 to 7 days after ROSC in combination with other predictors
for prognosticating a poor neurologic outcome in patients who are
comatose after cardiac arrest and who are treated with TTM (weak
recommendation, very-low-quality evidence).
Computed tomography (CT) of the brain
[56_TD$IF]Following cardiac arrest, hypoxic-ischaemic brain injury causes
cytotoxic oedema, which appears as an attenuation of the GM/WM
interface, and vasogenic oedema leading to brain swelling, visible as
an effacement of cortical sulci.385 Measurement of the ratio between
the GM and the WM densities (GWR), expressed in Hounsfield units is
a method to quantify the degree of oedema. The density of the GM is
higher than that of the WM, so that GWR is normally higher than 1. The
lower the GWR, the greater the severity of brain oedema.
GWR reduction occurs early in patients with severe hypoxic-
ischaemic brain injury. In a recent systematic review most studies on
reduced GWR showed that this sign was 100% specific for poor
neurological outcome as early as 1 h after ROSC.15 However, in
other studies,301,386 388 a reduced GWR was 100% specific for poor
neurological outcome up to 72 h after ROSC. The methods for GWR
measurement varied across studies. In most of them, GWR was
calculated between GM and WM areas within the basal ganglia. In
others, measurements within the cerebrum (centrum semiovale and
high convexity area) were performed.389 391 In almost all studies, a
GWR threshold for 100% specificity was identified. However, its
value varied across studies. For instance, the threshold for 100%
specificity of the average GWR measured at the basal ganglia and
the cerebrum ranged from 1.1 and 1.23 within 2 h from ROSC.15
GWR sensitivity also varied widely across studies, probably
 RESUSCITATION 161 (2021) 220
reflecting differences between scanners and software,392 in the
methods of calculation, or in the aetiology of the arrest.390,393 In one
substudy of the TTM trial, oedema on brain CT was assessed
visually without formal GWR measurement.394 In that study,
specificity for poor neurological outcome was 98.4 [94.3 99.6]%
with 33.6 [28.1 39.5]% sensitivity. Most studies on brain CT were
single centre with retrospective design.
[57_TD$IF]Magnetic resonance imaging (MRI) of the brain
[58_TD$IF]Along with CT, magnetic resonance imaging (MRI) of the brain is the
most investigated imaging-based predictive index in patients who are
comatose after cardiac arrest.15 Brain MRI is more challenging to
perform in ventilated ICU-patients and MRI was generally performed
later than brain CT, usually at 48 h or later from ROSC. On brain MRI,
cytotoxic oedema from hypoxic-ischaemic brain injury appears as a
hyperintensity on diffusion-weighted imaging (DWI) sequences.395 In
several studies, presence of DWI lesions is associated with poor
neurological outcome after cardiac arrest.389,396 399 However, the
assessment was done qualitatively, and specificity was inconsistent
(range 55.7 100%). Apparent diffusion coefficient (ADC) enables a
semiquantitative assessment of DWI changes, therefore limiting
subjectivity. However, the ADC metrics in prognostication studies
varied.15 These include lowest minimum or mean ADC,400 mean
ADC,401 the proportion of brain volume below a given ADC
threshold,401,402 and the maximum size of the MRI clusters with
minimum ADC.400 Most of these studies assessed global ADC, while
one of them assessed regional ADC.400 In all these studies, an ADC
threshold for 100% specificity was identified, often with sensitivities
above 50%. All studies on ADC MRI had a small sample size, which
limited their precision. In many studies, imaging was performed at the
discretion of the treating physician, which may have introduced a
selection bias.
Unlike clinical examination and EEG, imaging studies are not
prone to interference from sedative drugs. In addition, they can be
assessed blindly. Their major limitation is the lack of standardisation
of measurement techniques. Despite the available studies showed a
high accuracy both for brain CT and MRI, the number of studies was
limited with a wide variability in the adopted measurement
techniques which greatly limits the reproducibility of their results.
For this reason, it is reasonable to reserve the use of imaging
studies for prognostication only in centres where specific experi-
ence is available. Since there is currently no standard for CT-GWR
or MR-ADC measurements these techniques can be recommended
to confirm the presence of generalised and extensive ischaemic
injury apparent from conventional visual analysis by an experienced
neuroradiologist. Finally, imaging studies cannot be performed at
the bedside and MRI may not be feasible in the most unstable
patients, which limits its applicability especially in the early post-
resuscitation period.
[32_TD$IF]Multimodal prognostication
In 2015, the ERC-ESICM Guidelines on Post-Resuscitation Care
included an algorithm for the prediction of poor neurological outcome
in patients who are comatose after cardiac arrest.1 This algorithm has
been validated in recent retrospective studies. One study in 226
patients showed that the 2015 ERC-ESICM prognostication guide-
lines had a 0% FPR for predicting poor outcome (CPC from 3 to 5) both
at hospital discharge and at six months.302 Similarly, in a larger single-
centre cohort including 485 comatose resuscitated patients the ERC-
ESICM algorithm predicted CPC 3 5 with 0% FPR in 155 patients.403
269 245
Among the remaining 330 patients in whom no major predictor or
combination of predictors suggesting poor outcome were detected,
two thirds had good neurological outcome at three months. Finally, in a
retrospective multicentre cohort of 585 patients from the TTM trial, the
ERC-ESICM algorithm had 0% (95% CI 0 1.2%) FPR for predicting
poor neurological outcome at six months.313
The 2015 ERC-ESICM prognostication algorithm was based on a
combination of predictors including results of clinical examination
(absent or extensor motor response, absent pupillary and corneal
reflexes, status myoclonus), biomarkers (high blood values of NSE),
electrophysiology (unreactive burst-suppression or status epilepticus
on EEG, bilaterally absent N20 SSEP wave) and imaging (signs of
diffuse anoxic brain injury on CT or MRI). The evidence supporting
these predictors had been assessed in two reviews published in
2013.298,299 To facilitate an update for the present guidelines, a new
review has been conducted and its results are reported in the previous
paragraphs of the present guidelines focusing on individual
prognostication modalities.15 The 2020 review largely confirmed
the results of the 2013 reviews and the reliability of the predictors
suggested in the 2015 algorithm. However, some important differ-
ences were noted:
 Absent pupillary and corneal reflexes achieved 0% FPR
consistently only after day 4, rather than after day 3 as in the
previous review.
 Automated measurement of absent pupillary reflex using
pupillometry may enable a more accurate prediction than standard
(manual) assessment of pupillary reflex (s-PLR), and it is more
reproducible.
 The accuracy of NSE was higher at 48 72 h than at 24 h from
ROSC.
 The low FPR of unreactive EEG background documented in a few
of the studies on TTM-treated patients in the 2013 review was not
confirmed in the 2020 review.
 No consistent definition was found for status epilepticus, a
predictor suggested in the 2015 guidelines.
 Presence of a suppressed EEG background or burst-suppression
predicted poor outcome with very low FPR, especially when
recorded after 24 72 h from ROSC; in the previous reviews,
evidence supporting suppression was negligible, and definitions
of burst-suppression were heterogeneous.
 Several prognostication studies classified EEG according to the
Standardised Critical Care EEG Terminology (2012 version) of the
American Clinical Neurophysiology Society (ACNS).404
The risk of bias for most of the available studies was high. As in
previous reviews, a major limitation in most studies was lack of
blinding; furthermore, several predictors of poor neurological outcome
were used as criteria for WLST. In both cases, this may have resulted
in a self-fulfilling prophecy. However, the 2020 review included studies
where no WLST was performed, therefore limiting the risk of self-
fulfilling prophecy.300,358,387,393,398 Predictors assessed in these
studies included EEG, SSEPs, and brain CT. Based on results of
the 2020 review, most of the recommendations included in the
2015 prognostication algorithm remain valid.
Suggested prognostication strategy
Prognostic assessment should start with an accurate clinical
examination.405 Its main scope is to confirm that the patient is
comatose because of hypoxic-ischaemic brain injury. Clinical
examination should be performed daily to detect signs of neurological
246 RESUSCITATION 161 (2021) 220
recovery such as purposeful movements or to identify a clinical picture
suggesting impending brain death. The latter may include fixed,
dilated pupils, diabetes insipidus, and cardiovascular changes
suggesting herniation, such as bradycardia associated with hyper-
tension or an otherwise unexplained haemodynamic instability. Brain
death occurs in 5 10% of patients who die after cardiac arrest
resuscitated with conventional CPR and in about 25% of patients who
die after resuscitation with extracorporeal CPR.286 In most cases,
brain death occurs during the first 3 4 days after ROSC. A suggested
algorithm for brain death screening after cardiac arrest is shown in
Fig. 7. The World Brain Death Project (WBDP) consensus group has
published detailed guidance on the determination of brain death after
treatment with targeted temperature management (TTM).406
In most patients, awakening from coma following cardiac arrest
occurs within 3 4 days from ROSC.202,305 However, patients who are
initially unconscious following cardiac arrest are usually treated with
sedatives and neuromuscular blocking drugs to enable targeted
temperature management (TTM), and to facilitate mechanical
ventilation and other life support measures. Therefore, to enable a
reliable clinical examination, these drugs should be stopped for
sufficient time to avoid interference from their effects. The WBDP
consensus group recommends that clinical examination be delayed
until at least 5 elimination half-lives of the drug administered with the
longest half-life.406 Although this recommendation has been made in
the context of diagnosing brain death, it is equally relevant to
prognostic assessment if this is being used to make a WLST decision.
Short-acting drugs are preferred whenever possible but even a short-
acting drug such as propofol has a half-life of 2.3 4.7 h, which implies
the need to stop sedatives for at least 24 h in most cases. This will be
much longer if there is renal and/or hepatic impairment or if longer-
acting drugs have been given. When residual sedation or paralysis is
suspected, consider using antidotes to reverse the effects of these
drugs. Use caution when administering flumazenil to reverse the effect
of benzodiazepines because this may precipitate seizures. Apart from
sedation and neuromuscular blockade, other major confounders
include hypothermia, severe hypotension, sepsis, and metabolic or
respiratory derangements.
A poor motor response has a relatively low specificity, but a high
sensitivity for prediction of poor neurological outcome after cardiac
arrest. Therefore, it can be used to identify patients needing
prognostication. An absent or extensor motor response (M  2) of
the Glasgow Coma Scale was the entry point of the 2015 prognosti-
cation algorithm. However, recent evidence showed that using
M  3 as an entry point increases the sensitivity for prediction of
poor outcome without reducing specificity.313,407 The prognostication
strategy described below applies to patients who are comatose with a
motor response (M) equal to or below 3 (abnormal flexion, extension,
or nil) at 72 h after ROSC. Results of earlier prognostic tests are also
considered at this time.
Signs suggesting the potential for recovery should be actively
sought. These are often identified early in the clinical course after
resuscitation. In a study on 357 comatose survivors of cardiac arrest, a
benign EEG (continuous, reactive, non-suppressed background
without epileptiform discharges) recorded within 24 h from ROSC
predicted good neurological outcome with 76 [69 82]% sensitivity
and 88 [82 92]% specificity.338 In 250 patients with indeterminate
outcome on day 3 according to the 2015 ERC-ESICM prognostication
algorithm presence of a benign EEG was associated with good
neurological outcome in 184 cases (positive predictive value 74%).403
Among 14 patients who recovered after their outcome was defined as
269
indeterminate in another validation study, the majority had low and
decreasing NSE values and all but one had ventricular fibrillation on
the initial ECG.313 Other potentially useful indices of good neurological
outcome include absence of diffusion changes on brain MRI and low
blood values of neurofilament light chain within 72 h from
ROSC.231,389,397,398 Recent evidence showed that a benign EEG is
not associated with the presence of other predictors of poor
neurological outcome, especially a bilaterally absent N20 SSEP
wave.408 410 Therefore, when predictors suggesting a potential for
recovery coexist with others suggesting a poor outcome, there is a
chance that the latter signal is a false positive. We suggest that in this
case the results of predictive indices are reassessed, and index tests
be repeated if possible.
In a comatose patient with M  3 at 72 h from ROSC, in absence
of confounders, poor outcome is likely when two or more of the
following predictors are present: no pupillary and corneal reflexes at
72 h, bilaterally absent N20 SSEP wave at 24 h, highly malignant
EEG at >24 h, NSE >60 mg/L at 48 h and/or 72 h, status myoclonus
72 h, or a diffuse and extensive anoxic injury on brain CT/MRI. Most
of these signs can be recorded before 72 h from ROSC, however their
results will be evaluated only at the time of clinical prognostic
assessment. A recent study has shown that a strategy of using
2 predictors had 0 [0 8]% FPR compared with 7 [1 18]% of the
2015 ERC-ESICM stepwise strategy (due to false positives for
pupillary light reflexes).411
Evidence from both the 2013 and the 2020 reviews showed that a
bilaterally absent N20 SSEP wave is the most widely documented
predictor of poor outcome and the one most consistently associated
with 100% specificity. However, false positive predictions have
occasionally been reported. In some of these cases, the cause of a
false positive result was an incorrect reading of the SSEP record
because of artefacts.412 Neuromuscular blockade improves readabil-
ity of SSEPs and it should be considered whenever possible.413
Pupillary light reflex and corneal reflex are also very specific for poor
outcome when bilaterally absent at 72 h or more after ROSC. Based on
expert opinion, we suggest that both reflexes should be absent at the
time of prognostic assessment for them to reliably predict poor
outcome. Unlike SSEPs, ocular reflexes are prone to interference from
sedation. Corneal reflexes may also be affected by neuromuscular
blocking drugs. These confounders should be excluded before ocular
reflexes are assessed. Visual evaluation of PLR may be hampered
when the pupil size is less than 6 mm.308 Limited evidence shows that in
resuscitated comatose patients automated pupillometry is more
sensitive than s-PLR in detecting pupil response to light when pupil
size is small, which reduces the risk of false positive results.310 Unlike s-
PLR, automated pupillometry delivers a stimulating light source with
standard characteristics (intensity, duration, and distance from the eye)
and measures pupillary response quantitatively, which ensures
reproducibility. For this reason, we suggest detecting the absence of
PLR with a pupillometer, if available.
Status myoclonus is a prolonged period of myoclonic jerks.
Although there is no universal definition for status myoclonus, based
on our previous definition1 we suggest that, in comatose survivors of
cardiac arrest, status myoclonus should be defined as a continuous
and generalised myoclonus persisting for 30 min or more. In the
2020 review informing the present guidelines, status myoclonus was
documented in two studies, one of which used a definition comparable
to that given above. In total, among 113 patients showing this sign,
there was only one false positive result. Aside from duration and
continuity, other clinical features of myoclonus suggest poor outcome.
 RESUSCITATION 161 (2021) 220
These include a generalised (vs. focal), axial (vs. distal), or
stereotyped (vs. variable) distribution. Conversely, some EEG
features, such as a continuous or reactive background or presence
of spike-wave discharges synchronised with the myoclonic jerks
indicate a potential for good outcome.181 We suggest recording an
EEG in patients with post-arrest status myoclonus, in order both to
identify an associated epileptiform activity and to detect signs
associated with potential recovery.
Among unfavourable EEG patterns, those more consistently
associated with poor neurological outcome are suppression and burst
suppression. According to the ACNS, a suppressed EEG background
is defined as >99% of activity having a voltage less than 10 mV, while
burst-suppression is defined as 50 99% of the record consisting of
suppression, alternated with bursts. In the 2013 reviews, definitions of
these patterns were inconsistent. We suggest using the ACNS
terminology when assessing these patterns for prognostication, in
order to ensure an unequivocal identification.187 During the first 12
24 h after ROSC, both these patterns have a greater prevalence,
but also a higher risk of false positive prediction. Confounding from
sedatives used to facilitate TTM may contribute to this. We suggest
using these EEG patterns for prognostication only after 24 h from
ROSC. Absence of EEG background reactivity has an inconsistent
specificity for poor neurological outcome and we no longer
recommend using it for this purpose.
High blood NSE values are a sign of neuronal cell damage and
have long been recommended as a predictor of poor neurological
outcome after cardiac arrest.414 However, there is still uncertainty
about what are the optimal timings and thresholds. Evidence from our
review showed that, while prediction with 0% FPR can be achieved
anytime from 24 h to 7 days after ROSC, the sensitivity of an individual
NSE measurement for prediction of poor neurological outcome with
0% FPR is highest at 48 72 h after ROSC.15 However, our review
confirmed that the NSE threshold value for 0% FPR is inconsistent
because of a few patients with good neurological outcome despite
very high NSE values. The presence of these outliers can be partly
explained with a release of NSE from extracerebral sources, such as
red blood cells or neuroendocrine tumours. Repeated blood sampling
and careful exclusion of extracerebral sources is recommended when
using NSE for neuroprognostication. Another cause of variability for
the NSE thresholds is represented by the different measurement
techniques used.381 In our 2020 review, the highest recorded NSE
thresholds for 0% FPR at 48 and 72 h from ROSC were 120 mg L 1
and 79 mg L 1, respectively. However, these data refer to outliers, and
in most studies the 0% FPR threshold was 60 mg L 1 and 50 mg L 1,
respectively. Based on these data, we presume that the risk of a false
positive prediction associated with an NSE value of 60 mg L 1 is
minimal, especially because the NSE signal should be confirmed by at
least another predictor. Nevertheless, we suggest that hospital
laboratories using NSE create their own normal values and cut-off
levels based on the test kit used. Increasing NSE values between 24 h
and 48 h or between 24/48 h and 72 h also suggests a poor outcome
even if the incremental prognostic value of adding NSE trends to a
single NSE value is uncertain.15,375,379 We suggest performing serial
NSE samples at 24, 48, and 72 h after ROSC so that NSE trends can
be detected and confounding from occasional haemolysis can be
minimised.
Signs of diffuse and extensive hypoxic-ischaemic brain injury on
brain CT include an effacement of cortical sulci and reduced ventricle
size (mainly from vasogenic oedema) and a reduced density of the
grey matter with reduction or loss of the grey matter/white matter (GM/
269 247
WM) interface due to cytotoxic oedema. In the review informing these
guidelines, the first sign was evaluated qualitatively in one study,394
based on visual inspection from a neuroradiologist, while most studies
assessed the reduced GM/WM interface as the ratio of the densities of
the grey matter and the white matter (GWR) measured in Hounsfield
units. This was generally done within 2 h from ROSC, but some studies
assessed GWR within 24 h,301,386 and one within 72 h.388 As for other
predictors based on continuous variables, the GWR thresholds for 0%
FPR varied across studies, presumably because of variations in the
methods for GWR calculation, or in the software or scanner’
characteristics.15
Hypoxic-ischaemic brain injury reduces water diffusivity, which
appears on magnetic resonance imaging (MRI) as a hyperintensity on
diffusion weighted imaging (DWI) with corresponding low apparent
diffusion coefficient (ADC) values. In severe hypoxic-ischaemic brain
injury, hyperintensity on DWI involves the cerebral cortex extensively
and the basal ganglia. Measurement of ADC enables a quantitative
assessment of the severity of diffusion changes. In studies on
prognostication after cardiac arrest, three methods for ADC
measurement were described: the mean global or regional ADC
value of the brain,401 the proportion of voxels with low ADC,402 and the
maximum size of the MRI clusters with minimum ADC.400 All these
studies identified ADC thresholds for 0% FPR, often with a
corresponding high sensitivity. However, these thresholds were
inconsistent across different areas of the brain within the same study
and the same technique.
Because of the lack of standardisation in measurement methods
and the lack of multicentre validation studies using comparable
measurement techniques, we suggest that predictive indices based
on neuroimaging are used only in places where specific experience is
available. We also suggest that centres using neuroimaging for
prognostication after cardiac arrest create their own normal values
and threshold values based on the technique used.
When none of the criteria for poor outcome described above are
present, neurological outcome remains indeterminate (Fig. 5). We
therefore suggest observation and repeated re-evaluation of patients with
indeterminate outcome to detect signs of awakening. In three studies
conducted in resuscitated comatose patients treated with TTM for 24 h,
the prevalence of late awakening, defined as a recovery of consciousness
at 48 h from suspension of sedation was 20/89 (22%),415 56/194
(29%),305 and 78/228 (34%).204 Last awakening occurred on day 11, day
12, and day 23 from suspension of sedation, respectively. In two other
studies, the last patient awoke on day 22 and day 29.403,416 Organ
dysfunction, such as post-resuscitation shock or renal failure204,305 and
use of midazolam instead of propofol for sedation204,265 were associated
with a higher likelihood of late awakening, which suggests that at least
some of these cases may have been due to a reduced clearance of
sedation. In a before-and-after study comparing two sedative regimens
(propofol-remifentanil versus midazolam-fentanyl) in 460 comatose
resuscitated patients undergoing TTM, use of propofol-remifentanil was
associated with significantly lower odds of delayed awakening after
adjustment (OR 0.08 [0.03 0.2]),305 confirming indirect evidence from a
previous smaller study.264
Late awakening does not preclude full neurological recovery.
However, the likelihood of awakening in resuscitated patients who
remain comatose decreases progressively with time and the rates of
good neurological outcome are generally lower in late vs. early
awakeners.204,305,416
The present guidelines apply only to neurological prognostication.
Besides hypoxic-ischaemic brain injury, other, albeit less common,
248 RESUSCITATION 161 (2021) 220
causes of death in resuscitated comatose patients include cardiovas-
cular instability,23 and multiple organ failure.303,304 These factors may
result in treatment limitations independently from the patient's
neurological status or cause non-neurological death even after
neurological recovery has occurred.295,307,417 In clinical practice, a
comprehensive prognostic approach in resuscitated comatose
patients should inevitably consider the role of extracerebral factors
as well as patient characteristics such as age, comorbidities, and
functional status.
Withdrawal of life-sustaining therapy
While a minority of the resuscitated patients treated in an ICU die
during the first few days due to cardiovascular collapse or massive
brain swelling causing brain death, most deaths will be secondary to a
decision to withdraw life-sustaining therapy (WLST).22,23,26,303
Generally, a presumption that the final neurological outcome of the
patient will be poor is central to this decision.26 Pre-existing co-
morbidities may also contribute to a WLST decision.22 The clinical
team discussing the prognosis of an individual patient needs to
consider that inaccurately pessimistic prognostication could lead to
WLST in patients who might otherwise achieve a good functional
outcome but also that overly conservative prognostication could leave
patients in a severely disabled state undesired by themselves and
their relatives.418 Patients may not receive specific treatments
because they are not available, or because there is an active decision
to withhold them. The main reasons for withholding treatments are that
they will not benefit the patient or, if known, the patient's wishes not to
have a specific treatment.418,419 There are few specific data on
withholding life sustaining therapies in post-cardiac arrest patients
specifically.
The practice of WLST varies widely across Europe and impacts the
proportion of CA-patients surviving with severe brain injury (CPC 3
4). Lacking high-quality data, this fraction appears to vary widely
from approximately 10 50%.243,300,417 The most apparent effects are
seen for patients who remain in an unresponsive wakefulness/
vegetative state (CPC 4). As an example, 1/243 (0.4%) survivors in a
northern European study243 compared with 61/195 (31%) in an Italian
multi-centre study300 were in CPC 4 at 6 months. Evidence for
variation in WLST practice across Europe was also found in the
Ethicus Study: physicians from southern Europe were less prone to
withdraw treatment compared with those from northern Europe, and
there was also an effect of religion.420 The Ethicus-2 Study has shown
that the frequency of WLST and withholding decisions among general
ICU patients has increased over the last 15 20 years.421
Recent studies, based on propensity score matching, indicate that
premature (<72 h) WLST for neurological reasons are common and
may be the cause of death for a substantial proportion of patients who
might have recovered to a good outcome if their intensive care
treatment had been prolonged.422,423 The brain stem is more resistant
to hypoxic-ischaemic injury than the cerebrum and the recovery of
functions such as spontaneous breathing and sleep-wake cycle is part
of the trajectory towards an unresponsive wakefulness/vegetative
syndrome. The period when the patient is still dependent on intensive
care is sometimes referred to as the ‘window of opportunity for
death’.424 This perception may cause a sense of urgency for the
relatives and treating team indirectly impacting decisions on
premature WLST.425,426 One qualitative study identified limitations
in family-team communication as an important factor for premature
WLST after cardiac arrest.426 Caregivers’ inappropriate avoidance of
269
uncertainty may also be important, leading to overly pessimistic
perceptions of the prognosis.427
Although some tests show high specificity for predicting a poor
outcome before 72 h, we recommend that, in general, conclusions
about the neurological prognosis are postponed until at least 72 h after
the cardiac arrest and the influence of sedative and metabolic factors
have been ruled out. This will enable most patients with good outcome
to awaken before the prognostic assessment, decreasing the risk of
false predictions.265 We encourage local protocols on how to collect
information about the extent of brain injury during the first days. Use all
available resources to inform a multimodal assessment.9,15 Relatives
will require regular clear and structured information and an
understanding of their role in decision-making. Early indicators of
poor prognosis may be conveyed in a balanced fashion to inform
relatives that the situation is grave and enable time for adjustment
before critical decisions are made. The bedside nurses are confronted
by grieving caregivers, which may be very stressful.426 Allocate
sufficient time for communication around the prognosis within the
team and with the relatives.428
While the assessment of post-cardiac arrest neurological
prognosis and discussions about WLST are most often linked, try
to separate these processes in discussions and documentation.
Decisions about WLST need to consider several aspects other than
the perceived brain injury; for example, age, co-morbidities and the
prognosis for general organ function.22 Consequently, for ethical
reasons, WLST may be considered for patients in whom the
neurological prognosis is uncertain or even favourable. Conversely,
intensive care may be prolonged despite dismal neurological
prognosis because absolute certainty is unobtainable for an individual
patient.429 The patient's preferences are central. Since the patient
cannot be asked and advance directives are rare among cardiac
arrest victims, the relatives are usually the primary source of
information about the patient's likely wishes.
Long-term outcome after cardiac arrest
Long-term outcome
In countries where WLST is not practiced widely, poor outcome
because of hypoxic-ischaemic brain injury is common.387,430 The
prognosis of patients who are still comatose or in an unresponsive
wakefulness state one month after the cardiac arrest is poor and they
rarely recover.430,431 In contrast, in countries practising WLST, the
majority of survivors are defined as having a ‘good’ neurological
outcome based on global outcome measures such as Cerebral
Performance Categories (CPC), modified Rankin Scale (mRS) or the
Glasgow Outcome Scale/Extended (GOS/E).290,412,432 434 However,
these measures are not sufficiently sensitive to capture the problems
that many of the survivors experience, including cognitive, emotional
and physical problems and fatigue.435 437 In fact, approximately 40
50% of the survivors have long-term cognitive impairments.229,438,439
Impairments are mostly mild to moderate and, although all cognitive
domains can be affected, most problems are seen in memory, attention,
processing speed and executive functioning (e.g. planning, organisa-
tion, initiation, flexibility).229,435,438 440 In general, most cognitive
recovery occurs during the first three months after the cardiac
arrest.441 443
Emotional problems are also common. Three to six months after
the cardiac arrest anxiety is present in 15 30% of the survivors and
remains in 15 23% at 12 months.444 446 Depressive symptoms
range from 13 32% at 3 6 months and decrease to 5 15% at
 RESUSCITATION 161 (2021) 220
12 months.444 447 Symptoms of post-traumatic stress remain in
about a quarter of the survivors.436,444,447,448 Furthermore, some
survivors show behavioural problems, such as aggressive/
uninhibited behaviour or emotional lability.439
Fatigue is also frequently reported and is present in approximately
70% of the survivors at six months and remains in half of the survivors
one year after the event.444,449,450 Physical problems, including rib
fractures, muscle weakness and ambulation difficulties, have also
been reported.437,444,451,452 However, the impact of survival on
physical function has received little attention; when compared with
age and gender-matched populations, reduced physical functioning
has been reported in survivors at 3-months,453 6-months,452 12-
months,434 and three years.451 Almost half of survivors report
limitations because of physical difficulties at 6-months,452 with up
to 40% describing mobility problems434,439,444,454 and limitations in
usual activities at 12-months.434,444,454
After discharge, most survivors are able to return home and only a
small percentage (1 10%) need to be admitted to a long-term care
facility.444,454,455 The large majority (82 91%) are independent in
their basic activities of daily living (ADL).228,438,451,454 Although most
survivors are able to resume their pre-arrest activities, they
experience more restrictions in societal participation compared with
myocardial infarction patients.444,450 Cognitive impairments, depres-
sion, fatigue and restricted mobility are negative predictors for future
participation.450
Of those who were previously working, 63 85% are able to return
to work, although some need to adapt their working hours or
activities.434,444,450,451,454,456 458 Decreased likelihood of return to
work is associated with cognitive problems and fatigue, unwitnessed
OHCA, absence of bystander CPR, female gender, higher age and
lower socio-economic status.450,453,456 458
Cognitive impairments, emotional problems and female gender
are associated with a lower quality of life.434,442,452,453,459 464
However, general health related quality of life is, on average, reported
as good with overall scores approaching normal population values, as
was shown in two systematic reviews and confirmed in several more
recent studies.228,434,454,465,466 Such generic assessments lack
sufficient granularity to comprehensively capture the breadth of
problems experienced by survivors, with the result that the impact of
cardiac arrest survival may be incompletely captured.290 Supple-
menting such generic assessment with condition or problem-specific
assessment is recommended.290
More detailed information on recovery and long-term outcome
after cardiac arrest, as well as a description of the current rehabilitation
practices in Europe can be found in the epidemiology section of the
2021 European Resuscitation Council Guidelines.467
In-hospital assessment and follow-up after hospital
discharge
Early rehabilitation and assessment during hospital phase
[14_TD$IF]There are no studies of early rehabilitation interventions for cardiac
arrest survivors specifically but there is substantial overlap with the
post-intensive care syndrome (PICS). For other ICU patients,
interventions of early mobilisation and prevention of delirium are
described, and similar interventions are thought to be useful for
cardiac arrest patients as well.437,468 470 Recommendations in the
UK National Institute for Health and Care Excellence (NICE)
guidelines for rehabilitation after critical illness suggest that
individualised rehabilitation plans and information should be
269 249
provided before discharge from the ICU and the hospital, based
on functional assessments of physical and non-physical (e.g.
cognitive and emotional) impairments.471 However, a recent AHA
Scientific Statement focusing on survivorship highlights that
discharge planning and organisation of further rehabilitation needs
after cardiac arrest is often lacking.437
We therefore recommend providing information and performing
functional assessments of physical and non-physical impairments
before discharge from the hospital to identify potential rehabilitation
needs and arrange referral for rehabilitation if indicated (Fig. 6).
[59_TD$IF]Follow-up and screening after hospital discharge
[60_TD$IF]Although cognitive impairments, emotional problems and fatigue are
common after cardiac arrest, these ‘invisible problems’ are not always
recognised by healthcare professionals.442,450,453,457,464 Since these
problems have a significant impact on long-term outcome and quality
of life, follow-up should be organised in such a way that these
problems are detected early enabling appropriate care or rehabilita-
tion to be arranged.472 474
Evidence on this subject is scarce but results from one RCT
showed that an early intervention service for cardiac arrest survivors
and their caregivers improved emotional well-being and quality of life,
resulted in a faster return to work and was cost-effective.475,476 This
individualised programme is provided by a specialised nurse, starts
soon after discharge from the hospital and comprises one to six
consultations during the first three months. The intervention consists
of screening for cognitive and emotional problems, provision of
information and support, and referral to further specialised care if
indicated.477,478 There are several other examples of how follow-up
after cardiac arrest can be organised.474,479,480 UK NICE guidelines
for rehabilitation after critical illness likewise recommend a follow-up
and reassessment for physical and non-physical problems 2
3 months after discharge to enable identification of remaining
problems and to provide further support as needed.471 For cardiac
arrest survivors, reassessments have also been suggested at 3, 6 and
12 months.437
We therefore suggest the systematic follow-up of all cardiac arrest
survivors within three months following hospital discharge which
should, at least, include cognitive screening, screening for emotional
problems and fatigue, and the provision of information and support for
patients and their family (Fig. 6).
[61_TD$IF]Screening for cognitive problems
[62_TD$IF]To screen for cognition, the patient can be asked about common
cognitive complaints, such as memory problems, attention difficulties,
distractibility, slowness in thinking, irritability and problems in initiation,
planning, multi-tasking or flexibility. Family members can also provide
useful insight into changes in cognition and behaviour. A structured
questionnaire, such as the Informant Questionnaire of Cognitive
decline in the Elderly Cardiac Arrest version (IQCODE-CA) or the
Checklist Cognition and Emotion (CLCE-24), may be used.481,482
Formal cognitive screening is recommended because patients are not
always aware of their cognitive impairments.443,472,483 We suggest
use of the Montreal Cognitive Assessment (MoCA) tool, which takes
approximately 10 min to administer, is easy to use and available in
many languages (see www.mocatest.org).480,483 485 If there are
signs of cognitive impairment, consider referral to a neuropsychologist
for more extensive neuropsychological assessment or another
specialist in cognitive rehabilitation, such as an occupational therapist,
should be considered.486
250 RESUSCITATION 161 (2021) 220
[63_TD$IF]Screening for emotional problems and fatigue
[62_TD$IF]To screen for emotional problems, the presence of emotional
symptoms, including symptoms of anxiety, depression and posttrau-
matic stress, can be explored. Questionnaires, such as the Hospital
Anxiety and Depression Scale (HADS), may be useful.437,473,480,487 If
severe emotional problems are detected we suggest referral to a
psychologist or psychiatrist for further evaluation and treatment. We
also suggest assessing the presence of fatigue; however, assessment
guidance in this population is currently lacking. In case of severe
fatigue consider referral to a specialist in rehabilitation medicine for
advice on appropriate care.
[64_TD$IF]Provision of information and support for survivor and family
members
[65_TD$IF]Exploring the need for and subsequent provision of appropriate
information to patients and their family, preferably both in oral and
written form, is recommended.488 The active engagement of survivors
and their family members to better understand their needs and how
they would like to receive such information, is recommended as part of
this process.437 Information should cover not only medical subjects
such as cardiac disease, risk factors, medication and ICD, but can also
address other topics such as potential physical, cognitive and
emotional changes and fatigue, resuming daily activities, driving
and work, relationship and sexuality.477,488 491
It is also important to monitor the well-being of family members
because the impact and burden can be substantial.490,492 Partners
often have emotional problems, including symptoms of anxiety and
posttraumatic stress, especially in women and those who witnessed
the resuscitation.493,494 Consider referral to a social worker,
psychologist or psychiatrist when indicated.
[6_TD$IF]1Rehabilitation after cardiac arrest
In-patient neurological rehabilitation
In the presence of significant hypoxic-ischaemic brain injury, patients
may require inpatient neurological rehabilitation and, although the
evidence is limited, several small retrospective studies have shown
that functional improvements can be achieved, reducing the burden of
care on the family and society.495 497
Although specific guidelines and evidence for neurological
rehabilitation after cardiac arrest is lacking, there is more evidence
and multiple clinical practice guidelines for other types of acquired
brain injury such as traumatic brain injury and stroke which can guide
the treatment of patients with hypoxic-ischaemic brain injury due to
cardiac arrest.498 500 These guidelines provide practical recommen-
dations on topics such as motor function, physical rehabilitation,
cognition, communication, activities of daily living and psychosocial
issues. Guidelines on rehabilitation after critical illness/post-intensive
care syndrome (PICS) can also be useful.471,501 503
Cardiac rehabilitation
Many cardiac arrest survivors are eligible to enrol in a cardiac
rehabilitation programme.504 There is evidence that cardiac rehabili-
tation reduces cardiovascular mortality and hospital admissions,
improves quality of life, and is cost-effective.504 507 Cardiac
rehabilitation programmes are mostly generic programmes, in which
patients with different cardiac diseases, e.g. post-acute coronary
syndrome, heart failure or post cardiac surgery, can participate. It
involves exercise training, risk factor management, lifestyle advice,
education and psychological support.505 Cardiac rehabilitation is
269
frequently offered as a centre-based out-patient service, but can also
be organised in a home-based setting in combination with tele-
monitoring.508 In specific cases it can be provided as an inpatient
programme.505 Not all cardiac arrest survivors are eligible for or have
access to cardiac rehabilitation, either because of the cause of the
cardiac arrest or because of variation in national or insurance
policies.509
Within cardiac rehabilitation programmes little attention is paid to
potential cognitive problems. Among cardiac patients in general,
cognitive and emotional problems have not been addressed well in
cardiac rehabilitation programmes.510 512 For cardiac arrest survi-
vors, there are some examples in which cardiac and cognitive
rehabilitation have been integrated, although evidence of effects is still
lacking.474,480
Cognitive rehabilitation, fatigue management and
psychosocial interventions
The goal of cognitive rehabilitation is to reduce the impact of cognitive
impairments and to improve overall well-being and daily function-
ing.513 It can include additional neuropsychological assessment to get
more insight into the nature and severity of the cognitive impairments
and other influencing factors. Extensive patient education is essential
to give the patient and their family more insight into what has changed
in their cognition and behaviour. Compensation strategies, such as
memory strategy training and metacognitive strategy training (e.g.
self-monitoring, self-regulation and planning ahead) and the use of
external (memory) aids may be helpful.486 Although there are no
specific studies on the effects of cognitive rehabilitation in patients with
brain injury caused by cardiac arrest, a recent evidence-based review
on cognitive rehabilitation after stroke and traumatic brain injury, can
serve as a guideline.486
Fatigue management can be included in cognitive rehabilitation or
provided alone.514,515 There is weak evidence that a 4-week
telephone intervention, based on energy conservation and prob-
lem-solving therapy, can be of benefit for cardiac arrest survivors with
moderate to severe fatigue.516,517
There is also evidence that psychosocial interventions specifically
designed for cardiac arrest survivors can be valuable. Two RCTs
showed benefit from nurse-led psychosocial interventions, either by
telephone or face-to-face.518,519 These interventions addressed self-
management, coping strategies, relaxation, information and health
education.519,520
There are currently no studies on the effectiveness of social
support networks or virtual/online forums, but these may have
additional value as a new and easily accessible form of psychosocial
support and information after cardiac arrest.437
Organ donation
Comatose post cardiac arrest patients who do not survive have the
potential to become organ donors. This is important as demand for
organs exceeds supply.521 Post cardiac arrest patients are an
increasing source of solid organ donors.522 This guideline supports
giving the opportunity for organ donation to patients and families when
brain death occurs or there is a decision to withdraw life sustaining
treatment.
This guideline specifically addresses the organ donation pathways
following neurological (brain) death or controlled donation after
circulatory death (Maastricht category III donors) in patients that
achieve ROSC or are treated with E-CPR (Fig. 7).523 Uncontrolled
 RESUSCITATION 161 (2021) 220
donation after circulatory death uDCD (Maastricht category I/II
donors) is addressed in the Advanced Life Support section of the
guidelines.523
A previous 2015 ILCOR CoSTR and an ILCOR Scientific
Statement on organ donation following CPR underpin this guide-
line.122 Recent CPR should not prevent organ donation. Observa-
tional studies show that organs (heart, lung, kidney, liver, pancreas,
intestine) from donors who have had CPR have similar graft survival
rates compared with donors who have not had CPR.524,525
A systematic review identified 26 studies that showed the
prevalence of brain death in comatose ventilated patients with
hypoxic ischaemic brain injury who died following CPR was 12.6%
(95% CI 10.2 15.2%) with a higher prevalence following eCPR
(27.9% [19.7 36.6%] vs. 8.3% [6.5 10.4%]) and that approximately
40% of these proceeded to organ donation.286 The median time to
diagnose brain death was 3.2 days. This systematic review concluded
that patients who are unconscious after resuscitation from cardiac
arrest, especially when resuscitated using e-CPR, should be
assessed for signs of brain death.
Furthermore, in those who do not fulfil criteria for neurological
death, WLST because of a poor neurological prognosis is a common
cause of death. After OHCA, approximately two thirds of deaths will be
following WLST because of a poor neurological prognosis.22,23 This
group of patients provides an increasing source of donors following
controlled donation after circulatory death.526
There is variation between countries regarding organ donation
practices and clinicians must follow local legal and ethical
requirements.
Investigating sudden unexplained cardiac arrest
Many sudden cardiac death victims have silent structural heart
disease, most often coronary artery disease, but also primary
arrhythmia syndromes, cardiomyopathies, familial hypercholester-
olaemia and premature ischaemic heart disease. In the course of an
autopsy of victims of sudden unexplained death (SUD), blood or
tissue samples should be taken and stored for future genetic
analysis.527 Screening for genetic disorders is crucial for primary
prevention in relatives as it may enable preventive antiarrhythmic
treatment and medical follow-up.528 530 A multidisciplinary cardi-
ogenetic team should perform the family investigation. Initial
evaluation may include clinical examination, electrophysiology
and cardiac imaging. A genetic test should be considered according
to the combination the results of cardiac family screening and
pathology findings. The genetic test should be performed initially on
the DNA of the deceased and testing of relatives should then be
offered if a pathogenic or likely pathogenic variant is identi-
fied.527,531 Given the implications for relatives, there may be local
ethical guidelines for genetic testing.
Cardiac Arrest Centres
There is wide variation among hospitals in the availability and type of
post resuscitation care, as well as clinical outcomes.532 534 Cardiac
arrest centres are hospitals providing evidence-based resuscitation
treatments including emergency interventional cardiology, and bundled
critical care with targeted temperature management, and protocolised
cardiorespiratory support and prognostication.122,207 An expert con-
sensus paper published by the Association of Acute Cardiovascular
269 251
Care (ACVA), and many other European organisations including the
ERC and ESICM, states that the minimum requirements for a cardiac
arrest centre are 24/7 availability of an on-site coronary angiography
laboratory, an emergency department, an intensive care unit (ICU),
imaging facilities, such as echocardiography, computed tomography,
and magnetic resonance imaging.16
ILCOR suggests that wherever possible, adult patients with non-
traumatic OHCA cardiac arrest should be cared for in cardiac arrest
centres.17 This weak recommendation is based on very low certainty
evidence from a systematic review that included 21 observational
studies.535 555 and 1 pilot randomised trial.556 Seventeen of these
studies were included in a meta-analysis that found that patients cared
for at cardiac arrest centres had improved survival to hospital
discharge with favourable neurological outcome, but this was non-
significant at 30 days.535 541,545 552,554,555
One observational study reported higher adjusted patient survival
associated with direct transfer to a cardiac arrest centre compared
with secondary interfacility transfer,552 but two other studies making
the same comparisons report no difference in adjusted survival.536,541
One observational study reported higher adjusted survival in patients
who underwent secondary transfer to a cardiac arrest centre
compared with remaining at the initial non-cardiac arrest centre.550
Conflict of interest statement
Jerry P. Nolan, Editor in Chief Resuscitation; Claudio Sandroni,
Associate Editor, Intensive Care Medicine; Bernd W. Böttiger,
Treasurer of the European Resuscitation Council (ERC); Chairman
of the German Resuscitation Council (GRC); Member of the Advanced
Life Support (ALS) Task Force of the International Liaison Committee
on Resuscitation (ILCOR); Member of the Executive Committee of the
German Interdisciplinary Association for Intensive Care and Emergen-
cy Medicine (DIVI), Founder of the Deutsche Stiftung Wiederbelebung;
Associate Editor of the European Journal of Anaesthesiology (EJA),
Co-Editor of Resuscitation; Editor of Notfall + Rettungsmedizin, Co-
Editor of the Brazilian Journal of Anesthesiology. Received fees for
lectures from the following companies: Forum für medizinische
Fortbildung (FomF), Baxalta Deutschland GmbH, ZOLL Medical
Deutschland GmbH, C.R. Bard GmbH, GS Elektromedizinische Geräte
G. Stemple GmbH, Novartis Pharma GmbH, Philips GmbH Market
DACH, Bioscience Valuation BSV GmbH. Alain Cariou, Speaker's Fee
from Bard Medical; Tobias Cronberg; Hans Friberg; Cornelia
Genbrugge; Gisela Lilja; Véronique RM Moulaert; Nikolaos Nikolaou;
Theresa Mariero Olasveengen no conflicts of interest. Markus B.
Skrifvars, Speaker's Fee from Bard Medical (Ireland); Fabio Silvio
Taccone, Speaker's Fees from BD and Zoll; Jasmeet Soar, Editor,
Resuscitation.
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 RESUSCITATION 161 (2021) 270 290

Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

First aid

David A. Zideman a, *, Eunice M. Singletary b, Vere Borra c,d , Pascal Cassan e ,

Carmen D. Cimpoesu f , Emmy De Buck c,d,g , Therese Djärv l , Anthony J. Handley h ,
Barry Klaassen i,j , Daniel Meyran k , Emily Oliver j , Kurtis Poole a
a
Thames Valley Air Ambulance, Stokenchurch, UK
b
Department of Emergency Medicine, University of Virginia, USA
c
Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium
d
Cochrane First Aid, Mechelen, Belgium
e
International Federation of Red Cross and Red Crescent, France
f
University of Medicine and Pharmacy “ Grigore T. Popa” , Iasi, Emergency Department and Prehospital EMS SMURD Iasi Emergency County
Hospital “ Sf. Spiridon” Iasi, Romania
g
Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
h
Cambridge, UK
i
Emergency Medicine, Ninewells Hospital and Medical School Dundee, UK
j
British Red Cross, UK
k
French Red Cross, Bataillon de Marins Pompiers de Marseille, France
l
Department of Medicine Solna, Karolinska Institute and Division of Acute and Reparative Medicine, Karolinska University Hospital, Sweden

Abstract
The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on
Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and
trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for
asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration
solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For
trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine
motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint
injuries, straightening an angulated fracture, and eye injury from chemical exposure.

Introduction and scope
In 2015 the European Resuscitation Council published its initial First
Aid guidelines1 based on the International Liaison Committee on
Resuscitation (ILCOR) Consensus on First Aid Science with
Treatment Recommendations published in the same year.2,3 In
2015 ILCOR modified its consensus on science review process from a
five-year cycle to a continuous evidence evaluation process. This is
reflected in the 2020 ILCOR Consensus on Science with Treatment
Recommendations (CoSTRs).4,5
In 2016 the ILCOR First Aid Task Force assessed all the topics
reviewed by the American Heart Association and American Red Cross
in the 2010 evidence review6 and the 13 medical Population,
Intervention, Comparison, Outcome (PICO) questions, ten trauma
PICO questions and one education PICO examined in the ILCOR
2015 CoSTR review.2,3 Thirty-eight PICO topics were selected for
scoring and ranking by the task force members. Scoring was

* Corresponding author.
E-mail address: david.zideman@gmail.com (D.A. Zideman).
https://doi.org/10.1016/j.resuscitation.2021.02.013

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
 RESUSCITATION 161 (2021) 270
orientated as to whether there was any published new evidence that
would modify the 2015 CoSTRs. The top twenty ranked topics were
selected and submitted by the ILCOR Continuous Evidence
Evaluation (CEE) group, the constituent ILCOR councils for ratifica-
tion and then opened for public comment. The First Aid task force then
evaluated each selected topic. The task force selected topics where
they believed there was new published evidence (since 2015) and
submitted these for systematic review. For some topics the PICO
question was changed to address gaps identified by previous
reviews and these were also submitted for systematic review. The
control of life-threatening bleeding topics were combined into a
mega-PICO for an integrated systematic review. Where the task
force was uncertain that there was sufficient new published
evidence to support a systematic review, the PICO was submitted
to a scoping review process. Scoping reviews are based on a
broader search strategy, including grey literature, and provide a
narrative report of their findings rather than the critical appraisal of a
systematic review. The resulting manuscripts for both the system-
atic reviews and scoping reviews were subject to public comment
and published on the ILCOR CoSTR website and in the 2020
CoSTR summary.4,5 A number of the systematic reviews have been
directly published including ‘Immediate interventions for presyn-
cope’,7 ‘Management of hypoglycaemia’,8 ‘Early versus late
administration of aspirin for non-traumatic chest pain’,9 ‘Cooling
techniques for heat stroke and exertional hyperthermia’,10 ‘Com-
pression Wrapping for Acute Closed Extremity Joint Injuries’,11
‘Dental avulsion’12 and ‘Stroke Recognition for First Aid
Providers’.13
The European Resuscitation Council First Aid writing group has
used the published systematic reviews and scoping reviews together
with the ILCOR First Aid task force consensus on science and treatment
recommendations (ILCOR/CoSTR) as evidence for these first aid
guidelines. The writing group also carefully considered the evidence to
decision tables, narrative reviews and task force discussions when
writing these guidelines. In addition, the Writing Group considered five
additional topics, not included in the 2020 ILCOR process, that had
been previously included in the 2015 ILCOR process, for short evidence
reviews. The Writing Group has added these additional clinical
recommendations as expert consensual opinion and labelled them
as Good Practice Points to differentiate them from guidelines derived
directly from scientific review.
In total these guidelines include 20 PICO topics, subdivided into
eleven medical and nine trauma emergencies.
Medical emergencies
Recovery position
Optimal positioning for shock victims
Bronchodilator administration for asthma
Recognition of stroke
Early aspirin for chest pain
Anaphylaxis:
Second dose of adrenaline (epinephrine) in anaphylaxis
Recognition of anaphylaxis by first aid providers
Management of hypoglycaemia
Oral rehydration solutions for treating exertion-related dehydration
Management of heat stroke by cooling
Supplemental oxygen in acute stroke
Management of presyncope
290 271
Trauma emergencies
Control of life-threatening bleeding
Management of open chest wounds
Cervical spine motion restriction and stabilisation
Recognition of concussion
Thermal burns:
Cooling of thermal burns
Thermal burn dressings
Dental avulsion
Compression wrap for closed extremity joint injuries
Straightening an angulated fracture
Eye injury from chemical exposure
Definition of first aid
First aid is the initial care provided for an acute illness or injury. The
goals of first aid include preserving life, alleviating suffering, preventing
further illness or injury and promoting recovery. First aid can be initiated
by anyone in any situation, including self-care. General characteristics
of the provision of first aid, at any level of training include:
 Recognising, assessing and prioritising the need for first aid
 Providing care using appropriate competencies and recognising
limitations
 Seeking additional care when needed, such as activating the
emergency medical services (EMS) system or other medical
assistance.
Key principles include:
 First aid should be medically sound and based on the best
available scientific evidence
 First aid education should be universal: everyone should learn first
aid
 Helping behaviours should be promoted: everyone should act
 The scope of first aid and helping behaviours varies and may be
influenced by environmental, resource, training and regulatory
factors.
These guidelines were drafted and agreed by the First Aid Writing
Group members. The methodology used for guideline development is
presented in the Executive summary.13a The guidelines were posted
for public comment in October 2020. The feedback was reviewed by
the writing group and the guidelines were updated where relevant. The
Guideline was presented to and approved by the ERC General
Assembly on 10th December 2020.
Key messages from the guidelines are presented in Fig. 1.
Concise guideline for clinical practice
Recovery position
For adults and children with a decreased level of responsiveness due
to medical illness or non-physical trauma, who do NOT meet the
criteria for the initiation of rescue breathing or chest compressions
(CPR), the ERC recommends they be placed into a lateral, side-lying,
recovery position (see Fig. 2). Overall, there is little evidence to
suggest an optimal recovery position, but the ERC recommends the
following sequence of actions:
272 RESUSCITATION 161 (2021) 270 290

Fig. 1 – Infographic summary of key messages relating to first aid.

 Kneel beside the victim and make sure that both legs are straight
 Place the arm nearest to you out at right angles to the body with the
hand palm uppermost
 Bring the far arm across the chest, and hold the back of the hand
against the victim's cheek nearest to you
 With your other hand, grasp the far leg just above the knee and pull
it up, keeping the foot on the ground
 Keeping the hand pressed against the cheek, pull on the far leg to
roll the victim towards you onto their side
 Adjust the upper leg so that both hip and knee are bent at right
angles
 Tilt the head back to make sure the airway remains open
 Adjust the hand under the cheek if necessary, to keep the head
tilted and facing downwards to allow liquid material to drain from
the mouth
 Check regularly for normal breathing
 Only leave the victim unattended if absolutely necessary, for
example to attend to other victims.
 RESUSCITATION 161 (2021) 270
Fig. 2 – The recovery position.
It is important to stress the importance of maintaining a close check
on all unresponsive individuals until the EMS arrives to ensure that
their breathing remains normal. In certain situations, such as
resuscitation-related agonal respirations or trauma, it may not be
appropriate to move the individual into a recovery position.
Optimal position for shock victim
 Place individuals with shock into the supine (lying-on-back)
position.
 Where there is no evidence of trauma first aid, providers might
consider the use of passive leg raising as a temporising measure
while awaiting more advanced emergency medical care.
Bronchodilator administration for asthma
 Assist individuals with asthma who are experiencing difficulty in
If glucose or dextrose tablets are not available give other
breathing with their bronchodilator administration.
 First aid providers must be trained in the various methods of
administering a bronchodilator.
Repeat the administration of sugar if the symptoms are still
Recognition of stroke
If oral glucose is not available a glucose gel (partially held in the
 Use a stroke assessment scale to decrease the time to recognition
and definitive treatment for an individual suspected of acute stroke.
Call the emergency services if:
 The following stroke assessment scales are available:
Face Arm Speech Time to call (FAST)
Melbourne Ambulance Stroke Scale (MASS)
Cincinnati Prehospital Stroke Scale (CPSS)
Following recovery from the symptoms after taking the
Los Angeles Prehospital Stroke Scale (LAPSS) are the most
common.
 The MASS and LAPSS scales can be augmented by blood
glucose measurement.
Early aspirin for chest pain
For conscious adults with non-traumatic chest pain due to suspected
myocardial infarction:
 Reassure the casualty
 Sit or lie the casualty in a comfortable position
 Call for help
 First aid providers should encourage and assist the casualty in the
self-administration of 150 300 mg chewable aspirin as soon as
possible after the onset of chest pain
 Do not administer aspirin to adults with chest pain of unclear or
traumatic aetiology
290 273
 There is a relatively low risk of complications, particularly
anaphylaxis and serious bleeding. Do not administer aspirin to
adults with a known allergy to aspirin or contraindications such as
severe asthma or known gastrointestinal bleeding.
Anaphylaxis
The management of anaphylaxis has been described in the ERC
Special Circumstances Guidelines.
 If the symptoms of anaphylaxis do not resolve after 5 min of the first
injection of adrenaline or, if the symptoms begin to return after the
first dose, administer a second dose by intramuscular injection
using an autoinjector.
 Call for help.
 Train first aid providers regularly in the recognition and first aid
management of anaphylaxis.
Management of hypoglycaemia
 The signs of hypoglycaemia are sudden impaired consciousness:
ranging from dizziness, fainting, sometimes nervousness and deviant
behaviour (mood swings, aggression, confusion, loss of concentra-
tion, signs that look like drunkenness) to loss of consciousness.
 A person with mild hypoglycaemia typically has less severe signs
or symptoms and has the preserved ability to swallow and follow
commands.
 If hypoglycaemia is suspected in someone who has signs or
symptoms of mild hypoglycaemia and is conscious and able to
swallow:
Give glucose or dextrose tablets (15 20 g), by mouth
dietary sugars in an equivalent amount to glucose, such as
Skittles, Mentos, sugar cubes, jellybeans, or half a can of
orange juice
present and not improving after 15 min
cheek, and partially swallowed) can be given
& the casualty is/or becomes unconscious
& the casualty's condition does not improve
sugar, encourage taking a light snack such as a sandwich or a waffle
 For children who may be uncooperative with swallowing oral
glucose:
Consider administering half a teaspoon of table sugar (2.5 g)
under the child's tongue.
 If possible, measure and record the blood sugar levels before and
after treatment.
Oral rehydration solutions for treating exertion-related
dehydration
 If a person has been sweating excessively during a sports
performance and exhibits signs of dehydration such as feeling
thirsty, dizzy or light-headed and/or having a dry mouth or dark
yellow and strong-smelling urine, give him/her 3 8% carbohy-
drate-electrolyte (CE) drinks (typical ‘sports’ rehydration drinks) or
skimmed milk.
274 RESUSCITATION 161 (2021) 270
 If 3 8% CE drinks or milk are not available or not well tolerated,
alternative beverages for rehydration include 0 3% CE drinks, 8
12% CE drinks or water.
 Clean water, in regulated quantities, is an acceptable alternative,
although it may require a longer time to rehydrate.
 Avoid the use of alcoholic beverages.
 Call the emergency services if:
The person is or becomes unconscious
Upper body Hand clenching, neck flexion
The person shows signs of a heat stroke.  First aid providers will need to be trained in coaching casualties in
Management of heat stroke by cooling
Recognise the symptoms and signs of heat stroke (in the presence of a
high ambient temperature):
 Elevated temperature
 Confusion
 Agitation
 Disorientation
 Seizures
 Coma.
When exertional or non-exertional heat stroke is suspected:
 Immediately remove the casualty from the heat source and
commence passive cooling
 Commence additional cooling using any technique immediately
available
If the core temperature is above 40  C commence whole body
(neck down) cold water (1 26  C) immersion until the core
temperature falls below 39  C
If water immersion is not possible use alternative methods of
cooling e.g. ice sheets, commercial ice packs, fan alone, cold
shower, hand cooling devices, cooling vests and jackets or
evaporative cooling (mist and fan)
 Where possible measure the casualty's core temperature
(rectal temperature measurement) which may require special
training
 Casualties with exertional hyperthermia or non-exertional heat-
stroke will require advanced medical care and advance assistance
should be sought.
The recognition and management of heat stroke requires special
training (rectal temperature measurement, cold water immersion
techniques). However, the recognition of the signs and symptoms of a
raised core temperature and the use of active cooling techniques is
critical in avoiding morbidity and mortality.
Use of supplemental oxygen in acute stroke
 Do not routinely administer supplemental oxygen in suspected
acute stroke in the prehospital first aid setting.
 Oxygen should be administered if the individual is showing signs of
hypoxia.
 Training is required for first aid providers in the provision of
supplementary oxygen.
Management of presyncope
 Presyncope is characterised by light-headedness, nausea,
sweating, black spots in front of the eyes and an impending
sense of loss of consciousness.
290
 Ensure the casualty is safe and will not fall or injure themselves if
they lose consciousness.
 Use simple physical counterpressure manoeuvres to abort
presyncope of vasovagal or orthostatic origin.
 Lower body physical counterpressure manoeuvres are more
effective than upper body manoeuvres.
Lower body Squatting with or without leg crossing
how to perform physical counterpressure manoeuvres.
Control of life-threatening bleeding
Direct pressure, haemostatic dressings, pressure points and
cryotherapy for life-threatening bleeding
 Apply direct manual pressure for the initial control of severe, life-
threatening external bleeding.
 Consider the use of a haemostatic dressing when applying direct
manual pressure for severe, life-threatening bleeding. Apply the
haemostatic dressing directly to the bleeding injury and then apply
direct manual pressure to the dressing.
 A pressure dressing may be useful once bleeding is controlled to
maintain haemostasis but should not be used in lieu of direct
manual pressure for uncontrolled bleeding.
 Use of pressure points or cold therapy is not recommended for the
control of life-threatening bleeding.
Tourniquets for life-threatening bleeding
 For life-threatening bleeding from wounds on limbs in a location
amenable to the use of a tourniquet (i.e. arm or leg wounds,
traumatic amputations):
Consider the application of a manufactured tourniquet as soon
as possible:
& Place the tourniquet around the traumatised limb 5 7 cm
above the wound but not over a joint
& Tighten the tourniquet until the bleeding slows and stops.
This may be extremely painful for the casualty
& Maintain the tourniquet pressure
& Note the time the tourniquet was applied
& Do not release the tourniquet the tourniquet must only be
released by a healthcare professional
& Take the casualty to hospital immediately for further medical
care
& In some cases, it may require the application of two
tourniquets in parallel to slow or stop the bleeding.
 If a manufactured tourniquet is not immediately available, or
if bleeding is uncontrolled with the use of a manufactured
tourniquet, apply direct manual pressure, with a gloved
hand, a gauze dressing, or if available, a haemostatic
dressing.
 Consider the use of an improvised tourniquet only if a
manufactured tourniquet is not available, direct manual
pressure (gloved hand, gauze dressing or haemostatic
dressing) fails to control life-threatening bleeding, and the first
aid provider is trained in the use of improvised tourniquets.
Management of open chest wounds
 Leave an open chest wound exposed to freely communicate with
the external environment.
 RESUSCITATION 161 (2021) 270
 Do not apply a dressing or cover the wound.
 If necessary:
Control localised bleeding with direct pressure
Apply a specialised non-occlusive or vented dressing ensuring
a free outflow of gas during expiration (training required).
Cervical spine motion restriction and stabilisation
 The routine application of a cervical collar by a first aid provider is
not recommended.
 In a suspected cervical spine injury:
If the casualty is awake and alert, encourage them to self-
maintain their neck in a stable position.
If the casualty is unconscious or uncooperative consider
immobilising the neck using manual stabilisation techniques.
& Head squeeze:
 With the casualty lying supine hold the casualty's head
between your hands.
 Position your hands so that the thumbs are above the
casualty's ears and the other fingers are below the ear
 Do not cover the ears so that the casualty can hear.
 Trapezium squeeze:
 With the casualty lying supine hold the casualty's
trapezius muscles on either side of the head with your
hands (thumbs anterior to the trapezius muscle). In
simple terms hold the casualty's shoulders with the
hands thumbs up
 Firmly squeeze the head between the forearms with
the forearms placed approximately at the level of the
ears.
Recognition of concussion
 Although a simple single-stage concussion scoring system would
greatly assist first aid providers’ recognition and referral of victims
of suspected head injury there is currently no such validated
system in current practice.
 An individual with a suspected concussion must be evaluated by a
healthcare professional.
Thermal burns
Following a thermal burn injury:
 Immediately commence cooling the burn in cool or cold (not
freezing) water
 Continue cooling the burn for at least 20 min
 Loosley cover the burn with a dry sterile dressing or use cling wrap.
 Seek immediate medical care.
Care must be taken when cooling large thermal burns or burns in
infants and small children so as not to induce hypothermia.
Dental avulsion
 If the casualty is bleeding from the avulsed tooth socket:
Put on disposable gloves prior to assisting the victim
Rinse out the casualty's mouth with cold, clean water
Control bleeding by:
& Pressing a damp compress against the open tooth socket
& Tell the casualty to bite on the damp compress
290 275
& Do not do this if there is a high chance that the injured person
will swallow the compress (for example, a small child, an
agitated person or a person with impaired consciousness).
 If it is not possible to immediately replant the avulsed tooth at the
place of accident:
Seek help from a specialist
& Take the casualty and the avulsed tooth to seek expert help
from a specialist.
 Only touch an avulsed tooth at the crown. Do not touch the root
 Rinse a visibly contaminated avulsed tooth for a maximum of
10 seconds with saline solution or under running tap water prior
to transportation.
 To transport the tooth:
& Wrap the tooth in cling film or store the tooth temporarily in a
small container with Hank's Balanced Salt solution (HBSS),
propolis or Oral Rehydration Salt (ORS) solution
& If none of the above are available, store the tooth in cow's
milk (any form or fat percentage)
& Avoid the use of tap water, buttermilk or saline (sodium
chloride).
Compression wrap for closed extremity joint injuries
 If the casualty is experiencing pain in the joint and finds it difficult to
move the affected joint, ask him/her not to move the limb. It is
possible there is swelling or bruising on the injured joint.
 There is no evidence to support or not support the application of a
compression wrap to any joint injury.
 Training will be required to correctly and effectively apply a
compression wrap to a joint injury.
Straightening an angulated fracture
 Do not straighten an angulated long bone fracture.
 Protect the injured limb by splinting the fracture.
 Realignment of fractures should only be undertaken by those
specifically trained to perform this procedure.
Eye injury from chemical exposure
For an eye injury due to exposure to a chemical substance:
 Immediately irrigate the contaminated eye using continuous, large
volumes of clean water or normal saline for 10 20 min.
 Take care not to contaminate the unaffected eye.
 Refer the casualty for emergency health care professional review.
 It is advisable to wear gloves when treating eye injuries with
unknown chemical substances and to carefully discard them when
treatment has been completed.
Evidence informing the guidelines
Recovery position
The 2015 ILCOR CoSTR suggested that first aid providers position
individuals who are unresponsive and breathing normally into a
lateral, side-lying recovery (lateral recumbent) position as
opposed to leaving them supine (weak recommendation, very-
low-quality evidence). There is little evidence to suggest the
276 RESUSCITATION 161 (2021) 270
optimal recovery position.2,3 Since this review there have been a
series of publications evidencing delays in commencing resusci-
tation when the casualty is turned into the recovery position.14 16
In 2019 ILCOR revised its review population to ‘Adults and children
with decreased level of consciousness, due to medical illness or
nonphysical trauma, that do not meet criteria for the initiation of
rescue breathing or chest compressions (CPR)’ and undertook a
scoping review. The result of this scoping review for this modified
question was no change from the 2015 treatment recommendation
or guideline.
The subsequent 2020 scoping review4,5 with this modified
population identified over 4000 citations from which 34 were
selected for review. All studies were considered to be of low or very
low certainty of evidence with most being undertaken on conscious
healthy volunteers and focussing on comfort and non-occlusion of
the dependent arm vascular supply. Several studies did report on
patients with a decreased level of consciousness due to medical
aetiology or intervention.17 22 There were reported beneficial
outcomes, such as maintenance of a clear airway and in children,
decreased hospitalisation rates supporting the lateral recumbent
position for medical conditions resulting in a decreased level of
consciousness. However, in a single observational study, the semi-
recumbent position was favoured over the lateral position in opioid
overdose.23
The remainder were studies involved healthy volunteers with
normal level of consciousness, patients with obstructive sleep apnoea
or sleep disordered breathing or cadavers with surgically induced
cervical spine injuries.
The First Aid Task Force discussions reflected the lack of direct
evidence in favour of any one particular recovery position and
recommended that the 2015 treatment recommendation be upheld
but modified to:
‘For adults and children with decreased level of responsiveness,
due to medical illness or non-physical trauma that do not meet criteria
for the initiation of rescue breathing or chest compressions (CPR), the
ERC recommends positioning the individual into a lateral, side-lying
recovery (lateral recumbent) position as opposed to leaving them
supine.’
A person placed in the recovery position should be monitored for
continued airway patency/breathing and level of responsiveness. If
either of these deteriorate, the person should be repositioned in a
supine position and, if needed, CPR initiated.
The ILCOR First Aid Task Force recommended undertaking a
further systematic review on this topic.
Optimal position for shock victim
Shock is a condition in which there is failure of the peripheral
circulation. It may be caused by sudden loss of body fluids (such as in
bleeding), serious injury, myocardial infarction (heart attack), pulmo-
nary embolism, and other similar conditions.
This subject was reviewed in the 2015 ILCOR CoSTR2,3 and in the
2015 ERC guidelines.1 It was not formally reviewed in 2020 but was
subject to an evidence update.4,5
While the primary treatment is usually directed at the cause of
shock, support of the circulation is important. Although the evidence is
of low certainty, there is potential clinical benefit of improved vital signs
and cardiac function by placing individuals with shock into the supine
(lying-on-back) position, rather than by moving them into an
alternative position.
290
The use of passive leg raising (PLR) may provide a transient
(<7 min) improvement in heart rate, mean arterial pressure, cardiac
index, or stroke volume,24 26 for those with no evidence of trauma.
However, one study, published in 2018, reported adverse effects due
to PLR.27 The clinical significance of this transient improvement is
uncertain. The optimal degree of elevation has not been determined,
with studies of PLR ranging between 30- and 60-degrees elevation.
Because improvement with PLR is brief and its clinical significance
uncertain, it is not recommended as a routine procedure, although it
may be appropriate in some first aid settings.
These recommendations place an increased value on the
potential, but uncertain, clinical benefit of improved vital signs and
cardiac function, by positioning a victim with shock in the supine
position (with or without PLR), over the risk of moving the victim.
Bronchodilator administration for asthma
This CoSTR was not re-examined by ILCOR in 2020. In the
2015 CoSTR it was recommended that when an individual with
asthma is experiencing difficulty in breathing, we suggest that trained
first aid providers assist the individual with administration of a
bronchodilator (weak recommendation, very-low-quality evidence).2,3
This recommendation was made on the evidence provided by
8 double-blind randomised controlled trials (RCTs),28 35 2 observa-
tional studies36,37 and 1 meta-analysis.38 None of these studies
examined the administration of bronchodilators by first aid providers.
Two RCTs demonstrated a faster return to baseline levels following
the administration of a fast acting beta-2 agonist28,29 with only three
studies reporting complications.28,30,31 The remaining studies re-
ported an improvement in the specific therapeutic endpoints of Forced
Expiratory Volume in 1 second (FEV1)30 35 and Peak Expiratory Flow
Rate (PEFR).36,37
The 2015 first aid guideline remains unchanged.
Recognition of stroke
Stroke is one of the leading causes of death and disability worldwide.39
Over the last 20 years, new treatments such as rapid thrombolytic
delivery or endovascular reperfusion techniques for ischaemic stroke
and medical or surgical treatment for haemorrhagic stroke have been
shown to significantly improve outcomes.40 42 Earlier detection of
stroke in the prehospital setting will reduce time to treatment delays
and prenotification of the hospital is key to improve successful
treatment.43 45
In recent years, stroke recognition campaigns have proposed the
training of laypeople, first aid providers and paramedics in the use of
stroke scales or scoring systems to facilitate the early recognition of
stroke. An ideal stroke assessment system for first aid use must be
easily understood, learned and remembered, must have high
sensitivity and must take a minimal time to be completed.
The systematic review of the 2015 ILCOR First Aid task Force2,3
was rerun in late 2019. Four included studies which were published
following the 2015 First Aid CoSTR showed that achieving a rapid
stroke recognition score during the first aid assessment decreased the
key outcome time from onset to treatment.46 49 Use of the stroke
recognition scale in the prehospital setting increased the number of
patients with confirmed stroke diagnosis promptly admitted to hospital
and the rate of administering urgent treatment.46,48 51 First aid
providers should use stroke scale assessment protocols that provide
the highest sensitivity and the lowest number of false negatives.
 RESUSCITATION 161 (2021) 270
FAST, CPSS, LAPSS and MASS are commonly used in the
prehospital setting (strong recommendation, very-low-quality of
evidence).
In many of the prehospital setting studies, the stroke assessments
were performed by paramedics or nurses4,5,51 so this guideline was
based on extrapolation of potential benefit when these tools are used
by lay people or first aid providers.
The specificity of stroke recognition can be improved by using a
stroke assessment tool that includes blood glucose measurement
such as the LAPSS52 56 or MASS.53,54,57 (weak recommendation,
low certainty evidence). However, it is recognised that not all first aid
providers have access to or the skills or the authority to use a
calibrated glucose measurement device. For first aid providers,
assessment with a stroke recognition scale that includes blood
glucose measurement will require additional training and the
acquisition of measurement devices that can be costly.
Early aspirin for chest pain
The pathogenesis of acute coronary syndromes (ACS) including
acute myocardial infarction (AMI) is most frequently a ruptured
plaque in a coronary artery. As the plaque contents leak into the
artery, platelets clump around them and coronary thrombosis
occurs completely or partially occluding the lumen of the artery,
leading to myocardial ischaemia and possible infarction. The
symptoms of an AMI include chest pain often described as a
pressure with/without radiation of pain to the neck, lower jaw, or
left arm. However, some people, particularly women, present with
less typical symptoms such as dyspnoea, nausea/vomiting,
fatigue or palpitations.
The 2015 CoSTR recommended the administration of aspirin to
adults with chest pain due to suspected myocardial infarction.2,3 This
recommendation was based on the evidence from four studies.58 61 A
second 2015 CoSTR recommended aspirin administration early (i.e.
prehospital or the first few hours after symptom onset) rather than late
(at hospital).2,3
In 2020 the First Aid Task Force re-evaluated the question of early
versus late administration of aspirin for non-traumatic chest pain. Two
further observational studies were identified62,63 comparing the early
and late administration of aspirin in the prehospital environment. Both
studies reported an improvement in survival at 7 days and at 30 days,
although the dose of aspirin did vary between studies. One study
reported an improved survival at one year associated with the early
administration of aspirin.62 Both studies did not report any increase in
complications from early administration. Interestingly, one study63
reported a lower incidence in the occurrence of asystole and the need
for resuscitation with early administration whereas the second study62
reported a higher incidence of ventricular fibrillation and ventricular
tachycardia associated with early administration but the clinical
significance of these events is uncertain.
The use of a single low dose of aspirin as an antithrombotic agent
to potentially reduce mortality and morbidity in ACS/AMI is considered
beneficial even when compared with the low risk of complications,
particularly anaphylaxis and serious bleeding.60,61,64,65
Anaphylaxis
In the 2015 ILCOR CoSTR the Task Force suggested that a second
dose of epinephrine be administered by autoinjector to individuals with
severe anaphylaxis whose symptoms are not relieved by an initial
290 277
dose (weak recommendation, very-low-quality evidence).2,3 Nine
observational studies provided very-low-quality evidence to support
this recommendation.66 74 This CoSTR was the subject of a scoping
review in 2020.4,5,75 Two studies identified were included; both studies
found that for persons requiring treatment with adrenaline for
anaphylaxis, two or more doses were required in 8% of 582 patients,
and in 28% of 18 patients, respectively.75 These studies reaffirm the
2015 treatment recommendation for use of a second dose of
adrenaline in people with anaphylaxis who fail to improve within 5
15 min after an initial dose.
A question arose in the knowledge gaps of the 2015 CoSTR as to
the ability of first aid providers to be able to recognise the symptoms of
anaphylaxis. In 2019 the Task Force undertook a scoping review to
examine this question. 1081 records were identified but only two
studies were relevant.76,77 Both studies reported an improvement in
the knowledge, recognition and management of anaphylaxis with
education and training, but neither were tested in clinical scenarios.
Management of hypoglycaemia
Hypoglycaemia commonly occurs in individuals with diabetes but can
also occur in other individuals due to an imbalance in blood sugar
regulation. Someone experiencing hypoglycaemia will exhibit sudden
impaired consciousness: ranging from dizziness, fainting, sometimes
nervousness and deviant behaviour (mood swings, aggression,
confusion, loss of concentration, signs that look like drunkenness) to
loss of consciousness.78,79 First aid for this condition consists of
providing glucose tablets or other dietary forms of sugar such as juice,
candies or dried fruit strips, to quickly increase the blood sugar level.
These sugars can be self-administered but are also often provided by
family or friends.78,80 Glucose or sugar can be given orally, followed by
swallowing the substance. However, other forms of administration are
also possible, where the substance is not swallowed into the
gastrointestinal tract, leading to faster absorption than the oral route.
These other administration forms include ‘buccal administration’,
placing the glucose inside the cheek against the buccal mucosa or
‘sublingual administration’, taking it under the tongue. This 2020 guide-
line is based on two systematic reviews conducted by the ILCOR First
Aid Task Force.8,81
The first systematic review investigated the effect of oral glucose
(i.e. tablets) or other dietary sugars (search date June 2016, updated
September 2020). The review and update identified three randomised
controlled trials and one observational study comparing dietary
sugars, including sucrose, fructose, orange juice, jelly beans, Mentos,
corn-starch hydrolysate, Skittles and milk to glucose tablets.81 It was
shown in a meta-analysis that dietary sugars resulted in a lower
resolution of symptoms 15 min following treatment than glucose
tablets. The evidence has a low to very low certainty and led to a strong
recommendation concerning the use of glucose tablets, and a weak
recommendation concerning the use of other dietary sugars when
glucose tablets are not available.2,3
The second systematic review aimed to assess the effects of
different enteral routes for glucose administration as first aid treatment
for hypoglycaemia (search date January 2018).8 The review identified
two randomised controlled trials, including individuals with hypogly-
caemia, and two non-randomised controlled trials, including healthy
volunteers. It was shown that sublingual glucose administration, by
giving table sugar under the tongue to children with hypoglycaemia
and symptoms of concomitant malaria or respiratory tract infection,
had better results in terms of glucose concentration after 20 min, than
278 RESUSCITATION 161 (2021) 270
oral glucose administration. When comparing buccal administration to
oral administration, the buccal route was shown to be worse, with a
lower plasma glucose concentration after 20 min. When glucose was
administered in the form of a dextrose gel (resulting in a combined oral
and buccal mucosal route), no benefit could be shown compared to
oral glucose administration. The certainty of the evidence is moderate
to very low certainty and led to a strong recommendation concerning
the use of oral glucose (swallowed) and a weak recommendation in
favour of using a combined oral + buccal glucose (e.g. glucose gel)
administration if oral glucose (e.g. tablet) is not immediately available,
both in case of individuals with suspected hypoglycaemia who are
conscious and able to swallow. In addition, a weak recommendation
against buccal glucose administration compared with oral glucose
administration and a weak recommendation concerning the use of
sublingual glucose administration for suspected hypoglycaemia for
children who may be uncooperative with the oral (swallowed) glucose
administration route was formulated.4,5
Oral rehydration solutions for treating exertion-related
dehydration
Human body water accounts for 50 70% of the total body mass but,
despite this abundance, it is regulated within narrow ranges. During
prolonged exercise, sweat losses generally exceed fluid intake and
even low levels of dehydration (about 2% of the body mass) impair
thermoregulation82 and cardiovascular strain.83,84 Progressive fluid
loss can lead to impaired physical and cognitive performance,85,86
syncope due to hypotension and, finally, heat illness that can be
fatal.87,88 In such situations, it is of utmost importance to promote post-
exercise drinking to restore fluid balance. For rapid and complete
rehydration, the drink volume and composition are key.89,90 Although
the American College of Sports Medicine Guidelines on Nutrition and
Athletic Performance recommend drinking 1.25 1.5 L fluid per kg body
mass lost,91 there is no clear endorsement regarding the specific type of
rehydrating fluid. The most common forms of carbohydrate in sports
drinks are glucose, fructose, sucrose and maltodextrin; the carbohy-
drate concentration varies between brands of sports drinks, but typically
ranges are between 6 8%, compared to 10 12% carbohydrates in
sugared soft drinks and fruit juices. Lower carbohydrate concentrations
are sometimes promoted as ‘lite’ or reduced carbohydrate sports drinks.
The advantages of these varying concentrations of carbohydrate-
electrolyte drinks has been subject of many studies in athletes.
The ideal rehydration solution following exercise-induced dehy-
dration was the topic of an ILCOR review in 20152,3 and is now
updated by the ILCOR First Aid Task Force.4,5 An additional 15 studies
were identified (search date July, 2019), leading to the inclusion of a
total of 23 randomised controlled trials (RCTs) and four non-
randomised studies, comparing different concentrations of carbohy-
drate-electrolyte solutions (CES), beer of different alcohol percen-
tages, milk, coconut water or high alkaline water, yoghurt drink or tea
with regular water. The best available evidence was of low to very-low
certainty due to limitations in study design, imprecise results and
strongly suspected conflict of interest.4,5
Evidence for carbohydrate-electrolyte solutions (CES)
compared with water
8 12% CES compared with water
Very-low-certainty evidence from 2 RCTs92,93 could not demonstrate
benefit from 8 12% CES for cumulative urine output when compared
290
with water. Furthermore, very-low-certainty evidence from 2
RCTs89,92 showed benefit from 8 12% CES for fluid retention after
1 and 2 h and on dehydration after 1 and 2 h when compared with
water. Low-certainty evidence from 1 RCT could not show benefit for
the development of hyponatremia.93
3 8% CES compared with water
Very-low-certainty evidence from 3 RCTs94 96 and 3 non-RCTs97 99
showed benefit from 3 8% CES for cumulative urine output when
compared with water. In addition, benefit for cumulative urine output
could not be demonstrated in 3 RCTs.100 102 Very-low-certainty
evidence from 6 RCTs94 96,100,102,103 and 2 non-RCTs98,99 showed
benefit from 3 8% CES for fluid retention when compared with water.
In addition, a beneficial effect for fluid retention or rehydration could
not be demonstrated in 4 RCTs.89,101,104,105.
0 3% CES compared with water
Low-certainty evidence from 2 RCTs106,107 showed benefit from 0
3% CES for cumulative urine output, fluid retention and serum
sodium concentration when compared with water. A benefit for serum
potassium concentration could not be demonstrated.
Evidence for milk compared with water
Very-low-certainty evidence from 3 RCTs92,100,101 showed benefit
from skimmed milk for cumulative urine output, fluid retention and
dehydration when compared with water.
Additionally, very-low-certainty evidence from 1 RCT101 showed
benefit from skimmed milk with 20 mmol/L sodium chloride for
cumulative urine output and fluid retention.
Evidence for regular beer compared with water
Very-low-certainty evidence from 1 RCT108 showed harm from regular
beer (4.5 5% alcohol) for cumulative urine output and fluid retention
when compared with water. Additionally, in 2 other RCTs,102,109
benefit for cumulative urine output, fluid retention and serum sodium
and serum potassium concentration could not be demonstrated.
Other rehydration solutions compared with water
For the following rehydration solutions, insufficient evidence is
available to recommend their use: coconut water,96,104 maple
water,110 yoghurt drink,93 rooibos tea,111 Chinese tea plus caffeine,93
high alkaline water,112 deep ocean113,114 or commercial bottled
water,115 3% glycerol,116 low- or non-alcoholic beer102,108 or whey
protein isolate solution.117
Management of heat stroke by cooling
Heat stroke occurs when the core body temperature exceeds 40  C. It
is a medical emergency and can lead to severe organ damage and
death if the core temperature is not reduced promptly.118 Non-
exertional heat stroke is typically seen after prolonged exposure to the
sun and is often seen during heat waves.119 121 However, it may be
seen during hot weather in individuals with impaired heat regulation
such as in the elderly or children. Exertional heat stroke is associated
with physical exertion in a hot or warm environment.
In 2020 the ILCOR First Aid Task Force published a systematic
review of cooling methods for heat stroke.122 A total of 3289 records
were identified with 63 studies included in the quantitative GRADE
analysis. A detailed analysis of the science supporting various cooling
techniques was made and summarised by the ILCOR First Aid Task
 RESUSCITATION 161 (2021) 270
Force.4,5 In the systematic review most of the evidence was from
studies of healthy adult volunteers with induced exertional heat stroke,
although cohort studies and case series from exertional heat stroke
casualties were also used by the task force to inform their
recommendations. This review found that the fastest rate of cooling
was achieved with use of whole body (neck down) water immersion, at
a temperature between 1 26  C. Of surprise, cooling was nearly as
fast with the use of temperate water for immersion as it was for ice
water. Water immersion cooled faster than all other forms of active
cooling, including the use of ice packs to the axillae, groin and neck,
use of showers, ice sheets or towels, and misting/fanning. Passive
cooling was slightly faster than evaporative cooling and was felt, by the
Task Force, to be an essential component of cooling for heat stroke or
exertional hyperthermia.
A Task Force consensus opinion was that core temperature (rectal
or oesophageal) should be measured if possible when evaluating or
managing heat stroke. For adults with exertional or non-exertional
heat stroke actively, cool the casualty using whole body (neck down)
water immersion at 1 26  C until a core body temperature below
39  C has been reached (weak recommendation, very low certainty
evidence). If cold water immersion is not available use any other
cooling technique immediately available (weak recommendation, very
low certainty evidence) that will provide the most rapid rate of cooling
(weak recommendation, very low certainty evidence). No recommen-
dation was made for non-exertional heat stroke (no recommendation,
very low certainty evidence) as only scientific evidence was found for
exertional heat stroke. No recommendation was made for cooling
children with exertional or non-exertional heat stroke (no recommen-
dation, very low certainty evidence) as all the science referred to adult
subjects.
Fig. 3 shows cooling techniques reviewed in the systematic
review, in decreasing order of effectiveness, included ice water
immersion (1 5  C), temperate water immersion (20 25  C), cold
Fig. 3 – Weighted mean cooling rates ( C/min) by cooling method.
290 279
water immersion (14 17  C), colder water immersion (8 12  C),
commercial ice packs, showers (20  C), ice sheets and towels (3  C),
hand and feet cold water immersion (16 17  C), cooling vests and
jackets, cold intravenous fluids, fanning, passive cooling, hand cooling
devices and evaporative cooling.122
Use of supplemental oxygen in acute stroke
The use of supplemental oxygen in acute stroke is controversial. The
ILCOR First Aid Task Force undertook a systematic review and
published a CoSTR.4,5 The treatment recommendation suggested
against the routine use of supplementary oxygen in the first aid setting
compared with no use of supplementary oxygen (weak recommen-
dation, low to moderate certainty of evidence).
Direct evidence was provided by one prehospital observational
study123 supported by 8 in-hospital randomised controlled trials124
131
comparing supplementary oxygen, at different flow rates and
delivery methods, to no supplementary oxygen. The overall majority of
these studies failed to show any improvement in survival, quality of life
or neurologic outcome, including National Institutes of Health Stroke
Scale (NIHSS) score. One retrospective observational study did
report that when comparing three acute stroke groups (oxygen
provided for hypoxia, routine provision of oxygen, no oxygen) there
was no increase in respiratory complications or neurologic compli-
cations at hospital discharge suggesting that early supplementary
oxygen may be safe.
The Task Force also considered that the provision of supplemental
oxygen may not be considered as routine first aid. Oxygen
administration does require the provision and use of equipment
and an understanding of the mechanisms and risks of oxygen
administration. It was recognised that this may not be available or
applicable to all first aid providers and that further specific training
would be required for providers.
280 RESUSCITATION 161 (2021) 270
Management of presyncope
Syncope (fainting) is a temporary loss of consciousness. In many
cases it is preceded by a prodromal phase, presyncope, which is
characterised by light-headedness, nausea, sweating, black spots in
front of the eyes and an impending sense of loss of consciousness.
The estimated worldwide incidence is between 15 and 39%, 50% of
females and 25% of males having a syncopal event in their lifetime.132
134
Injuries from syncope related falls include fractures, intracranial
haemorrhage, internal organ injury and neurologic injury and accounts
for approximately 30% of patients admitted to emergency rooms.135
Syncope may be of vasovagal (50%) or orthostatic (7%) or cardiac
(7%) origin136 and there is laboratory evidence to suggest that
physical counterpressure manoeuvres may abort syncope if applied in
the presyncopal phase.137 140 Physical counterpressure manoeu-
vres (PCM) include muscle contraction of the large muscles of arms,
legs and abdomen - leg-pumping, tensing, crossing, squatting, hand-
grip, and abdominal compression (Fig. 4).
In 2020 the ILCOR First Aid Task Force published a systematic
review of immediate interventions for presyncope of vasovagal or
orthostatic origin7 and a CoSTR statement.4,5 Of 5160 citations initially
identified, 81 studies were included for full text review and eight studies
were ultimately included in the GRADE analysis (two randomised
controlled studies141,142 and six prospective cohort studies.143 148 All
studies investigated the effects of physical counter-pressure manoeu-
vres with six of the eight studies examining presyncope of vasovagal
origin141,143,144,146 148 whilst the other studies examined presyncope of
orthostatic origin.142,146 All eight studies showed mostly beneficial
results for key outcomes for both the combined vasovagal and
orthostatic presyncope group, as well as for those with presyncope of
vasovagal origin alone. Pooled observational studies of various types of
PCM did not show a benefit for aborting syncope, but several studies
comparing the use of one method of PCM compared with an alternate
method, or compared to control, showed benefit for aborting syncope.
There was low-certainty evidence suggesting a modest benefit with the
use of PCM for aborting syncope, and there was also low-certainty
evidence showing a strong association of the use of PCM with symptom
reduction.141 148 No adverse events were reported, suggesting that the
use of PCM may be a safe and effective first aid intervention in the
specific population of individuals with suspected or recurrent vasovagal
or orthostatic presyncope origin.143,144
The ILCOR First Aid Task Force recommended the use of any type
of physical counter-pressure manoeuvre by individuals with acute
symptoms of presyncope due to vasovagal or othostatic origin (strong
recommendation, low and very-low-certainty evidence). Lower body
physical counter-pressure manoeuvres (squatting, squatting with leg
crossing, marching action) were recommended in preference to upper
body manoeuvres (hand gripping, neck flexion, core tensioning)
(weak recommendation, very low certainty evidence).7 The Task
Force acknowledged that many of these studies were laboratory
studies in individuals with pre-existing vasovagal or orthostatic
syncope. They also acknowledged that to promulgate this recom-
mendation, first aid providers would need to be trained in coaching
techniques so that the provider could instruct the victim in how to
perform the physical counter-pressure manoeuvre.
Control of life-threatening bleeding
Trauma is the leading cause of injury-related morbidity and mortality
across the globe. Uncontrolled bleeding is the primary cause of death
290
in up to 35% of victims of trauma.149,150 Exsanguination can occur in
as little as 5 min, making the immediate control of life-threatening
bleeding a critical skill for first aid. Life-threatening bleeding can be
recognised by rapidly flowing or spurting blood from a wound, pooling
of blood on the ground, or bleeding that cannot be controlled by direct
manual pressure alone. Although direct manual pressure has been
the gold standard for the initial control of bleeding, alternative
techniques such as the use of tourniquets and haemostatic dressings
are being applied more commonly for life-threatening bleeding in the
prehospital military and civilian settings.
A recent systematic review by the International Liaison
Committee on Resuscitation (ILCOR) evaluated multiple methods
for the control of life-threatening external bleeding.151 Evidence
included for this review was identified from the prehospital civilian
setting, supplemented by studies from the military prehospital
setting, the in-hospital setting, and some simulation studies.
Although evidence was identified to support recommendations
for the use of direct pressure, tourniquets, and haemostatic
dressings, the sequence of application has yet to be studied. In
addition, no comparative evidence was identified for the use of
pressure points, ice (cryotherapy) or elevation for control of life-
threatening bleeding. There was inadequate evidence to support
the use of junctional tourniquets or wound clamping devices by lay
providers.
Direct pressure, pressure dressings, haemostatic dressings,
pressure points and cryotherapy for life-threatening
bleeding
Despite being considered the traditional ‘gold standard’ for bleeding
control, the evidence supporting the use of direct manual pressure for
the control of life-threatening bleeding is limited and indirect, with
3 three in-hospital randomised controlled trials of endovascular
procedures in 918 patients showing a longer time to haemostasis with
the use of mechanical pressure devices compared with direct manual
pressure.152 154
The use of pressure dressings for maintaining haemostasis
following control of life-threatening bleeding is also supported by
limited, low certainty evidence. A cohort study of 64 patients with
arteriovenous fistula puncture reported bleeding cessation in 45.5%
with the use of direct manual pressure compared with 82% with the
use of a commercial elastic compression bandage, while a case series
of 62 victims of penetrating wounds in the prehospital civilian setting
reported control of bleeding with the use of a commercial pressure
dressing in 87% and reduced bleeding in the remaining 11%.155,156
Haemostatic dressings vary in design or mechanism of action, but
typically are specially treated gauze sponges containing an agent that
promotes blood clotting. These dressings are applied to or packed
inside a wound and work when combined with direct manual pressure.
First aid providers have demonstrated the ability to use haemostatic
dressings in addition to direct manual pressure for the treatment of life-
threatening bleeding.157 Although primarily indirect, evidence sup-
ports the use of haemostatic dressings, with direct manual pressure,
for control of life-threatening bleeding.
One low-certainty randomised controlled trial of 160 patients with
stab wounds to the limbs demonstrated cessation of bleeding in less
than 5 min in 51.2% of those who had a chitosan-coated haemostatic
dressing applied with direct pressure compared with 32.5% of those
who had direct pressure alone.158 Fourteen in-hospital RCTs with
2419 civilian adults undergoing endovascular procedures also
demonstrated more rapid haemostasis (4.6 17.8 min) with the use
 RESUSCITATION 161 (2021) 270 290 281

Fig. 4 – Physical counterpressure manoeuvres to prevent syncope.

of a haemostatic dressing compared with direct manual pressure
(12.4 43.5 min).159 172
While haemostatic dressings may be considered costly, the First
Aid Task Force felt strongly that the cost of a single dressing in a first
aid kit would not compare with the value of a life lost to uncontrollable
bleeding.
Tourniquets
Tourniquets have been shown to stop life-threatening bleeding from
wounds to the limbs and to improve survival.173,174 In a cohort study of
281 adults with traumatic extremity injuries, use of a tourniquet in the
prehospital setting was associated with a lower mortality rate
compared with the use of a tourniquet after hospital arrival [3% (8/
252) vs 14% (2/29); p = 0.01].173 A second, larger cohort study of
1025 adults with traumatic peripheral vascular injury reported a
reduction in mortality rate associated with use of a tourniquet (7/181
[3.9%]) compared with no tourniquet use (44/845 [5.2%], adjusted OR,
5.86; 95% CI, 1.4 24.5)
Manufactured tourniquets may be of a windlass, ratcheting or
elastic design and are intended to distribute pressure circumferentially
in a manner that prevents tissue damage while effectively stopping
blood flow when properly tightened. There are no randomised trials in
the prehospital setting that show superiority in control of bleeding or
survival based on the design of a manufactured tourniquet.175 181
Compared with improvised tourniquets, a manufactured tourni-
quet has been shown to have a higher success rate for cessation of
bleeding in simulation studies with healthy volunteers.182,183 A
manikin study reported 100% cessation of simulated bleeding with
the use of a Combat Application Tourniquet (CAT), 40% with the use of
an improvised bandage tourniquet and 10% with the use of an
282 RESUSCITATION 161 (2021) 270
improvised bandana tourniquet.184 There is some evidence that
trained first aid providers are capable of proper and successful
application of an improvised tourniquet to stop bleeding.182 184
A tourniquet may not be immediately available. In this case, direct
manual pressure remains the initial means of controlling life-threatening
bleeding, although when combined with use of a haemostatic dressing it
may be more effective than direct pressure alone.152 154,173,174
There is concern that manufactured tourniquets designed for
adults may not be able to be tightened adequately on the very small
limbs of young children or infants. A 2020 ILCOR scoping review4,5
identified one recent human study in children that demonstrated
successful occlusion of pulses with use of a manufactured windlass
tourniquet in children as young as two years of age.185 When caring for
children younger than two, if a first aid provider has difficulty with
tightening a manufactured tourniquet, it may be reasonable to use
direct manual pressure with or without a haemostatic dressing to
control life-threatening bleeding from an extremity wound.
Management of open chest wounds
This topic was not reviewed in the 2020 round of CoSTR reviews. The
correct management of an open chest wound is critical, as inadvertent
sealing of the wound through use of occlusive dressings or devices
may result in the potential life-threatening complication of a tension
pneumothorax.186 The 2015 ILCOR CoSTR treatment recommenda-
tion suggested against the application of an occlusive dressing or
device by first aid providers to individuals with an open chest wound
(weak recommendation, very-low-quality evidence)2,3 based on one
animal study187 showing benefit from applying a non-occlusive
dressing for respiratory arrest, oxygen saturation, therapuetic
endpoint (tidal volume) and the vital signs heart rate and respiratory
rate but not mean blood pressure. The Task Force considered that any
recommendation on this subject was being made based on a single
animal study. They concluded that not recommending the use of any
dressing or an occlusive device would protect against the occurence
of a potentialy fatal tension pnuemothorax.4,5
However if a specialised non-occlusive dressing is available and
the first aid provider has been trained in the application of the device
and its subsequent management, including close monitoring of the
casualty's condition, it could be used.4,5
Cervical spine motion restriction and stabilisation
In trauma patients, cervical spine injuries are rare but may be
present.188,189 First aid interventions aim to minimise additional
movement of the neck in order to prevent potential injury of the cervical
spine.
Definitions:
 Spinal immobilisation is defined as the process of immobilising the
spine using a combination of devices (e.g. scoop-stretcher and
cervical collar) intended to restrict spinal motion.
 Cervical spinal motion restriction is defined as the reduction or
limitation of cervical spine movement using mechanical devices
such as cervical collars and/or sandbags with tape.
 Spinal stabilisation is defined as the physical maintenance of the
spine in a neutral position, such as by manual stabilisation, prior to
the application of spinal motion restriction devices.
 Manual stabilisation is defined as any technique used to hold the
neck in a consistent position using a provider's hands or arms, i.e.
no use of devices.
290
In a suspected cervical spine injury, it has historically been routine
to apply a cervical collar to the neck in order to avoid a cervical spine
injury. However, this intervention has been based on consensus and
opinion rather than on scientific evidence.190,191 The 2015 ILCOR
CoSTR suggested against the use of cervical collars by first aid
providers (weak recommendation, very-low-quality evidence).2,3 This
recommendation was made in 2015 and upheld in 2020 as the Task
Force felt that it was consistent with the first aid principle of preventing
further harm compared with the potential benefits of applying a
cervical collar.4,5 Adverse effects have been reported from the use of
cervical collars such as delayed transportation to definitive care,192,193
patient discomfort and pain,194 raised intracranial pressure195,196 and
reduced tidal volume.197
In 2019 the First Aid Task Force undertook an extensive scoping
review of cervical spinal motion restriction. A total of 3958 records
were screened of which six studies were identified as relevant.198 203
These studies included three which did report the ability to restrict
cervical spine movement to varying degrees199,202,203 but also found
one case report200 showing worsening of neurologic signs until the
collar was removed and one small cohort study201 reporting the
development of false midline cervical pain from the use of a cervical
collar and rigid backboard. One literature review198 of five studies
reported that alert casualties exhibited proficient self-immobilisation
and protective mechanisms. Furthermore, they reported that a
casualty who self-extricates from a vehicle may move their neck up
to four times less than a casualty who is extricated by traditional
methods.
The Task Force did not feel that there was sufficient evidence to
prompt a further systematic review and that the recommendation
made in 2015 still stands. Where manual stabilisation is being
considered, there is insufficient evidence to recommend one manual
stabilisation technique (head-squeeze, trapezium squeeze).4,5
Recognition of concussion
Minor head injuries without loss of consciousness are common in
adults and children. First aid providers may find it difficult to recognise
concussion (minor traumatic brain injury (mTBI) due to the complexity
of the symptoms and signs. The recognition of concussion is important
as not recognizing it can lead to serious consequences including
further injury and even death. Some of the symptoms of concussion
may present immediately following the event. Others may not be
noticed for days or months after the injury, or until the person resumes
their everyday life preceding the injury.204 In certain circumstances
individuals do not recognise or admit that they are experiencing
symptoms of a concussion. Others may not understand the different
ways they have been affected and how the symptoms they are
experiencing impact on their daily activities.
In 2015 the ILCOR CoSTR2,3 made no recommendation but
acknowledged the role that a simple, validated, single stage
concussion scoring system could play in the recognition of concussion
by first aid providers.
First aid providers are often faced with situations where they must
decide what advice to offer an individual following head trauma,1,205
especially during sport. One study206 identified insufficient confidence
and knowledge in lay responders to make a decision about how to act
in a head injury scenario other than seeking medical assistance, but
this varied according to contextual and situational factors.
An extensive scoping review carried out in late 2019 did not find
any published manuscript reporting the use of a single stage
 RESUSCITATION 161 (2021) 270
concussion assessment tool.4,5 The following validated concussion
assessment tools were identified but they do not fulfil the requirements
for reliable concussion assessment to be made by first aid providers.
Sport Concussion Assessment Tool (SCAT 5)
Sport has taken the subject of concussion very seriously and the fifth
version of the Sport Concussion Assessment Tool (SCAT 5) together
with the rationale for it, has been published for use by healthcare
professionals.207,208 The implementation of SCAT 5 has resulted in
fundamental changes in many sports which has improved both the
recognition of concussion and its subsequent management for
participants of all ages in sport. However, SCAT 5 is a two-stage
concussion scoring system and is not appropriate in the first aid
environment by first aid providers.
Concussion Recognition Tool (CRT 5)
In 2017 the Concussion Recognition Tool, CRT 5,209,210 was
introduced to be used by non-healthcare professionals but, to date,
there are no published validation data for this tool.
Glasgow Coma Scale (GCS)
The adult and paediatric Glasgow Coma Scales (GCS) are commonly
used to assess for and grade, a minor traumatic brain injury. However,
the Glasgow Coma Scale was first designed with 3 scale components
with which to determine the level of consciousness of patients with an
acute brain injury.211 The three components of the scale were
eventually combined into a single index despite losing some of the
detail and discrimination conveyed by the full scale212 and this is now
commonly used in the prehospital setting and emergency department
by healthcare providers to assess and monitor a person's level of
consciousness following a head injury. The GCS is not an appropriate
tool for use by first aid providers to assess for a possible concussion
following a head injury as the majority of concussion events do not
result in a loss or alteration in consciousness.
AVPU scale
The Alert, Responds to Verbal Stimuli, Responds to Pain,
Unresponsive (AVPU) Scale is another commonly used scale in
the prehospital setting that was discussed. This simple assessment
scale is used to establish a person's level of responsiveness but
should not be used to establish the presence of a concussion.213
Using this tool, anyone who does not score ‘A’ (alert) requires
immediate evaluation by a healthcare provider. It is not an
appropriate tool to be used by first aid providers to assess for a
possible concussion following a head injury.
2-Stage concussion scoring scales
The Immediate Post-Concussion Assessment and Cognitive Testing
(ImPACT), the Standardized Assessment of Concussion (SAC), and
the Sport Concussion Assessment Tool (current version, SCAT 5)
were explored. These scales are designed for use by trained
healthcare providers who are able to establish baseline normative
data. They are not suitable as a single-stage scoring system for first
aid.
Thermal burns
Cooling of thermal burns
The 2015 ILCOR CoSTR recommended immediate cooling of burns
(strong recommendation, low-quality evidence).2,3 Cooling thermal
290 283
burns will minimise the resulting depth of the burn214,215 and possibly
decrease the number of patients that will eventually require hospital
admission for treatment.216 The other perceived benefits of cooling
are pain relief and reduction of oedema (swelling), reduced infection
rates and a faster wound healing process. There are no scientifically
supported recommendations for the specific cooling temperature or
the method of cooling (e.g. gel pads, cold packs or water). This CoSTR
was not repeated in 2020.
The 2015 ERC Guideline recommended a cooling period of at least
10 min that was the perceived minimum acceptable length of cooling.1
Although there have been multiple studies of cooling burns in porcine
models,217 220 it is well recognised that the differences between
porcine and human skin makes these findings unreliable.221 One
human model study has subsequently shown that cooling burns at
16  C for 20 min favourably modified the injury.222
The ILCOR Task Force, when discussing its 2019 Scoping Review
of the management of burns,4,5 made an additional recommendation
as a good practice point to actively cool burns by cool or cold (but not
freezing) water for at least 20 min. The ERC guideline has therefore
been updated to lengthen the recommended cooling time for burns to
at least 20 min. The ERC acknowledges that this may be challenging in
practice in some instances and urges any cooling as opposed to no
cooling as circumstances allow.
Thermal burn dressings
The 2015 ILCOR CoSTR compared wet and dry dressings for burns
but failed to find any supporting evidence for either type of dressing for
thermal burns in the prehospital setting2,3 and the subsequent ERC
guideline recommended loosley covering a burn with a dry sterile
dressing as a good practice point.1
A subsequent 2020 ILCOR scoping review4,5 of 1482 citations
looked at first aid dressings for superficial thermal burns. The review
showed that most publications concentrated on the in-hospital
management of partial or full-thickness burns (ILCOR First Aid CoSTR)
and that no one burn dressing could be recommended above any other
for the first aid management of superficial burns. Task Force
discussions did reflect that, following initial cooling, cling wrap could
be used to protect the wound, reduce heat and evaporation, reduce pain
and to allow the wound to be visualised more easily.223 It was also noted
that the risk of infection from using cling wrap was extremely low.224
Dental avulsion
Avulsion of permanent teeth is one of the most serious dental injuries
and accounts for 0.6 to as much as 20.8% of all traumatic dental
injuries.225,226 The avulsed tooth should be replanted as quickly as
possible for a good healing prognosis, but first responders such as
parents227 and teachers228 lack knowledge regarding appropriate
emergency treatment after tooth avulsion. This undoubtedly leads to
delayed replantation and extensive desiccation of the tooth with
subsequent necrosis of the periodontal ligament (PDL) which
progressively may cause the loss of the tooth.229 Although immediate
replantation of the avulsed tooth at the site of the accident has been
suggested to result in the greatest chance of tooth survival,230 first aid
providers may lack the required skills and the willingness to attempt this
painful procedure, and may choose to temporarily store the tooth until
professional care is available. The use of a suitable temporary storage
solution or technique for an avulsed tooth should not delay efforts at
replantation, but it may aid in preserving PDL viability in avulsed teeth
prior to receiving professional assistance and improving long-term tooth
284 RESUSCITATION 161 (2021) 270
survival. This urges the need to identify the most effective storage
methods for avulsed teeth which are available to laypeople.
This guideline is based on a new 2020 systematic review
conducted by the ILCOR First Aid Task Force.4,5,12 They reviewed
the best available evidence on the effectiveness of any technique
available to laypeople for storing an avulsed tooth compared with
storage in milk or saliva, which are currently the most recommended
temporary storage solutions in a prehospital setting. Out of
4118 references (search date September 2019), 33 studies were
included and reported on 23 comparisons of which 10 were
synthesised in a meta-analysis. It was found that the following
techniques demonstrated higher efficacy at preserving tooth cell
viability compared with milk: HBSS, propolis, ORS, rice water or cling
film. Furthermore, cow's milk (any form or fat percentage) was shown
to extend the tooth cell viability before replantation compared with
saline, tap water, buttermilk, castor oil, turmeric extract and GC tooth
mousse. There is insufficient evidence to recommend for or against
temporary storage of an avulsed tooth in saliva compared with
alternative solutions. The evidence has a low to very low certainty due
to limitations in study design, indirect study populations (extracted
teeth instead of avulsed teeth) and outcome measures (cell viability as
a measure for tooth viability) and imprecise results and led to weak
recommendations concerning the use of storage techniques for an
avulsed tooth when immediate replantation is not possible.12
Compression wrap for closed extremity joint injuries
A lateral ankle sprain is a common closed joint injury encountered by first
aid providers.231,232 Approximately 23,000 to 27,000 ankle sprains are
estimated to occur each day in the United States (US)233,234 while the
crude incidence rate of ankle sprains in accident and emergency (A&E)
units in the United Kingdom is approximately 52.7 injuries per 10,000
people.235 This may be less disruptive in people with a sedentary lifestyle;
nevertheless for athletes and those working in more physically
demanding jobs, these injuries may have life-long critical effects.236
Different acronyms are known for the treatment of simple acute
closed joint injuries in the prehospital, hospital, and primary care
setting, such as RICE (either “Rest, Immobilization [requires
compression], Cold, and Elevation” or “Rest, Ice, Compression,
Elevation”), PRICE (adding “protection” to RICE), or POLICE
(Protection, Optimal Loading, Ice, Compression, Elevation.237 More
recently, PEACE & LOVE was introduced (Protection, Elevation,
Avoid anti-inflammatories, Compression, Education & Load, Opti-
mism, Vascularization, Exercise),238 where PEACE focuses on the
prehospital setting, while LOVE is the care during the subsequent
days. All these acronyms have compression in common.
A new 2020 systematic review was conducted by the ILCOR First
Aid Task Force, where they reviewed the best available evidence for
the use of a compression wrap as a treatment for closed extremity joint
injuries.4,5 A total of 1193 references were identified, of which finally
six randomised controlled trials236,239 243 and two non-randomised
controlled trials244,245 were included. Benefit could not be demon-
strated for reduction of pain, being free from walking pain, pain at rest,
pain at walking, and reduction of swelling or oedema when comparing
a compression bandage with no compression (in the form of not using
a compression bandage, or using non-compressive stockings, a splint
or a brace [Air Stirrup1 ankle brace]).236,239,241,243 245 Also, benefit
could not be demonstrated for range of motion and recovery time,
when using compression bandage compared with an ankle
brace.240,242 In one study242 less benefit was shown for time to
290
return to work, when comparing compression bandage with an Air
Stirrup1 ankle brace, whereas in two other studies,236,239 a difference
could not be demonstrated. Finally, one RCT239 showed benefit for
time to return to sports when using a compression bandage compared
with using non-compressive stockings. In summary, a clear beneficial
effect could not be demonstrated for any of the studied outcomes. All
evidence is of low to very low certainty, due to limitations in study
design, indirect study population (all studies were performed in a
hospital setting) and imprecise results.11
The 2020 ILCOR First Aid Task Force CoSTR made a neutral
recommendation suggesting either the application of a compression
bandage or no application of a compression bandage for adults with an
acute closed ankle injury. (weak recommendation, very low certainty
evidence).4,5,11 Furthermore, the Task Force was unable to
recommend for or against the use of a compression bandage for
other closed joint injuries, apart from ankle injuries, due to the lack of
available evidence. The Task Force recognised that all studies were
performed in-hospital and that there were none from the out-of-
hospital setting. They also acknowledged that it may require specific
training to be able to apply a compression bandage safely and
effectively to an injured joint.4,5,11
Straightening an angulated fracture
Fractures, dislocations, sprains and strains are extremity injuries
commonly cared for by first aid providers. The first aid management of
fractures begins with the manual stabilisation of the fracture, followed
by splinting in the position found. Splinting, to include the joint above
and the joint below the break, protects the injury from further
movement and thus prevents or reduces pain and the potential for
converting a closed fracture to an open fracture. Long bone fractures,
particularly of the leg or forearm, may be angulated on presentation
and severe angulation may limit the ability to properly splint the
extremity or move the injured individual.
This topic was reviewed in 2015 but no published data were found
that supported the use of splints to immobilise the injured extremity.2,3
An evidence update, carried out in 2020 also found no published
studies and therefore the guideline for 2020 remains the same as for
2015.
Common sense and expert opinion support the use of a splint to
immobilise an extremity fracture (Good Practice Statement).
Do not straighten angulated fracture but immobilise in the position
found with as little movement as possible to apply the splint (Good
Practice Statement).
In some cases, an extremity fracture will present with severe
angulation, making the application of a splint and transportation
extremely difficult or impossible. Severe angulation may also
compromise the vascular supply to the distal limb (absent peripheral
pulse, distal to the fracture). In these cases, the first aid provider may
request the assistance of a healthcare provider with specific training to
perform fracture realignment to facilitate splinting and to re-establish a
distal vascular circulation before transportation to a hospital.
Eye injury from chemical exposure
Accidental exposure of the eye to chemical substances is a common
problem in both the household and industrial setting and it is often
difficult to identify precisely what chemical has entered the eye.
The 2015 ILCOR CoSTR suggested that first aid providers use
continuous, large volumes of clean water for irrigation of chemical eye
 RESUSCITATION 161 (2021) 270
injuries (weak recommendation, very-low-quality evidence). This
recommendation was made for alkaline pH solutions entering the eye
and was for irrigation treatment only.2,3 The recommendation was
evidenced from a single animal study demonstrating a reduction of the
high, alkaline pH with irrigation using water. No difference in maximum
alkalinity was found when using equal volumes of water on 0.9%
saline. This topic was not reviewed in 2020.
Alkali injury to the cornea has been shown to cause severe corneal
injury and risk of blindness.1 3 In contrast, acidic substances cause
protein coagulation in the epithelium, a process that limits further
penetration into the eye.246 Irrigation with large volumes of water was
found to be more effective at improving corneal pH as compared to
using low volumes or saline irrigation.247 It has been suggested that
the use of solutions such as lactated ringers (LR) or balanced salt
solution (BSS) or, in industrial settings, amphoteric - hypertonic
solutions (e.g. Diphoterine) have been proposed as the preferred
option for emergency neutralisation.246 However, the choice of
aqueous solution is of less prognostic importance than the timing of
treatment and any delay in irrigation should be avoided. In addition to
accidental and occupational exposure, there has been an increase in
the number of violent assaults when acid is thrown in the face. This
results in life-changing cutaneous and ocular injuries and may require
consideration of more extensive first aid training and the wider
provision of specific neutralisation measures.248
Conflict of interest
AH declared his role of Medical advisor British Airways and Medical
Director of Places for People.
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Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Newborn resuscitation and support of transition of
infants at birth

John Madar a, *, Charles C. Roehr b,c,d, Sean Ainsworth e, Hege Ersdal f,g,
Colin Morley h,i, Mario Rüdiger j,k, Christiane Skåre l, Tomasz Szczapa m, Arjan te [126_TD$IF]Pas n,
Daniele Trevisanuto o, Berndt Urlesberger p, Dominic Wilkinson q,r,s, Jonathan P. Wyllie t
a
Department of Neonatology, University Hospitals Plymouth, Plymouth, UK
b
Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
c
Department of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, UK
d
Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Medical Sciences Division, University of Oxford, Oxford, UK
e
Directorate of Women’s and Children’s Services, Victoria Hospital, Kirkcaldy, UK
f
Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
g
Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
h
University of Melbourne, Australia
i
Department of Obstetrics, University of Cambridge, UK
j
Department for Neonatology and Pediatric Intensive Care Medicine, Clinic for Pediatrics, University Hospital C.G.Carus, Technische Universität
Dresden, Germany
k
Center for Feto-Neonatal Health, Technische Universität Dresden, Germany
l
Department of Anaesthesiology, Oslo University Hospital, Norway
m
Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical
Sciences, Poznan, Poland
n
Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
o
Department of Woman’s and Child’s Health, University Hospital of Padova, Padova, Italy
p
Division of Neonatology, Medical University Graz, Austria
q
Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, UK
r
John Radcliffe Hospital, Oxford, UK
s
Murdoch Children’s Research Institute, Melbourne, Australia
t
James Cook University Hospital, Middlesbrough, UK

Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on
Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the
management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors
before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the
newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

* Corresponding author.
E-mail address: john.madar@nhs.net (J. Madar).
https://doi.org/10.1016/j.resuscitation.2021.02.014

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
292 RESUSCITATION 161 (2021) 291
Introduction and scope
[1264_TD$IF]These guidelines are based on the International Liaison Committee on
Resuscitation (ILCOR) 2020 Consensus on Science and Treatment
Recommendations (CoSTR) for Neonatal Life Support.1 For the
purposes of the ERC Guidelines the ILCOR recommendations were
supplemented by focused literature reviews undertaken by the ERC
NLS guidelines Group for topics not reviewed by 2020 ILCOR CoSTR.
When appropriate, the guidelines were informed by the expert
consensus of the ERC guidelines group membership.
These guidelines were drafted and agreed by the Newborn Life
Support Writing Group members. The methodology used for guideline
development is presented in the Executive summary.2 The guidelines
were posted for public comment in October 2020. The feedback was
reviewed by the writing group and the guidelines were updated where
relevant (see supplemental material). The Guideline was presented to
and approved by the ERC General Assembly on 10th December 2020.
Key messages from these guidelines are summarised in Fig. [1265_TD$IF]2 .
COVID 19 context
The ERC has produced guidance on newborn life support in the
context of coronavirus disease 2019 (SARS-CoV-2),3 this is based
on an ILCOR CoSTR and systematic review.4,5 Our understanding
of the risks to infants potentially exposed to SARS-CoV-2 and the
risk of virus transmission and infection to those providing care is
evolving. Please check ERC and national guidelines for the latest
guidance and local policies for both treatment and rescuer
precautions.
Summary of changes since the 2015 guidelines
Management of the umbilical cord
Clamping after at least 60 s is recommended, ideally after the lungs are
aerated. Where delayed cord clamping is not possible cord milking should
be considered in infants >28 weeks gestation.
Infants born through meconium-stained liquor
In non-vigorous infants, recommendations are against immediate
laryngoscopy with or without suction after delivery, because this may delay
aeration and ventilation of the lungs.
Use of the laryngeal mask
If facemask ventilation is unsuccessful or if tracheal intubation is
unsuccessful or not feasible a laryngeal mask may be considered as an
alternative means of establishing an airway in infants of >34 weeks
gestation (about 2000 g, although some devices have been used
successfully in infants down to 1500 g).
Inflation pressure
If there is no response to initial inflations despite an open airway then a
gradual increase in the inflation pressure is suggested.
A starting pressure of 25 cm H2O is suggested for preterm infants <32
weeks gestation.
Air/oxygen for preterm resuscitation
Recommendations are for starting in air at 32 weeks gestation or more, 21-
30% inspired oxygen at 28-31 weeks gestation and 30% inspired oxygen at
<28 weeks gestation.
The concentration should be titrated to achieve saturations of 80% at 5 min
of age because there is evidence of poorer outcomes where this is not
achieved.
Chest compressions
If chest compressions are required, the inspired oxygen concentration
should be increased to 100% and consideration given towards securing the
airway ideally with a tracheal tube.
326
Vascular access
The umbilical vein is still favoured as the optimal route of access but,
intraosseous access is an alternative method of emergency access for
drugs/fluids.
Adrenaline
Where the heart rate has not increased after optimising ventilation
and chest compressions an intravenous dose of adrenaline of
10 30 micrograms kg 1 is recommended, repeated every 3 5 min in the
absence of a response.
Glucose during resuscitation
An intravenous dose of 250 mg kg 1 (2.5 mL kg 1 of 10% glucose) is
suggested in a prolonged resuscitation to reduce the likelihood of
hypoglycaemia.
Prognosis
Failure to respond despite 10 20 mins of intensive resuscitation is
associated with high risk of poor outcome. It is appropriate to consider
discussions with the team and family about withdrawal of treatment if there
has been no response despite the provision of all recommended steps of
resuscitation and having excluded reversible causes
Concise guideline for clinical practice
Factors before delivery
Transition and the need for assistance after birth
Most, but not all, infants adapt well to extra-uterine life but some
require help with stabilisation, or resuscitation. Up to 85% breathe
spontaneously without intervention; a further 10% respond after
drying, stimulation and airway opening manoeuvres; approximately
5% receive positive pressure ventilation. Intubation rates vary
between 0.4% and 2%. Fewer than 0.3% of infants receive chest
compressions and only 0.05% receive adrenaline.
Risk factors
A number of risk factors have been identified as increasing the
likelihood of requiring help with stabilisation, or resuscitation (Fig. [1274_TD$IF]1).
Staff attending delivery
Any infant may develop problems during birth. Local guidelines
indicating who should attend deliveries should be developed,
based on current understanding of best practice and clinical
audit, and taking into account identified risk factors (Fig. [1275_TD$IF]1 ). As a
guide,
 Personnel competent in newborn life support should be available
for every delivery.
 If intervention is required, there should be personnel available
whose sole responsibility is to care for the infant.
 A process should be in place for rapidly mobilising a team with
sufficient resuscitation skills for any birth.
Equipment and environment
 All equipment must be regularly checked and ready for use.
 Where possible, the environment and equipment should be
prepared in advance of the delivery of the infant. Checklists
facilitate these tasks.
 Resuscitation should take place in a warm, well-illuminated,
draught-free area with a flat resuscitation surface and a radiant
heater (if available).
 Equipment to monitor the condition of the infant and to support
ventilation should be immediately available.
 RESUSCITATION 161 (2021) 291
Fig. 1 – Common factors associated with an increased
regular practice and drills,
risk of a need for stabilization, or resuscitation at birth.
team and leadership training,
multi-modal approaches,
simulation-based training,
feedback on practice from different sources (including feedback
 Additional equipment, that might be required in case of more
prolonged resuscitation should be easily accessible.
objective, performance focused debriefings.
Planned home deliveries
 Ideally, two trained professionals should be present at all home
deliveries.
 At least one must be competent in providing mask ventilation and
chest compressions to the newborn infant.
 Recommendations as to who should attend a planned home
delivery vary from country to country, but the decision to undergo
such a delivery, once agreed with medical and midwifery staff,
should not compromise the standard of initial assessment,
stabilisation or resuscitation at birth.
 There will inevitably be some limitations to the extent of the
resuscitation of a newborn infant in the home, due to the distance
from healthcare facilities and equipment available, and this must
be made clear to the mother at the time plans for home delivery are
made.
 When a birth takes place in a non-designated delivery area a
minimum set of equipment of an appropriate size for the newborn
infant should be available, including:
clean gloves for the attendant and assistants,
means of keeping the infant warm, such as heated dry towels Environment
and blankets,
a stethoscope to check the heart rate, air-conditioning appropriately programmed.
a device for safe assisted lung aeration and subsequent  Keep the environment in which the infant is looked after (e.g.
ventilation such as a self-inflating bag with appropriately sized
facemask,
sterile instruments for clamping and then safely cutting the temperature should be >25  C.
umbilical cord.
 [1276_TD$IF]Unexpected deliveries outside hospital are likely to involve
emergency services who should be trained and prepared for
such events and carry appropriate equipment.
 Caregivers undertaking home deliveries should have pre-defined
plans for difficult situations.
[127_TD$IF]Briefing
 If there is sufficient time, brief the team to clarify responsibilities,
check equipment and plan the stabilisation, or resuscitation.
 Roles and tasks should be assigned checklists are helpful.
 Prepare the family if it is anticipated that resuscitation might be
required.
326 293
Training/education
Recommendations
 Newborn resuscitation providers must have relevant current
knowledge, technical and non-technical skills.
 Institutions or clinical areas where deliveries may occur should
have structured educational programmes, teaching the knowl-
edge and skills required for newborn resuscitation.
 The content and organisation of such training programmes may
vary according to the needs of the providers and the organisation
of the institutions.
 Recommended programmes include:
devices),
 [1278_TD$IF]Ideally, training should be repeated more frequently than once per
year.
[1279_TD$IF]Updates may include specific tasks, simulation and/or behav-
ioural skills and reflection.
Thermal control
Recommendations
Standards
 The infant's temperature should be regularly monitored after birth
and the admission temperature should be recorded as a
prognostic and quality indicator.
 The temperature of newborn infants should be maintained
between 36.5  C and 37.5  C.
 Hypothermia (36.0  C) and hyperthermia (>38.0  C) should be
avoided. In appropriate circumstances, therapeutic hypothermia
may be considered after resuscitation (see post-resuscitation
care)
 Protect the infant from draughts. Ensure windows are closed and
delivery room or theatre) warm at 23 25  C.
 For infants 28 weeks gestation the delivery room or theatre
Term and near-term infants >32 weeks gestation
 Dry the infant immediately after delivery. Cover the head and body
of the infant, apart from the face, with a warm and dry towel to
prevent further heat loss.
 If no resuscitation is required place the infant skin-to-skin with
mother and cover both with a towel. On-going careful observation
of mother and infant will be required especially in more preterm
and growth restricted infants to ensure they both remain
normothermic.
 If the infant needs support with transition or when resuscitation is
required, place the infant on a warm surface using a preheated
radiant warmer.
294 RESUSCITATION 161 (2021) 291 326

Fig. 2 – NLS infographic.

Preterm infants 32 weeks gestation
 Completely cover with polyethylene wrapping (apart from face)
without drying and use a radiant warmer.
 If umbilical cord clamping is delayed and a radiant warmer is not
accessible at this point, other measures (such as those listed
below) will be needed to ensure thermal stability while still
attached to the placenta.
 A combination of further interventions may be required in infants
32 weeks including increased room temperature, warm
blankets, head cap and thermal mattress.
 Skin-to-skin care is feasible in less mature infants however caution
is required in the more preterm or growth restricted infant in order
to avoid hypothermia.
 For infants receiving respiratory support, use of warmed
humidified respiratory gases should be considered.
 A quality improvement program including the use of checklists and
continuous feedback to the team has been shown to significantly
reduce hypothermia at admission in very preterm infants.
Out of hospital management
 Infants born unexpectedly outside a normal delivery environment
are at higher risk of hypothermia and subsequent poorer
outcomes.
 They may benefit from placement in a food grade plastic bag after
drying and then swaddling. Alternatively, well newborns >30
weeks gestation may be dried and nursed skin-to-skin to maintain
their temperature whilst they are transferred as long as mothers
are normothermic. Infants should be covered and protected from
draughts and watched carefully to avoid hypothermia and ensure
airway and breathing are not compromised.
 RESUSCITATION 161 (2021) 291 326 295

Management of the umbilical cord after birth Heart rate

 The options for managing cord clamping and the rationale should
be discussed with parents before birth.
 Where immediate resuscitation or stabilisation is not required, aim
to delay clamping the cord for at least 60 s. A longer period may be
Slow (60 100 min 1) intermediate, possible hypoxia
more beneficial.
Very slow/absent (<60 min 1) critical, hypoxia likely
 Clamping should ideally take place after the lungs are aerated.
 Where adequate thermal care and initial resuscitation interven-
tions can be safely undertaken with the cord intact it may be
possible to delay clamping whilst performing these interventions.
 Where delayed cord clamping is not possible consider cord milking
in infants >28 weeks gestation.
Initial assessment (Fig. 3)
 Determine the heart rate with a stethoscope and a saturation
monitor  ECG (electrocardiogram) for later continuous
assessment.
Fast (100 min 1) satisfactory
If the infant fails to establish spontaneous and effective breathing
following assessment and stimulation, and/or the heart rate does not
increase (and/or decreases) if initially fast, respiratory support should
be started.
Classification according to initial assessment
On the basis of the initial assessment, the infant can usually be placed
into one of three groups as the following examples illustrate.

1.

Fig. 3 – Assessment of tone, breathing and heart rate help

determine the need for intervention.
Fig. 4a – Satisfactory transition.
May occur before the umbilical cord is clamped and cut (typically
performed in this order): Good tone
 Observe Tone (& Colour) Vigorous breathing or crying
 Assess adequacy of Breathing Heart rate fast (100 min 1)
 Assess the Heart Rate
 Take appropriate action to keep the baby warm during these initial Assessment: Satisfactory transition Breathing does not require
steps. support. Heart rate is acceptable (Fig. 4[125_TD$IF]a ).
 This rapid assessment serves to establish a baseline, identify the
need for support and/or resuscitation and the appropriateness and Actions:
duration of delaying umbilical cord clamping.  Delay cord clamping.
 Frequent re-assessment of heart rate and breathing indicates  Dry, wrap in warm towel.
whether the infant is adequately transitioning or whether further  Keep with mother or carer and ensure maintenance of temperature.
interventions are needed.  Consider early skin-to-skin care if stable.

Tactile stimulation 2.
Initial handling is an opportunity to stimulate the infant during
assessment by
 Drying the infant.
 Gently [1280_TD$IF]stimulating as you dry them, for example by rubbing the
soles of the feet or the back of the chest. Avoid more aggressive
methods of stimulation.

Tone and colour

Fig. 4b – Incomplete transition.
 A very floppy infant is likely to need ventilatory support.
 Colour is a poor means of judging oxygenation. Cyanosis can be Reduced tone
difficult to recognise. Pallor might indicate shock or rarely hypovolaemia Breathing inadequately (or apnoeic)
consider blood loss and plan appropriate intervention. Heart rate slow (<100 min 1)

Breathing Assessment: Incomplete transition Breathing requires support,

 Is the infant breathing?
work/effort of breathing as
Adequate
Inadequate/abnormal pattern
Absent
Note the rate, depth and symmetry, slow heart rate may indicate hypoxia (Fig. [128_TD$IF]4b).
Actions:
such as gasping or grunting  Delay cord clamping only if you are able to appropriately support
the infant.
296 RESUSCITATION 161 (2021) 291
 Dry, stimulate, wrap in a warm towel.
 Maintain the airway, lung inflation and ventilation.
 Continuously assess changes in heart rate and breathing
 If no improvement in heart rate, continue with ventilation.
 Help may be required.
3.
Fig. 4c – Poor/failed transition.
Floppy  Pale
Breathing inadequately or apnoeic
Heart rate very slow (<60 min 1) or undetectable
Assessment: Poor/Failed transition Breathing requires support,
heart rate suggestive of significant hypoxia (Fig. [128_TD$IF]4c).
Actions:
 Clamp cord immediately and transfer to the resuscitation platform.
Delay cord clamping only if you are able to appropriately support/
resuscitate the infant.
 Dry, stimulate, wrap in warm towel.
 Maintain the airway lung inflation and ventilation.
 Continuously assess heart rate, breathing, and effect of
ventilation.
326
 Continue newborn life support according to response.
 Help is likely to be required.
Preterm infants
 Same principles apply.
 Consider alternative/additional methods for thermal care e.g.
polyethylene wrap.
 Gently support, initially with CPAP if breathing.
 Consider continuous rather than intermittent monitoring (pulse
oximetry  ECG)
Newborn life support
Following initial assessment and intervention, continue respiratory
support if:
 The infant has not established adequate, regular breathing, or
 The heart rate is <100 min 1.
[1283_TD$IF]Ensuring an open airway, aerating and ventilating the lungs[1284_TD$IF] is
usually all that is necessary. Without these, other interventions will be
unsuccessful.
Airway
Commence life support if initial assessment shows that the infant has
not established adequate regular normal breathing, or has a heart rate
<100 min 1 [1285_TD$IF](Fig. 5).
Establishing and maintaining an open airway is essential to
achieve postnatal transition and spontaneous breathing, or for further
resuscitative actions to be effective.[1286_TD$IF]
RESUSCITATION 161 (2021) 291 326 297

Fig. 5 – NLS algorithm.

298 RESUSCITATION 161 (2021) 291
Techniques to help open the airway
 Place the infant on their back with the head supported in a neutral
position (Fig. [1287_TD$IF]6a).
Fig. 6a – Head in a neutral position. Face is horizontal
(middle picture), neither flexed (left) or extended (right).
 In floppy infants, pulling the jaw forwards (jaw lift) may be
essential in opening and/or maintaining the airway and reducing
mask leak (Fig. [128_TD$IF]6b). When using a facemask, two person
methods of airway support are superior and permit true jaw
thrust to be applied.
Fig. 6b – Jaw lift jaw lift enlarges the pharyngeal space.
 An oropharyngeal airway may be useful in term infants when
having difficulty providing both jaw lift and ventilation, or where the
upper airway is obstructed, for instance in those with micrognathia.
However, oropharyngeal airways should be used with caution in
infants 34 weeks gestation as they may increase airway
obstruction.
 A nasopharyngeal airway may also be considered where there is
difficulty maintaining an airway and mask support fails to achieve
adequate aeration.
Airway obstruction
A slow or very slow heart rate usually suggests continued
 Airway obstruction can be due to inappropriate positioning,
decreased airway tone and/or laryngeal adduction, especially in
preterm infants at birth.
 Suction is only required if airway obstruction due to mucus, vernix,
meconium, blood clots, etc. is confirmed through inspection of the
pharynx after failure to achieve aeration.
 Any suctioning should be undertaken under direct vision, ideally
using a laryngoscope and a wide bore catheter.
Meconium
 Non-vigorous newborn infants delivered through meconium-
stained amniotic fluid are at significant risk for requiring advanced
resuscitation and a neonatal team competent in advanced
resuscitation may be required.
 Routine suctioning of the airway of non-vigorous infants is likely
to delay initiating ventilation and is not recommended. In the
absence of evidence of benefit for suctioning, the emphasis
326
must be on initiating ventilation as soon as possible in apnoeic or
ineffectively breathing infants born through meconium-stained
amniotic fluid.
 Should initial attempts at aeration and ventilation be unsuccessful
then physical obstruction may be the cause. In this case inspection
and suction under direct vision be considered. Rarely, an infant
may require tracheal intubation and tracheal suctioning to relieve
airway obstruction.
Initial inflations and assisted ventilation
Lung [1289_TD$IF]inflation (Fig. 7)
 If apnoeic, gasping or not breathing effectively, aim to start positive
pressure ventilation as soon as possible ideally within 60 s of
birth.
 Apply an appropriately fitting facemask connected to a means of
providing positive pressure ventilation, ensuring a good seal
between mask and face.
 Give five “inflations” maintaining the inflation pressure for up
to 2 3 s.
 Provide initial inflation pressures of 30 cm H2O for term
infants commencing with air. Start with 25 cm H2O for preterm
infants 32 weeks using 21 30% inspired oxygen (see ‘air/
oxygen’).
Fig. 7 – Five 2 3 s inflations are given via facemask.
Assess heart rate response and chest movement.
Assessment

Check the heart rate
An increase (within 30 s) in heart rate, or a stable heart rate if
initially high, confirms adequate ventilation/oxygenation.
hypoxia and almost always indicates inadequate ventilation.
 Check for chest movement
 Visible chest movement with inflations indicates a patent airway
and delivered volume.
 Failure of the chest to move may indicate obstruction of the
airway, or insufficient inflation pressure and delivered volume to
aerate the lungs.
Ventilation (Fig. [1290_TD$IF]8 )
If there is a heart rate response
 Continue uninterrupted ventilation until the infant begins to
breathe adequately and the heart rate is above 100 min 1.
 Aim for about 30 breaths min 1 with an inflation time of under 1 s.
 Reduce the inflation pressure if the chest is moving well.
 Reassess heart rate and breathing at least every 30 s.
 Consider a more secure airway (laryngeal mask/tracheal tube) if
apnoea continues or if mask ventilation is not effective.
 RESUSCITATION 161 (2021) 291 326 299

 Where possible use a T-piece resuscitator (TPR) capable of

providing either CPAP or PPV with PEEP when providing
ventilatory support, especially in the preterm infant.
 Nasal prongs of appropriate size may be a viable CPAP alternative
to facemasks.
 If a self-inflating bag is used it should be of sufficient volume to deliver an
adequate inflation. Care should be taken not to deliver an excessive
volume. The self-inflating bag cannot deliver CPAP effectively.

Laryngeal mask
Fig. 8 – Once inflation breaths have been successfully  Consider using a laryngeal mask
delivered, ventilate at 30 breaths min 1. Assess heart In infants of 34 weeks gestation (about 2000 g) although some
rate continuously. devices have been used successfully in infants down to 1500 g.
If there are problems with establishing effective ventilation with

Failure to respond a facemask.

If there is no heart rate response and the chest is not moving with Where intubation is not possible or deemed unsafe because

inflations of congenital abnormality, a lack of equipment, or a lack of

 Check if the equipment is working properly. skill.
 Recheck the head-position and jaw lift/thrust Or as an alternative to tracheal intubation as a secondary

 Recheck mask size, position and seal. airway.

 Consider other airway manoeuvres:
2-person mask support if single handed initially.
Inspection of the pharynx and suction under direct vision to
remove obstructing foreign matter if present.
Securing the airway via tracheal intubation or insertion of a
laryngeal mask.
Insertion of an oropharyngeal/nasopharyngeal airway if unable
to secure the airway with other means.
Where ventilation is prolonged, to enable a more secure airway
Tracheal tube
 Tracheal intubation may be considered at several points during
neonatal resuscitation:
When ventilation is ineffective after correction of mask
technique and/or the infant's head position, and/or increasing
inspiratory pressure with TPR or bag-mask.

 Consider a gradual increase in inflation pressure. to be established.

 If being used, check on a respiratory function monitor that expired When suctioning the lower airways to remove a presumed

tidal volume is not too low or too high (target about 5 8 mL kg 1). tracheal blockage.
When chest compressions are performed.

Then: In special circumstances (e.g., congenital diaphragmatic hernia

 Repeat inflations. or to give surfactant).

 Continuously assess heart rate and chest movement.  Exhaled CO2 detection should be used when undertaking
intubation to confirm tube placement in the airway.
If the insertion of a laryngeal mask or tracheal intubation is  A range of differing sized tracheal tubes should be available to
considered, it must be undertaken by personnel competent in the permit placement of the most appropriate size to ensure adequate
procedure with appropriate equipment. Otherwise continue with ventilation with minimal leak and trauma to the airway [129_TD$IF]Table 1.
mask ventilation and call for help.  Respiratory function monitoring may also help confirm tracheal
Without adequate lung aeration, chest compressions will be tube position and adequate ventilation through demonstrating
ineffective; therefore, where the heart rate remains very slow, confirm adequate expired tidal volume (about 5 8 mL kg 1) and minimal
effective ventilation through observed chest movement or other leak.
measures of respiratory function before progressing to chest  The use of a video laryngoscope may aid tube placement.
compressions.  If retained, the position of the tracheal tube should be confirmed by
radiography.
[129_TD$IF]CPAP and PEEP/airway adjuncts and assisted ventilation
Table 1 – Approximate oral tracheal tube size by
Continuous positive airway pressure (CPAP) and positive gestation (for approximate nasotracheal tube length
end expiratory pressure (PEEP) add 1 cm).
 In spontaneously breathing preterm infants consider CPAP as the Gestational Length at Internal
initial method of breathing support after delivery using either age (weeks) lips (cm) diameter (mm)
mask or nasal prongs.
23 24 5.5 2.5
 If equipment permits, apply PEEP at minimum of 5 6 cm H2O 25 26 6.0 2.5
when providing positive pressure ventilation (PPV) to these 27 29 6.5 2.5
infants. 30 32 7.0 3.0
33 34 7.5 3.0
Assisted ventilation devices 35 37 8.0 3.5
38 40 8.5 3.5
 Ensure a facemask of appropriate size is used to provide a good
41 43 9.0 4.0
seal between mask and face.
300 RESUSCITATION 161 (2021) 291
Air/[21_TD$IF]oxygen
 Pulse-oximetry and oxygen blenders should be used during
resuscitation in the delivery room.
 Aim to achieve target oxygen saturation above the 25th percentile
for healthy term infants in the first 5 min after birth (Table 2).
Table 2 – Approximate target SpO2 in the first 10 min
for healthy term infants (derived from Dawson
et al.281).
Time after birth (min) Lower SpO2 target (%)
2 65
5 85
10 90
 If, despite effective ventilation, there is no increase in heart rate, or
saturations remain low, increase the oxygen concentration to
achieve adequate preductal oxygen saturations.
 Check the delivered inspired oxygen concentration and satu-
rations frequently (e.g. every 30 s) and titrate to avoid both hypoxia
and hyperoxia.
 wean the inspired oxygen if saturations >95% in preterms.
Term and late preterm infants 35 weeks
 In infants receiving respiratory support at birth, begin with air
(21%).
Preterm infants <35 weeks
 Resuscitation should be initiated in air or a low inspired oxygen
concentration based on gestational age:
[1293_TD$IF]32 weeks 21%
28 31 weeks 21 30%
<28 weeks 30%
 In infants <32 weeks gestation the target should be to avoid an
oxygen saturation below 80% and/or bradycardia at 5 min of age.
Both are associated with poor outcome.
Chest compressions
Assessment of the need for chest compressions (Fig. [1294_TD$IF]9 )
 If the heart rate remains very slow (<60 min 1) or absent after 30 s
of good quality ventilation, start chest compressions.
 When starting compressions:
Increase the delivered inspired oxygen to 100%.
Call for experienced help if not already summoned.
Intravenous or intraosseous is the preferred route:
Fig. 9 – Deliver 30 s of good quality ventilation before
reassessment of the heart rate.
326
Delivery of chest compressions
 [1295_TD$IF]Use a synchronous technique, providing three compressions to
one ventilation at about 15 cycles every 30 s.
 [1296_TD$IF]Use a two-handed technique for compressions if possible.
 Re-evaluate the response every 30 s.
 If the heart rate remains very slow or absent, continue ventilation
and chest compressions but ensure that the airway is secured
(e.g. intubate the trachea if competent and not done already).
 Titrate the delivered inspired oxygen against oxygen saturation if a
reliable value is achieved on the pulse oximeter.
Consider
 Vascular access and drugs.
Vascular access
During the resuscitation of a compromised infant at birth peripheral
venous access is likely to be difficult and suboptimal for vasopressor
administration.
Umbilical venous access
 The umbilical vein offers rapid vascular access in newborn
infants and should be considered the primary method during
resuscitation.
 Ensure a closed system to prevent air embolism during insertion
should the infant gasp and generate sufficient negative pressure.
 Confirm position in a blood vessel through aspiration of blood prior
to administering drugs/fluids.
 Clean, rather than sterile, access technique may be sufficient in an
emergency.
 The umbilical route may still be achievable some days after birth
and should be considered in cases of postnatal collapse.
Intraosseous access
 Intraosseous (IO) access can be an alternative method of
emergency access for drugs/fluids.
Support of transition/post-resuscitation care
 If venous access is required following resuscitation, peripheral
access may be adequate unless multiple infusions are required in
which case central access may be preferred.
 IO access may be sufficient in the short term if no other site is
available.
Drugs
During active resuscitation
Drugs are rarely required during newborn resuscitation and the
evidence for the efficacy of any drug is limited. The following may
be considered during resuscitation where, despite adequate
control of the airway, effective ventilation and chest compressions
for 30 s, there is an inadequate response and the HR remains
below 60 min 1.
 Adrenaline
When effective ventilation and chest compressions have failed
to increase the heart rate above 60 min 1
& At a dose of 10 30 micrograms kg 1 (0.1 0.3 mL kg 1 of
1:10,000 adrenaline [1000 micrograms in 10 mL]).
 RESUSCITATION 161 (2021) 291
Intra-tracheally if intubated and no other access available. Therapeutic hypothermia
& At a dose of 50 100 micrograms kg 1.
Subsequent doses every 3 5 min if heart rate remains < 60 min 1.
 Glucose
In a prolonged resuscitation to reduce likelihood of
hypoglycaemia.
Intravenous or intraosseous:
& 250 mg kg
1
bolus (2.5 mL kg 1 of 10% glucose solution).
 Volume replacement
With suspected blood loss or shock unresponsive to other
resuscitative measures.
Intravenous or intraosseous:
1
& 10 mL kg of group O Rh-negative blood or isotonic
crystalloid.
 Sodium bicarbonate
May be considered in a prolonged unresponsive resuscitation
with adequate ventilation to reverse intracardiac acidosis.
[1297_TD$IF]Intravenous or intraosseous:
& 1 2 mmol kg 1 sodium bicarbonate (2 4 mL kg 1 of 4.2%
solution) by slow intravenous injection.
In situations of persistent apnoea
 Naloxone
Intramuscular
& An initial 200 microgram dose may help in the
few infants who, despite resuscitation, remain apnoeic
with good cardiac output when the mother is known
to have received opiods in labour. Effects may be
transient so continued monitoring of respiration is
important.
In the absence of an adequate response
Consider other factors which may be impacting on the response to
resuscitation and which require addressing such as the presence of
pneumothorax, hypovolaemia, congenital abnormalities, equipment
failure etc.
Post-resuscitation care
Infants who have required resuscitation may later deteriorate. Once
adequate ventilation and circulation are established, the infant should
be cared for in, or transferred to, an environment in which close
monitoring and anticipatory care can be provided.
Glucose
 Monitor glucose levels carefully after resuscitation.
 Have protocols/guidance on the management of unstable glucose
levels.
 Avoid hyper- and hypoglycaemia.
 Avoid large swings in glucose concentration.
 Consider the use of a glucose infusion to avoid hypoglycaemia.
Thermal care
 Aim to keep the temperature between 36.5  C and 37.5  C.
 Rewarm if the temperature falls below this level and there are no
indications to consider therapeutic hypothermia (see below).
326 301
 Once resuscitated, consider inducing hypothermia to 33 34  C in
situations where there is clinical and/or biochemical evidence of
significant risk of moderate or severe HIE (hypoxic-ischaemic
encephalopathy).
 Ensure the evidence to justify treatment is clearly documented;
include cord blood gases, and neurological examination.
 Arrange safe transfer to a facility where monitoring and treatment
can be continued.
 Inappropriate application of therapeutic hypothermia, without
concern about a diagnosis of HIE, is likely to be harmful (see
temperature maintenance).
Prognosis (documentation).
 Ensure clinical records allow accurate retrospective time-based
evaluation of the clinical state of the infant at birth, any
interventions and the response during the resuscitation to
facilitate any review and the subsequent application of any
prognostic tool.
Communication with the parents
Where intervention is anticipated
 Whenever possible, the decision to attempt resuscitation of an
extremely preterm or clinically complex infant should be taken in
close consultation with the parents and senior paediatric,
midwifery and obstetric staff.
 Discuss the options including the potential need and magnitude of
resuscitation and the prognosis before delivery in order to develop
an agreed plan for the birth.
 Record carefully all discussions and decisions in the mother's
notes prior to delivery and in the infant's records after birth.
For every birth
 Where intervention is required it is reasonable for mothers/fathers/
partners to be present during the resuscitation where circum-
stances, facilities and parental inclination allow.
 The views of both the team leading the resuscitation and the
parents must be taken into account in decisions on parental
attendance.
 Irrespective of whether the parents are present at the resuscita-
tion, ensure wherever possible, that they are informed of the
progress of the care provided to their infant.
 Witnessing the resuscitation of their infant may be distressing for
parents. If possible, identify a member of healthcare staff to
support them to keep them informed as much as possible during
the resuscitation.
 Allow parents to hold or even better to have skin-to-skin contact
with their infant as soon as possible after delivery or resuscitation,
even if unsuccessful.
 Provide an explanation of any procedures and why they were
required as soon as possible after the delivery.
 Ensure a record is kept of events and any subsequent
conversations with parents.
 Allow for further discussions later to enable parents to reflect and
to aid parental understanding of events.
 Consider what additional support is required for parents following
delivery and any resuscitation.
302 RESUSCITATION 161 (2021) 291
Withholding and discontinuing resuscitation
 Any recommendations must be interpreted in the light of current
national/regional outcomes.
 When discontinuing, withdrawing or withholding resuscitation,
care should be focused on the comfort and dignity of the infant and
family.
 Such decisions should ideally involve senior paediatric staff.
Discontinuing resuscitation
 National committees may provide locally appropriate recommen-
dations for stopping resuscitation.
 When the heart rate has been undetectable for longer than 10 min
after delivery review clinical factors (for example gestation of the
infant, or presence/absence of dysmorphic features), effective-
ness of resuscitation, and the views of other members of the
clinical team about continuing resuscitation.
 If the heart rate of a newborn term infant remains undetectable for
more than 20 min after birth despite the provision of all
recommended steps of resuscitation and exclusion of reversible
causes, consider stopping resuscitation.
 Where there is partial or incomplete heart rate improvement
despite apparently adequate resuscitative efforts, the choice is
much less clear. It may be appropriate to take the infant to the
intensive care unit and consider withdrawing life-sustaining
treatment if they do not improve.
 Where life-sustaining treatment is withheld or withdrawn, infants
should be provided with appropriate palliative (comfort focused) care.
Withholding resuscitation
 Decisions about withholding life-sustaining treatment should
usually be made only after discussion with parents in the light
of regional or national evidence on outcome if resuscitation and
active (survival focused) treatment is attempted.
 In situations where there is extremely high (>90%) predicted
neonatal mortality and unacceptably high morbidity in surviving
infants, attempted resuscitation and active (survival focused)
management is usually not appropriate.
 Resuscitation is nearly always indicated in conditions associated
with a high (>50%) survival rate and what is deemed to be
acceptable morbidity. This will include most infants with gestational
age of 24 weeks or above (unless there is evidence of fetal
compromise such as intrauterine infection or hypoxia-ischaemia)
and most infants with congenital malformations. Resuscitation
should also usually be commenced in situations where there is
uncertainty about outcome and there has been no chance to have
prior discussions with parents.
 In conditions where there is low survival (<50%) and a high rate of
morbidity, and where the anticipated burden of medical treatment
for the child is high, parental wishes regarding resuscitation should
be sought and usually supported.
Evidence informing the guidelines
Factors before delivery
Transition
Survival at birth involves major physiological changes during transition
from fetal to newborn life. First, lung liquid-clearance and aeration need
326
to occur after which pulmonary gas exchange can be established.6 This
critical event initiates a sequence of inter-dependent cardiopulmonary
adaptations which enable transition to independent life.7 Spontaneous
breathing effort (negative pressure) or less effective, artificial ventilation
(positive pressure) are essential to generate the transpulmonary
pressures required to aerate the liquid-filled lung to form and then
maintain a functional residual capacity.8,9 Most, but not all, infants
transition smoothly. Some infants have problems with transition, and
without timely and adequate support, might subsequently need
resuscitation. Recent, large-scale observational studies confirm that
approximately 85% of infants born at term initiate respiration
spontaneously; 10% will respond to drying, stimulation, opening the
airway and/or applying CPAP or PEEP, approximately 5% will breathe
following positive pressure ventilation. Estimates of intubation rates
vary between 0.4% and 2%; <0.3% receive chest compressions and
approximately 0.05% adrenaline.10 16
Risk factors
Several maternal and fetal pre- and intrapartum factors increase the risk
for compromised birth or transition and the need for resuscitation. In a
recent ILCOR evidence update most recent studies confirm previously
identified risk factors for needing assistance after birth.1,17 26 There is
no universally applicable model to predict risk for resuscitation or need
of support during transition, and the list of risk factors in the guidelines is
not exhaustive.
Elective caesarean delivery at term, in the absence of other risk
factors, does not increase the risk of needing newborn resuscita-
tion.18,27,28 Following the review of evidence, ILCOR recommendations
are unchanged: When an infant is delivered at term by caesarean delivery
under regional anaesthesia a provider capable of performing assisted
ventilation should be present at the delivery. It is not necessary for a
provider skilled in neonatal intubation to be present at that delivery.1
Staff attending delivery
It is not always possible to predict the need for stabilisation or
resuscitation before an infant is born. Interventions may not be
necessary but those in attendance at a delivery need to be able to
undertake initial resuscitation steps effectively. It is essential that
teams can respond rapidly if not present and needed to provide
additional support. The experience of the team and their ability to
respond in a timely manner can influence outcome.29 Units have
different guidelines for when teams attend in advance, potentially
leading to widely different outcomes.30 A prospective audit of 56
Canadian neonatal units found that, with the guidelines in force at that
time, the need for resuscitation was unanticipated in 76% of cases.31
In a series of video recorded resuscitations in 2 Norwegian tertiary
level units, the need for resuscitation was not anticipated in 32%.32
Approximately 65% of all deliveries in a single Canadian unit were
attended by the resuscitation team only 22% of these infants
required IPPV, as did another 4.6% where resuscitation was not
anticipated.17
Equipment and environment
The detailed specification of the equipment required to support
stabilisation and resuscitation of the newborn may vary and those
using the equipment need to be aware of any limitations. Suggestions
have been made on standardising an optimal layout of a resuscitation
area,33 but no published evidence has demonstrated improvement in
outcome as a result of specific arrangements. The guidelines are
based on international expert opinion.1,34
 RESUSCITATION 161 (2021) 291
Planned home deliveries
A systematic review of 8 studies involving 14 637 low risk planned
home deliveries compared to 30 177 low risk planned hospital births
concluded that the risks of neonatal morbidity and mortality were
similar.35 Those attending deliveries at home need to recognise that
despite risk stratification and measures to avoid the event, infants born
at home may still require resuscitation and they must be prepared for
this possibility.34
Briefing and checklists
Briefing with role allocation to improve team functioning and dynamics
is recommended36 although there is a lack of evidence of improved
clinical outcomes.37 Likewise, use of checklists during briefings (and
debriefings) may help improve team communication and process, but
again, there is little evidence of effect on clinical outcome.38,39 A recent
ILCOR scoping review on the effect of briefing/debriefing on the
outcome of neonatal resuscitation concluded that briefing or debrief-
ing may improve short-term clinical and performance outcomes for
infants and staff but the effects on long-term clinical and performance
outcomes were uncertain.1
The opportunity to brief the family before delivery can significantly
influence their expectation and understanding of events, decision-
making and interactions with health providers. Therefore, anticipatory
liaison often forms part of national recommendations on practice (see
section parents and family).33
Training/education
Meta-analysis of adult resuscitations showed that attendance by one
or more personnel on an advanced life support course improves
outcome.40 Research on educational methods in neonatal resuscita-
tion is evolving, but due to study heterogeneity with non-standardised
outcome measures, there is still little evidence on the effect of different
training modalities on clinical outcome.41 43
For those taking resuscitation courses training or retraining
distributed over time (spaced learning) may be an alternative to
training provided at one single time point (massed learning) (weak
recommendation, very low certainty of evidence).44 Intermittent,
infrequent training without interval refreshment leads to skills decay in
neonatal resuscitation.45 whereas frequent and brief, on-site simula-
tion-based training has been shown to improve patient 24 h survival in
a low-resource setting.46 Two observational studies analysing video
recordings of real-time resuscitations against checklists of expected
actions indicated frequent errors in the application of structured
guidelines in newborn resuscitation.15,47 This suggests that training
should be repeated more frequently than once per year, however, the
optimal interval remains to be established.48,49
A structured educational programme in neonatal resuscitation was
recommended in the 2015 ERC guidelines and supported by two
systematic reviews and meta-analyses.34 A Cochrane review of 14
studies (187 080 deliveries) concluded that there was moderate
quality evidence that such training decreased early neonatal mortality
(typical RR 0.88 95% CI 0.78 1.00).50 Findings of a meta-analysis of
20 trials comparing periods before and after neonatal resuscitation
training and including 1 653 805 births showed an 18% reduction in
perinatal mortality (RR 0.82 95% CI 0.74 0.91) but these findings had
to be downgraded for risk of bias and indirectness.43 The optimal
content or organisation of such training programmes will vary
according to the needs of the providers and the organisation of the
institutions.
326 303
A recent ILCOR systematic review included several studies on
team training in neonatal resuscitation.51 55 Team performance and
patient safety appeared to be enhanced by regular practice and drills
that enabled those likely to be involved to rehearse and improve their
abilities at an individual level and in teams. This suggested that
specific team and leadership training be included as part of Advanced
Life Support training for healthcare providers (weak recommendation,
very low certainty of evidence).37
Multi-modal approaches to teaching neonatal resuscitation are
thought to be the most beneficial for learning, especially when
simulation-based training with emphasis on feedback on practice is
incorporated as a teaching method.42,50,56 60 Feedback may come
from different sources such as the facilitator, the manikin itself or digital
recordings (video, audio, respiratory function monitor etc.).37,60 62
The role of modalities such as virtual reality, tele-education and board
game simulation in resuscitation training remain to be established. A
review of 12 such neonatal resuscitation-based games concluded that
they had a potential to improve knowledge, skills and adherence to the
resuscitation algorithm.63
Feedback devices providing information on the quality of interven-
tion may also be used in real-life settings to improve performance and
compliance with guidelines.37,64,65 Debriefing on individual and team
performance at resuscitations supported by objective data are
recommended after cardiac arrest for both adult and children (weak
recommendation, very low certainty of evidence).37,66 69 This
approach to debrief also applies to neonatal resuscitation.53,70,71
Thermal control
Exposed, wet, newborn infants cannot maintain their body tempera-
ture in a room that feels comfortably warm for adults. The mechanisms
and effects of cold stress and how to avoid these have been
reviewed.72,73 Heat loss can occur though convection, conduction,
radiation and evaporation meaning unprotected infants will drop their
body temperature quickly. Cold stress lowers the arterial oxygen
tension and increases the risk of metabolic acidosis. Compromised
infants are particularly vulnerable to cold stress. The admission
temperature of newborn non-asphyxiated infants is a strong predictor
of mortality and morbidity at all gestations and in all settings.74,75
ILCOR recommendations are that it should be recorded as a predictor
of outcomes as well as a quality indicator (strong recommendation,
moderate-quality evidence).49 Immediate drying and wrapping infants
in a warm towel to avoid exposure to a cold environment will help them
maintain their temperature.
Preterm infants are especially vulnerable and hypothermia is also
associated with serious morbidities such as intraventricular haemor-
rhage, need for respiratory support, hypoglycaemia, and in some
studies late onset sepsis.49 In a European cohort study of 5697 infants
<32 weeks gestation admitted for neonatal care, an admission
temperature <35.5  C was associated with increased mortality in the
first 28 days.76 For each 1  C decrease in admission temperature
below the recommended range, an increase in the baseline mortality
by 28% has been reported.77
A Cochrane review involving 46 trials and 3850 dyads of infants
>32 weeks gestation where resuscitation was not required
concluded that skin-to-skin care may be effective in maintaining
thermal stability (low quality evidence) and also improves maternal
bonding and breast feeding rates (low to moderate quality
evidence).78 However, most trials were small and unblinded with
heterogeneity between groups. Skin-to-skin care is feasible in less
304 RESUSCITATION 161 (2021) 291
mature infants however caution is required in the more preterm or
growth restricted infant in order to avoid hypothermia. In one single
centre observational study of 55 infants between 28+0 and 32+6
weeks gestation randomised to either skin-to-skin or conventional
thermal care the mean body temperature of the skin-to-skin group
was 0.3  C lower 1 h after birth (36.3  C  0.52, p = 0.03);79 further
studies are ongoing.80
Following a recent ILCOR evidence update including a
Cochrane systematic review of 25 studies including 2433 preterm
and low birth weight infants, treatment recommendations are
unchanged from 2015.75 It is recommended that newborn temper-
atures be kept between 36.5  C and 37.5  C in order to reduce the
metabolic stress on the infant (strong recommendation, very low
quality of evidence).1,49 For newborn preterm infants of 32 weeks
gestation under radiant warmers in the hospital delivery room, a
combination of interventions is suggested which may include raising
the environmental temperature to 23  C 25  C, use of warmed
blankets, plastic wrapping without drying, cap and thermal mattress
to reduce hypothermia on admission to the neonatal intensive care
unit (NICU) (weak recommendation, very-low quality of evidence).1
For infants <28 weeks gestation the room temperature should
ideally be above 25  C.72,73,81 In the absence of exothermic devices,
food grade plastic wrap and swaddling can be effective in preterm
infants.72,73,82
It is suggested that hyperthermia (greater than 38.0  C) should
be avoided because it introduces potential associated risks (weak
recommendation, very-low quality of evidence).1,49 Infants born to
febrile mothers have a higher incidence of perinatal respiratory
compromise, neonatal seizures, early mortality and cerebral
palsy.83 85 Animal studies indicate that hyperthermia during or
following ischaemia is associated with a progression of cerebral
injury.85
Temperature monitoring is key to avoiding cold stress. However,
there is very little evidence to guide the optimal placement of
temperature monitoring probes on the infant in the delivery room. In an
observational study of 122 preterm infants between 28 and 36 weeks
gestation randomised to different sites for temperature monitoring,
dorsal, thoracic and axillary sited probes measured comparable
temperatures.29 There are, to date, no published studies comparing
the use of rectal temperature probes.
Heated humidified gases reduced the incidence of moderate
hypothermia in preterm infants.86 A meta-analysis of two RCTs involving
476 infants <32 weeks gestation indicated that heated, humidified
inspired gases immediately following delivery reduced the likelihood of
admission hypothermia in preterm infants by 36% (95% CI 17 50%)
(high level of evidence).87,88 There was no significant increase in the risk
of hyperthermia or a difference in mortality between humidified and non-
humidified groups. It is unclear if other outcomes are improved.
Quality improvement programs including the use of checklists and
continuous feed-back to the team have been shown to significantly
reduce hypothermia at admission in very preterm infants.81,89
Clamping the umbilical cord
There is no universally accepted definition of ‘delayed’ or ‘deferred’
cord clamping’ (DCC), only that it does not occur immediately after the
infant is born. In recent systematic reviews and meta-analyses early or
immediate cord clamping (ICC) has been defined as application of the
clamp within 30 s of birth, later or delayed cord clamping as application
of a clamp to the cord greater than 30 s after birth or based on
326
physiological parameters (such as when cord pulsation has ceased or
breathing has been initiated), without cord milking.90,91
Physiology of cord clamping
Observational data, physiological studies, animal models and some
clinical studies suggest that ICC, currently widely practiced and
introduced primarily to prevent maternal postpartum haemorrhage, is
not as innocuous as was once thought.92,93 ICC significantly reduces
ventricular preload whilst simultaneously adding to left ventricular
afterload.7,94 Effects of this are seen in observational studies, with a
decrease in cardiac size for 3 4 cardiac cycles95 and bradycardia,96
and in experimental animal models.97
Differences with gestation
In term infants, DCC results in the transfer of approximately 30 mL kg 1
of blood from the placenta.98 This improves iron status and
haematological indices over the next 3 6 months in all infants and
reduces need for transfusion in preterm infants.99,100 Concerns about
polycythaemia and jaundice requiring intervention do not seem to be
borne out in randomised trials. Concerns about the position of the infant
in relation to the introitus also seem unfounded as the effects of uterine
contraction and lung expansion seem to exert a greater impact on
umbilical blood flow than gravity.101,102
In an ILCOR meta-analysis of 23 studies of 3514 eligible infants
comparing ICC versus a delay of at least 30 s in preterm infants <34
weeks gestation the conclusion was that compared to ICC DCC may
marginally improve survival (RR 1.02, 95% CI 0.993 1.04)
(certainty of evidence moderate).90 Early cardiovascular stability
was improved with less inotropic support (RR 0.36, 95% CI 0.17
0.75) and higher lowest mean blood pressure (MD 1.79 mmHg,
95% CI 0.53 3.05) in the first 12 24 h. Infants had better
haematological indices: The peak haematocrit appeared higher at
24 hrs (MD 2.63, 95% CI 1.85 3.42) and at 7 days (MD 2.70, 95%
CI 1.88 3.52). Infants required fewer blood transfusions (MD
0.63, 95% CI 1.08 to 0.17). No effects were seen on any of the
complications of prematurity such as severe IVH, NEC or chronic
lung disease, nor was there any obvious adverse impact on other
neonatal or maternal outcomes (moderate to high quality evidence).
In sub-group analyses of DCC vs. ICC, there seemed to be an
almost linear relationship between survival to discharge and
duration of DCC; DCC for 1 min, RR 1.00 (95% CI 0.97 1.04);
DCC for 1 2 min, RR 1.03 (95% CI 1.00 1.05); DCC for >2 min, RR
1.07 (95% CI 0.99 1.15). None of these results were statistically
significant due to the relatively small numbers involved.
In term and late preterm infants an ILCOR meta-analysis of 33
trials (5236 infants) of DCC vs ICC updated the findings of a
previous 2013 Cochrane study.91,103 Analysis demonstrated no
significant effect on mortality (RR 2.54, 95% CI 0.50 12.74; 4 trials,
537 infants) or need for resuscitation (RR 5.08, 95% CI 0.25
103.58; 3 trials, 329 infants) There were improved early
haematological and circulatory parameters (haemoglobin 24 h
after birth (MD 1.17 g dL 1 95% CI 0.48 1.86, 9 trials, 1352 infants)
and 7 days after birth (MD 1.11 g dL 1 95% CI 0.40 1.82, 3 trials,
695 infants) but no impact on longer term anaemia. This updated
review does not suggest clear differences in receipt of phototherapy
(RR 1.28, 95% CI 0.90 1.82) (all findings low or very low certainty
evidence). The analysis did not provide clear evidence on longer
term neurodevelopmental outcomes.
Further study is warranted; most studies used a temporal definition
for the timing of cord clamping, there are insufficient data to
 RESUSCITATION 161 (2021) 291
recommend ‘physiological’ cord clamping (i.e. after the onset of
respirations),104 although this may confer benefit.105 Physiological
studies suggest that the hypoxic and bradycardic response observed
after immediate clamping is not seen when clamping occurs after the
first breaths.96,97,106
The question of resuscitating infants with the intact cord warrants
further study; in most studies of delayed cord clamping infants who
required resuscitation at birth were excluded, as resuscitation could
only be undertaken away from the mother. Equipment now exists that
allows mother-side resuscitation and initial studies show that delayed
cord clamping is feasible in such infants.107 109 However, it remains
unclear which is the optimum strategy in these infants.
Cord milking
Delayed umbilical cord clamping is contra-indicated when placental
blood flow is compromised by placental abruption, cord prolapse, vasa
praevia, cord avulsion or maternal haemorrhage. Umbilical cord
milking with intact or cut cords has been considered an alternative in
these situations. In ‘intact cord milking’ the cord is milked 3 5 times,
resulting in a faster blood flow towards the baby than occurs with
passive return due to uterine contraction. A term infant can receive up
to 50 mL of ‘placental’ blood through this action. After milking the cord
is clamped and cut, and the infant can be taken to the resuscitation
area.110
‘Cut cord milking’ involves milking from a length of cord (25 cm)
after clamping and cutting. The volume of blood is less than from an
intact cord, but still gives the term infant about 25 mL. The infant is
taken to the resuscitation area immediately and milking occurs during
resuscitation or stabilisation.111
In preterm infants born before 34 weeks gestation, intact cord
milking shows only transient benefits over ICC including less use of
inotropic support, fewer infants needing blood transfusion, and higher
haemoglobin and haematocrit on day 1 but not at 7 days, There were
no differences in major neonatal morbidities (low to moderate quality
evidence). There was no demonstrable benefit over DCC.90 In the
meta-analyses, there was no effect on mortality (RR 0.99; 95% CI 0.95
1.02), but of particular concern is that one large study of intact cord
milking versus delayed cord clamping was terminated early when
analysis demonstrated an excess of severe intraventricular haemor-
rhage (RD 16% 95% CI 6% to 26%; p = 0.002) in those infants born
before 28 weeks allocated to the intact cord milking arm.112
In term and late preterm infants there are insufficient data to allow
meta-analysis of umbilical cord milking.91
Initial assessment
Initial assessment
The Apgar score was not designed to identify infants in need of
resuscitation.113 However, individual components of the score,
namely respiratory rate, heart rate (HR) and tone, if assessed rapidly,
may help identify infants likely to need resuscitation.
Tactile [1298_TD$IF]stimulation
Methods of tactile stimulation vary widely but the optimal method
remains unknown.114,115 In preterm infants, tactile stimulation is often
omitted,115 118 but in a single centre RCT of repetitive stimulation
against standard stimulation only if deemed necessary in 51 infants
between 28 and 32 weeks gestation, repetitive stimulation was shown
to improve breathing effort and oxygen saturation (SpO2 87.6  3.3%
vs 81.7  8.7%, p = 0.007).119 Stimulation of more infants at birth (after
326 305
introduction of a basic resuscitation training program) was associated
with an increased 24-h survival in a multi-centre observational study in
Tanzania, including 86,624 mainly term/near-term infants.120
Tone and colour
Healthy infants are cyanosed at birth but start to become pink within
approximately 30 s of the onset of effective breathing.121 Peripheral
cyanosis is common and does not, by itself, indicate hypoxia.
Persistent pallor despite ventilation may indicate significant acidosis,
or, more rarely, hypovolaemia with intense cutaneous vascular
vasoconstriction. A pink upper-part of the body and a blue lower part
can be a sign of right-left shunting over an open duct.
Colour is an unreliable marker of oxygenation which is better
assessed using pulse oximetry. There are few studies in the newborn.
In an observational study involving 27 clinicians making a subjective
assessment of oxygenation status using videos of preterm infants
where saturations were known there was a lack of concordance with
both under and over estimation of values.122
Breathing
Not crying may be due to apnoea but can also function as a marker
of inadequate breathing needing support. In an observational study
of 19 977 infants just after birth in a rural hospital setting 11% were
not crying, around half of whom were assessed as apnoeic. About
10% of those assessed as breathing at birth became apnoeic. Not
crying but breathing was associated with a 12-fold increase in
morbidity.123
The presence or adequacy of breathing effort in preterm infants
can be difficult to assess as breathing can be very subtle and is often
missed.121,124 Breathing perceived as inadequate will prompt an
intervention. In a retrospective video based observational study of 62
preterm infants delivered at <28 weeks or with birth weight <1000 g
80% were assessed as showing signs of breathing but all received
respiratory support with CPAP or intubation.125
Heart rate
Immediately after birth, the heart rate is assessed to evaluate the
condition of the infant and subsequently, heart rate is the most
sensitive indicator of a successful response to interventions.126 128
There is no published evidence unambiguously defining the thresh-
olds for intervention during newborn resuscitation. The rates of
100 min 1 and 60 min 1 around which interventions are prompted are
essentially pragmatic in nature.129
In uncompromised breathing term infants, where umbilical cord
clamping was delayed, the heart rate is usually above 100 min 1.128 In
an observational study of 1237 term/near-term infants
resuscitated in a rural setting the initial heart rates at birth were
distributed in a bimodal peak around 60 and 165 min 1. Ventilation
increased heart rate in most bradycardic newborns to a final median of
161 min 1. Lower initial and subsequent heart rates were associated
with poorer outcomes.130 In preterm infants <30 weeks gestation the
heart rate does not stabilise until it reaches approximately 120 min 1
and, in some, stability was only achieved once the heart rate was
>150 min 1.131
Auscultation by stethoscope is inexpensive, simple, and permits a
reasonably accurate rapid assessment of heart rate. In delivery room
studies of low risk infants heart rate determination was possible within
14(10 18) seconds (median(IQR)) and was found to underestimate
ECG or pulse oximetry (PO) values by between 9(7) and 14
(21) min 1 (mean difference (95% CI)).132,133
306 RESUSCITATION 161 (2021) 291
Palpation for a pulse at the base of the umbilical cord or (less
reliably) the brachial or femoral arteries is also simple and rapid.
Values may be considered valid if the heart rate is determined to be
fast (>100 min 1), however they are often inaccurate, intermittent and
affected by movements with a tendency to significantly underestimate,
potentially prompting inappropriate interventions.133,134
Continuous monitoring provides a more dynamic indication of
heart rate change during resuscitation and is preferable to intermittent
counting. A pulse oximeter (ideally connected to the right hand) can
give an accurate heart rate as well as information on oxygenation.
Initial values may underestimate the ECG a little: In a study of 53
infants pulse oximeter values were significantly lower than ECG over
the first 2 min (81 (60 109) vs 148 (83 170) min 1 at 90 seconds
(p < 0.001)).135 Later differences of 2(26) min 1 (mean(SD)) were
observed when compared with ECG,136 but the time to obtain reliable
values may take longer than auscultation.137 Findings differ as to
whether advantage is gained from connecting the sensor to infant138
or oximeter139 first, however, signal acquisition can be achieved within
about 15 s once connected. Peripheral hypoperfusion, signal dropout,
movement, arrhythmias, and ambient lighting can interfere with PO
measurements. Pulse oximetry may significantly underestimate
values when signal quality is poor.140 141,142
ECG has been demonstrated to be a practical and rapid means of
accurately determining the heart rate which may be a few seconds
faster than pulse oximetry and more reliable, especially in the first
2 min after birth.141,142 Two RCTs reported faster times to HR
assessment using ECG compared to PO with a mean(SD) 66(20) vs
114(39) seconds and a median(IQR) 24(19 39) vs 48(36 69)
seconds both p = 0.001.132,143
A recent ILCOR evidence update concluded that the 7 new studies
identified since 2015 (2 systematic reviews, 2 RCTs and 3
observational studies) supported the previous recommendations that
in infants requiring resuscitation.1 ECG can be used to provide a rapid
and accurate estimation of heart rate (weak recommendation, low
quality of evidence).49,144
It is important to be aware of the limitations of the methods. ECG
does not replace oximetry as whilst ECG may indicate a heart rate in
the absence of output (PEA),145 pulse oximetry has advantages over
ECG in providing a measure of perfusion and oxygenation. Newer
technologies such as dry electrodes may improve signal; and methods
such as plethysmography and Doppler may permit rapid reliable
output-based determination of heart rate, but clinical validation is still
needed before they can be recommended.141,142
Airway
Airway
With flexion and extension, the airway can become occluded.146 The
evidence on the mechanisms of airway occlusion in the newborn is
limited. A retrospective analysis of images of the airway of 53 sedated
infants between 0 and 4 months undergoing cranial MRI indicates
how, in extension, obstruction might occur through anterior displace-
ment of the posterior airway at the level of the tongue.147 Therefore, a
neutral position is favoured to ensure optimal airway patency.
Jaw [129_TD$IF]lift
There are no studies of jaw thrust/lift in the newborn. Studies in
children demonstrate that anterior displacement of the mandible
enlarges the pharyngeal space through lifting the epiglottis away from
the posterior pharyngeal wall, reversing the narrowing of the laryngeal
326
inlet.148 Two-person manual ventilation techniques are superior to
single handed airway support.146
Oropharyngeal/nasopharyngeal airway
Although the oropharyngeal airway (OPA) has been shown to be
effective in children,149 there is no published evidence demonstrating
effectiveness in helping maintain the patency of the airway at birth. In a
randomised study of 137 preterm infants where gas flow through a mask
was measured, obstructed inflations were more common in the OPA
group (complete 81% vs. 64%; p = 0.03, partial 70% vs. 54%;
p = 0.04).150 However, by helping lift the tongue and preventing it
occluding the laryngeal opening, an OPA may facilitate airway support
where difficulty is experienced and manoeuvres, like jaw lift, fail to
improve ventilation. A nasopharyngeal airway (NPA) may help establish
an airway where there is congenital upper airway abnormality151 and
has been used successfully in preterm infants at birth.152
Airway obstruction
The cause of airway obstruction is usually unknown. It may be due to
inappropriate positioning of the head, laryngeal adduction, or pushing
a facemask onto the mouth and nose too hard, especially in preterm
infants at birth. In an animal model of premature birth Crawshaw used
phase contrast X-ray to demonstrate that the larynx and epiglottis
were predominantly closed (adducted) in those with unaerated lungs
and unstable breathing patterns, making intermittent positive
pressure ventilation (IPPV) ineffective unless there was an inspiratory
breath, and only opening once the lungs were aerated.153 In an
observational study of 56 preterm infants <32 weeks gestation
significant mask leak (>75%) and/or obstruction to inspiratory flow
(75%) were identified using respiratory function monitoring in 73% of
interventions during the first 2 min of PPV.154 There is no evidence that
normal lung fluid and secretions cause obstruction, and thus no need
to aspirate fluid from the oropharynx routinely.
Oropharyngeal and nasopharyngeal suction
Oropharyngeal and nasopharyngeal suction has in newborn infants
not been shown to improve respiratory function and may delay other
necessary manoeuvres and the onset of spontaneous breathing,
Consequences may include irritation to mucous membranes,
laryngospasm, apnoea, vagal bradycardia, hypoxaemia, desaturation
and impaired cerebral blood flow regulation.155 159 A recent ILCOR
scoping review of 10 studies (8 RCTs,1 observational study and 1
case study) into the suctioning of clear fluid involving >1500 mainly
term/near-term infants found no evidence to challenge the current
recommendations: Routine intrapartum oropharyngeal and naso-
pharygeal suction for newborn infants with clear or meconium-stained
amniotic fluid is not recommended (very low certainty evidence
downgraded for risk of bias, indirectness and imprecision).1 If
suctioning is attempted it should be undertaken under direct vision,
ideally using a laryngoscope and a wide bore catheter.
There have been few studies investigating the effectiveness of
suction devices for clearing the newborn airway. An in vitro study using
simulated meconium demonstrated the superiority of the Yankauer
sucker in clearing particulate matter when compared to large bore (12
14F) flexible catheters and bulb devices. Most devices could clear
non-particulate matter but the only devices that cleared simulated
particulate meconium were a Yankauer sucker or a bulb syringe device.
Bulb suction devices are less effective but do not require a separate
vacuum source. Smaller diameter suction catheters were much less
effective.160 The paediatric Yankauer sucker has the advantage of
 RESUSCITATION 161 (2021) 291
single-handed use and effectiveness at lower vacuum pressures which
may be less likely to damage mucosa. A meconium aspirator, attached
to a tracheal tube functions in a similar manner and can be used to
remove tenacious material from the trachea. These devices should be
connected to a suction source not exceeding 150 mmHg (20 kPa).161
Meconium
Lightly meconium-stained liquor is common and does not, in general,
give rise to much difficulty with transition. The less common finding of
very thick meconium-stained liquor is an indicator of perinatal distress
and should alert to the potential need for resuscitation.
There is no evidence to support intrapartum suctioning nor routine
intubation and suctioning of vigorous infants born through meconium-
stained liquor.162,163 Retrospective registry based studies do not
demonstrate an increase in morbidity following a reduction in delivery
room intubation for meconium.164,165 An ILCOR systematic review of
three RCTs involving 449 infants and one observational study of 231
infants demonstrated no benefit from the use of immediate
laryngoscopy with or without tracheal suctioning compared with
immediate resuscitation without laryngoscopy (RR 0.99; 95% CI 0.93
1.06; p = 0.87).1 Parallel meta-analyses including a further RCT with
132 infants derived similar conclusions.166 168 A post policy change
impact analysis of the resuscitation of 1138 non-vigorous neonates
born through meconium-stained amniotic fluid, found reduced NICU
admissions and no increase in the incidence of Meconium Aspiration
Syndrome (MAS) where suctioning was omitted in favour of
immediate ventilation.169
Routine suctioning of non-vigorous infants may result in delays
in initiating ventilation although some newborn infants may still
require laryngoscopy with or without tracheal intubation in order to
clear a blocked airway or for subsequent ventilation. Therefore, in
apnoeic or ineffectively breathing infants born through meconium-
stained amniotic fluid ILCOR treatment recommendations sug-
gest against routine immediate direct laryngoscopy and/or
suctioning after delivery with the emphasis on initiating ventilation
in the first minute of life (weak recommendation, low certainty
evidence).1
In infants with respiratory compromise due to meconium
aspiration, the routine administration of surfactant or bronchial lavage
with either saline or surfactant is not recommended.170,171
Initial inflations and assisted ventilation
After initial assessment at birth, if breathing efforts are absent or
inadequate, lung aeration is the priority and must not be delayed. An
observational study in low resource settings suggested those
resuscitating took around 80  55 s to commence ventilation with a
16% (p = 0.045) increase in morbidity/mortality in apnoeic infants for
every 30 s delay in starting ventilation after birth.10 In term infants,
respiratory support should start with air.172
Inflation pressure and duration
In newborn infants, spontaneous breathing or assisted initial inflations
create the functional residual capacity (FRC).9,173 When assisting
ventilation, the optimum inflation pressure, inflation time and flow
required to establish an effective FRC are subject to technical and
biological variation and have not yet been conclusively determined.
Debate continues about the validity of longer inflation breaths with
recent discussion on the merits of sustained inflation (see below).1
Current ERC NLS recommendations on inflation breaths are for a
326 307
longer duration although there is a lack of evidence demonstrating
advantage or disadvantage over other recommended approaches.
Once an airway is established, five initial breaths with inflation
pressures maintained for up to 2 3 s are suggested and may help lung
expansion.49,173 175
The evidence for the optimal initial pressure for lung aeration is
limited The consensus is that inflation pressures of 30 cm H2O are
usually sufficient to inflate the liquid filled lungs of apnoeic term infants.
This value was originally derived from historical studies of limited
numbers of infants.173,176,177 A more recent prospective study of 1237
term and near-term infants resuscitated in a rural setting using a bag-
mask without PEEP suggests that higher initial pressures may
sometimes be required, with median peak pressures of 37 cm H2O
required for successful stabilisation.178 In preterm infants, critical
review of the available evidence suggests that previously advocated
initial inflations pressures of 20 cm H2O are probably to be too low to
recruit the lungs effectively.175,179 181 Therefore, it is suggested that a
starting pressure of 25 cm H2O would be reasonable. Acknowledging
that smaller airways have greater resistance than larger airways,
some preterm infants may need higher pressures than 25 cm H2O for
lung inflation.
The time to initiation of spontaneous breathing is reported to be
inversely correlated with the peak inflation pressure and the inflation
time.174 If the infant has any respiratory effort, ventilation is most
effective when inflation coincides with the inspiratory efforts.181
However, the tidal volume of positive pressure ventilations may then
exceed that of spontaneous breaths.124,182 It is acknowledged that
such synchronisation is difficult to achieve.183
A recent observational study in preterm infants under 32 weeks
suggested that the application of a mask to support breathing
might induce apnoea in spontaneously breathing infants.184
However, the significance of this effect on outcome is currently
unclear.185
Ventilation
There is limited evidence on the optimal rate of ventilation for newborn
resuscitation. In an observational study of 434 mask ventilated late
preterm and term infants, ventilation at a rate of about 30 min 1
achieved adequate tidal volumes without hypocarbia and the
frequency of 30 min 1 with VTE of 10 14 mL kg 1 was associated
with the highest CO2 clearance.186 In an observational study of 215
near-term/term infants there was a non-linear relationship between
delivered tidal volume and heart rate. The minimum volume necessary
to produce an increase in heart rate was 6.0 (3.6 8.0) mL kg 1. A tidal
volume of 9.3 mL kg 1 produced the most rapid and largest increase in
heart rate.127
The delivered tidal volume required to form the FRC may exceed
that of the exhaled TV: Foglia et al. describe this as being over
12 mL kg 1 for a term infant.183 Exhaled tidal volumes increase during
the first positive pressure ventilations as aeration takes place,
compliance increases and the FRC is established.178 In most
instances, it should be possible to reduce peak pressures once the
lungs are aerated to prevent excessive tidal volumes.183
There are no published studies clearly determining the optimal
inflation time when providing positive pressure ventilation. Longer
inspiratory times may permit lower pressures.183 Observational
studies on spontaneously breathing newborn infants suggest that
once lung inflation has been achieved they breathe at a rate between
30 and 40 breaths min 1, and regardless of which breathing pattern,
an inspiratory time of 0.3 0.4 s is used.187
308 RESUSCITATION 161 (2021) 291
Assessment
The primary response to adequate initial lung inflation is a prompt
improvement in heart rate.126,127 Most newborn infants needing
respiratory support will respond with a rapid increase in heart rate
within 30 s of lung inflation.188 Chest wall movement usually indicates
aeration/inflation. This may not be so obvious in preterm infants.189
Large chest excursions during positive pressure ventilation may be a
marker of excessive tidal volumes, which should be avoided.
Continued ventilation is required if the heart rate increases but the
infant is not breathing adequately.
Failure of the heart rate to respond is most likely secondary to
inadequate airway control or inadequate ventilation. Mask position or
seal may be suboptimal.182,190,191 Head/Airway position may be in
need of adjustment.146 Inflation pressures may need to be higher to
achieve adequate inflation/tidal volumes.178 In preterm infants
excessive mask pressure and glottal closure have been demonstrated
to be factors.8,153,154,192
Using a two-person approach to mask ventilation reduces mask
leak in term and preterm infants and is superior to the single handed
approach.191,193 Published evidence on the incidence of physical
matter as a cause of obstruction is lacking but it is recognised that
meconium or other matter (e.g. blood, mucus, vernix) may cause
airway obstruction.194 The use of adjuncts to support the airway is
discussed elsewhere (see airway and adjuncts).
Sustained inflations (SI) > 5 s
Animal studies have suggested that a longer SI may be beneficial for
establishing functional residual capacity at birth during transition
from a liquid filled to air-filled lung.195,196 A Cochrane systematic
review of initial inflation >1 s vs. standard inflations 1 s was
updated in 2020. Eight RCTs enrolling 941 infants met inclusion
criteria for the primary comparison of the use of SI without chest
compressions. SIs were of 15 20 s at 20 30 cm H2O. No trial used
SIs of 5 s. SI was not better than intermittent ventilation for
reducing mortality in the delivery room (low quality evidence
limitations in study design and imprecision) and during hospital-
isation (moderate quality evidence limitations in study design).
There was no benefit for SI vs. intermittent ventilation for the
secondary outcomes of intubation, need for respiratory support or
BPD (moderate quality evidence).197
A large multicentre RCT which was not included in this analysis
investigating effects of SI vs. IPPV among extremely preterm
infants (23 26 weeks gestational age) concluded that a ventilation
strategy involving 2 SIs of 15 s did not reduce the risk of BPD or
death at 36 weeks postmenstrual age. The study enrolled 460
infants out of a planned 600 but was stopped early due to excess
early mortality in the SI group possibly attributable to resuscitation.
Death at less than 48 h of age occurred in 16 infants (7.4%) in the SI
group vs 3 infants (1.4%) in the standard resuscitation group
(adjusted risk difference (aRD), 5.6% [95% CI, 2.1% to 9.1%];
p = 0.002). but this finding could not be attributed to the SI
directly.198
A recent ILCOR systematic review identified 10 eligible RCTs
including those above with 1509 newborn infants.1 For the
primary outcome of death before discharge no significant benefit
or harm was noted from the use of SI >1 s (actually >5 s)
compared to PPV with inflations of 1 s (low certainty evidence
downgraded for risk of bias and inconsistency). No studies were
identified reporting on the secondary critical outcomes of long-
term neurodevelopmental outcome or death at follow up.
326
Subgroup analysis of different lengths of SI (6 15 s 9 RCTs
1300 infants, >15 s 2 RCTs 222 infants) and of different
inspiratory pressures (>20 mmHg 6 RCTs 803 infants, 20
mmHg 699 infants) demonstrated no significant benefit or harm
from SI compared to IPPV of 1 s (downgraded for risk of bias
and variously for imprecision and inconsistency).
In subgroup analyses comparing SI >1 s to inflations of 1 s in
infants at <28+0 weeks there was low certainty evidence (downgraded
for risk of bias and imprecision) from 5 RCTs enrolling 862 infants of
potential harm (RR 1.38 95% CI 1.00 1.91). In infants 28+1 31+6
weeks there was very low certainty evidence (downgraded for risk of
bias and very serious imprecision) from 4 RCTs enrolling 175 preterm
infants demonstrating no significant benefit or harm (RR 1.33 95% CI
0.22 8.20). No SIs were <5 s. There was no published data available
for more mature infants.
Further sub-analyses excluding studies with a high risk of bias (9
RCTs 1390 infants RR 1.24 95%CI 0.92 1.68), studies with only a
single breath (9 RCTs 1402 infants RR 1.17 95%CI 0.88 1.55) and
those with sustained inflation with mask only (9 RCTs 1441 infants (RR
1.06 95%CI 0.61 1.39) demonstrated no difference in outcome
between SI and normal inflations (low certainty evidence, downgraded
for risk of bias and imprecision).
ILCOR treatment recommendations suggest that the routine
use of initial SI 5 s cannot be recommended for preterm newborn
infants who receive positive pressure ventilation prompted by
bradycardia or ineffective respirations at birth (weak recommen-
dation, low-certainty evidence) but that a sustained inflation might
be considered in research settings. There was insufficient
evidence to make any specific recommendation on the duration
of inflations in late preterm or term infants. It was recognised
that the total number of infants studied were insufficient to
have confidence in the estimate of effect; larger trials being
needed to determine if there are benefits or harms from sustained
inflation.1
There are no randomised trials comparing the use of initial breaths
of 1 s with breaths of 2 3 s. A recent RCT in 60 preterm infants <34
weeks gestation of 2 3 s inflation breaths vs. a single 15 SI
demonstrated no difference in minute volume or end tidal CO2.199
Infants receiving the SI made a respiratory effort sooner (median 3.5
(range 0.2 59) versus median 12.8 (range 0.4 119) seconds,
p = 0.001). SI was associated with a shorter duration of ventilation in
the first 48 h (median 17 (range 0 48) versus median 32.5 (range 0
48) h, p = 0.025)
PEEP [130_TD$IF]and CPAP/airway adjuncts and assisted ventilation
devices
PEEP
Animal studies have shown that immature lungs are easily damaged
by large tidal volume inflations immediately after birth200,201 and
suggest that maintaining a PEEP immediately after birth may help
reduce lung damage202,203 although one study suggests no bene-
fit.204 PEEP applied immediately after birth improves lung aeration,
functional residual capacity, compliance and gas exchange, particu-
larly oxygenation.205,206
PEEP is more reliably be delivered by pressure limiting devices
which use continuous gas flow, like TPR devices. A recent review of
the evidence undertaken by ILCOR identified two randomized trials
and one quasi-randomized trial (very low quality evidence)
comparing ventilation with TPR vs. SIB and reported similar rates
 RESUSCITATION 161 (2021) 291
of death and chronic lung disease.1 There was no difference in SpO2
at 5 min after birth in 80 infants <29 weeks gestation (61% [13
72%] versus 55% [42 67%]; p = 0.27).207 No difference was
identified in achieving HR >100 min 1 in 1027 infants 26 weeks (1
(0.5 1.6) vs 1 (0.5 1.8) p = 0.068 (min(IQR)).208 There were
reductions in the magnitude of some interventions with TPR. 86
(17%) vs. 134(26%) were intubated in the delivery room (OR 0.58
(0.4 0.8) 95% CI p = 0.002). The maximum positive inspiratory
pressure was 26(2) cm H2O TPR vs 28(5) cm H2O SIB (p < 0.001)
mean (SD).
In a quasi-randomised study of 90 infants of 34 (3.7) (mean (SD))
weeks gestation the duration of PPV in delivery room was significantly
less with TPR (median (IQR) 30 s (30 60) vs. 60 s (30 90)
(p < 0.001)).209 A higher proportion were intubated in the SIB group
(34 vs 15% p = 0.04). In one large multicentre observational study of
1962 infants between 23 and 33 weeks gestation improved survival
and less BPD was seen when PEEP was used at birth (OR = 1.38;
95% CI 1.06 1.80).210
All term and preterm infants who remain apnoeic despite
adequate initial steps must receive positive pressure ventilation.
ILCOR treatment recommendations are unchanged from 2015,
suggesting PEEP should be used for the initial ventilation for
premature newborn infants during delivery room resuscitation (weak
recommendations, low-quality evidence).1 It is suggested that
positive end expiratory pressure (PEEP) of approximately 5 6 cm
H2O to begin with should be administered to preterm newborn
infants receiving PPV. No clear recommendations on the level of
PEEP can be made for term infants because of a lack of
evidence.49,144
CPAP
A Cochrane systematic review of CPAP applied within the first 15 min
of life in preterm infants <32 weeks identified 7 RCTs involving 3123
infants and concluded that CPAP reduced the need for additional
breathing assistance but with insufficient evidence to evaluate
prophylactic CPAP compared to oxygen therapy and other supportive
care.211 Evidence was downgraded to low quality because of
considerable heterogeneity, imprecision and lack of blinding. In 3 of
the studies involving 2354 infants comparing CPAP with assisted
ventilation, prophylactic nasal CPAP in very preterm infants reduced
the need for mechanical ventilation and surfactant and also reduced
the incidence of BPD and death or BPD (evidence downgraded due to
imprecision).
Another systematic review included 4 RCTs 3 of which were
included in the Cochrane analysis and one additional study.212 Pooled
analysis showed a significant benefit for the combined outcome of
death or bronchopulmonary dysplasia, or both, at 36 weeks corrected
gestation for infants treated with nasal CPAP (RR 0.91, 95% CI
0.84 0.99, RD 0.04, 95% CI 0.07 to 0.00) NNT 25. Following a
review of the evidence ILCOR recommendations are unchanged from
2015, that for spontaneously breathing preterm newborn infants with
respiratory distress requiring respiratory support in the delivery room,
it is suggested that CPAP should be used initially rather than intubation
and IPPV (weak recommendation, moderate certainly of evi-
dence).1,49,144 There are few data to guide the appropriate use of
CPAP in term infants at birth.213,214 Caution is prompted by
retrospective cohort studies which suggest that delivery room CPAP
may be associated with an increased incidence of pneumothorax in
term/near term infants.215 217
326 309
Assisted ventilation devices
Effective ventilation in the newborn can be achieved with a flow-
inflating bag (FIB), a self-inflating bag (SIB) or with a pressure limited
TPR.207,208,218 220 An attribute of a TPR device is its ability to deliver a
consistent measure of PEEP or CPAP when compared to standard
SIB's and this may be a factor contributing to any observed difference
in outcomes between the devices (see section on PEEP).
Whilst the TPR appears to confer benefit it cannot be used in all
circumstances. Unlike the TPR, the self-inflating bag can be used in
the absence of a positive pressure gas supply. However, the blow-off
valves of SIB are flow-dependent and pressures generated may
exceed the value specified by the manufacturer, usually 30 40 cm
H2O, if the bag is compressed vigorously.221,222 More training is
required to provide an appropriate peak and end pressure using FIBs
compared with self-inflating bags. In an observational manikin-based
study of 50 clinicians, technical difficulties with the FIB impaired
performance when compared to an SIB.223
A qualitative review identified 30 studies comparing TPR against
other neonatal manual ventilation devices and noted that the majority
of studies were manikin based with 2 infant based studies.154,207
Users of the TPR could provide PIPs closest to the target PIP, with
least variation when compared to SIB and FIB.224 228 Similarly TPR
users provided a PEEP closer to the predetermined PEEP value with
potentially less volutrauma with the TPR as tidal volumes are smaller
and less variable in comparison to the SIB.225 228 TPR provided a
more consistent inspiratory time than SIB independent of experience.
Prolonged inflation could be more reliably provided by the TPR.229
Limitations of the TPR device were identified. Resuscitation is a
dynamic process where the resuscitator needs to adapt to the
response or non-response of the newborn. TPR users were not as
good at detecting changes in compliance as users of the SIB and
FIB.230 PEEP valves could be inadvertently screwed down leading to
excess PEEP.231 TPR users needed more time to change the inflating
pressures during resuscitation compared to users of the SIB or FIB.
Mask leak can be greater with the TPR than with SIB227,228 and
changes to TPR gas flow rate had significant effects on PIP, PEEP232
235
and mask leak.232 The TPR can require more training to set up
properly but once in use provided more consistent ventilation than the
SIB even with inexperienced operators.236 The SIB cannot deliver
CPAP and may not be able to achieve a consistent end expiratory
pressure even with a PEEP valve.224 226,237 240 The performance of
various TPRs and self-inflating bags may differ considerably.241 A
newer upright design of SIB and revised mask confers advantages in
use including improved delivery of PEEP.188,242 244
In addition to the 1107 infants in the two RCTs included in the 2015
analysis,207,208 a recent ILCOR scoping review of TPR vs. SIB for
ventilation1,245 reported a substantial number of additional patients in
one further RCT (n = 90)209 and one large observational study
(n = 1962).210 Studies differed regarding the investigated populations
(two studies included term and preterm infants,208,209 two studies
were in preterm infants only).207,210 The findings of these studies are
outlined in the section on PEEP and suggest improved survival and
less need for intubation and BPD with TPR use compared to SIB,
particularly in preterm infants.
The ILCOR task force concluded that whilst the direction of
evidence is shifting towards support for the use of TPR devices, until a
further systematic review is conducted recommendations would
remain unchanged.1 The 2015 consensus on science stated that the
use of the TPR showed marginally but not statistically significant
310 RESUSCITATION 161 (2021) 291
benefits for the clinical outcome of achieving spontaneous
breathing.49
Facemask versus nasal prong
A problem when using a facemask for newborn ventilation is a
potentially large and variable leak and loss of inflating gas volume
arising from suboptimal selection of mask size and poor technique.
In manikin studies using a T-piece and different masks, 50
volunteer operators had variable mask leak up to 80% with
improvement after written instruction and demonstration of
alternative mask hold techniques.190,191 Using flow monitoring
recordings of the airway management of 56 newborn preterm
infants Schmölzer demonstrated variable degrees of either
obstruction (75%) and/or leak (>75%) during first 2 min of
support in 73% of cases.154
Nasopharyngeal tubes have been suggested as an alternative.
An observational study investigating respiratory function found
that when using a single nasopharyngeal tube it took longer before
PPV was given, leak was increased and obstruction occurred
more frequently, inadequate tidal volumes were delivered more
often and SpO2 was lower in the first minutes during PPV.246
However, two randomised trials in preterm infants of <31 weeks
gestation involving 507 infants did not find any difference in
intubation rates in the delivery room between facemask and single
nasal prong.152,247
Laryngeal mask
The laryngeal mask (LM) may be used in ventilation of the newborn,
particularly if facemask ventilation or tracheal intubation is unsuc-
cessful or not feasible.49 A recent systematic review of seven trials
(794 infants) showed that the laryngeal mask was more effective than
bag-mask in terms of shorter resuscitation and ventilation times, and
less need for tracheal intubation (low- to moderate-quality evi-
dence).248 Of note, bag-mask was effective in more than 80% of
enrolled infants. Efficacy of the laryngeal mask was comparable to that
offered by tracheal intubation (very low to low quality evidence),
suggesting that it is a valid alternative airway device when attempts at
tracheal intubation are unsuccessful during resuscitation or where
those involved lack the skills or equipment to intubate safely.
As available studies included infants with birth weight >1500 g or
34 or more weeks gestation, evidence supporting laryngeal mask use
in more premature infants is lacking.248,249 The laryngeal mask has
not been evaluated in the setting of meconium-stained fluid, during
chest compressions, or for the administration of emergency intra-
tracheal medications.
Tracheal tube placement
The use and timing of tracheal intubation will depend on the skill and
experience of the available resuscitators. Formulae may be unreliable
in determining tracheal tube lengths.250,251 Appropriate tube lengths
for oral intubation derived from observational data based on gestation
are shown in Table 1.[130_TD$IF]252 Nasotracheal tube length was found to be
approximately 1 cm more than the oral length.253 Uncuffed tubes are
typically used. There is no published evidence to support the routine
use of cuffed tubes during neonatal resuscitation. Efficacy has been
demonstrated in infants <3 kg during perioperative respiratory
support.254
The diameter of the narrowest part of the airway and varies with
gestational age and size of the infant whereas the external diameter of
the tube (of the same internal diameter) may vary depending on
326
manufacturer.255 A range of differing sized tubes should be available
to permit placement of that most appropriate to ensure adequate
ventilation with only a small leak of gas around the tracheal tube and
without trauma to the airway. A narrow diameter tube in a large airway
may be confirmed in the correct position but fail to provide adequate
ventilation because of low lung compliance and excessive leak. The
tube diameter may be estimated as 1/10 of the gestational age.256
Tracheal tube placement should be confirmed by exhaled CO2
detection (see below), the length inserted assessed visually during
intubation and the tip position confirmed clinically and ideally
radiographically. Markings on the tips of tracheal tubes to aid tube
placement distal to the vocal cords vary considerably between
manufacturers.257 Within institutions users will likely gain familiarity
with specific types. Tube position may alter during the securing
process.252 A systematic review of published literature on methods of
confirming correct tube placement concluded that objective assess-
ments of tube position were better validated than subjective ones such
as visual assessment of chest movement.258 Following tracheal
intubation and IPPV, a prompt increase in heart rate and observation
of expired CO2 are good indications that the tube is in the trachea.258
End tidal CO2 and respiratory function monitoring
Detection of exhaled CO2 in addition to clinical assessment is
recommended to confirm correct placement of a tracheal tube in
neonates with spontaneous circulation.49 Even in VLBW in-
fants,259,260 detecting evidence of exhaled CO2 confirms tracheal
intubation in neonates with a cardiac output more rapidly and more
accurately than clinical assessment alone.260,261 However, studies
have excluded infants in need of extensive resuscitation. Failure to
detect exhaled CO2 strongly suggests tube misplacement, most likely
oesophageal intubation or tube dislodgement.259,261 False negative
end tidal carbon dioxide (ETCO2) readings have been reported during
cardiac arrest.259 and in VLBW infants despite models suggesting
effectiveness with low tidal volumes.262 Poor or absent pulmonary
blood flow or tracheal obstruction may prevent detection of exhaled
CO2 despite correct tracheal tube placement. There is a lack of
evidence in the neonate as to the effect of drugs on exhaled CO2
monitoring, however studies in adults suggest drugs such as
adrenaline and bicarbonate may affect end-tidal CO2 determina-
tion.263 Insufficient inflating pressure to recruit an adequate FRC and
generate sufficient expiratory flow might also be a factor. The inability
to detect exhaled CO2 despite correct placement may lead to a
decision to extubate. Where CO2 detection is unreliable tube position
should be confirmed by direct laryngoscopy.
Both qualitative (colorimetric) and quantitative (waveform) meth-
ods have been successfully used after delivery.264 Studies in adults
suggest that waveform capnography may be more sensitive than
colorimetry in detecting exhaled CO2, however, due to lack of data on
the validity of waveform capnography in neonates, caution must be
exercised when considering its use.263,265,266
Flow monitoring is useful for confirming tracheal tube position. In a
randomised controlled trial a flow sensor confirmed appropriate tube
placement faster and more reliably than capnography.267
Respiratory flow/volume monitoring268 and end tidal CO2 269,270
may be used in non-intubated patients. The effectiveness of
quantitative capnography in confirming mask ventilation has been
demonstrated but may not provide reliable ETCO2 values.270 The use
of exhaled CO2 detectors to assess ventilation with other interfaces
(e.g., nasal airways, laryngeal masks) during positive pressure
ventilation in the delivery room has not been reported.
 RESUSCITATION 161 (2021) 291
Video-laryngoscopy
A systematic review of studies of video-laryngoscopy in newborn
infants concluded by suggesting that video-laryngoscopy increases
the success of intubation in the first attempt but does not decrease the
time to intubation or the number of attempts for intubation (moderate to
very low-certainty evidence). However, included studies were
conducted with trainees performing the intubations and highlight
the potential usefulness of video-laryngoscopy as a teaching tool.
Well-designed, adequately powered RCTs are necessary to confirm
efficacy and address safety and cost-effectiveness of video-
laryngoscopy for neonatal endotracheal intubation by trainees and
those proficient in direct laryngoscopy.271 The effectiveness in the
context of resuscitation at birth has not been fully evaluated.
Air/oxygen
Term infants and late preterm infants 35 weeks
A recent ILCOR CoSTR suggests that for term and late preterm
newborns (35 weeks gestation) receiving respiratory support at
birth, support should start with 21% oxygen (weak recommendation,
low certainty evidence).1 It recommends against starting with 100%
inspired oxygen (strong recommendation, low certainty evidence). A
systematic review and meta-analysis of 5 RCTs and 5 quasi RCTs
included 2164 patients demonstrated a 27% relative reduction in
short-term mortality when initial room air was used compared with
100% oxygen for neonates 35 weeks gestation receiving respiratory
support at birth (RR = 0.73; 95% CI 0.57 0.94).172 No differences
were noted in neurodevelopmental impairment or hypoxic-ischaemic
encephalopathy (low to very low certainty evidence). Use of low
concentrations of inspired oxygen may result in suboptimal oxygen-
ation where there is significant lung disease272 and in term infants a
high inspired oxygen may be associated with a delay in onset of
spontaneous breathing.273 Therefore oxygen should be titrated to
achieve adequate preductal saturations. If increased oxygen
concentrations are used, they should be weaned as soon as
possible.274 276
Preterm infants <35 weeks
In an ILCOR systematic review and meta-analysis of 10 RCTs and 4
cohort studies including 5697 infants comparing initial low with high
inspired oxygen for preterm infants <35 weeks gestation who
received respiratory support at birth, there were no statistically
significant benefits or harms from starting with lower compared to
higher inspired oxygen in short or long term mortality (n = 968;
RR = 0.83 (95% CI 0.50 1.37)), neurodevelopmental impairment or
other key preterm morbidities.277 It is suggested that low (21 30%)
rather than a higher initial concentration (60 100%) be used (weak
recommendation, very low certainty evidence). The range selected
reflects the low oxygen range used in clinical trials. Oxygen
concentration should be titrated using pulse oximetry (weak
recommendation, low certainty evidence).1
In contrast to term infants, in preterm infants the use of
supplemental oxygen to reach adequate oxygenation increases
breathing efforts. In an animal experimental study278 and one RCT in
52 preterm infants <30 weeks gestation,279 initiating stabilisation with
higher oxygen concentrations (100% vs. 30%) led to increased
breathing effort, improved oxygenation, and a shorter duration of
mask ventilation. Minute volumes were significantly higher at 100%
(146.34  112.68 mL kg 1 min 1) compared to 30% (74.43  52.19
mL kg 1 min 1), p = 0.014.
326 311
Fig. 10 – Oxygen saturations in healthy infants at birth
without medical intervention (3rd, 10th, 25th, 50th, 75th,
90th, 97th centiles). Reproduced with permission from
Dawson 2010.
A recent European consensus statement recommended the use of
an initial inspired oxygen concentration of 30% for newborns <28
weeks gestation, of 21 30% for 28 31 weeks gestation, and of 21%
for >32 weeks gestation.280
Target oxygen saturation
The target range recommended for both term and preterm infants
are similar and based upon time based values for preductal
saturations in normal term infants in air.281 Consensus recom-
mendations suggest aiming for values approximating to the
interquartile range,282 or using the 25th centile as the lower
threshold value49 (Fig. [1302_TD$IF]6710).
A systematic review of 8 RCTs with 768 preterm infants <32 weeks
involving low (30%) vs higher (60%) initial oxygen concentrations,
concluded that failure to reach a minimum SpO2 of 80% at 5 min was
associated with a two-fold risk of death (OR 4.57, 95% CI 1.62 13.98,
p < 0.05), and had an association with lower heart rate (mean
difference 8.37, 95% CI 15.73 to 1.01, p < 0.05) and a higher
risk of severe intraventricular haemorrhage (OR 2.04, 95% CI 1.01
4.11, p < 0.05).283 It remained unclear whether this was because of
the severity of illness, or the amount of oxygen administered during
stabilisation.
Available data suggest nearly all preterm newborns <32 weeks
gestation will receive oxygen supplementation in the first 5 min after
delivery in order to achieve commonly recommended oxygen
saturation targets.276,281,283 However, it may be difficult to titrate
the oxygen concentration in the first minutes and preterm infants <32
weeks gestation may spend a significant time outside the intended
target range.284,285 In an individual patient analysis of the 706 preterm
infants enrolled in the RCTs only 12% reached the threshold SpO2 of
80% at 5 min after birth.283
Titration of oxygen
It is important to select the appropriate initial oxygen concentration,
with careful and timely titration of inspired oxygen against time
sensitive threshold saturation levels in order to avoid extremes of
hypoxia and hyperoxia and avoid bradycardia. A recent review
suggested that oxygen delivery should be reviewed and titrated as
necessary every 30 s to achieve this.286
An important technical aspect of the titration of supplemental
oxygen when using a TPR device is that it takes a median 19 s (IQR 0
57) to achieve the desired oxygen concentration at the distal end of
312 RESUSCITATION 161 (2021) 291
the TPR.287 Although the cause of this delay is unclear, mask leak
contributes significantly. A good mask seal can lead to a longer delay
with a resulting lag between adjustment and response.
Circulatory support
Circulatory support with chest compressions is effective only if the
lungs have been successfully inflated and oxygen can be delivered to
the heart. Ventilation may be compromised by compressions so it is
vital to ensure that satisfactory ventilation is occurring before
commencing chest compressions.288
The most effective traditional technique for providing chest
compressions is with two thumbs over the lower third of the sternum
with the fingers encircling the chest and supporting the back.289 292
This technique generates higher blood pressures and coronary artery
perfusion with less fatigue than the alternative two-finger tech-
nique.293,294 In a manikin study, overlapping the thumbs on the
sternum was more effective than adjacent positioning but more likely
to cause fatigue.295 The sternum is compressed to a depth of
approximately one-third of the anterior-posterior diameter of the chest
allowing the chest wall to return to its relaxed position between
compressions.296 300 Delivering compressions from ‘over the head’
appears as effective as the lateral position.301
A recent ILCOR review of the evidence identified 19 studies
published since 2015 including one systematic review and 18 RCTs all
of which were manikin studies.302 No evidence was found to alter
treatment recommendations from 2015 in suggesting that chest
compressions in the newborn should be delivered by the two thumb,
hand encircling the chest method as the preferred option (weak
recommendation, very low certainty evidence).1 However newer
techniques, one using two thumbs at an angle of 90 to the chest and
the other a ‘knocking finger’ technique, have been reported in
manikins. Further studies are required to determine if they have any
clear advantage over the standard two thumb technique.1,303
A recent evidence update was undertaken by ILCOR to identify the
most effective compression to ventilation ratio for neonatal resuscita-
tion.1 13 trials published since 2015 were found to be relevant. Four
neonatal manikin studies comparing alternative compression to
ventilation ratios or asynchronous ventilation strategies found no
advantage over traditional synchronised 3:1 techniques. A number of
animal trials compared the delivery of cardiac compressions during a
sustained inflation with traditional 3:1 compression to ventilation. No
consistently clear advantages were identified. Some trials are
ongoing.
ILCOR found no evidence to change the 2015 recommendations for a
3:1 compression to ventilation ratio (weak recommendation, very low
quality evidence), aiming to achieve a total of approximately 90
compressions and 30 ventilations per minute.1,49,144 Compressions
and ventilations should be coordinated to avoid simultaneous delivery.304
There are theoretical advantages to allowing a relaxation phase that is
slightly longer than the compression phase, however, the quality of the
compressions and breaths are probably more important than the rate.305
A 3:1 compression to ventilation ratio is used at all times for
resuscitation at birth where compromise of gas exchange is nearly
always the primary cause of cardiovascular collapse. Rescuers may
consider using higher ratios (e.g. 15:2) if the arrest is believed to be of
cardiac origin, more likely in a witnessed postnatal collapse than at
birth.When chest compressions are indicated by a persistent very
slow/absent heart rate, it would appear reasonable to increase the
supplementary inspired oxygen to 100%. However, there are no
326
human studies to support this and animal studies demonstrate no
advantage to 100% inspired oxygen during CPR.306 312
Unless using continuous monitoring such as pulse oximetry or
ECG, check the heart rate after no longer than 30 s and periodically
thereafter. Whilst chest compressions may be discontinued when the
spontaneous heart rate is faster than 60 min 1, a continued increase
in rate is necessary to truly demonstrate improvement. It is not until the
heart rate exceeds 120 min 1 that it becomes stable.130,131
Exhaled carbon dioxide monitoring and pulse oximetry have been
reported to be useful in determining the return of spontaneous
circulation313 316; however, current evidence does not support the
use of any single feedback device in a clinical setting and extrapolation
of their use from adult and paediatric settings have, for a variety of
reasons, been proven error prone in neonates.49,144,265
Vascular access
Umbilical vein catheterisation (UVC) and intraosseous (IO)
access
In a systematic review no evidence was identified comparing the
umbilical venous route or use of intravenous (IV) cannulas against
the IO route in the newborn for drug administration in any setting.1
No case series or case reports on IO administration in the delivery
room setting were identified. Consensus suggests UVC as the
primary method of vascular access. If umbilical venous access is not
feasible, or delivery occurs in another setting, the IO route is
suggested as a reasonable alternative (weak recommendation, very
low certainty of evidence).
A systematic review on the use of IO in neonates in any situation
identified one case series and 12 case reports of IO device insertion
into 41 neonates delivering several drugs including adrenaline and
volume.317 However, whilst the IO route has been demonstrated to be
a practical alternative to the UVC significant adverse events include
tibial fractures, osteomyelitis, and extravasation of fluid and
medications resulting in compartment syndrome and amputation.1
The actual route and method used may depend on local availability
of equipment, training and experience.1 There is limited evidence on
the effective use of IO devices immediately after birth, or the optimal
site or type of device318 although simulation studies undertaken in a
delivery room setting suggest that the IO route can be faster to insert
and use than UVC.319
Peripheral access
No studies were identified reviewing the use of peripheral IV
cannulation in infants requiring resuscitation at birth. A retrospective
analysis of 61/70 newborn preterm infants requiring i/v access in a
single centre showed that peripheral i/v cannulation is feasible and
successful in most cases at first attempt.320
Drugs
Drugs are rarely indicated in resuscitation of the newborn infant.11,12
Bradycardia is usually caused by profound hypoxia and the key to
resuscitation is aerating the fluid filled lungs and establishing
adequate ventilation. However, if the heart rate remains less than
60 min 1 despite apparently effective ventilation and chest com-
pressions, it is reasonable to consider the use of drugs.
Knowledge of the use of drugs in newborn resuscitation is largely
limited to retrospective studies, as well as extrapolation from animals
and adult humans.321
 RESUSCITATION 161 (2021) 291
Adrenaline
A recent systematic review identified 2 observational studies
involving 97 newborn infants comparing doses and routes of
administration of adrenaline.322 There were no differences between
IV and endotracheal adrenaline for the primary outcome of death at
hospital discharge (RR = 1.03 [95% CI 0.62 1.71]) or for failure to
achieve return of spontaneous circulation, time to return of
spontaneous circulation (1 study; 50 infants), or proportion
receiving additional adrenaline (2 studies; 97 infants). There were
no differences in outcomes between 2 endotracheal doses (1
study). No human infant studies were found addressing IV dose or
dosing interval (very low certainty evidence). Despite the lack of
newborn human data it is reasonable to use adrenaline when
effective ventilation and chest compressions have failed to increase
the heart rate above 60 min 1. ILCOR treatment recommendations
suggest that if adrenaline is used, an initial dose of 10 30 micro-
grams kg 1 (0.1 0.3 mL kg 1 of 1:10,000 adrenaline [1 mg in
10 mL)) should be administered intravenously (weak recommen-
dation, very low certainty evidence). If intravascular access is not
yet available, endotracheal adrenaline at a larger dose of 50
100 micrograms kg 1 (0.5 1.0 mL kg 1 of 1:10,000 adrenaline
[1 mg in 10 mL]) is suggested (weak recommendation, very low
certainty evidence) but should not delay attempts at establishing
venous access (weak recommendation, very low certainty evi-
dence). If the heart rate remains less than 60 min 1 further doses
preferably intravascularly every 3 5 min are suggested (weak
recommendation, very low certainty evidence). If the response to
tracheal adrenaline is inadequate it is suggested an intravenous
dose is given as soon as venous access is established regardless
of the interval between doses (weak recommendation, very low
certainty evidence).1
Glucose
Hypoglycaemia is an important additional risk factor for perinatal
brain injury.323 Endogenous glycogen stores are rapidly depleted
during prolonged hypoxia. In one study infants with birth asphyxia
had, prior to administration of glucose in the delivery room,
significantly lower blood glucose (1.9  0.6 mmol/L vs. 3.2  0.3
mmol/L),324 therefore in protracted resuscitation it is reasonable to
use glucose by giving a 250 mg kg 1 bolus (2.5 mL kg 1 of 10%
glucose). After successful resuscitation formal steps to prevent both
hypoglycaemia and hyperglycaemia should be instituted (see post-
resuscitation care).
Volume replacement
A recent ILCOR evidence update1 identified no further human studies
and a single animal RCT which supported the 2010 CoSTR
recommendations.34,274 Early volume replacement is indicated for
newborn infants with blood loss who are not responding to
resuscitation. Therefore, if there has been suspected blood loss or
the infant appears to be in shock (pale, poor perfusion, weak pulse)
and has not responded adequately to other resuscitative measures
then consider giving volume replacement with crystalloid or red cells.
Blood loss causing acute hypovolaemia in the newborn infant is a rare
event. There is little to support the use of volume replacement in the
absence of blood loss when the infant is unresponsive to ventilation,
chest compressions and adrenaline. However, because blood loss
may be occult and distinguishing normovolaemic infants with shock
due to asphyxia from those who are hypovolaemic can be problematic,
a trial of volume administration may be considered.1
326 313
In the absence of suitable blood (i.e. group O Rh-negative blood),
isotonic crystalloid rather than albumin is the solution of choice for
restoring intravascular volume. Give a bolus of 10 mL kg 1 initially. If
successful it may need to be repeated to maintain an improvement.
When resuscitating preterm infants, volume is rarely needed and has
been associated with intraventricular and pulmonary haemorrhages
when large volumes are infused rapidly.325
Sodium bicarbonate
If effective spontaneous cardiac output is not restored despite
adequate ventilation and adequate chest compressions, reversing
intracardiac acidosis may improve myocardial function and achieve
a spontaneous circulation. There are insufficient data to recommend
routine use of bicarbonate in resuscitation of the newborn. The
hyperosmolarity and carbon dioxide-generating properties of
sodium bicarbonate may impair myocardial and cerebral
function.326
A recent review of the evidence1 concluded that there were no
reasons to change the 2010 recommendations.34,274 Use of sodium
bicarbonate is not recommended during brief cardiopulmonary resusci-
tation. Use, however, may be considered during prolonged cardiac arrest
unresponsive to other therapy, when it should be given only after
adequate ventilation is established and chest compressions are being
delivered. A dose of 1 2 mmol kg 1 sodium bicarbonate (2 4 mL kg 1 of
4.2% solution) may be given by slow intravenous injection.
Naloxone
There is no strong evidence that naloxone confers any clinically
important benefits to newborn infants with respiratory depression due
to hypoxia.327,328 Current recommendations do not support use of
naloxone during resuscitation with the preference being to concen-
trate on providing effective respiratory support.
Use is best reserved for those infants whose cardiac output has
been restored but who remain apnoeic despite resuscitation and
where the mother has received opioid analgesia in labour. An initial
intramuscular 200 microgram dose, irrespective of weight, provides a
pragmatic delivery room approach suitable for most infants. An IM
dose provides steady plasma concentrations for about 24 h.329 Infants
whose breathing is suppressed by opioids may show a rebound
tachypnoea after naloxone is given.330
Post-resuscitation care
Hypo and hyperglycaemia
Perinatal hypoxia interferes with metabolic adaptation and mainte-
nance of cerebral energy supply in several ways. Significantly lower
blood glucose levels in the delivery room promote ketogenesis.324
Hypoglycaemia is common; a quarter of infants with moderate to
severe HIE reported to a national cooling registry had a blood glucose
less than 2.6 mmol/L.331
Animal studies suggest hypoxic cerebral injury is worsened by both
hypoglycaemia and hyperglycaemia.332 334 In human infants with
hypoxic ischaemic encephalopathy an abnormal early postnatal
glycaemic profile (i.e. hypoglycaemia, hyperglycaemia or labile blood
glucose) is associated with distinct patterns of brain injury on MRI
compared to normoglycaemia.324 Hyperglycaemia and a labile blood
glucose were also associated with amplitude-integrated electroen-
cephalography evidence of worse global brain function and seizures.335
Both hypoglycaemia and hypoglycaemia were associated with
poorer neurological outcomes in the CoolCap study336 and there is a
314 RESUSCITATION 161 (2021) 291
clear association between initial hypoglycaemia and poorer neuro-
logical outcome in infants with perinatal hypoxia.337,338
A recent ILCOR review of the evidence on the post resuscitation
management of glucose identified no systematic reviews or RCTs
specifically addressing the management of blood glucose in the first
few hours after birth.1 13 non randomised trials or observational
studies were identified published since 2015 investigating whether the
maintenance of normoglycaemia during or immediately after resusci-
tation improved outcome.
The update suggests that infants who require significant
resuscitation should be monitored and treated to maintain glucose
in the normal range. Protocols for blood glucose management should
be used that avoid both hypo and hyperglycaemia and also avoid large
swings in blood glucose level. The evidence update suggests that
research to determine the optimal protocols for glycaemic manage-
ment for preterm and term infants in the aftermath of resuscitation, and
the optimal target range should be a high priority. Overall no change
has been made to the previous recommendation that intravenous
glucose infusion should be considered soon after resuscitation with
the goal of avoiding hypoglycaemia (low certainty evidence).339
Rewarming
If therapeutic hypothermia is not indicated, hypothermia after birth
should be corrected because of evidence of poor outcomes.76,77
Infants should be maintained within the normal range of temperature.
A recent ILCOR evidence review identified no systematic reviews or
RCTs published since the previous guidelines.1 Two retrospective
observational studies involving 182340 and 98341 patients were
identified which investigated whether in hypothermic infants (36  C
on admission) rapid or slow rewarming changed outcome. The findings
of both studies were that the rate of rewarming (after adjustment for
confounders) did not affect the critical and important outcomes.
However, one study suggested that rapid rewarming reduces risk for
respiratory distress syndrome.340 The conclusion was that there was no
new evidence to alter the 2015 ILCOR consensus that a recommenda-
tion for either rapid (0.5  C/h or greater) or slow rewarming (0.5  C/h or
less) of unintentionally hypothermic newborn infants (temperature less
than 36  C) at hospital admission would be speculative.274,339,342
Induced hypothermia
This topic has not been reviewed as part of the most recent ILCOR
process. A Cochrane review including 11 randomised controlled trials
comprising 1505 term and late preterm infants calculated that
therapeutic hypothermia resulted in a statistically significant and
clinically important reduction in the combined outcome of mortality or
major neurodevelopmental disability to 18 months of age (typical RR
0.75 (95% CI 0.68 0.83); typical RD 0.15 (95% CI 0.20 0.10)) and
concluded that newborn infants at term or near-term with evolving
moderate to severe hypoxic-ischaemic encephalopathy should be
offered therapeutic hypothermia.343 Cooling should be initiated and
conducted under clearly defined evidence-based protocols with
treatment in neonatal intensive care facilities and with the capabilities
for multidisciplinary care. Treatment should commence within 6 h of
birth, target a temperature between 33.5  C and 34.5  C, continue for
72 h after birth and re-warm over at least 4 h. A four way clinical trial of
364 infants randomised to receive longer (120 h) or deeper (32  C)
cooling found no evidence of benefit of longer cooling or lower
temperatures.344 Animal data strongly suggests that the effectiveness of
cooling is related to early intervention. Hypothermia initiated at 6 24 h
after birth may have benefit but there is uncertainty in its
326
effectiveness.345 Such therapy is at the discretion of the treating team
on an individualised basis. Current evidence is insufficient to
recommend routine therapeutic hypothermia for infants with mild
encephalopathy.346
Prognostic tools
This subject was not reviewed through the ILCOR process. No
systematic or scoping reviews have been identified.
The APGAR score was proposed as a “simple, common, clear
classification or grading of newborn infants” to be used “as a basis for
discussion and comparison of the results of obstetric practices, types
of maternal pain relief and the effects of resuscitation” (our
emphasis).113 Although widely used in clinical practice and for
research purposes, the applicability has been questioned due to large
inter- and intra-observer variations. In a retrospective study involving
42 infants between 23 and 40 weeks gestation O’Donnell found a
significant discrepancy (average 2.4 points) between observers
retrospectively scoring the APGAR from videos of the deliveries
compared to the scores applied by those attending the delivery.347
A lack of correlation with outcome is partly explained by a lack of
agreement on how to score infants receiving medical interventions or
being born preterm. Variations in the APGAR score have been
proposed attempting to correct for maturity and the interventions
undertaken, such as the Specified, Expanded and Combined versions
(which incorporates elements of both). These might have greater
precision in predicting outcome in preterm and term infants when
compared to the conventional score, but are not used widely.348,349
Communication with the parents
The principles governing the need for good communication with
parents are derived from clinical consensus and enshrined in
published European and UK guidance.350,351
Mortality and morbidity for newborns varies according to region,
ethnicity and to availability of resources.352 354 Social science studies
indicate that parents wish to be involved in decisions to resuscitate or to
discontinue life support in severely compromised infants.355,356 Local
survival and outcome data are important in appropriate counselling of
parents. The institutional approach to management (for example at the
border of viability) affects the subsequent results in surviving infants.357
European guidelines are supportive of family presence during
cardiopulmonary resuscitation.358 Healthcare professionals are
increasingly offering family members the opportunity to remain
present during resuscitation and this is more likely if this takes place
within the delivery room. Parents’ wishes to be present during
resuscitation should be supported where possible.1,359,360
There is insufficient evidence to indicate an interventional effect on
patient or family outcome. Being present during the resuscitation of
their baby seems to be a positive experience for some parents but
concerns about an effect upon performance exist in professionals and
family members (weak recommendation very low certainty of
evidence).1,360
In a single centre review of management of birth at the bedside,
parents who were interviewed were supportive but some found
witnessing resuscitation difficult.361 Clinicians involved felt the close
proximity improved communication but interviews suggested support
and training in dealing with such situations might be required for
staff.362 In a retrospective questionnaire based survey of clinicians’
workload during resuscitation the presence of parents appeared to be
beneficial in reducing perceived workload.363
 RESUSCITATION 161 (2021) 291
Qualitative evidence emphases the need for support during and after
any resuscitation, without which the birth may be a negative experience
with post traumatic consequences.364,365 There should be an opportunity
for the parents to reflect, ask questions about details of the resuscitation
and be informed about the support services available.359 It may be helpful
to offer any parental witness of a resuscitation the opportunity to discuss
what they have seen at a later date.364,365
Decisions to discontinue or withhold resuscitation should ideally
involve senior paediatric staff.
Discontinuing or withholding treatment
Discontinuing resuscitation
Failure to achieve return of spontaneous circulation in newborn infants
after 10 20 min of intensive resuscitation is associated with a high risk
of mortality and a high risk of severe neurodevelopmental impairment
among survivors. There is no evidence that any specific duration of
resuscitation universally predicts mortality or severe neurodevelop-
mental impairment.
When the heart rate has been undetectable for longer than 10 min
outcomes are not universally poor.366 368 For the composite outcome
of survival without neurodevelopmental impairment a recent ILCOR
systematic review identified low certainty evidence (downgraded for
risk of bias and inconsistency) from 13 studies involving 277 infants
reporting neurodevelopmental outcomes. Among all 277 infants 69%
died before last follow up, 18% survived with moderate to severe
neurodevelopmental impairment and 11% were judged to have
survived without moderate or severe neurodevelopmental impairment
(2% lost to follow up).1 It can be helpful to consider clinical factors,
effectiveness of resuscitation and the views of other members of the
clinical team about continuing resuscitation.369
If despite provision of all the recommended steps of resuscitation,
and excluding reversible causes a newborn infant requires ongoing
cardiopulmonary resuscitation for a prolonged period, it would be
appropriate to discontinue resuscitative efforts. A reasonable time
frame to consider this is around 20 min after birth (weak recommen-
dation, very low certainty evidence).1
The decision to cease resuscitation is a clinical decision, but it is
important, where possible, to give the family updates during the
resuscitation and advance warning that there is a high chance the
baby will not survive. In extremely preterm infants, prolonged
resuscitation is associated with lower survival rates and higher
morbidity, the decision should be individualised.370,371
Withholding resuscitation
In situations where there is extremely high predicted mortality and
severe morbidity in surviving infants, withholding resuscitation may be
reasonable, particularly when there has been the opportunity for prior
discussion with parents.372 379 Examples from the published
literature include: extreme prematurity (gestational age less than
22 weeks and/or birth weight less than 350 g),380 and anomalies such
as anencephaly and bilateral renal agenesis.
Withholding resuscitation and discontinuation of life-sustaining
treatment during or following resuscitation are considered by many to
be ethically equivalent and clinicians should not be hesitant to
withdraw treatment when it would not be in the best interests of the
infant.381
A consistent and coordinated approach to individual cases by the
obstetric and neonatal teams and the parents is an important goal. In
conditions where there is low survival (<50%) and a relatively high rate
326 315
of morbidity, and where the anticipated burden to the child is high,
parental wishes regarding resuscitation should be sought and
supported.351
Conflict of interest
CR declares speaker honorarium from Chiesi and funding from the
National Institute for Health Research. JM declares occasional advice
to Laerdal Medical and Brayden on Newborn Resuscitation
Equipment. HE declares research funding for Safer Births project
from Laerdal foundation, Governmental, World Bank, Global Financ-
ing Facility and Laerdal Global Health. CM declares honorarium from
Dräger and Chiesi, and his role of consultant for Fisher and Paykel and
Laerdal. TS declares educational funding from GE and Chiesi. CS
Research declares funding from Government and ZOLL foundation.
ATP is science advisor for CONCORD neonatal; he is patent holder of
the Concord resuscitation table. MR declares his role of consultant for
surfactant study Chiesi. JW declares NIH grant as co-applicant for
“Baby-OSCAR” project.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.resuscitation.2021.02.014.
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Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Paediatric Life Support

Patrick Van de Voorde a,b, * , Nigel M. Turner c, Jana Djakow d,e, Nieves de Lucas f ,
Abel Martinez-Mejias g , Dominique Biarent h , Robert Bingham i , Olivier Brissaud j ,
Florian Hoffmann k , Groa Bjork Johannesdottir l , Torsten Lauritsen m , Ian Maconochie n
a
Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium
b
EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium
c
Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Netherlands
d
Paediatric Intensive Care Unit, NH Hospital, Horovice, Czech Republic
e
Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
f
SAMUR Protección Civil, Madrid, Spain
g
Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
h
Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
i
Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
j
Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin Hôpital des Enfants de Bordeaux, Université de Bordeaux,
Bordeaux, France
k
Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University, Munich, Germany
l
Paediatric gastroenterology, Akureyri Hospital, Akureyri, Iceland
m
Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
n
Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK

Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary
Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children,
before, during and after cardiac arrest.

Keywords: Resuscitation child, Infant, Paediatric, CPR, Basic life support, Advanced life support, Defibrillation, Pediatric, Respiratory failure,
Circulatory failure, Shock, Oxygen, Cardiac arrest, Bag-mask ventilation

local healthcare organisation and resource availability can lead to

Introduction and scope
Many of the underlying aetiologies and pathophysiological processes
involved in critically ill children and infants differ from those in adults.
Critical illness is less common in children and those responsible for its
management might have limited experience. The available evidence
is often scarce and/or extrapolated from adult literature. Differences in
significant variation in practice. The ERC Paediatric Life Support
(PLS) writing group (PWG) acknowledges this and has tried to make
guidelines unequivocal, yet contextual. When writing these guide-
lines, we focused not only on science, but equally on feasibility of
education and implementation.1
We identified 80 questions needing review. Search strategies and
results, as well as identified knowledge gaps, are described in detail in

* Corresponding author.
E-mail address: patrick.vandevoorde@uzgent.be (P. Van de Voorde).
https://doi.org/10.1016/j.resuscitation.2021.02.015

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
328 RESUSCITATION 161 (2021) 327
the appendix document to this guideline chapter (Appendix A) and will
not be repeated here, providing only a summary of the evidence
available and its implications for practice and research. In general,
search strategies were in the form of ‘rapid reviews’ (RR) and these
were updated in June 2020. [https://www.who.int/alliance-hpsr/resour-
ces/publications/rapid- review-guide/en/]. Where available, searches
were primarily informed by reviews included in the International Liaison
Committee on Resuscitation Consensus on Cardiopulmonary Resus-
citation Science with Treatment Recommendations (ILCOR COSTR).
For topics not covered or only partially covered by ILCOR, we explored
both existing guidelines and systematic (SR) or narrative reviews
(STEP 0) and additional clinical studies (both randomised controlled
trials (RCT) and observational studies) directly related to the defined
PICOST (Population Intervention Control Outcomes Setting
Times) (STEP 1). The quality of existing guidelines and SR was
assessed using the AGREE II and AMSTAR II tool respectively.2,3 For
clinical studies, we reported results and limitations, yet did not
systematically assess for certainty of the evidence. We also considered
indirect evidence (STEP 2) from adult, animal, or non-clinical papers to
inform our insights.
This ERC guideline chapter focuses on the management of
critically ill infants and children, before, during and after cardiac arrest.
It should be read in conjunction with other chapters, that focus on
specific relevant topics, e.g. information on epidemiology, ethics,
education, and certain special circumstances, pertaining to children.
The guidelines for resuscitation of newborn babies (transition at
birth) are described in a separate chapter. The ERC PLS guidelines
apply to all other children, be it neonates (within 4 weeks of being
born), infants (up to one year of age) or children (from the age of 1 to 18
years).4 From a practical perspective, adult guidelines can be used for
anyone who appears to be an adult.
In the following text, unless otherwise specified, ‘child’ refers to both
infants and children. We used the term ‘healthcare provider’ to identify
those people who look after patients and should have a higher level of
training than lay persons. We specifically used the term ‘competent’
provider to specify those providers with sufficient knowledge, skills,
attitudes, expertise, and ongoing training to perform or lead a certain
procedure or action to the level demanded by society. It is not always
possible to define unequivocally what sufficient means and consider it
the responsibility of the provider to reflect upon their competence.
There are relatively few major changes introduced in these
guidelines compared to our guidelines in 2015. Key points to note
include (Fig. 1):
 PLS guidelines apply to all children, aged 0 18 years, except for
‘newborns at birth’. Patients who look adult can be treated as an
adult.
 Oxygen therapy should be titrated to an SpO2 of 94 98%. Until
titration is possible, in children with signs of circulatory/respiratory
failure where SpO2 (or PaO2) is impossible to measure, we advise
to start high flow oxygen.
 For children with circulatory failure, give 1 or more fluid bolus(es) of
10 ml/kg. Reassess after each bolus to avoid fluid overload. Start
vasoactive drugs early. Limit crystalloid boluses and as soon as
available give blood products (whole blood or packed red cells with
plasma and platelets) in case of haemorrhagic shock.
 Any person trained in paediatric BLS should use the specific PBLS
algorithm.
 For PBLS providers, immediately after the 5 rescue breaths,
proceed with chest compressions unless there are clear signs of
circulation. Single rescuers should first call for help
387
(speakerphone) before proceeding. In case of sudden witnessed
collapse, they should also try to apply an AED if directly
accessible. If they have no phone available, they should perform
1 min of CPR before interrupting CPR.
 A single PBLS-trained provider preferably uses a two-thumb
encircling technique for infant chest compression.
 For PALS providers, we emphasise even more the importance of
actively searching for (and treating) reversible causes.
 2-Person bag-mask ventilation is the first line ventilatory support
during CPR for all competent providers. Only if a patient is
intubated, we advise asynchronous ventilation and this at an age-
appropriate rate (10 25 per minute).
 For PALS providers, when in doubt, consider the rhythm to be
shockable.
These guidelines were drafted and agreed by the Paediatric Life
Support Writing Group members. The methodology used for guideline
development is presented in the Executive summary.5 The guidelines
were posted for public comment in October 2020. The feedback was
reviewed by the writing group and the guidelines was updated where
relevant. The Guideline was presented to and approved by the ERC
General Assembly on 10th December 2020.
Concise guideline for clinical practice
Recognition and management of critically ill children
Assessment of the seriously ill or injured child

Use the Paediatric Assessment Triangle or a similar quick-look
tool for the early recognition of a child in danger.
 Follow the ABCDE approach
 Perform the necessary interventions at each step of the
assessment as abnormalities are identified.
 Repeat your evaluation after any intervention or when in doubt.
 A is for Airway establish and maintain airway patency.
 B is for Breathing check
 Respiratory rate (see Table 1; trends are more informative than
single readings)
 Work of breathing, e.g. retractions, grunting, nasal flaring, . . .
 Tidal volume (TV) air entry clinically (chest expansion; quality
of cry) or by auscultation
 Oxygenation (colour, pulse oximetry). Be aware that hypoxae-
mia can occur without other obvious clinical signs.
 Consider capnography
 Consider thoracic ultrasound
 C is for Circulation check
 Pulse rate (see Table 2; trends are more informative than single
readings)
 Pulse volume
 Peripheral & end-organ circulation: capillary refill time (CRT),
urinary output, level of consciousness. Be aware that CRT is not
very sensitive. A normal CRT should not reassure providers.
 Preload evaluation: jugular veins, liver span, crepitations
 Blood Pressure (see Table 3)
 Consider serial lactate measurements
 Consider point-of-care cardiac ultrasound
 D is for Disability check
 Conscious level using the AVPU (Alert- Verbal-Pain-Unrespon-
sive) score, (paediatric) Glasgow Coma Scale (GCS) total
 RESUSCITATION 161 (2021) 327 387 329

Fig. 1 – Main messages of the 2021 paediatric guidelines.

score, or the GCS motor score. AVPU score of P or less, a
Glasgow motor score of 4 and total GCS score of 8 or less define
a level of consciousness where airway reflexes are unlikely to be
preserved.
 Pupil size, symmetry, and reactivity to light.
 Presence of posturing or focal signs.
 Recognise seizures as a neurological emergency.
 Check blood glucose if altered consciousness and/or potential
hypoglycaemia.
 Sudden unexplained neurological symptoms, particularly those
persisting after resuscitation, warrant urgent neuroimaging.
Management of the seriously ill or injured child
Whilst ABCDE is described in a stepwise manner, in practice,
interventions are best carried out by multiple team members acting in
parallel in a coordinated manner. Teamwork is important in the
management of any seriously ill or injured child.
Key components of teamwork include:
 Anticipate: what to expect, allocate tasks, . . .
 Prepare: materials, checklists to support decision making, patient
data, . . .
 Choreography: where to stand, how to access the child, effective
team size, . . .
330 RESUSCITATION 161 (2021) 327 387

Table 1 – Normal values for age: respiratory rate.

Respiratory rate for age 1 month 1 year 2 year 5 year 10 year
Upper limit of normal range 60 50 40 30 25
Lower limit of normal range 25 20 18 17 14

Table 2 – Normal values for age: heart rate.

Heart rate for age 1 month 1 year 2 year 5 year 10 year
Upper limit of normal range 180 170 160 140 120
Lower limit of normal range 110 100 90 70 60

Table 3 – Normal values for age: systolic and mean arterial blood pressure (MAP). Fifth (p5) and fiftieth (p50)
percentile for age.
Blood pressure for age 1 month 1 year 5 year 10 year
p50 for systolic BP 75 95 100 110
p5 for systolic BP 50 70 75 80
p50 for MAP 55 70 75 75
p5 for MAP 40 50 55 55

 Communicate: both verbal, and non-verbal. Use closed-loop  Open the airway and keep it patent using

communication and standardised communication elements (e.g. Adequate head and body alignment,
to count compression pauses, plan patient transfers). Keep non- Head tilt ￢ﾬﾜ chin lift or jaw thrust,

essential communications ‘as low as reasonably practicable’. Careful suctioning of secretions.

Ensure a low-stress working environment. Implement a culture Awake children will likely assume their own optimal position.
that strongly condemns inappropriate behaviour, be it from  Consider oropharyngeal airway in the unconscious child, in whom
colleagues or family. there is no gag reflex.
 Interact: Team members have pre-defined roles as per protocol & Use the appropriate size (as measured from the central incisors

and perform tasks in parallel. The team-leader (clearly recognis- to the angle of the mandible) and avoid pushing the tongue
able) monitors team performance, prioritises tasks to achieve backward during insertion.
common goals and keeps the whole team informed. Hands-off  Consider nasopharyngeal airway in the semi-conscious child
leadership is preferred, if feasible. Shared situational awareness & Avoid if there is a suspicion of a basal skull fracture or of

is considered crucial. coagulopathy.

& The correct insertion depth should be sized from the nostrils to

We describe below the ‘first-hour’ management of different life- or the tragus of the ear.
organ-threatening emergencies in children, each of them potentially  In children with a tracheostomy,
leading to cardiac arrest if not properly treated. Quite often children will & Check patency of the tracheostomy tube and suctioning if

present with a combination of problems that demand a far more needed.

individualised approach. Treatment recommendations in children & In case of suspected blockage that cannot be solved by

often differ from those in adults but will also differ between children of
different age and weight. To estimate a child's weight, either rely on the
parents or caretakers or use a length-based method, ideally corrected
for body-habitus (e.g. Pawper MAC). Use, whenever possible,
decision aids providing pre-calculated dose advice for emergency
drugs and materials.
Where it is possible to accurately measure SpO (or partial
Management of respiratory failure: general approach (AB)
The transition from a compensatory state to decompensation may
occur unpredictably. Therefore, any child at risk should be monitored
to enable early detection and correction of any deterioration in their
physiology. Most airway procedures are considered aerosol-generat-
ing and thus require proper (risk-adjusted) personal protection
equipment (PPE) in cases of presumed transmittable diseases.
suctioning, immediately remove the tracheostomy tube, and
insert a new one. If this is not possible, providers should have a
(pre-defined) emergency plan for airway reestablishment.
 To support oxygenation, consider supplemental oxygen and/or
positive end-expiratory pressure (PEEP).
2
oxygen pressure (PaO2)): start oxygen therapy if SpO2 < 94%.
The goal is to reach an SpO2 of 94% or above, with as little
supplemental FiO2 (fraction of inspired oxygen) as possible.
Sustained SpO2 readings of 100% should generally be avoided
(except for instance in pulmonary hypertension, CO intoxica-
tion). Do not give pre-emptive oxygen therapy in children
without signs of or immediate risk for hypoxaemia or shock.
 RESUSCITATION 161 (2021) 327 387 331

Specific recommendations exist for children with certain chronic Use appropriate medication to facilitate intubation and provide
conditions. subsequent analgosedation in all children unless they are in
Where it is impossible to accurately measure SpO2 or PaO2: cardiorespiratory arrest.
start oxygen therapy at high FiO2, based upon clinical signs of Monitor haemodynamics and SpO2 during intubation and be
circulatory or respiratory failure, and titrate oxygen therapy as aware that bradycardia and desaturation are late signs of hypoxia.
soon as SpO2 and/or PaO2 become available. Avoid prolonged laryngoscopy and/or multiple attempts.
Where possible, competent providers should consider either Anticipate potential cardiorespiratory problems and plan an
high-flow nasal cannula (HFNC) or non-invasive ventilation alternative airway management technique in case the trachea
(NIV) in children with respiratory failure and hypoxaemia not cannot be intubated.
responding to low-flow oxygen. Competent providers should consider the (early) use of
Tracheal intubation and subsequent mechanical videolaryngoscopy, in cases where direct laryngoscopy is
ventilation enable secure delivery of FiO2 and PEEP. The expected to be difficult.
decision to intubate should be balanced against the existing Once intubated, confirmation of proper TT position is mandato-
risks of the procedure and the available resources (see ry. Evaluate clinically and by means of imaging. Use
below). capnography in all intubated children for early detection of
In hypoxaemic children despite high PEEP (>10 cmH2O) and obstruction, mal- or displacement.
standard optimisation measures, consider permissive hypo-
xaemia (oxygenation goal lowered to SpO2 88 92%).  Supraglottic airways SGAs (such as I-gel, LMA) may be an
alternative way to provide airway control and ventilation, although
 To support ventilation, adjust respiratory rate (and expiratory they do not totally protect the airway from aspiration. Easier to
time) and/or tidal volume [TV] according to age. insert than a TT, an SGA should also only be inserted by a

Use a TV of 6 to 8 ml/kg IBW (ideal body weight), considering competent provider.
among others physiological and apparatus dead space
(especially in younger children). Apparatus dead space should  Sudden rapid deterioration of a child being ventilated (via mask or
be minimalised. Look for normal chest rise. Avoid hyperinfla- TT) is a time- critical event that demands immediate action.
tion, as well as hypoventilation. Aim for normocapnia. Seek Consider ‘DOPES’:

early expert help. D stands for displacement (TT, mask)
In acute lung injury, consider permissive hypercapnia (pH O for obstruction (TT, airway circuit, airway head position)
> 7.2), thus avoiding overly aggressive ventilation. Permissive P for pneumothorax

hypercapnia is not recommended in pulmonary hypertension or E for equipment (oxygen, tubing, connections, valves)

severe traumatic brain injury (TBI). S for stomach (abdominal compartment)

Only use ETCO or venous partial carbon dioxide pressure

2
(PvCO2) as a surrogate for arterial PaCO2 when correlation has Management of status asthmaticus
been demonstrated.  Recognition of a severe asthma crisis is based upon clinical signs,
brief history taking, as well as monitoring of SpO2.
 Bag-mask ventilation (BMV) is the recommended first line Lung function determination (PEF or PEV1) is of added value in

method to support ventilation. children >6 years old, if this can be easily measured without

Ensure a correct head position and mask size and a proper seal delaying treatment.
between mask and face. Arterial blood gas analysis is not routine but might be

Use an appropriately sized bag for age. To provide adequate
TV, the inspiratory time should be sufficiently long (approx. 1 s);
avoid hyperinflation.
Use a 2-person approach, especially if ventilation is difficult or
when there is a risk of disease transmission. Consider airway
A chest X-ray is not routine but might be indicated if an
informative when the child does not respond to treatment or
deteriorates. Continue oxygen therapy when taking the sample.
Due to compensation, PaCO2 might initially be normal or
decreased. Hypercapnia is a sign of decompensation.

adjuncts. alternative diagnosis or a complication is suspected.

If competent, consider early placement of a supraglottic airway
(SGA) or a tracheal tube (TT) in cases where BMV does not
improve oxygenation and/or ventilation or is anticipated to be
prolonged.
Give supplemental oxygen titrated to achieve a SpO of 94
 Tracheal intubation(TI) should only be performed by a compe-
tent provider, following a well-defined procedure, and having the
necessary materials and drugs. The decision to intubate should
Use short-acting beta-2 agonists (SABA) via an inhaler with
 Timely, aggressive and protocolised treatment is needed in case
of status asthmaticus:
Provide a comfortable environment and body position. Avoid
sedative drugs, even if there is agitation.
2
98%. Give oxygen at high dose if SpO2 cannot be measured
but only until titration is possible.

always be balanced against the associated risk of the procedure.
The oral route for TI is preferable during emergencies.
External laryngeal manipulation should only be applied at the
discretion of the provider performing the intubation.
Use cuffed tracheal tubes (TT) for PLS (except maybe in small
infants). Monitor cuff inflation pressure and limit this according to
manufacturer's recommendations (usually <20 to 25 cmH2O).
spacer (e.g. salbutamol 2 10 puffs) or nebuliser (e.g.
salbutamol 2.5 5 mg (0.15 mg/kg)). Adjust doses to response
and repeat as needed (up to continuously in the first hour). The
effect of SABA begins within seconds and reaches a maximum
at 30 min (half- life 2 4 h). Add short-acting anticholinergics
(e.g. ipratropium bromide 0.25 0.5 mg) either nebulised or as
an inhaler with spacer.
332 RESUSCITATION 161 (2021) 327
Give systemic corticosteroids within the first hour, either oral or
intravenously (IV). Providers are advised to use the corticoid
they are most familiar with (e.g. prednisolone 1 2 mg/kg, with a
maximum of 60 mg/day).
Consider IV magnesium sulfate for severe and life-threatening
asthma. Give a single dose of 50 mg/kg over 20 min (max 2 g). In
children, isotonic magnesium sulfate might alternatively be
used as nebulised solution (2.5 ml of 250 mmol/l; 150 mg).
Inhaled SABA (and/or inhaled adrenaline) for bronchospasm.
Additional drugs can be considered by competent providers e.g.
IV or oral H1 and H2 antihistamines to alleviate subjective
IV ketamine, IV aminophylline etc. Providers should be aware
that IV SABA carry a significant risk of electrolyte disorders,
Glucocorticosteroids (e.g. methylprednisolone 1 2 mg/kg)
hyperlactatemia, and more importantly cardiovascular failure. If
used, the child should be monitored carefully.
Specific treatments related to the context.
Antibiotics are not recommended unless there is evidence of
bacterial infection.
There is no place for routine systemic or local adrenaline in
asthma, but anaphylaxis should be excluded as an
alternative diagnosis in all children with sudden onset of
symptoms.
If available, consider NIV or HFNC in children with status
asthmaticus needing oxygenation support beyond standard
FiO2 and/or not responding to initial treatment.
Management of anaphylaxis
 Early diagnosis of anaphylaxis is crucial and will guide further
treatment:
Acute onset of an illness (minutes to hours) with involvement of
the skin, mucosal tissue, or both and at least one of the
following:
a Respiratory compromise e.g. dyspnoea, wheeze-bron-
chospasm, stridor, reduced PEF, hypoxaemia
b Reduced blood pressure or associated symptoms of end-
organ dysfunction e.g. collapse, syncope
c Severe gastrointestinal symptoms, especially after expo-
sure to non-food allergens
OR
Acute onset (minutes to several hours) of hypotension or
bronchospasm or laryngeal involvement after exposure to a
known or probable allergen, even in the absence of typical skin
involvement.
 As soon as anaphylaxis is suspected, immediately administer
intramuscular (IM) adrenaline (anterolateral mid-thigh, not
subcutaneous). Provide further ABCDE care as needed: call for
help, airway support, oxygen therapy, ventilatory support,
venous access, repetitive fluid boluses and vasoactive drugs.
Early administration of IM adrenaline might also be considered
for milder allergic symptoms in children with a history of
anaphylaxis.
The dose for IM adrenaline is 0.01 mg/kg; this can be
administered by syringe (1 mg/ml solution) but in most settings
auto-injectable adrenaline will be the only form available
(0.15 mg (<6 y) 0.3 mg (6 12 y) 0.5 mg (>12 y)).
If symptoms do not improve rapidly, give a second dose of IM
adrenaline after 5 10 min.
In cases of refractory anaphylaxis competent physicians might
consider the use of IV or intraosseous (IO) adrenaline. Be
careful to avoid dosage errors.
 Prevent any further exposure to the triggering agent. In the case of
a bee sting, remove the sting as quickly as possible.
 Recognise cardiac arrest and start standard CPR when indicated.
387
Rescuers only having access to IM adrenaline might consider
giving this when cardiac arrest has just occurred.
 Consider early TI in case of respiratory compromise. Anticipate
airway oedema. Airway management in case of anaphylaxis
can be very complicated and early support by highly competent
physicians is mandatory.
 In addition to IM adrenaline, consider the use of:
symptoms (especially cutaneous symptoms).
only for children needing prolonged observation.
 After treatment, further observe for potential late or biphasic
symptoms. Those children who responded well to one dose of
IM adrenaline without any other risk factor can generally be
discharged after 4 8 h. Prolonged observation (12 24 h) is
advised for children with a history of biphasic or protracted
anaphylaxis or asthma, those who needed more than one dose
of IM adrenaline or had a delay between symptoms and first
adrenaline dose of more than 60 min.
 Efforts should be made to identify the potential trigger. Without
delaying treatment, take blood samples for mast cell tryptase
upon arrival and ideally 1 2 h later. Refer patients to a
dedicated healthcare professional for follow-up. Every child
who had an anaphylactic reaction should have auto-injectable
adrenaline prescribed and receive instructions how to use it
(both the child, if feasible, and their caregivers).
Management of circulatory failure [C]
 Healthcare systems should implement context-specific protocols
for the management of children with shock including strategies for
early recognition and timely emergency treatment.
 The management of a child in circulatory failure needs to be
tailored to the individual, considering aetiology, pathophysiology,
age, context, comorbidities, and available resources. The
transition from a compensated state to decompensation may be
rapid and unpredictable. No single finding can reliably identify the
severity of the circulatory failure and/or be used as a goal for
treatment. Reassess frequently and at least after every interven-
tion. Consider among others clinical signs, MAP, trends in lactate,
urine output and if competent, ultrasound findings. Competent
physicians might also measure advanced haemodynamic varia-
bles such as cardiac index, systemic vascular resistance, and
central venous oxygen saturation (ScvO2), but this is not a priority
in the first hour of care.
 The management of a child in circulatory failure, in accordance
with the ABCDE approach, should always include proper
management of airway, oxygenation and ventilation.
 Vascular Access:
 Peripheral IV lines are the first choice for vascular access.
Competent providers might use ultrasound to guide cannula-
tion. In case of an emergency, limit the time for placement to
5 min (2 attempts) at most. Use rescue alternatives earlier when
the chances of success are considered minimal.
 For infants and children, the primary rescue alternative is
intraosseous (IO) access. All paediatric advanced life
support (ALS) providers should be competent in IO placement
and have regular retraining in the different devices (and
puncture sites) used in their setting. Provide proper analgesia
 RESUSCITATION 161 (2021) 327
-in every child unless comatose. Use a properly sized needle.
Most standard pumps will not infuse via IO, so use either
manual infusion or a high- pressure bag. Confirm proper
placement and monitor for extravasation which can lead to
compartment syndrome.
 Fluid therapy:
 Give one or more early fluid bolus(es) of 10 ml/kg in children
with recognised shock. Repeated fluid boluses -up to 40 60 ml/
kg- might be needed in the first hour of treatment of (septic)
shock.
 Reassess after each bolus and avoid repeated boluses in
children who cease to show signs of decreased perfusion or show
signs of fluid overload or cardiac failure. Combine clinical signs
with biochemical values and if possible, imaging such as cardiac
and lung ultrasound to assess the need for additional boluses. In
case of repeated fluid boluses, consider vasoactive drugs and
respiratory support early on. In settings where intensive care is
not available, it seems prudent to be even more restrictive.
 Use balanced crystalloids as first choice of fluid bolus, if
available. If not, normal saline is an acceptable alternative.
Consider albumin as second-line fluid for children with sepsis,
especially in the case of malaria or dengue fever. In non-
haemorrhagic shock, blood products are only needed when
blood values fall below an acceptable minimum value.
 Give rapid fluid boluses in children with hypovolemic non-
haemorrhagic shock. Otherwise, fluid resuscitation of severe-
ly dehydrated children can generally be done more gradually
(up to e.g. 100 ml/kg over 8 h).
 In cases of haemorrhagic shock, keep crystalloid boluses to a
minimum (max. 20 ml/kg). Consider early blood products -or if
available, full blood- in children with severe trauma and
circulatory failure, using a strategy that focuses on improving
coagulation (using at least as much plasma as RBC and
considering platelets, fibrinogen, other coagulation factors).
Avoid fluid overload but try to provide adequate tissue perfusion
awaiting definitive damage control and/or spontaneous haemo-
stasis. Permissive hypotension (MAP at 5th percentile for age)
can only be considered in children when there is no risk of
associated brain injury.
 Give tranexamic acid (TxA) in all children requiring transfusion
after severe trauma -as soon as possible, within the first 3 h after
injury- and/or life-threatening haemorrhage. Consider TxA in
children with isolated moderate TBI (GCS 9 13) without
pupillary abnormalities. Use a loading dose at 15 20 mg/kg
(max. 1 g), followed by an infusion of 2 mg/kg/h for at least 8 h or
until the bleeding stops (max. 1 g).
 Vasoactive/Inotropic drugs:
 Start vasoactive drugs early, as a continuous infusion (diluted
as per local protocol) via either a central or peripheral line, in
children with circulatory failure when there is no improvement
of the clinical state after multiple fluid boluses. Attention
should be given to proper dilution, dosing and infusion
management. Preferably use a dedicated line with proper
flow, avoiding inadvertent boluses or sudden dose changes.
Titrate these drugs based on a desired target MAP, which may
differ with pathology, age and patient response; in an ICU
setting other haemodynamic variables may also be taken into
account.
 Use either noradrenaline or adrenaline as first-line inoconstric-
tors and dobutamine or milrinone as first-line inodilators.
387 333
Dopamine should be considered only in settings where neither
adrenaline nor noradrenaline are available. All paediatric ALS
providers should be competent in the use of these drugs during
the first hour of stabilisation of a child in circulatory failure.
 Also use vasoactive drugs in cases of hypovolemic shock, when
fluid-refractory -especially when there is loss of sympathetic
drive such as during anaesthesia-, as well as for children with
hypovolemic shock and concomitant TBI. A sufficiently high
MAP is needed to attain an adequate cerebral perfusion
pressure (e.g. MAP above 50th percentile). Evaluate and, if
necessary, support cardiac function.
 Additional therapies in septic shock:
 Consider a first dose of stress-dose hydrocortisone (1 2 mg/
kg) in children with septic shock, unresponsive to fluids and
vasoactive support, regardless of any biochemical or other
parameters.
 Give stress-dose hydrocortisone in children with septic shock who
also have acute or chronic corticosteroid exposure, hypothalamic-
pituitary-adrenal axis disorders, congenital adrenal hyperplasia, or
other corticosteroid- related endocrinopathies, or have recently
been treated with ketoconazole or etomidate.
 Start broad-spectrum antibiotics as soon as possible after initial
ABCD management. Preferably, this is within the first hour of
treatment. Obtain blood cultures (or blood samples for PCR)
before starting, if this can be done without delaying therapy.
 Obstructive shock in children:
 Tension pneumothorax requires immediate treatment by either
emergency thoracostomy or needle thoracocentesis. Use
ultrasound to confirm the diagnosis if this does not delay
treatment. For both techniques, use the 4th or 5th intercostal
space (ICS) slightly anterior to the midaxillary line as the primary
site of entry. In children, the 2nd ICS midclavicular remains an
acceptable alternative. Convert to standard chest tube drainage
as soon as practically feasible.
 Systems that do not implement immediate thoracostomy should
at least consider thoracostomy as a rescue option in paediatric
severe trauma and train their providers accordingly.
 If available, use ultrasound to diagnose pericardial tamponade.
Tamponade leading to obstructive shock demands immediate
decompression by pericardiocentesis, thoracotomy or (re)
sternotomy according to circumstances and available exper-
tise. Depending on their context, systems should have protocols
in place for this.
 Unstable primary bradycardia:
 Consider atropine (20 mcg/kg; max. 0.5 mg per dose) only in
bradycardia caused by increased vagal tone.
 Consider emergency transthoracic pacing in selected cases
with circulatory failure due to bradycardia caused by complete
heart block or abnormal function of the sinus node. Early expert
help is mandatory.
 Unstable primary tachycardia:
 In children with decompensated circulatory failure due to either
supraventricular (SVT) or ventricular tachycardia (VT), the first
choice for treatment is immediate synchronised electrical
cardioversion at a starting energy of 1 J/kg body weight. Double
the energy for each subsequent attempt up to a maximum of 4 J/
kg. If possible, this should be guided by expert help. For children
who are not yet unconscious, use adequate analgosedation
according to local protocol. Check for signs of life after each
attempt.
334 RESUSCITATION 161 (2021) 327
 In children with a presumed SVT who are not yet decom-
pensated, providers can try vagal manoeuvres (e.g. ice
application, modified Valsalva techniques). If this has no
immediate effect, proceed with IV adenosine. Give a rapid
bolus of 0.1 0.2 mg/kg (max 6 mg) with immediate saline flush
via a large vein; ensure a rhythm strip is running for later expert
evaluation. Especially in younger children, higher initial doses
are preferable. In case of persistent SVT, repeat adenosine
after at least 1 min at a higher dose (0.3 mg/kg, max 12 18 mg).
Be cautious with adenosine in children with known sinus node
disease, pre-excited atrial arrhythmias, heart transplant or
severe asthma. In such cases, or when there is no prolonged
effect of adenosine, competent providers (with expert consul-
tation) might give alternative medications.
 Wide QRS tachycardias can be either VT or SVT with bundle
branch block aberration, or antegrade conduction through an
additional pathway. In case the mechanism of the arrhythmia is
not fully understood, wide QRS arrhythmia should be treated as
VT. In a child who is haemodynamically stable, the response to
vagal manoeuvres may provide insight into the mechanism
responsible for the arrhythmia and competent providers (with
expert help) can subsequently try pharmacological treatment.
Even in stable patients, electrical cardioversion should always
be considered. In case of Torsade de pointes VT, IV magnesium
sulfate 50 mg/kg is indicated.
Management of ‘neurological’ and other medical
emergencies [D] [E]
Recognise and treat neurological emergencies quickly, because
prognosis is worsened by secondary injury (due to e.g. hypoxia,
hypotension) and treatment delays. In accordance with the ABCDE
approach, such treatment includes proper management of airway,
oxygenation and ventilation, and circulation.
Status epilepticus
 Identify and manage underlying diagnoses and precipitant causes
including hypoglycaemia, electrolyte disorders, intoxications,
brain infections and neurological diseases, as well as systemic
complications such as airway obstruction, hypoxaemia or shock.
 If convulsions persist for more than 5 min, give a first dose of a
benzodiazepine. Immediate treatment should be considered in
specific situations. Which benzodiazepine via which route to give will
depend on the availability, context, social preference, and expertise of
the providers. Non-IV benzodiazepines should be used if an IV line is
not (yet) available. Adequate dosing is essential, we suggest:
 IM midazolam 0.2 mg/kg (max 10 mg) or prefilled syringes: 5 mg
for 13 40 kg, 10 mg > 40 kg); intranasal/buccal 0.3 mg/kg; IV
0.15 mg/kg (max 7.5 mg)
 IV lorazepam 0.1 mg/kg (max 4 mg)
 IV diazepam 0.2 0.25 mg/kg (max 10 mg)/rectal 0.5 mg/kg
(max 20 mg)
 If convulsions persist after another 5 min, administer a second
dose of benzodiazepine and prepare a long-acting second line
drug for administration. Seek expert help.
 Not later than 20 min after convulsions started, give second line
anti-epileptic drugs. The choice of drug will again depend on
context, availability, and expertise of the provider. Adequate
dosing is again essential:
 Levetiracetam 40 60 mg/kg IV (recent papers suggest the
higher dose; max. 4.5 g, over 15’)
387
 Phenytoin 20 mg/kg IV (max. 1.5 g, over 20 min; or alternatively
phosphenytoin)
 Valproic acid 40 mg/kg IV (max 3 g; over 15 min; avoid in cases
of presumed hepatic failure or metabolic diseases which can
never be ruled out in infants and younger children-, as well as in
pregnant teenagers).
 Phenobarbital (20 mg/kg over 20 min) IV is a reasonable
second-line alternative if none of the three recommended
therapies are available.
 If convulsions continue, consider an additional second-line drug
after the first second-line drug has been given.
 Not later than 40 min after convulsions started, consider anaesthetic
doses (given by a competent provider) of either midazolam,
ketamine, pentobarbital/thiopental, or propofol; preferably under
continuous EEG monitoring. Prepare for adequate support of
oxygenation, ventilation and perfusion as needed.
 Non-convulsive status epilepticus can continue after clinical
convulsions cease; all children who do not completely regain
consciousness need EEG monitoring and appropriate treatment.
Hypoglycaemia
 Recognise hypoglycaemia using context, clinical signs, and
measurement (50 70 mg/dl; 2.8 3.9 mmol/L), and promptly treat
this. Also identify and treat any underlying cause. Specific dosage
of IV glucose maintenance might be indicated in specific metabolic
diseases.
 Mild asymptomatic hypoglycaemia may be treated with standard
glucose administration, either by maintenance infusion glucose (6
8 mg/kg/min) or by oral rapid acting glucose (0.3 g/kg tablets or
equivalent), followed by additional carbohydrate intake to prevent
recurrence.
 Severe paediatric hypoglycaemia (<50 mg/dl (2.8 mmol/L) with
neuroglycopenic symptoms) demands:
 IV glucose 0.3 g/kg bolus; preferably as 10% (100 mg/ml; 3 ml/
kg) or 20%-solution (200 mg/ml; 1.5 ml/kg)
 When IV glucose is not available, providers may administer
glucagon as temporary rescue, either IM or SC (0.03 mg/kg or
1 mg >25 kg; 0.5 mg <25 kg) or intranasally (3 mg; 4 16 y).
 Retest blood glucose 10 min after treatment and repeat
treatment if the response is inadequate. Reasonable targets
are an increase of at least 50 mg/dl (2.8 mmol/L) and/or a target
glycaemia of 100 mg/dL (5.6 mmol/L).
 Start a glucose maintenance infusion (6 8 mg/kg/min) to
reverse catabolism and maintain adequate glycaemia.
Hypokalaemia
 For severe hypokalaemia (<2.5 mmol/L) in a pre-arrest state, give
IV boluses of 1 mmol/kg (max 30 mmol) over at least 20 min to a
monitored child and repeat until the serum potassium is above
2.5 mmol/L avoiding inadvertent hyperkalaemia. Also give IV
magnesium sulfate 30 50 mg/kg.
 In all other cases, enteral potassium is preferred for those who
tolerate enteral supplementation. The eventual dose should
depend on the clinical presentation, the value measured and the
expected degree of depletion.
Hyperkalaemia
 To evaluate the severity of hyperkalaemia, consider the potassium
value in the context of the underlying cause and contributing
factors, and the presence of potassium-related ECG changes.
 RESUSCITATION 161 (2021) 327
Eliminate or treat underlying causes and contributing factors as
soon as possible.
 Tailor emergency treatment to the individual child. Consider early
expert help. In children with acute symptomatic life- threatening
hyperkalaemia give:
 Calcium (e.g. calcium gluconate 10% 0.5 ml/kg max 20 ml) for
membrane stabilisation. This works within minutes and the
effect lasts 30 60 min.
 Fast-acting insulin with glucose to redistribute potassium, which
is effective after about 15 min, peaks at 30 60 min and lasts 4
6 h (e.g. 0.1 U/kg insulin in a 1 IU insulin in 25 ml glucose 20%
solution; there is no need for initial glucose when the initial
glycaemia is >250 mg/dl (13.9 mmol/L)). Repeated dosing
might be necessary. To avoid hypoglycaemia, once hyper-
kalaemia is treated, continue with a glucose maintenance
infusion without insulin. Monitor blood glucose levels.
 Nebulised beta-agonists at high dose (e.g. 5 times the
bronchodilation dose), however be aware that the maximal
effect is reached only after 90 min.
 Sodium bicarbonate 1 mmol/kg IV (repeat as necessary) in case
of a metabolic acidosis (pH < 7.2) and/or in cardiac arrest. The
effect of sodium bicarbonate is slow (hours).
 Continue potassium redistribution measures until potassium
removal treatments become effective. Potassium removal can
be done by potassium binding agents, furosemide (in well-
hydrated children with preserved kidney function) and/or dialysis.
Hyperthermia
 In cases of heat stroke (i.e. a central body temperature  40
40.5  C with central nervous system (CNS) dysfunction):
 Monitor central body temperature as soon as possible (rectal,
oesophageal, bladder, intravascular).
 Prehospital treatment consists of full ABCDE management and
rapid aggressive cooling. Remove the child from the heat
source. Undress and fan with cold air and mist. Apply ice packs.
Provide early evaporative external cooling. Consider cold-water
immersion for adolescents and young adults.
 Further cooling in hospital can be done by placing the child
on a cooling blanket; applying ice packs to the neck,
axilla and groin or alternatively on the smooth skin surfaces
of the cheeks, palms, and soles; and infusion of IV
crystalloids at room temperature. Stop cooling measures
once the core temperature reaches 38  C. Benzodiazepines
are suggested to avoid trembling, shivering or seizures
during cooling measures. Classic antipyretic medications
are ineffective.
 All children with heat stroke should be admitted to a (paediatric)
intensive care unit to maintain adequate monitoring and to treat
associated organ dysfunction.
Paediatric basic life support
The sequence of actions in paediatric BLS (PBLS) support will
depend upon the level of training of the rescuer attending: those
fully competent in PBLS (preferred algorithm), those trained only in
adult BLS and those untrained (dispatcher- assisted lay rescuers).
Sequence of actions in PBLS
 Ensure safety of rescuer and child. Check for responsiveness to
verbal and tactile stimulation (Fig. 2). Ask bystanders to help.
387 335
 If the child does not respond, open the airway, and assess
breathing for no longer than 10 s.
 If you have difficulty opening the airway with head tilt chin lift
or specifically in cases of trauma, use a jaw thrust. If needed,
add head tilt a small amount at a time until the airway is open.
 In the first few minutes after a cardiac arrest a child may be
taking slow infrequent gasps. If you have any doubt whether
breathing is normal, act as if it is not normal.
 Look for respiratory effort, listen and feel for movement of air
from the nose and/or mouth. If there is effort but no air
movement, the airway is not open.
 In cases where there is more than one rescuer, a second
rescuer should call the EMS immediately upon recognition of
unconsciousness, preferably using the speaker function of a
mobile phone.
 In the unresponsive child, if breathing is absent or abnormal: give
five initial rescue breaths.
 For infants, ensure a neutral position of the head. In older
children, more extension of the head will be needed (head tilt).
 Blow steadily into the child's mouth (or infant's mouth and nose)
for about 1 second, sufficient to make the chest visibly rise.
 If you have difficulty achieving an effective breath, the airway
may be obstructed (see below): remove any visible obstruction.
Do not perform a blind finger sweep. Reposition the head or
adjust airway opening method. Make up to five attempts to
achieve effective breaths, if still unsuccessful, move on to chest
compressions.
 Competent providers should use BMV with oxygen, when
available, instead of expired air ventilation. In larger children
when BMV is not available, competent providers can also use a
pocket mask for rescue breaths.
 If there is only one rescuer, with a mobile phone, he or she
should call help first (and activate the speaker function)
immediately after the initial rescue breaths. Proceed to the
next step while waiting for an answer. If no phone is readily
available perform 1 min of CPR before leaving the child.
 In cases where PBLS providers are unable or unwilling to start
with ventilations, they should proceed with compressions and
add into the sequence ventilations as soon as these can be
performed.
 Immediately proceed with 15 chest compressions, unless there
are clear signs of circulation (such as movement, coughing).
Rather than looking at each factor independently, focus on
consistent good quality compressions as defined by:
 Rate: 100 120 min 1 for both infants and children.
 Depth: depress the lower half of the sternum by at least one third
of the anterior posterior dimension of the chest. Compressions
should never be deeper than the adult 6 cm limit (approx. an
adult thumb's length).
 Recoil: Avoid leaning. Release all pressure between compres-
sions and allow for complete chest recoil.
When possible, perform compressions on a firm surface. Move the
child only if this results in markedly better CPR conditions (surface,
accessibility). Remove clothes only if they severely hinder chest
compressions.
Preferably use a two-thumb encircling technique for chest
compression in infants be careful to avoid incomplete recoil. Single
rescuers might alternatively use a two-finger technique.
336 RESUSCITATION 161 (2021) 327 387

Fig. 2 – Paediatric basic life support.

In children older than 1 year, depending on size and hand span,
use either a one-hand or two-hand technique. In case the one-hand
technique is used, the other hand can be positioned to maintain an
open airway throughout (or to stabilise the compression arm at the
elbow).
 After 15 compressions, 2 rescue breaths should follow and then
alternating (15:2 duty cycle). Do not interrupt CPR at any moment
unless there are clear signs of circulation (movement, coughing)
or when exhausted. Two or more rescuers should change the
rescuer performing chest compressions frequently and the
individual rescuer should switch hands (the hand compressing,
the hand on top) or technique (one to 2-handed) to avoid fatigue.
 In case there are clear signs of life, but the child remains
unconscious but not breathing normally, continue to support
ventilation at a rate appropriate for age.
Rescuers only trained in adult BLS
BLS providers who are untrained in PBLS, should follow the adult
CPR algorithm with ventilations, as they were trained, adapting the
techniques to the size of the child. If trained, they should consider
 RESUSCITATION 161 (2021) 327
giving 5 initial rescue breaths before proceeding with
compressions.
Untrained lay rescuers
 Cardiac arrest is determined to have occurred based on the
combination of being unresponsive and absent or abnormal
breathing. As the latter is often difficult to identify or when there are
concerns about safety (e.g. risk of viral transmission), rather than
look-listen-feel, bystanders might also be guided by specific word
descriptors or by feeling for respiratory movement.
 Bystander CPR should be started in all cases when feasible. The
EMS dispatcher has a crucial role in assisting lay untrained
bystanders to recognise CA and provide CPR. When bystander
CPR is already in progress at the time of the call, dispatchers
should probably only provide instructions when asked for or when
issues with knowledge or skills are identified.
 The steps of the algorithm for paediatric dispatcher-assisted CPR
are very similar to the PBLS algorithm. To decrease the number of
switches, a 30:2 duty cycle might be preferable. If bystanders
cannot provide rescue breaths, they should proceed with chest
compressions only.
Use of an automated external defibrillator (AED)
 In children with a CA, a lone rescuer should immediately start CPR
as described above. In cases where the likelihood of a primary
shockable rhythm is very high such as in sudden witnessed
collapse, if directly accessible, he or she can rapidly collect and
apply an AED (at the time of calling EMS). In case there is more
than one rescuer, a second rescuer will immediately call for help
and then collect and apply an AED (if feasible).
 Trained providers should limit the no-flow time when using an AED
by restarting CPR immediately after the shock delivery or no shock
decision; pads should be applied with minimal or no interruption in
CPR.
 If possible, use an AED with a paediatric attenuator in infants and
children below 8 years. If such is not available, use a standard AED
for all ages.
PBLS in case of traumatic cardiac arrest (TCA)
 Perform bystander CPR when confronted with a child in CA after
trauma, provided it is safe to do so. Try to minimise spinal
movement as far as possible during CPR without hampering the
process of resuscitation, which clearly has priority.
 Do not routinely apply an AED at the scene of paediatric TCA
unless there is a high likelihood of shockable underlying rhythm
such as after electrocution.
 Apply direct pressure to stop massive external haemorrhage if
possible, using haemostatic dressings. Use a tourniquet (prefera-
bly manufactured but otherwise improvised) in case of an
uncontrollable, life- threatening external bleeding.
Recovery position
 Unconscious children who are not in CA and clearly have normal
breathing, can have their airway kept open by either continued
head tilt chin lift or jaw thrust or, especially when there is a
perceived risk of vomiting, by positioning the unconscious child in
a recovery position.
 Once in recovery position, reassess breathing every minute to
recognise CA as soon as it occurs (lay rescuers might need
Non-shockable rhythms are pulseless electrical activity (PEA),
dispatcher guidance to do so).
387 337
 Avoid any pressure on the child's chest that may impair breathing
and regularly change side to avoid pressure points (i.e. every
30 min).
 In unconscious trauma victims, open the airway using a jaw thrust,
taking care to avoid spinal rotation.
Paediatric foreign body airway obstruction (FBAO)
 Suspect FBAO -if unwitnessed- when the onset of respiratory
symptoms (coughing, gagging, stridor, distress) is very sudden
and there are no other signs of illness; a history of eating or playing
with small items immediately before the onset of symptoms might
further alert the rescuer.
 As long as the child is coughing effectively (fully responsive,
loud cough, taking a breath before coughing, still crying, or
speaking), no manoeuvre is necessary. Encourage the
child to cough and continue monitoring the child's condition
(Fig. 3).
 If the child's coughing is (becoming) ineffective (decreasing
consciousness, quiet cough, inability to breathe or vocalise,
cyanosis), ask for bystander help and determine the child's
conscious level. A second rescuer should call EMS, preferably by
mobile phone (speaker function). A single trained rescuer should
first proceed with rescue manoeuvres (unless able to call
simultaneously with the speaker function activated).
 If the child is still conscious but has ineffective coughing, give back
blows. If back blows do not relieve the FBAO, give chest thrusts to
infants or abdominal thrusts to children. If the foreign body has not
been expelled and the victim is still conscious, continue the
sequence of back blows and chest (for infant) or abdominal (for
children) thrusts. Do not leave the child.
 The aim is to relieve the obstruction with each thrust rather than to
give many of them.
 If the object is expelled successfully, assess the child's clinical
condition. It is possible that part of the object may remain in the
respiratory tract and cause complications. If there is any doubt or if
the victim was treated with abdominal thrusts, urgent medical
follow up is mandatory.
 If the child with FBAO is, or becomes, unconscious, continue
according to the paediatric BLS algorithm. Competent providers
should consider the use of Magill forceps to remove a foreign body.
Paediatric advanced life support
Sequence of actions in PALS
Although the sequence of actions is presented stepwise, ALS is a
team activity, and several interventions will be done in parallel. ALS
teams should not only train in knowledge and skills but also in
teamwork and the ‘choreography’ of ALS interventions (Fig. 4).
 Commence and/or continue with paediatric BLS. Recognition of
CA can be done on clinical grounds or based on monitored vital
signs (ECG, loss of SpO2 and/or ETCO2, loss of blood pressure
etc.). Importantly, also start CPR in children who become
bradycardic with signs of very low perfusion despite adequate
respiratory support.
 If not already in place, apply cardiac monitoring as soon as
possible using ECG-electrodes or self-adhesive defibrillator pads
(or defibrillation paddles). Differentiate between shockable and
non-shockable cardiac rhythms.
bradycardia and asystole. If bradycardia (<60 per minute) is the
338 RESUSCITATION 161 (2021) 327
Fig. 3 – Foreign body airway obstruction.
result of hypoxia or ischaemia, CPR is needed even if there is
Change the person doing compressions at least every 2 min.
still a detectable pulse. Therefore, providers should rather
assess signs of life and not lose time by checking for a pulse. In
the absence of signs of life, continue to provide high- quality
CPR should be continued unless:
CPR. Obtain vascular access and give adrenaline IV (10 mcg/
kg, max 1 mg) as soon as possible. Flush afterwards to facilitate
drug delivery. Repeat adrenaline every 3 5 min. In cases
where it is likely to be difficult to obtain IV access, immediately
go for IO access.
Shockable rhythms are pulseless ventricular tachycardia
(pVT) and ventricular fibrillation (VF). As soon identified,
defibrillation should immediately be attempted (regardless of
the ECG amplitude). If in doubt, consider the rhythm to be
shockable.
If using self-adhesive pads, continue chest compressions while
the defibrillator is charging. Once charged, pause chest
compressions, and ensure all rescuers are clear of the child.
Minimise the delay between stopping chest compressions and
delivery of the shock (<5 s). Give one shock (4 J/kg) and
immediately resume CPR. Reassess the cardiac rhythm every
2 min (after the last shock) and give another shock (4 J/kg) if a
shockable rhythm persists. Immediately after the third shock,
give adrenaline (10 mcg/kg, max 1 mg) and amiodarone (5 mg/
kg, max 300 mg) IV/IO. Flush after each drug. Lidocaine IV (1 mg/
kg) might be used as an alternative to amiodarone by providers
competent in its use. Give a second dose of adrenaline (10 mcg/
kg, max 1 mg) and amiodarone (5 mg/kg, max 150 mg) after the
5th shock if the child still has a shockable rhythm. Once given,
adrenaline should be repeated every 3 5 min.
387
Watch for fatigue and/or suboptimal compressions and switch
rescuers earlier if necessary.
& An organised potentially perfusing rhythm is recognised (upon
rhythm check) and accompanied by signs of return of
spontaneous circulation (ROSC), identified clinically (eye
opening, movement, normal breathing) and/or by monitoring
(etCO2, SpO2, blood pressure, ultrasound)
& There are criteria for withdrawing resuscitation (see the ERC
guideline chapter on ethics).
Defibrillation during paediatric ALS
Manual defibrillation is the recommended method for ALS, but if this is
not immediately available an AED can be used as alternative.
 Use 4 J/kg as the standard energy dose for shocks. It seems
reasonable not to use doses above those suggested for adults
(120 200 J, depending on the type of defibrillator). Consider
escalating doses -stepwise increasing up to 8 J/Kg and max.
360 J- for refractory VF/pVT (i.e. more than 5 shocks needed).
 Defibrillation via self-adhesive pads has become the standard. If
unavailable, the use of paddles (with preformed gel pads) is still
considered an acceptable alternative yet demands specific
alterations to the choreography of defibrillation. Charging should
then be done on the chest directly, already pausing compressions
at that stage. Good planning before each action will minimise
hands-off time.
Pads should be positioned either in the antero-lateral (AL) or the
antero- posterior (AP) position. Avoid contact between pads as this will
 RESUSCITATION 161 (2021) 327 387 339

Fig. 4 – Paediatric advanced life support.

340 RESUSCITATION 161 (2021) 327
create charge arcing. In the AL position, one pad is placed below the
right clavicle and the other in the left axilla. In the AP position the
anterior pad is placed mid-chest immediately left to the sternum and
the posterior in the middle of the back between the scapulae.
Oxygenation and ventilation during paediatric ALS
 Oxygenate and ventilate with BMV, using a high concentration of
inspired oxygen (100%). Do not titrate FiO2 during CPR.
 Consider insertion of an advanced airway (TT, SGA) in cases
where CPR during transport or prolonged resuscitation is
anticipated and a competent provider is present. Where it is
impossible to ventilate by BMV, consider the early use of an
advanced airway or rescue technique. Use ETCO2 monitoring
when an advanced airway is in place.
 Always avoid hyperventilation (due to excessive rate and/or
TV). However, also take care to ensure that lung inflation is
adequate during chest compressions. TV can be estimated by
looking at chest expansion.
 In cases of CPR with positive pressure ventilation via a TT,
ventilations can be asynchronous and chest compressions
continuous (only pausing every 2 min for rhythm check). In this
case, ventilations should approximate to the lower limit of normal
rate for age e.g. breaths/min: 25 (infants), 20 (>1 y), 15 (>8 y), 10
(>12 y).
 For children already on a mechanical ventilator, either disconnect
the ventilator and ventilate by means of a self-inflating bag or
continue to ventilate with the mechanical ventilator. In the latter
case, ensure that the ventilator is in a volume-controlled mode,
that triggers and limits are disabled, and ventilation rate, TV and
FiO2 are appropriate for CPR. There is no evidence to support any
specific level of PEEP during CPR. Ventilator dysfunction can itself
be a cause of cardiac arrest.
 Once there is sustained ROSC, titrate FiO2 to an SpO2 of
94 98%. Competent providers should insert an advanced airway,
if not already present, in children who do not regain consciousness
or for other clinical indications.
Measurable factors during ALS
 Capnography is mandatory for the monitoring of TT position. It
however does not permit identification of selective bronchial
intubation. When in place during CPR, it can help to rapidly detect
ROSC. ETCO2 values should not be used as quality indicator or
target during paediatric ALS, nor as an indication for or against
continuing CPR.
 Invasive blood pressure should only be considered as a target
during paediatric ALS by competent providers for children with in-
hospital CA [IHCA] where an arterial line is already in place. Blood
pressure values should not be used to predict outcome.
 Point of care ultrasound can be used by competent providers to
identify reversible causes of CA. Its use should not increase
hands-off time or impact quality of CPR. Image acquisition is best
done during pauses for rhythm check and/or for ventilations; the
team should plan and anticipate (choreography) to make the most
of the available seconds for imaging.
 Point of care serum values (of e.g. potassium, lactate, glucose,
. . . ) can be used to identify reversible causes of cardiac arrest but
should not be used for prognostication. Providers should be aware
that the measured values may differ significantly, depending on
the measurement technique and sampling site.
387
Special circumstances reversible causes
 The early identification and proper treatment of any reversible
cause during CPR is a priority for all ALS providers. Use the
mnemonic “4H4T” to remember what to actively look for: Hypoxia;
Hypovolemia; Hypo- or hyperkalaemia/-calcaemia/-magnesemia &
hypoglycaemia; Hypo- or Hyperthermia; Tension pneumothorax;
Tamponade; Thrombosis (Cardiac Pulmonary); Toxic Agents.
 Unless otherwise specified, the specific treatment for each of
these causes is the same in CA as in acute life-threatening disease
(see above and the dedicated chapter on special circumstances
within these guidelines).
 Providers should consider (as per protocol and if possible, with
expert help) specific treatments for intoxications with high-risk
medications (e.g. beta-blockers, tricyclic antidepressants, calcium
channel blockers, digitalis, or insulin). For certain life-threatening
intoxications extracorporeal treatments should be considered
early on and these patients should be transferred to a centre that
can perform these in children, ideally before cardiovascular or
neurological failure occurs (based upon the context of the
intoxication rather than the actual symptoms).
 Specific conditions such as cardiac surgery, neurosurgery,
trauma, drowning, sepsis, pulmonary hypertension also demand
a specific approach. Importantly, the more widespread use of
extracorporeal life support/CPR (ECLS/eCPR) has thoroughly
redefined the whole concept of ‘reversibility’.
 Institutions performing cardiothoracic surgery in children should
establish institution-specific algorithms for cardiac arrest after
cardiothoracic surgery.
 Standard ALS may be ineffective for children with CA and
pulmonary hypertension (PHT). Actively search for reversible
causes of increased pulmonary vascular resistance such as
cessation of medication, hypercarbia, hypoxia, arrhythmias,
cardiac tamponade, or drug toxicity. Consider specific treat-
ments like pulmonary vasodilators.
Traumatic cardiac arrest (TCA)
 In case of TCA, start standard CPR while searching for and
treating any of the reversible causes of paediatric TCA:
 airway opening and ventilation with oxygen
 external haemorrhage control including the use of tourniquets in
exsanguinating injury to the extremities
 bilateral finger or tube thoracostomy (or needle thoracocentesis)
 IO/IV access and fluid resuscitation (if possible, with full blood or
blood products), as well as the use of the pelvic binder in blunt
trauma.
 Chest compressions are performed simultaneously with these
interventions depending on the available personnel and proce-
dures. Based on the mechanism of injury, correction of reversible
causes might precede adrenaline administration.
 Consider emergency department (ED) thoracotomy in paediatric
TCA patients with penetrating trauma with or without signs of life
on ED arrival. In some EMS systems, highly competent
professionals might also consider pre-hospital thoracotomy for
these patients (or for children with selected blunt injury).
Hypothermic arrest
 Adapt standard paediatric ALS actions for hypothermia (see also the
chapter on special circumstances). Start standard CPR for all victims
in CA. If continuous CPR is not possible and the child is deeply
hypothermic (<28  C), consider delayed or intermittent CPR.
 RESUSCITATION 161 (2021) 327
 Any child who is considered to have any chance of a favourable
outcome should ideally be transported as soon as possible to a
(paediatric) reference centre with ECLS or cardiopulmonary
bypass capacity.
Extracorporeal life support
 E-CPR should be considered early for children with ED or IHCA
and a (presumed) reversible cause when conventional ALS does
not promptly lead to ROSC, in a healthcare context where
expertise, resources and sustainable systems are available to
rapidly initiate ECLS.
 For specific subgroups of children with decompensated cardiore-
spiratory failure (e.g. severe refractory septic shock or cardiomy-
opathy or myocarditis and refractory low cardiac output), pre-
arrest use of ECLS can be beneficial to provide end-organ support
and prevent cardiac arrest. IHCA shortly prior to or during
cannulation should not preclude ECLS initiation.
 Competent providers might also decide to perform E-CPR for
OHCA in cases of deep hypothermic arrest or when cannulation
can be done prehospitally by a highly trained team, within a
dedicated healthcare system.
Post-resuscitation care
The eventual outcome of children following ROSC depends on
many factors, some of which may be amenable to treatment.
Secondary injury to vital organs might be caused by ongoing
cardiovascular failure from the precipitating pathology, post-
ROSC myocardial dysfunction, reperfusion injury, or ongoing
hypoxaemia.
 Haemodynamic: Avoid post-ROSC hypotension (i.e. MAP <5th
percentile for age). Aim for a blood pressure at or above the p50,
taking into account the clinical signs, serum lactate and/or
measures of cardiac output. Use the minimum necessary doses of
parenteral fluids and vasoactive drugs to achieve this. Monitor all
interventions and adjust continuously to the child's physiological
responses.
 Ventilation: Provide a normal ventilatory rate and volume for the
child's age, to achieve a normal PaCO2. Try to avoid both
hypocarbia and hypercarbia. In a few children the usual values for
PaCO2 and PaO2 may deviate from the population normal values
for age (e.g. in children with chronic lung disease or congenital
heart conditions); aim to restore values to that child's normal
levels. Do not use ETCO2 as a surrogate for PaCO2 when aiming
for normocapnia as part of neuroprotective care unless there is a
proven correlation.
 Oxygenation: Titrate FiO2 to achieve normoxaemia or, if arterial
blood gas is not available, maintain SpO2 in the range of 94 98%.
Maintain high FiO2 in presumed carbon monoxide poisoning or
severe anaemia.
 Use targeted temperature management TTM: Avoid fever
( 37.5 ), maintain a specific set temperature, by means of, for
instance, external cooling. Lower target temperatures (e.g. 34  C)
demand appropriate systems of paediatric critical care and should
only be used in settings with the necessary expertise. Alternative-
ly, the attending team can aim for higher target temperature, e.g.
36  C.
 Glucose control: monitor blood glucose and avoid both hypo-
and hyperglycaemia. Be aware that tight glucose control may be
harmful, due to a risk of inadvertent hypoglycaemia.
387 341
Although several factors are associated with outcome after cardio-
pulmonary arrest, no single factor can be used in isolation for
prognostication. Providers should use multiple variables in the pre-,
intra-, and post-CA phases in an integrated way, including biological
markers and neuroimaging.
Evidence informing the guidelines
The context of the regional healthcare system and specifically the
availability of resources will highly influence practice and should
always be considered when interpreting and implementing these
guidelines.6
COVID-19: impact on the recommendations within these
guidelines
The COVID-19 pandemic emerged just as these guidelines were
being drafted. This required specific changes to the CA algorithms, as
well as to the care provided to the critically ill child. These changes
were the topic of specific ERC guidelines on ‘Resuscitation during the
COVID pandemic’ and will not be repeated here.7
Future guidelines will have to balance the aim of providing optimal
treatment for the child with the epidemiology (of this and future viruses)
and available resources. Assuring the safety of the rescuer has always
been a priority in ERC guidelines but lack of evidence has made it
difficult to precisely define the associated risks. Rescuers may value
the benefit for the child more highly than their personal risk but should
equally be aware of their responsibility towards their relatives,
colleagues, and the wider community. In general, when there is a risk
of transmission of a severe disease, rescuers should use appropriate
personal protection equipment (PPE) before providing life support.
Systems should be in place to facilitate this, and if extra time is
required to achieve safe care this should be considered an acceptable
part of the resuscitation process. Procedures and techniques that limit
the risk of disease transmission (for instance by aerosol spread) are to
be preferred.
A detailed discussion on COVID-19 in children is beyond the scope
of the current guidelines. In general, children show milder disease and
might be less contagious for others than adults.8 10 However, this
could be different for individual cases or with other viruses in the
future.11 13
Epidemiology of cardiac arrest in children
See the epidemiology section of the ERC Guidelines for more detail.
Key points include:
 Paediatric OHCA is a relatively rare event, with a dismal prognosis.
Rates of 30-day survival have improved recently but still vary
between 5 and 10% overall. Less than half of these survivors have a
favourable neurological outcome. Initial shockable rhythms are
seen in 4 8.5% of reported cases, with far better outcomes (up to
50% survival). Infants make up 40 50% of all paediatric OHCA and
their prognosis is much worse than older children. About 40 50% of
all paediatric OHCA are presumed to be respiratory in nature.
‘Sudden death of Infancy’ is reported in 20 30%. Trauma-related
cardiac arrest makes up 10 40% of the reported cohorts.14 20
 The incidence of paediatric IHCA has remained relatively
unchanged over the last years. At least 50% of all cases appear
to be non-pulseless events.21 Survival to discharge is significantly
342 RESUSCITATION 161 (2021) 327
better than for OHCA, averaging 37.2% (95% CI 23.7; 53) in a
systematic review of 16 datasets.15 How this translates into
favourable neurological outcome is less clear. A large cohort of
IHCA study from the United Kingdom (n = 1580, 2011 2018, 4.3%
initial shockable rhythm) documented 69.1% ROSC and 54.2%
unadjusted survival to discharge.22 Good neurological outcome
was seen in more than 70% of survivors.
 Overall, there is a lack of adequate ‘global’ data on the incidence,
circumstances and outcome of paediatric CA. A less fragmented
approach would improve the utility of registration data and
eventually benefit children.23
Signs of respiratory failure signs of circulatory failure
In the absence of a recent COSTR, we based our advice on existing
guidelines, reviews, and clinical data on the topic (APPENDIX RR
1 A.1 & 1 A.2). The recently published guidelines of the Surviving
Sepsis Campaign on the management of septic shock in children were
considered of high quality and largely informed our insights in all RRs
concerning septic shock.48
Respiratory and cardiovascular emergencies together account for
most of the paediatric morbidity and mortality worldwide, especially in
infants and young children. Rapid recognition and proper treatment
improve outcome.24 28 Presenting symptoms are usually not specific
to a particular illness, and no single finding can reliably measure
severity nor differentiate the underlying aetiology.29 35 Obvious signs
of decompensation (decreased consciousness, hypotension) are
generally late, closely preceding cardiorespiratory collapse. Early
recognition and treatment is crucial, yet initial clinical signs of
(compensated) failure are unreliable and there is significant
interobserver variability, especially in young children.27,30,36 44
Proper assessment therefore demands an integrative approach,
looking at clinical symptoms, but also considering additional information
from history, biomarkers and/or imaging. Complex models using artificial
intelligence do not necessarily perform better than clinical decision
making by a competent bedside physician.45 47 We deliberately do not
differentiate between ‘cold’ and ‘warm’ shock as this is often difficult to
appreciate clinically and might mislead clinicians.48
Quick first recognition of a child at risk (‘five second hands- off’ first
assessment) is recommended using the Paediatric Assessment
Triangle (PAT) or similar models.49 52 Any abnormality should trigger
a subsequent full stepwise pathophysiology driven ABCDE
evaluation.
Respiratory rate, heart rate, blood pressure
Values considered as normal or abnormal for different age groups in
paediatric textbooks and PLS manuals were recently questioned in
several studies and SR including large datasets of healthy children as
well as children seen in the ED. It seems the simple dichotomy of
normal/abnormal does not reflect precisely enough the commonly seen
variations among children.53 61 Recently derived centile graphs better
represent the variations between different age groups, but their use in
clinical practice and impact on outcomes require verification. Previous
‘normal values’ as described in textbooks clearly do not match the
ranges presented in recent studies and we therefore propose some
corrections, to avoid under- and over- triage. Importantly, none of these
values taken in isolation has sufficient test performance and should
always be considered in relation to other signs and symptoms. Each of
them might be influenced by conditions such as fever, anxiety or pain.
Overall, trends are more informative than single readings.
387
Pulse oximetry
Hypoxaemia is often present in sick children,62 both in respiratory
and non-respiratory illness (e.g. sepsis) and is a major risk factor for
death regardless of the diagnosis. Early identification of hypoxae-
mia helps in the assessment of severity and allows for proper
treatment.63 Clinical signs may underestimate the degree of
hypoxaemia and ‘silent hypoxaemia’ has been described in e.g.
adult COVID-19 patients.64 While measurement of PaO2 is
considered the gold standard, pulse oximetry provides a rapid
non-invasive way of assessing oxaemia and is the standard of care
for continuous monitoring of oxygenation.24,26,65 Robust data on
‘normal’ values distribution in children are surprisingly scarce. An
SpO2 of 95% has been cited as a lower cut-off value.66 Different
studies and reviews seem to suggest similar.67 70 Given the lack of
strong evidence and in view of consistency between different RR
and ease of teaching, the PWG continues to advise 94 98% as the
‘normal range’. Many factors (including altitude, technical limita-
tions, quality of perfusion, carbon monoxide, during sleep) must be
considered when interpreting pulse oximetry values, and this
knowledge should be part of any training in PLS.71
Non-invasive end-tidal ETCO2/capnography
Arterial PaCO2 and other ABG parameters are considered the gold
standard for assessing ventilation. Capillary or venous ABG can also
be used in the absence of arterial access. Venous PvCO2 is higher
than arterial PaCO2 but generally correlates with PaCO2. Unlike PaO2,
normal values of PaCO2 (35 45 mmHg; 1 kPa = 7.5 mmHg approx.)
are well defined and do not change with age. Non-invasive ETCO2
devices are increasingly used in both pre-hospital and in-hospital
care. Several studies show reasonable correlation between ETCO2
and PaCO2. Capnography is the preferred method of ETCO2
measurements in intubated children but should also be considered
in spontaneously breathing children who for instance undergo deep
procedural sedation or present in acute respiratory failure.72 76 High
flow oxygen might lead to artificially lower ETCO2 values.77 The
addition of ETCO2 to visual assessment and pulse oximetry was
associated with a significant reduction in desaturation and/or
hypoventilation during procedural sedation.73,78 ETCO2 changes
appear minutes before desaturation could be identified by pulse
oximetry.79 ETCO2 should not be used as a surrogate for PaCO2 when
aiming for normocapnia as part of neuroprotective care.80
Serum lactate
The evidence for monitoring serum lactate in children with circulatory
failure is limited. Early hyperlactataemia is associated with critical
illness, but organ dysfunction can equally occur in those with normal
lactate values.81 84 Moreover, lactate can increase for other reasons
than cellular dysoxia and thus neither is a specific measure of dysoxia
or organ dysfunction. Use trends in blood lactate values, in addition to
clinical assessment, to guide resuscitation of children with septic
shock.48,85 A persistent elevation in blood lactate may indicate
incomplete haemodynamic resuscitation.
Central venous oxygen saturation (ScvO2)
Continuous or intermittent measurement of ScvO2 was considered a
crucial part of early goal-directed therapy and identified as potentially
beneficial in previous guidelines. The PWG could however not find
sufficient evidence to suggest for or against its use in children with
septic shock. The use of ScvO2 requires a central line which might
detract from other ‘first hour’ priorities. Advanced haemodynamic
 RESUSCITATION 161 (2021) 327
variables might be of value to guide the ongoing resuscitation of
children with septic shock beyond the first hour.28,48
Signs of neurological impairment
Early recognition and treatment of neurological emergencies is of
particular importance (Appendix RR 1A.3). Prognosis is often related to
secondary injury due to associated hypoxaemia or ischaemia. Treatment
delays worsen outcome.86 88 For the management of some of these
emergencies we also refer to dedicated guidelines.87,89,90
Both level of consciousness, presence of posturing and pupil size,
symmetry and light reactivity inform prognosis but are insufficient to
allow definite prognostication.
Level of consciousness
The Glasgow Coma Scale (GCS) is commonly used to describe a
patient's level of consciousness and trend over time. Its use in
children is complicated. Several studies confirmed near equal
performance of simplified scores.91 96 AVPU is easy and correlates
well with the total GCS in children older than five years. The limited
levels between alert and fully unresponsive hamper its discrimina-
tive power. The GCS motor score has more levels than AVPU and
seems to have almost the same information content as the total
GCS. It can be used at all ages.
Stroke
Stroke is among the top ten causes of death in children and more than
half of survivors have long-term impairments. Stroke in children is
uncommon and thus easily mistaken for more common conditions,
such as migraine or intoxication. Early recognition of stroke is crucial,
as any delay in treatment will affect outcome. Red flags include
sudden onset of severe headache or focal neurological deficits, but
stroke in children can also often present as an altered mental state or
seizures. Adult stroke recognition tools have limited performance in
children and are not recommended. Children presenting with sudden
onset of any of the above symptoms are at high risk of stroke and
should undergo immediate neurological assessment and consider-
ation of urgent neuroimaging.90,97 101
Meningitis/encephalitis
The diagnosis of encephalitis requires a high level of suspicion,
especially in infants.86,87,102 Delays in diagnosis and treatment are
associated with worse outcomes. Immediate lumbar puncture is
recommended only after initial stabilisation and in the absence of
contraindications (such as impaired consciousness, signs of intracra-
nial hypertension or coagulation abnormalities). In children with a first
febrile seizure, the pooled prevalence of bacterial meningitis is low,
and diagnosis is mostly clinical for children above the age of 6 months.
The utility of routine lumbar puncture in children with an apparent first
febrile seizure is low.103
Paediatric early warning scores (PEWS) medical
emergency teams (MET) rapid response teams (RRT)
The topics of PEWS, MET and RRT were explored by ILCOR as a
scoping review (PLS 818) and an evidence update (EvUp) respectively
(PLS 397). The PLS taskforce concluded that the implementation of
PEWS and the use of paediatric MET/RRT systems should be part of an
overall clinical response system. They acknowledged the potential cost
and impact on resources of implementing such systems. They also
387 343
identified multiple difficulties in research on PEWS.104 The results of a
large cluster RCT examining the impact of implementing PEWS and
paediatric track and trigger tools are awaited.105
Point-of-care ultrasound imaging (POCUS) in critically ill
children
The available evidence suggests POCUS to be an effective method
for both rapid diagnosis and procedure guidance in a variety of
paediatric emergencies (Appendix RR 1C).106,107 Technology con-
tinues to evolve, and ongoing research is extending the use of POCUS
to new clinical scenarios. Formal training is needed to standardise and
expand its use. Guidelines for the practice of POCUS in paediatric
emergencies have been published.108
POCUS and the lung
Recent publications highlight the added value of lung POCUS in
paediatric respiratory failure.109 118 POCUS has at least similar
sensitivity and specificity to chest X-ray for diagnosing childhood
pneumonia and might have better cost- and time-effectiveness,
depending on the context of its use. POCUS is more accurate for
pleural effusions or pneumothorax and helps guide needle thoraco-
centesis and thoracostomy. It has also been described as an adjunct
tool for confirmation of correct tracheal tube placement but the
evidence in children is limited.119,120
POCUS for circulatory failure
With adequate training, the accuracy of cardiac US performed by non-
cardiologists seems particularly good.121 Paediatricians and paediat-
ric emergency physicians with focused training were able to
accurately diagnose pericardial effusions, cardiac contractility
abnormalities, and left ventricular enlargement. Further potential
uses include the detection of cardiac tamponade, dilated cardiomy-
opathy, congenital heart disease and infective endocarditis.
In adults, POCUS has also been advocated as a guide to the
treatment of shock, but evidence in children is limited. In a systematic
review, respiratory variation in inferior vena cava (IVC) diameter
performed only moderately (pooled specificity 0.73) in predicting fluid
responsiveness.122 Importantly, a negative ultrasound could not be
used to rule out fluid responsiveness (pooled sensitivity 0.63). Standard
measurements of the IVC/aorta in children are not well established for
all age groups and serial exams may therefore be more useful to guide
resuscitation.110,123 Lung US might have a role in guiding fluid therapy in
paediatric sepsis. The number of B-lines on lung US seems to correlate
with extra-vascular lung water in children.124,125
Extended FAST examination (E-FAST) in paediatric trauma
Evidence for E-FAST US in children is far more limited than in
adults, and equally conflicting. Abdominal US seems to have only
modest sensitivity for the detection of hemoperitoneum.126 128
Based on the available evidence, the PWG does not advise FAST as
the sole diagnostic test to rule out the presence of intra-abdominal
bleeding. FAST examination may be incorporated into other aspects
of trauma evaluation to improve the accuracy of the test.
Observational data demonstrated that a FAST examination has
limited impact on abdominal CT use in injured children at very low
(<1%) and very high risk (>10%) of intra-abdominal injury.
However, use of FAST in children considered to have 1 10% risk
of intra-abdominal injury decreased abdominal CT use. One small
study found that when combined with transaminase values >100 IU/
344 RESUSCITATION 161 (2021) 327
L the specificity of the FAST was 98%, suggesting that a negative
FAST and transaminases <100 IU/L could be an indication for
patient observation instead of abdominal CT scanning. Extended
FAST includes US of heart and lung which has a much higher
accuracy and information content.
Teamwork
The 2020 ILCOR COSTR suggested specific team training as part of
ALS training for healthcare providers (weak recommendation, very
low certainty of evidence).129 We specifically looked at the impact on
outcome from a ‘team-based’ approach and likewise what ‘proper’
teamwork should constitute (team effectiveness) (appendix RR 2).
Despite the large amount of literature, the evidence base for
teamwork is limited. Earlier papers indicated that lack of teamwork and
communication failures are important reasons for medical errors and
adverse outcomes.130 Based on this and the identified literature in the
RR, the PWG advises a team-based approach to the acute treatment
of critically ill children. We emphasise the importance of a structured
implementation strategy for those not already using this and an
ongoing evaluation of effectiveness for those who already use team-
based approach. A team-based approach has many defining factors
and is more than just bringing different professionals together in the
same room.131 139 Ideally, written protocols should exist for children
in all departments where they might present. New team members
should ideally be trained in teamwork and the specific existing
protocols, establishing shared mental models. This continuous
education process should be an integral part of the implementation
protocols for a team-based approach.
In addition, the PWG wants to highlight the potential
negative impact on performance of rudeness and other external
stressors.140 142 All team members, especially the team leader,
should work to establish a culture that condemns rude behaviour.
Finally, the PWG agrees with the ILCOR EIT437 COSTR that
suggests a relationship between exposure and outcome.129 They
suggested that EMS systems: (1) monitor exposure of their clinical
personnel to resuscitation and (2) implement strategies, where
possible, to address low exposure or ensure that treating teams have
members with recent exposure (weak recommendation, very-low
certainty of evidence).
Drug calculation tools and rules
The PWG largely based its insights on the 2020 ILCOR EvUp PLS
420,143 three additional SRs,144 146 and one guideline,147 and
identified the need for a change in the current advice with regard to
weight estimation methods (appendix RR 3). The dosing of
emergency drugs requires a functional estimate of the child's weight.
Parental estimates are usually more accurate than estimates by
health professionals. Length-based methods, such as the Broselow
tape, are also accurate but tend to underestimate weight in
populations with a high incidence of obesity. Systems including a
correction for body-habitus (e.g. Pawper) are more accurate. Such
systems often include a pre-calculated dose advice for emergency
drugs which has been shown to reduce administration errors. Care
provider estimates and age-based formulas are inaccurate and
therefore not advised. Finally, although the pharmacokinetics of some
drugs (e.g. fentanyl, propofol, midazolam) vary between obese and
non-obese children, there is too much variation between medications
and individuals to advocate any specific strategy to correct for this.
387
Airway management in critically ill children
We included in our analysis one guideline,48 three SRs,148 150 nine
narrative reviews,151 159 two RCTs,160,161 and 27 observational
papers (appendix RR 4.1).162 188
Overall, the evidence available in children is weak, being based
mainly on observational (registry) data. Evidence from adult studies or
from the operating room should be considered as indirect. Importantly,
as practice and team composition vary broadly between regions and
settings, one cannot draw universal conclusions.
Evidence suggests that TI by providers with limited experience
influences outcome. This is even more so in complex settings (e.g.
small child, haemodynamic instability). Despite that about 5% of EMS
encountered children need an airway management procedure,
individual provider exposure is often less than needed. Each of the
existing techniques for advanced airway management (TT with or
without videolaryngoscopy, SGA, BMV with optional airway adjunct)
has its own advantages and disadvantages and competent operators
should be knowledgeable of these. Importantly, as far as reasonably
possible, teams should prepare in a structured and timely way before
performing any airway procedure. This preparation includes consid-
eration of ‘rescue’ and ‘fallback’ procedures.
Despite a suggestion of worse outcome in certain settings, for many
healthcare providers, TI remains the preferred way of managing the
airway of a critically ill or injured child, regardless of the context. The risk of
failed or incorrect positioned TI in children is significantly higher than in
adults. Multiple TI attempts are associated with increased risk of
hypoxaemia, desaturations, adverse haemodynamic events and
subsequent morbidity and mortality. The number of attempts should
therefore be limited before considering alternative airway management.
Providers should always evaluate the balance between presumed benefit
and risk of harm when considering TI, and not solely decide based on pre-
defined dogmatic rules (e.g. GCS 8, burn percentage) nor without first
considering alternatives. In children, difficult airways are rarely because of
their anatomy but usually related to physiological and situational
difficulties (e.g. failing to prepare).158 Conditions may be optimised by
standardising equipment and its location, use of checklists, multi-
disciplinary team training in both technical and non-technical aspects of
emergency TI, and regular audit of performance.
For many settings, BMV appears to be at least non-inferior to TI. It
is a far easier skill to master and should be taught to all providers
involved in the care of critically ill children. To optimise efficiency,
providers can either use a 2-person technique and/or use an airway
adjunct. Most difficulties with mask ventilation can be overcome by
recognising and treating anatomical airway obstructions (e.g. using
airway adjuncts or a SGA) or functional ones (e.g. muscle paralysis).
Avoid muscle paralysis in children with mucopolysaccharidosis,
airway masses/foreign bodies or external airway compression but in
many other settings such agents allow for controlled ventilation before
TI and fewer adverse events. Difficult BMV should not prompt a rushed
TI but should serve as a red flag for more thorough preparation.
A front of neck airway (FONA) in children should only be attempted
as a last resort in a “cannot oxygenate-cannot intubate” situation. It is
difficult to gain sufficient expertise for this situation, especially given
the variability of anatomy at different ages. In most cases, needle
cricothyroidotomy with jet ventilation is used. Surgical cricothyroidot-
omy procedures are extremely rare. There is no evidence that a
quicker decision to use FONA would increase the overall survival
without neurological impairment. Importantly, “cannot oxygenate-
cannot intubate” situations might themselves result from previous
 RESUSCITATION 161 (2021) 327
suboptimal airway management and repeated TI attempts and
therefore most authors emphasise the importance of other difficult
airway techniques before using FONA.
The use of ETCO2 during intubation
The 2020 ILCOR EvUp (PLS 385) confirmed the earlier recommen-
dation to use ETCO2 for intubated children with a perfusing cardiac
rhythm in all settings.143 In view of that and considering the potential
harm of dis- or misplaced TT, we consider capnography an essential
tool for TT confirmation in children, but proper evaluation of TT position
should also include clinical evaluation and either ultrasound or X-ray
(appendix RR 4.2).
The use of cricoid pressure for intubation
The 2020 ILCOR EvUp (PLS 376) confirmed the earlier recommen-
dation to discontinue cricoid pressure if it impedes ventilation or
interferes with the speed or ease of intubation.143 We further
considered one SR189 and two overlapping clinical studies (appendix
RR 4.3).190,191 We could not find sufficient evidence to recommend the
use of cricoid pressure to prevent regurgitation or aspiration during
rapid sequence or emergent TI in children. It might impair airway
handling in children and infants in the emergency setting.
Videolaryngoscopy
The available evidence for the use of videolaryngoscopy in
critically ill children is limited (appendix RR 4.4). Primary endpoints
in most studies were time to intubate or TT first pass success rate.
Some SRs suggest an increased risk of prolonged intubation time
and unsuccessful intubation with videolaryngoscopy.192 194 More
recent RCT and observational papers suggest a benefit, but the
evidence remains conflicting.195 202 Importantly, such a benefit
will strongly depend on who is performing the intubation, which
technique and device is used and for which indication. Those who
plan to use it should be properly trained. Many devices exist which
differ in technique but there is no evidence that one is superior to
another. Considering this, the PWG cannot advise for or against
the use of videolaryngoscopy over direct laryngoscopy in the
emergency setting. The decision to use videolaryngoscopy and for
which indication remains at the discretion of the competent
physician performing the procedure. It should be considered
earlier in cases where direct laryngoscopy is expected to be
difficult such as with manual in-line stabilisation of the cervical
spine.
The use of atropine for intubation
A 2020 ILCOR EvUp (PLS 821) did not find any new evidence to
enable a recommendation.143 Bradycardia occurs during intubation,
presumably because of either hypoxia or vagal stimulation due to
laryngoscopy. This temporary bradycardia is accompanied by
vasoconstriction and will normally respond to re-oxygenation and
removal of the vagal stimulation. However, several induction drugs
also induce bradycardia that may be accompanied by vasodilation,
leading to ‘unstable bradycardia’. In the context of a child with for
instance sepsis this bradycardia induces low cardiac output and
hypoperfusion, which can be potentially fatal.203 In young children the
incidence of dysrhythmias may be reduced when atropine is included
in the drugs used for emergency intubation.204 The use of atropine
decreases the incidence of bradycardia during intubation of both
neonates and older children but the consequences of such
bradycardia are unclear.205 207
387 345
Atropine may be used for the intubation of critically ill children
(1 month 8 years) to decrease the incidence of bradycardia and
dysrhythmias especially in younger children, when suxamethonium is
used, and/or when vasodilation is present (appendix RR 4.5).
The use of cuffed tracheal tubes
A 2020 ILCOR EvUp (PLS 412) did not find any new evidence to
change the 2010 ‘equivocal’ recommendation.143 The PWG agrees
with the specific insights of the authors of this EvUp who argue in
favour of the exclusive use of cuffed TT for paediatric ALS “in an effort
to reduce tube selection errors, improve capnography accuracy, have
less need of TT change, reliable TV delivery and/or pressure, reduction
in sore throat, reduced risk of aspiration and standardise practice
(appendix RR 4.7). MRI images have shown the cricoid ring in children
to be elliptical, rather than circular as traditionally taught.208 Therefore,
there may still be a leak around a perfectly sized circular uncuffed
tracheal tube while the TT causes increased pressure on other areas
of the tracheal mucosa. If cuffed tracheal tubes are used, cuff inflation
pressure should be monitored and limited according to manufacturer's
recommendations. The traditional rules for TT selection per age were
made for uncuffed tubes and thus likely overestimate the optimal size
of cuffed TT.
The use of supplementary oxygen in the management of
critically ill or injured children
Our RR identified three guidelines,28,66,209 2 SRs,210,211 three
RCTs,212 214 and one observational study215 on the topic (appendix
RR 5.1). The results of both the Oxy-PICU trial and the COAST trial
are likely to further inform our guidelines but are not yet
available.216,217 The use of supplemental oxygen before TI, in
cardiac arrest and post-ROSC is reported separately. Supplemen-
tary oxygen has been a mainstay in the treatment of virtually any
critically ill or injured child untill recently. Growing concerns about
the potential negative impact of hyperoxygenation on outcome has
led to changing guidelines in adults and neonates. The PWG
recognises the risk of inadvertent hypoxaemia with an overly
conservative approach to oxygen therapy, especially in situations
where continuous monitoring is difficult such as prehospital or in
shock states. However, too much supplementary oxygen caries an
undefined risk and is also costly, especially in resource-limited
environments. Importantly, while the evidence base is limited, any
guideline about supplemental oxygen will need to consider the local
situation. Oxygen can be delivered in many ways. The provider
needs to be aware of the oxygen concentration delivering capacity
of the device, the FiO2 requirements and the acceptability of the
device to the child. In children with specific chronic conditions or
existing cardiac disease, oxygen therapy should be tailored to the
underlying condition, the baseline SpO2 (if known) and the
intercurrent disease process. Early expert advice is warranted.
Far less frequent than in adults, high-concentrated oxygen can also
lead to hypoventilation in some children with chronic conditions.213
Non-invasive ventilation and high-flow nasal cannula (HFNC)
In the absence of a specific COSTR on this topic, we performed a RR
(appendix RR 5.2). The results of the large multicentre RCT ‘FIRST
ABC’ comparing HFNC to nasal CPAP in the paediatric critical care
setting are not yet available.218
Invasive ventilation can be damaging to the lungs, carries an
increased risk of secondary infections, is more costly and demands
346 RESUSCITATION 161 (2021) 327
more analgosedation. Non- invasive ventilation on the other hand is
sometimes poorly tolerated by children, requires that children still have
sufficient respiratory drive and might carry a risk of delaying appropriate
care. Nasal CPAP and HFNC improve the work of breathing and
oxygenation by increasing distending pressure and allowing reliable
delivery of high concentrations of warm humidified oxygen. HFNC
appears to improve alveolar ventilation but does not actively increase
TV. Both HFNC and NIV seem easy and safe to implement.219 230
There is currently insufficient evidence, especially when also
considering the potential impact on resources, to advise for or against
their use in hypoxaemia due to non-pulmonary causes nor in
compensated respiratory failure without hypoxaemia.231 The decision
to use HFNC or NIV in these groups of children is typically taken in an
advanced care setting, by a critical care provider. In children with
respiratory failure and hypoxaemia (due to e.g. bronchiolitis, pneumo-
nia), NIV or HFNC may improve outcome and prevent further
deterioration. This is especially important in low-resource settings
where there is often no access to high-quality intensive care.232 236
Start HFNC or CPAP in infants with bronchiolitis and hypoxaemia not
responding to low-flow oxygen.228 Very low certainty evidence
suggests that a flow of 1 L/kg/min might be as effective as 2 L/kg/
min.237 Although HFNC might not increase the risk of droplet and
contact infection,238 it likely increases aerosol dispersal239 and, in
settings where this might be a problem, we advise the use of HFNC only
under conditions of guaranteed airborne protection.
Ventilation
We identified three recent guidelines48,209,240 and six observational
studies,241 246 as well as several additional older studies or papers
with indirect evidence on this topic (appendix RR 6). Details of
mechanical ventilation and PICU management are beyond the scope
of these guidelines but see existing recent reviews.247 250
Minute ventilation is influenced by both TV and respiratory rate. A
TV of 6 8 ml/kg ideal body weight, taking into account (apparatus)
dead space, is an appropriate initial target.209,250,251 Apparatus dead
space can be reduced by using appropriate child circuits and reduction
of swivels. Adequacy of TV can be estimated by observing chest rise
and measuring paCO2 trend.
Adjust ventilation to achieve a normal arterial paCO2 in children
who have normal lungs. However, in acutely ill children aiming for
normal might require overly aggressive ventilation. In this case,
permissive hypercapnia can be considered standard practice unless
there is pulmonary hypertension or severe TBI.
Self-inflating bags are preferred over anaesthetic bags for
ventilation for all providers not specifically trained in the use of an
anaesthetic bag. Self-inflating bags should be properly sized to enable
sufficient TV while avoiding overinflation and inadvertent gastric
insufflation. Existing bags vary from 180 240 ml (neonatal), 450
650 ml (paediatric) and 1300 1600 ml (adult). Providers should
be aware that one- handed compression of an ‘adult’ bag can easily
generate volumes above 500 ml.245,252 BMV is easy and the mainstay
of initial ventilatory support but is not without risks and demands
providers to be properly (re)trained.253,254
A one-handed BMV technique gives the provider the freedom to
use the other hand but increases the risk of leak. We therefore
advocate a two-person approach in all cases where either there is
difficulty in providing an adequate seal or there is a risk of infectious
disease transmission via aerosols. In the latter case, one should also
apply a viral filter between bag and mask.7
387
During resuscitation, ventilation can also be provided by mouth-to-
mouth or mouth-to mouth and nose. This is less efficient than BMV and
does not enable additional oxygenation. Moreover, it does not protect
the rescuer from infectious disease transmission and the fear of which
might be a barrier for rescuers to provide ventilations in the first place.
Fluid therapy for circulatory failure
This RR concerns the use of fluid resuscitation during the first hour of
shock, once recognised and as part of a general approach to a child in
shock (appendix RR 7.1). Later fluid therapy might also impact
outcome but is beyond the scope of this review. We included the 2020
ILCOR EvUp on fluid bolus for septic shock (PLS1534) and the
scoping review on graded volume resuscitation for traumatic shock
(PLS 400), as well as several guidelines, SR and clinical studies on
topic.143 Results from both the SQUEEZE and the ProMPT bolus trial
are currently still awaited.255,256
It is difficult to study individual interventions in the multifaceted
approach to sepsis. As a result of equivocal guidelines based on very
low certainty evidence and contextual in nature, large variations in
practice currently exist and these do not serve the individual child well.
Early goal directed therapy (EGDT) has been the mainstay of the
worldwide Surviving Sepsis campaigns but more recent RCTs have
shown that this strategy does not improve outcome.
Shock is not one disease but the end stage of many different
pathologies and there are many subtypes (hypovolaemic, cardiogen-
ic, obstructive, distributive, and dissociative). Moreover, circulatory
failure is a spectrum and the result of many concomitant processes
related to both the causal agent and the host response. Treatment
should be individualised, taking into consideration the underlying
aetiology and pathophysiology, age, context, comorbidities, and
available resources.257 A strategy of frequent re-assessment and
careful, but concise treatment steps seems prudent.
Presumed septic shock
Although septic shock still generates significant mortality and
morbidity in infants and children globally, its prevalence and
presentation are changing due to vaccination, comorbidity, and the
incidence of immune suppression.258 260 Treatment strategies and
outcomes of specific types of septic shock (e.g. toxic shock,
neutropenic) vary considerably. Until recently, early aggressive fluid
resuscitation was considered the most important intervention for
septic shock in children, despite this being based on very low certainty
evidence. Publication of the FEAST trial challenged this strategy.261
There is ongoing discussion about the general applicability of the
FEAST results and how these should inform our practice.262,263 Most
existing protocols would still advise repeated boluses of fluid at 20 ml/
kg during the first hour of paediatric septic shock to counteract
presumed hypovolemia due to transcapillary leak.28,257 The recently
updated Surviving Sepsis Campaign guidelines advocate 10 20 ml/
kg boluses with a maximum of 40 60 ml/kg in the first hour in
situations where there is ICU availability. When there is no access to
ICU, fluid boluses are still advised but only in the case of hypotension
(10 20 ml/kg up to 40 ml/kg in the first hour).
Current evidence suggests that a more restrictive approach to fluid
resuscitation is at least as effective and might decrease side effects.
Even a single fluid bolus can influence respiratory function. Perfusion
improves in the first hour after a fluid bolus, but this effect does not
persist.124,263,264 Identifying children in distributive shock who need
fluid is challenging, as other reasons of tissue dysoxia will generate a
 RESUSCITATION 161 (2021) 327
similar clinical picture. Even more challenging is identifying which
children are fluid responsive. Clinical signs, combined with biochemi-
cal values (pH, lactate), give an acceptable test performance when
combined but not when considered individually. Ultrasound evalua-
tion of fluid responsiveness is gaining interest but the evidence
supporting it in children is lacking. On the other hand, echocardiogra-
phy guidance might help to recognise myocardial dysfunction and
hypovolemia early.
In view of the above, the PWG advises smaller fluid boluses,
namely 10 ml/kg. This smaller volume enables faster reassessment
but does not necessarily limit the total amount of fluid to be given in the
first hour of treatment. An individual child might still need volumes of up
to 40 60 ml/kg to treat shock. In case of repeated fluid boluses, early
consideration of vasoactive or inotropic drugs and respiratory support
is crucial. In settings where these options are not readily available, it
seems prudent to be even more restrictive. Equally important is the
type of fluid used.28,263,265 There seems to be consensus on avoiding
synthetic colloids and the current data on hypertonic solutions is too
limited to permit a practice recommendation. The general advice
advocating the use of crystalloids as first-line fluid still stands.
Crystalloids are effective, inexpensive and are widely available.266,267
The evidence base for balanced crystalloids (e.g. Lactated Ringer’s) is
limited. Systematic reviews on the topic show no more than a trend
towards a better outcome.268 270 However, normal saline (NS)
induces hyperchloraemic acidosis and might be associated with a
worse outcome.263 Considering the limited extra cost, the PWG
would therefore consider balanced crystalloids the first choice (and
NS an acceptable alternative). Albumin appears to be at least
equivalent to crystalloids in terms of outcome but should be second-
line due to the higher cost.48 Specific diseases (e.g. dengue, cerebral
malaria) might benefit from earlier use of albumin 4.5% as a
resuscitation fluid.28,271
Shock is defined by the degree of cellular dysoxia generated;
haemoglobin has an important role and higher transfusion goals may
be appropriate when there is cardiovascular compromise. There is
insufficient evidence to advocate a single cut-off value for transfusion
and the trend may also be important. Repeated crystalloid boluses will
inevitably lead to haemodilution as may underlying pathophysiological
mechanisms.
Septic shock affects the integrity of the endothelial glycocalyx and
the microvasculature. It also activates and consumes coagulation
factors and often induces diffuse intravascular coagulation in children
who already have suboptimal coagulation caused by acidosis and
dilution. There is insufficient evidence to advocate the prophylactic
use of plasma for all children in septic shock, but we would suggest its
early use in cases of presumed diffuse intravascular coagulation and
worsening coagulopathy.
Cardiogenic shock
Cardiogenic shock can be either primary or secondary to other types of
shock. The diagnosis is based on both clinical signs and echocardiogra-
phy. Once confirmed, the general approach is to avoid fluid resuscitation.
However, children with proven preload insufficiency on echocardio-
graphic, clinical, or biochemical grounds, due to, for instance, low intake
or associated sepsis, might benefit from cautious fluid resuscitation.38
Hypovolemic non-haemorrhagic shock
As the primary mechanism of circulatory failure in hypovolemic shock
is fluid loss, the mainstay of treatment is fluid resuscitation. However,
depending on the underlying aetiology, consider also co-existing
387 347
distributive or cardiogenic shock. Treatment focuses on electrolyte
disorders and possible severe hypoalbuminemia or hypoglycaemia,
which might cloud the clinical assessment.272,273
Severe acute gastroenteritis can lead to severe dehydration (>10%
body weight loss) and hypovolemic shock. Whilst its incidence is
decreasing in many countries, severe acute gastroenteritis remains an
important cause of paediatric mortality worldwide. Mortality is highest in
children with severe comorbidity, including those that have severe
malnutrition. The identification of children with severe dehydration/
hypovolemic shock from acute gastroenteritis is not always easy and
the degree often overestimated. Considering the setting where acute
gastroenteritis with severe dehydration frequently occurs (limited
resources, with comorbidity) and the very limited existing evidence, a
‘non-bolus’ approach to IV fluid resuscitation is advisable, except when
associated with septic shock. Such an approach is probably also
reasonable for children with severe malnutrition.274 277
Haemorrhagic shock
Blood loss not only generates a decrease in circulating volume but
also in blood components. The aim of therapy apart from restitution
of blood volume is to stop the bleeding via direct or indirect pressure
or by surgery or interventional radiology. Coagulopathy due to
consumption, blood loss, dilution from fluid therapy, acidosis from
hypoperfusion and/or hyperchloraemia, and hypothermia is pivotal in
the pathophysiology of trauma-related mortality.
Consider giving blood products early during the fluid resuscita-
tion of children with severe trauma using a strategy that focuses on
improving coagulation.278 285 Fluid resuscitation is guided by
specific endpoints (MAP, lactate, Hb, clinical assessment, pH,
coagulation) to avoid fluid overload yet still provide adequate tissue
perfusion.286 288 Adult data suggest that overly aggressive fluid
resuscitation worsens outcome and supports a more restrictive
approach including permissive hypotension.289 292 However,
severe paediatric trauma is often associated with TBI, in which
restrictive resuscitation might be deleterious. Even in children with
no risk of associated brain injury, a minimal MAP above p5 is
needed to avoid brain hypoperfusion.
Burn fluid management
Burn injury is a specific type of trauma where fluid loss is related to skin
loss. Standard fluid regimens are ‘preventive’ in nature and beyond the
scope of these guidelines.293 Importantly, early circulatory failure should
alert the clinician to look for other causes for shock than burn fluid loss.
Vascular access
For many paediatric emergencies, not being able to obtain reliable
vascular access will impact outcome, although the evidence
supporting this is uncertain. Importantly, obtaining vascular access
in children is often difficult with risks of repeated attempts or failure and
associated complications (e.g. extravasation). Deciding upon the
proper technique will depend upon ease of use and timely
effectiveness but, especially in areas with less resources, also
availability and cost. Whatever technique used, those performing it
should be competent in its use. For this RR, we considered two recent
SRs,294,295 one guideline,28 2 RCT,296,297 and 19 clinical studies
(appendix RR 7.2).298 313
Peripheral intravenous lines are still considered first-line as they
are cheap, easy to use and effective, with a low risk of complications.
Some authors suggest the use of either electro-optical visual aids or
348 RESUSCITATION 161 (2021) 327
ultrasonography to facilitate the procedure, but evidence is limited,
and both are operator dependent. Providers should not lose time in
obtaining peripheral access when there is an urgent need and should
be aware that multiple attempts might generate distress. There is no
clear evidence to suggest the optimal immediate rescue procedures if
peripheral IV cannulation fails, but if a provider considers the chances
of success of peripheral IV access to be minimal, they should use such
rescue procedures even earlier.
For infants and children, the primary rescue alternative is
intraosseous (IO) access. This has almost the same functionality
as (central) intravenous access, although there are some doubts
about delivery of certain drugs (e.g. adenosine) and about reliability of
blood sampling. In general, ABO-typing, pH and sodium are
considered reliable, and to a lesser degree glucose and bicarbonate.
Intraosseous can be a bridge to IV, until peripheral IV access can be
achieved. Intraosseous access is painful, especially when infusing
fluids, and analgesia (e.g. IO lidocaine, intranasal fentanyl, or
ketamine) should be given to every child unless they are deeply
comatose. Different devices are available and perform differently in
terms of ease of use, success rate, cost, and risk for complications.
Manual IO-devices primarily have a place in very young children or in
low-resource settings. In infants, reports suggest one can even use a
18G needle (and optionally a reusable needle holder). Power-driven
IO-devices are generally fast and easy to use. They have a
significantly higher cost than manual devices and still carry a risk of
misplacement (too shallow or too deep) Choosing the properly sized
needle is therefore important. Overall, the complication rate for IO is
low but providers should watch for extravasation, with a risk of
compartment syndrome, and infection. Correct needle position can be
evaluated clinically or potentially by colour doppler ultrasound.314,315
Many different puncture sites exist, and each of them has specific
indications and/or contra-indications and require a specific technique
and training. Importantly, flow differs depending on the puncture site
e.g. placement in the humeral head allows for higher flows. Although a
central venous line provides secure and multifunctional access, its
placement is generally slower, carries a risk of comorbidity, is more
operator dependent and less cost-effective. In settings where it is
feasible, use ultrasound to guide placement of a central venous line,
especially for the internal jugular or axillary routes.316,317 Venous cut-
down has largely been abandoned.
Care bundles in the management of paediatric shock
The use of care bundles in the management of paediatric septic shock
is central to the 2014 ACCCM guidelines and advocated in the more
recent surviving sepsis campaign guidelines (appendix RR 8.1).28,48
Systematic screening of acutely unwell children using a ‘recognition
bundle’ can be tailored to the type of patients, resources, and
procedures within each institution. Clinical decision- support systems
and electronic medical record-based sepsis recognition tool might be
of specific help, but the supporting evidence is very limited.318,319 The
success of multiple interventions applied simultaneously (a ‘bundle’) is
not necessarily evidence that each individual intervention is neces-
sary for the bundle's effectiveness.320 Some of these interventions
may even induce harm and/or merely increase costs.
While many different observational studies showed a positive
impact on outcome of care bundle implementation, this effect was far
less in other studies.318,321 329 Reasons for such differences are not
always easy to identify, but might be related to selection bias,
differences in implementation strategies or differences in care of
387
control populations. Importantly, protocols should be tailored to the
local reality.
Timing of antibiotics in sepsis
We identified two guidelines28,48 and 10 observational studies on this
issue (appendix RR 8.2).321,330 338 Antibiotics are a necessary part of
sepsis treatment and early (first hour) empiric broad-spectrum
antibiotics are advocated in international guidelines. Consider local
resistance patterns, antecedents, co-morbidity, and the presumed
source when selecting antibiotics. Unless meningitis has been ruled
out, the chosen antibiotic(s) should be able to cross the blood-brain
barrier. The indications for lumbar puncture are beyond the scope of
this RR but in the case of septic shock, it is generally sufficient to obtain
blood cultures before starting antibiotics. Outcome might be worse if
antibiotics are delayed for more than 3 h after recognition of sepsis.
Vasoactive/inotropic drugs in critically ill or injured children
Vasoactive/inotropic drugs in distributive shock
A 2020 ILCOR scoping review (PLS 1604) included two RCTs but did
not find sufficient evidence to suggest a change in recommenda-
tion.143,339,340 Both RCTs compared adrenaline and dopamine in
paediatric septic patients with fluid-refractory shock. Both have
several limitations making their usage for clinical guidelines develop-
ment difficult. Moreover, they were performed in low-to-middle-
income countries and their applicability in higher resource settings
was questioned. To inform our insights we further considered two
guidelines,28,48 two SR,341,342 and five observational studies
(appendix RR 8.3A).343 347
The new Surviving Sepsis Campaign Guidelines 2020 recom-
mend noradrenaline or adrenaline as first line vasoactive agents
over dopamine (weak recommendation based on low certainty
evidence) but could not find sufficient evidence to recommend one
above the other, suggesting to base the choice on individual child
physiology, clinician preference, and local system factors. Once
echocardiography or other advanced monitoring is available,
selection of vasoactive therapy might be driven by individual
patient pathophysiology.
There is insufficient evidence to identify the criteria for starting
vasoactive drugs in children with septic shock. Knowing that
excessive fluid resuscitation can lead to increased mortality in
critically ill children, we suggest early use of vasoactive drugs in
children with shock, especially when there is no clear improvement of
the clinical state after multiple fluid boluses (e.g. 40 ml/kg). Given their
overall safety profile, we suggest starting with either noradrenaline or
adrenaline, depending on local practices and infusing via either a
central or a peripheral line. Dopamine should only be considered in
settings where neither adrenaline nor noradrenaline is available. If
there is any evidence of cardiac dysfunction, an inodilator might be
added.
As with fluid, vasoactive drugs should be initiated and titrated
based upon consideration of multiple factors (including MAP, lactate
and clinical signs). Re- evaluate repeatedly and at least after every
treatment change. Vasoactive drugs are typically given as a
continuous infusion. Boluses of vasoactive medications should be
given only in (pre-) arrest situations, but competent physicians might
consider small boluses of a vasoconstrictor to treat acute hypotension
in specific settings (e.g. medication induced). Evidence guiding this
practice is lacking.
 RESUSCITATION 161 (2021) 327
Vasoactive/inotropic drugs in cardiogenic shock
A 2020 ILCOR EvUp (PLS 418) did not find sufficient evidence to
suggest a change in recommendation.143 We additionally considered
two guidelines (appendix RR 8.3B).28,38 Vasoactive drugs are only
one part of the treatment options for cardiogenic shock. Treatment
choices are aetiology-driven and early consideration of mechanical
support is recommended.
Given the current absence of direct paediatric evidence, we cannot
advise for or against the use of any specific vasoactive drug. The
decision which vasoactive drugs to use as first- or second-line is
complex and there are likely to be differences between patient groups
in terms of both aetiology and haemodynamic responses. The
treatment strategy should therefore be tailored to the individual child
and titrated to specific targets. Good knowledge of the activity and
effects of each of the vasoactive drugs at different doses is imperative
and should guide treatment choices. For this we also refer to the two
existing paediatric guidelines which advocate noradrenaline as first-
line inoconstrictor and dobutamine or milrinone as first-line inodilators.
A recent before-after cohort study suggests a strongly positive
impact on outcome of bolus adrenaline (1 mcg/kg) in paediatric
cardiac ICU patients developing hypotension, although this was part
of an overall quality improvement initiative and the results might have
been influenced by other covariables.348
Vasoactive/inotropic drugs in hypovolemic shock (8.3C)
We identified one SR349 and one narrative review350 on this topic
(appendix RR 8.3C). Given the current absence of direct paediatric
evidence, our advice is only based on indirect evidence from adult
papers and pathophysiological reasoning. While the initial phase of
hypovolemic shock is most often characterised by a marked increase
in systemic vascular resistance, this response can be lost once
decompensation occurs or sedative drugs are given. Vasopressors
could then be used to ensure adequate perfusion pressure. As they
can increase afterload, it is prudent to also assess cardiac function
when starting these drugs. Vasopressors also permit decreased fluid
administration and may reduce inflammatory reactions. Although
‘permissive hypotension’ might be considered in children with isolated
penetrating trauma without TBI, there is insufficient evidence to
advocate this in any other situation. Importantly for TBI, a sufficiently
high mean arterial pressure is needed to attain minimal levels of
cerebral perfusion pressure (e.g. MAP > 50th percentile).
Tranexamic acid TxA
Severe bleeding in children is most caused by trauma and/or
emergency surgery. It is beyond the scope of the current review to
consider the use of tranexamic acid in elective surgery or non-life-
threatening problems. For the topic of critical bleeding, we identified
one guideline,351 one RCT352 and six observational studies (appendix
RR 8.3D).353 357
TxA in traumatic bleeding
Adult evidence strongly suggests that TxA reduces mortality in trauma
patients with bleeding without increasing the risk of adverse events.358
TxA should be given as early as possible and within 3 h of injury, as
later treatment was ineffective and may be harmful. Limited evidence
from paediatric studies seems to suggest similar results. Overall TxA
seems cost-effective and safe. It has been used in children for a long
time, without identifying important side-effects even at much higher
doses. There is some concern about post-administration seizures, but
387 349
this seems to be rare with the doses used for trauma. No specific dose-
finding studies are available, but the (derived) dosing scheme
proposed in literature seems reasonable.
For the specific subpopulation of isolated TBI, paediatric data are
even more limited. However, considering the results of the CRASH-3
trial and the reasoning above, consider giving TxA to children with
isolated moderate TBI (GCS 9 13) without pupillary abnormalities.359
The results of CRASH-3 were equivocal for patients in coma, but this
might be due to them being unsalvageable. CRASH-3 enrolled only
adults without major extracranial bleeding. Where a significant
extracranial haemorrhage cannot be excluded, the PWG suggests
acting as above and giving TxA regardless.
TxA in non-traumatic bleeding
Intravenous and inhaled TxA has been reported to improve outcome in
children with pulmonary bleeding. Given that mucosal surfaces are
rich in fibrinolytic enzymes, the use of TxA for bleeding in such areas
might be as effective as in trauma. No paediatric studies are currently
available to support this. Considering the safety profile and potential
effectiveness, we suggest using TxA in paediatric non-traumatic life-
threatening bleeding.
Corticosteroids for shock
Our RR, which informed the 2020 ILCOR EvUp (PLS 413), included
two guidelines,28,48 one SR,360 1 RCT,361 and five observational
studies (appendix RR 8.4).362 366 All these studies had small sample
sizes and major risk of selection bias. Study populations, timings and
type and doses of steroids all differed between different populations.
We could not identify sufficient evidence to change the 2010 ILCOR
treatment recommendation: stress-dose corticosteroids may be
considered in children with septic shock unresponsive to fluids and
requiring (moderate to high dose) vasoactive support, regardless of
any biochemical or other parameters. Stress-dose hydrocortisone is
always indicated for specific populations at risk such as hypothalamic-
pituitary- adrenal axis disorders. Preliminary research further
suggests there might be other specific subpopulations that would
benefit or experience harm from steroid administration. However,
these subpopulations cannot yet be identified at the bedside.
Paediatric status asthmaticus
Asthma still causes significant morbidity and even mortality in children
globally. Timely aggressive and protocolised treatment for status
asthmaticus is required. We consider here only the emergency ‘first
hour’ management (appendix RR 9).
We identified one guideline (ginasthma.org), eight SRs,224,367 373
three narrative reviews,374 376 nine RCTs,213,226,377 383 and five
observational studies,384 388 published in the last 5 years. Older
papers were considered when informative.389 394 The search update
June 2020 additionally revealed one guideline,395 3 SR,396 398 one
narrative review,399 1 RCT400 and four observational trials.401 404 We
evaluated the guidelines published by the Global Initiative for Asthma
(ginasthma.org) and those of the French paediatric emergency
societies to be of high quality (AGREE II) and largely based our
insights on them.395
Recognition of a severe asthma crisis is primarily based on clinical
signs, brief history, and oxygen saturation. Hypoxaemia is a sign of
decompensated respiratory failure. It might induce agitation or
decreased perception of breathlessness. Differential diagnosis
350 RESUSCITATION 161 (2021) 327
includes pneumonia, pneumothorax, cardiac failure, laryngeal
obstruction, pulmonary embolism, foreign body aspiration and
anaphylaxis.
Despite being first-line treatment, the actual evidence for short-
acting beta-2 agonists (SABA) in severe crises is limited. High-dose
inhaled SABA are relatively safe, although they do cause certain side
effects (cardiovascular, electrolyte disorders, hyperlactatemia, hypo-
tension). They might also induce transient hypoxaemia because of
increased ventilation-perfusion mismatch. Short-acting anticholiner-
gics, particularly ipratropium bromide, seem to have added value
although the evidence is conflicting. Systemic steroids are indicated
within the first hour. Oral steroids are as effective as intravenous. They
require at least 4 h to produce clinical improvement. The evidence is
too limited to advocate one steroid over another. The evidence for high
dose inhaled steroids in a severe crisis is less clear but seems to
suggest a benefit. Intravenous magnesium sulfate might be of added
value for a severe crisis, with few side effects. In children, isotonic
magnesium sulfate might also be used as nebulised solution. There is
no evidence for an added benefit of intravenous SABA, nor for a
specific dosing scheme. IV SABA carry an inherent risk of electrolyte
disorders, hyperlactatemia, and most importantly cardiovascular
failure. Limited and conflicting evidence exist for many other therapies
(IV ketamine, aminophylline, Helium, isoflurane, leukotriene receptor
antagonists, ICS-LABA, macrolides, monoclonal antibodies) and
each of them should only be used by physicians competent in their
use. Antibiotics are not recommended unless there is proven bacterial
infection. NIV or HFNC might be considered in children with status
asthmaticus remaining hypoxic with standard oxygen therapy and/or
not responding to initial treatment. The available evidence on NIV or
HFNC is conflicting and, especially in children with asthma
exacerbations not meeting respiratory failure guidelines, these
therapies may be associated with greater resource utilisation without
evidence of improved outcome. Their use should never delay the
decision to intubate when indicated. Severe exhaustion, deteriorating
consciousness, poor air entry, worsening hypoxaemia and/or
hypercapnia, and cardiopulmonary arrest are indications for intuba-
tion. Mechanical ventilation of a child with status asthmaticus is
extremely challenging. Due to high airway resistance, there is a risk of
gastric distension, pneumothorax, and dynamic hyperinflation with
decreased venous return. This in turn might lead to cardiovascular
collapse.
Anaphylaxis
We also refer to the 2021 ERC guideline chapter on special
circumstances.405 Our RR identified 11 guidelines,406 416 four
SRs,417 420 five narrative reviews,421 425 as well as 21 observational
studies (appendix RR 10).426 446
Anaphylaxis is life-threatening and requires immediate treatment.
The incidence of anaphylaxis in children varies worldwide, ranging
from 1 to 761/100,000 person-year. One-third have had a previous
episode. Food items are the most frequent trigger in children (2/3),
followed by insect venom and drugs (antibiotics, NSAIDs). Food
anaphylaxis can cause respiratory arrest 30 35 min after contact,
insect bites can produce shock very early (10 15 min), and
anaphylaxis from medications usually occurs in a few minutes. No
‘acute’ death has been reported occurring more than 6 h after contact
with the trigger. Biphasic reactions occur in up to 15% of cases and
mostly where there was more than one dose of epinephrine required or
a delay between the onset of anaphylaxis symptoms and the
387
administration of epinephrine >60 min. Early diagnosis of anaphylaxis
is crucial and will guide further treatment; for this we refer to the 2019
WAO criteria for diagnosis.415 For the proposed emergency
treatment, we essentially refer to the existing guidelines from relevant
societies. We did not find any additional evidence but also considered
issues of education and implementation in making our advice.
In addition to IM adrenaline, several supportive treatment options
are proposed, based on limited evidence: inhaled beta-agonists and/
or adrenaline for bronchospasm; IV Glucagon for children receiving
beta-blockers; IV or oral H1 and/or H2 antihistamines to alleviate
subjective symptoms (especially cutaneous). Corticosteroids might
have a positive impact on late respiratory symptoms but otherwise
there is no evidence of any effect on biphasic reactions or other
outcomes. Corticosteroids are not without side effects and therefore
should only be considered in children who need prolonged observa-
tion. Specific treatments might be considered in relation to the
identified trigger and context (e.g. methylene blue).
Severe intoxications
Paediatric emergency consultations for intoxications are frequent,
although there is significant variation in incidence between regions.447
A Cochrane review could not identify sufficient evidence to advise for
or against specific first aid treatments for oral poisoning.448 There is
large geographic variation in the use of different decontamination
techniques.449
It is important to consult an expert early. For further information we
refer to the chapter on special circumstances within the 2020
guidelines.405 In appendix, we report on some of the more important
paediatric papers on the topic (appendix RR 11 RR 33.1).
Obstructive shock (12.1)
Obstructive shock is a topic in the 2021 chapter on special
circumstances.405 We refer to appendix RR 12.1 and also to RR 34
on traumatic cardiac arrest and RR 33.1 on ‘4H4T’. There is no clear
evidence for any recommendation regarding decompression of a
tension pneumothorax in small children. Most data come from adult
literature. Especially in small children the risk of iatrogenic injury to
vital structures by needle decompression is high. The 4th intercostal
space (ICS) at the anterior axillary line (AAL) offers a smaller chest
wall thickness. Deviations from the correct angle of entry are
accompanied by a higher risk of injury to intrathoracic structures at
the second ICS.450 452 In line with adult guidelines, we prefer the 4th
(or 5th) ICS slightly anterior of the midaxillary line as the primary site of
insertion, but the 2nd ICS midclavicular is still an acceptable
alternative.452a There is insufficient evidence to suggest immediate
thoracostomy over needle thoracocentesis as the first-line interven-
tion in children with traumatic cardiac arrest, tension pneumothorax
and massive haemothorax. Needle thoracocentesis seems easier to
learn and faster to perform but might be less efficient.450 However,
systems that do not implement immediate thoracostomy should at
least consider it as a rescue option. If immediately available,
ultrasound should be used for confirmation of a pneumothorax, to
measure chest wall thickness and confirm lack of underlying vital
structures (e.g. the heart) before puncture and hence minimise depth
of needle insertion and reduce the risk of injuring vital structures.
Pulmonary embolism may be more common than previously
reported in adolescent sudden cardiac arrest.453 Early recognition,
high-quality CPR, and treatment with thrombolytic therapy resulted in
 RESUSCITATION 161 (2021) 327
good survival in patients with pulmonary embolism.454 Evidence does
not exist on dose and timing of thrombolytic therapy in children.
Catheter- directed therapy seems to be effective and safe for sub-
massive and massive pulmonary embolism in children when instituted
in a timely fashion.455,456
There are no comparative studies focusing on the treatment of
cardiac tamponade. Weak evidence shows that survival improved
when tamponade is detected early and treated promptly emphasising
the importance of echocardiography.457 Pericardiocentesis (prefera-
bly ultrasound-guided) should only be considered if immediate
thoracotomy or (re) sternotomy is not possible (expert consensus).
Atropine or pacing for unstable bradycardia
We included two narrative reviews458,459 and one observational
study460 but found no new evidence to support changes to the ILCOR
2010 recommendations (appendix RR 13.1 13.2). If bradycardia is
the consequence of decompensated respiratory or circulatory failure
then this needs to be treated, rather than the bradycardia itself. Futile
at best, atropine in hypoxic bradycardia could even be harmful as the
temporary increase in heart rate might increase oxygen demand.
Moreover, decreasing the parasympathetic drive might worsen those
pathologies that are primary catecholamine-mediated (e.g. Takotsu-
bo). An indication for atropine in bradycardia caused by increased
vagal tone might still exist.
Historically, a minimum dose of atropine of 100 mcg has been
recommended to avoid paradoxical decreases in heart rate supposed
to occur with lower dosages. A recent observational study in infants did
not confirm this for doses as low as 5 mcg/kg. A significant increase in
heart rate was seen within 5 min of this low dose, tachycardia
developed in half of all children and lasted for a few minutes.
Moreover, several neonatal publications highlighted the potential for
overdose in children weighing less than 5 kg if a minimum dose of
100 mcg was given.
Concerning emergency pacing the ILCOR paediatric taskforce
could not identify any evidence and thus still recommended as in 2010:
“in selected cases of bradycardia caused by complete heart block or
abnormal function of the sinus node, emergency transthoracic pacing
may be lifesaving. Pacing is not helpful in children with bradycardia
secondary to a post-arrest hypoxic/ischaemic myocardial insult or
respiratory failure. Pacing also was not shown to be effective in the
treatment of asystole in children”.143
Unstable tachycardia
The 2020 ILCOR EvUp (PLS 379 & 409) did not find sufficient
evidence to suggest a change in recommendation.143 The ILCOR PLS
taskforce specifically noted the importance of expert consultation
before using procainamide or amiodarone for supraventricular
tachycardia SVT. See the European Society of Cardiology ESC
guidelines for in-depth information about subtypes, diagnosis and
treatment options.461,462 Our search identified an additional three
narrative reviews,463 466 two RCTs467,468 and nine observational
studies (appendix RR 13.3).469 477 Different approaches to treatment
are suggested for children who are haemodynamically unstable
(decompensated) versus stable and/or have either narrow or wide
QRS tachycardia.
Intravenous adenosine is the first-line treatment for narrow QRS
tachycardia in children who are not yet in a decompensated state. Starting
doses of 0.1 mg/kg for children and 0.15 mg/kg for infants are generally
387 351
advised. Providers should consider a higher initial dose (0.2 mg/kg),
especially in younger children.464,472 Younger age is associated with
decreased response to the first dose of adenosine and increased odds of
adenosine- refractory SVT (Lewis 2017 177).476 Use of a stopcock in
small children may also lead to sub-therapeutic dosing.478 There is
insufficient evidence for or against the use of an intra-osseous access for
adenosine delivery, but the IV route is preferable. Once decompensated,
emergency electrical cardioversion is the preferred option and services
should have a protocol in place for this procedure, including the use of
analgosedation (e.g. IV/IO or intranasal ketamine, midazolam or fentanyl)
for children who are still conscious.
Alternative medications include calcium channel blockers, beta-
blockers, flecainide, digoxin, amiodarone, dexmedetomidine and
ibutilide. Each of these medications has specific side effects and
contraindications and should be used by competent providers, after
expert consultation. Verapamil might provoke severe hypotension in
younger children.
Hypokalaemia
Hypokalaemia is a topic in the 2021 chapter on special circum-
stances.405 We further included in our RR one narrative review,479 one
RCT480 and two observational studies (appendix RR 14.1).481,482 We
found no new studies on the treatment of hypokalaemia in paediatric
cardiac arrest. Studies on the treatment of hypokalaemia in intensive
care settings are limited to cardiac patients and differ significantly in
treatment threshold and dosage. Overall, enteral potassium seems to
be equally effective to parenteral. Hyperkalaemia after treatment is
rarely reported. Concomitant repletion of magnesium stores will
facilitate more rapid correction of hypokalaemia and is strongly
recommended in cases of severe hypokalaemia.
Hyperkalaemia
For hyperkalaemia we again refer to the ‘special circumstances’
chapter.405 We identified in our search one SR,483 one narrative
review,484 and four observational studies (appendix RR 14.2).485 488
Although the evidence base is limited, especially in children with
cardiac arrest, a clear treatment algorithm is important to ensure
consistent and effective interventions and avoid dosing errors or
inadvertent side effects.
Children have specific underlying causes of hyperkalaemia
and these should be considered early as they might alert the
clinician to recognise hyperkalaemia and inform the therapeutic
approach. Identification and treatment of all contributing factors of
hyperkalaemia should, as far as possible, be performed simulta-
neously with the acute pharmacological treatment. This latter
consists of:
 Membrane stabilisation with a calcium salt. Hypertonic saline
might also provide membrane stabilisation but there is no
evidence in children and the potential for side-effects is higher.
Sodium bicarbonate, when indicated, has a similar effect.
 Potassium redistribution: Fast-acting insulin in a glucose
infusion to avoid hypoglycaemia is usually effective after
15 min and lasts for 4 6 h. Repeated dosing might be
necessary. There are different dosing regimens in the literature
but no evidence to make strong recommendations for any one
regimen. The effectiveness of inhaled beta-agonists has been
described in adult and neonatal observational studies, but not
for children specifically. The proposed dose is significantly
352 RESUSCITATION 161 (2021) 327
higher (4 8 times) than that for bronchodilation. The effect of
nebulised beta-agonists is maximal only after 90 min. A peak
effect is reached significantly earlier (30 min) with IV beta-
agonists as a single bolus but the potential side effects are
significant and dangerous and we suggest their use only in
resistant hyperkalaemia and (imminent) cardiac arrest. Adren-
aline is also a beta-agonist. Finally, despite ongoing contro-
versy, we suggest the use of sodium bicarbonate in the
emergency treatment of children with hyperkalaemia and
metabolic acidosis (pH < 7.2) and/or in cardiac arrest. Give
repeated doses of 1 mEq/kg to correct pH and concomitantly
shift potassium intracellularly. The effect of sodium bicarbon-
ate is slow (hours) but consistent and sodium might further
stabilise the cell membrane.
 Potassium removal: Continue potassium redistribution measures
until potassium removal treatments can be started. Dialysis is the
most efficient treatment option but might not be readily available.
Watch for post-dialysis rebound. Furosemide increases urinary
potassium excretion. It is mostly indicated in well-hydrated
children with preserved kidney function. Its effect is far less clear
when there is also renal impairment. Potassium-binding agents
like sodium polystyrene sulfonate (SPS in sorbitol) have not been
studied prospectively in children. In adults, there are concerns
regarding safety of SPS. Newer drugs might be safer and efficient
but are unstudied in children.
Hypoglycaemia
We identified one guideline,489 2 SRs,490,491 one narrative review,492
as well as four observational studies (appendix RR 15).493 496 The
ILCOR First Aid taskforce specifically performed a COSTR on the
methods of glucose administration for hypoglycaemia.497
The threshold at which hypoglycaemia becomes harmful is
uncertain and might depend on age, cause, and rate of onset.
Standard threshold values have been defined in the literature at 50
70 mg/dl (2.8 3.9 mmol/L). While 70 mg/dl should alert physicians
(considering symptoms and the risk of further decrease), a value of
50 mg/dl, especially if combined with neuroglycopaenic symptoms, is
an absolute indication for prompt treatment. Systems should evaluate
the test performance of their point-of-care tests when developing
protocols.
Considering the pathophysiology, existing guidelines, and addi-
tional very low certainty evidence, we suggest an IV bolus of glucose
for severe paediatric hypoglycaemia. Whereas adult protocols use
50% glucose, for children we advise the use of less hypertonic
solutions in view of causticity and risk of dosing errors. In situations
where IV glucose is not feasible, glucagon can be administered as
temporary rescue, either IM or SC or intranasally. Start a maintenance
infusion of glucose to reverse catabolism and maintain adequate
glycaemia.
Less severe hypoglycaemia can be treated with standard glucose
administration, without a glucose bolus or glucagon. This can be either
by maintenance infusion or by oral glucose, followed by additional
carbohydrates to prevent recurrence.
In both severe and non-severe hypoglycaemia, the underlying
cause should be resolved when possible. This might include removing
the trigger or administering additional treatments (e.g. corticoste-
roids). Severe hypoglycaemia might directly or indirectly lead to
cardiac arrest. Although reversal of hypoglycaemia might not
necessarily improve long-term outcomes in children who are in
387
cardiac arrest, non-reversal of severe hypoglycaemia will cause brain
damage and likely prevent ROSC. Therefore, it seems logical to
include hypoglycaemia as one of the 4H, actively search for it,
specifically in children at risk (metabolic, septic, intoxicated), and treat
it when found.
Hyperthermia
We identified two guidelines (MHAUS.org 2019),498 three narrative
reviews499 501 and two observational studies (appendix RR
17.1).502,503 The ILCOR First Aid taskforce specifically performed a
COSTR on the First Aid Cooling Techniques for Heat Stroke and
Exertional Hyperthermia.497 Fever, hyperthermia, malignant hyper-
thermia, heat exhaustion and heat stroke are all distinct concepts with
specific definitions. Fever is generally a beneficial physiological
mechanism to fight infection and is not associated with long-term
neurological complications. Heat-related illness and malignant
hyperthermia both demand specific management (https://www.
mhaus.org/healthcare-professionals/mhaus- recommendations/).
For severe heat-related illness, rapid recognition, assessment,
cooling, and advanced planning are key to minimise the risk of
morbidity and mortality. Symptoms associated with different heat
related illnesses are similar. Although their distinction is not clear,
children with elevated body temperature and CNS abnormalities
should be treated as victims of heat stroke, which can be a life-
threatening event.
Status epilepticus
We report on only the emergency first-hour management, excluding
further treatment for super-refractory status epilepticus [SE] or
evidence on specific aetiologies (appendix RR 18). We included
three guidelines,504 506 13 SRs,507 519 six narrative reviews,520 525
15 RCT526 542 and 13 non-RCT clinical studies.543 556
The incidence of paediatric SE is roughly 20 per 100,000 children per
year, with an overall mortality of 3%. Prognosis is related to age, seizure
duration and underlying cause. Despite mounting evidence that early
treatment of SE is more effective and safer, both the initial and subsequent
treatment is often delayed. Delayed treatment leads to decreased
response to treatment, longer seizures, greater need of continuous
infusions, potential brain injury and increased in-hospital mortality.
The current operational definition of SE includes seizures that
have not stopped spontaneously within 5 min, as the likelihood of
spontaneous cessation after this interval is low. Timely aggressive
treatment of SE requires implementation of strict protocols. Imple-
mentation strategies should focus both on training of all professionals
involved, as well as regular audit of performance and protocol
adherence.
Time points in the algorithm represent maximum times before
implementing the relevant step, but, depending on the cause and
severity, children may go through the phases faster or even skip the
second phase and move rapidly to the third phase, especially in sick or
intensive care unit patients. Identify and manage underlying
precipitant causes early on including metabolic derangements (e.g.
hypoglycaemia, electrolyte disorders) and other causes (e.g.
neurological, cardiological, metabolic, intoxications), as well as the
systemic complications caused by underlying aetiology or treatment
that could result in secondary brain injury.
Benzodiazepines are the initial therapy of choice, given their
demonstrated efficacy, safety, and tolerability. Which benzodiazepine
 RESUSCITATION 161 (2021) 327
to use via which route will depend on the availability, context, social
preference, and expertise as there is no strong evidence to prefer one
over the other. A first-line benzodiazepine (at least a first dose) can
also be administered by properly trained lay caregivers or first
responders. Although IV benzodiazepines are generally considered
easy to administer and effective, in cases where there is not yet an IV-
line, other routes might be preferable to avoid delay. A very recent
RCT suggests intramuscular midazolam to be more efficient than
buccal midazolam.527 Although IV phenobarbital is effective and well
tolerated, its slower rate of administration makes it an alternative initial
therapy rather than the drug of first choice. Adequate dosing of the
chosen benzodiazepine is essential for early SE cessation.
The approach in resource-limited settings is similar, considering
potential differences in underlying aetiology and co-morbidity.
Administration of more than two doses of benzodiazepine is
associated with an increased risk of respiratory failure and subse-
quent death in settings where ventilation is not available.
A timely transition from first-line drugs to other anti-epileptic drugs
could contribute to reducing treatment resistance in convulsive SE. IV
Phenytoin/fosphenytoin, valproic acid and levetiracetam have been
proposed for step 2. Where most protocols still include phenytoin as
drug of choice, recent evidence favours levetiracetam in view of both
cost-effectiveness, ease of use and safety profile. Valproic acid has
similar response rates but is teratogenic and there is an associated risk
of acute encephalopathy, related to hepatic abnormalities, hyper-
ammonaemia and/or metabolic underlying diseases. Especially in
infants and younger children this warrants extreme caution. IV
phenobarbital is a reasonable alternative if none of the three above
mentioned therapies are available. Here too, adequate dosing is
essential. In resource-limited settings, when parenteral formulations of
long-acting anti-epileptic drugs are not available, the use of enteral
formulations delivered nasogastrically is feasible and potentially
effective. Oral levetiracetam syrup has excellent bioavailability and
produces therapeutic serum levels within approximately 1 h of delivery.
Recent papers also describe the use of lacosamide in paediatric
SE. While lacosamide seems safe and effective, the evidence is
currently too limited for widespread use.
Additional rescue medications should be considered for prolonged
SE (step 3, no later than at 40 min). It is acceptable and potentially
effective to use one of the second-line drugs not yet given immediately
after the first second-line drug is given, as this might prevent the need
for and thus complications of anaesthesia and intubation. Alternative-
ly, depending on aetiology, vital signs and circumstances, anaesthetic
doses of midazolam, pentobarbital/thiopental, ketamine or propofol
can be considered, ideally with continuous EEG monitoring. Health-
care providers should be thoroughly familiar with the properties of
each of these drugs when using them.
Non-convulsive SE can occur after cessation of visible seizures in
convulsive SE, especially if the underlying cause is an acute central
nervous system infection. EEG monitoring after treatment of CSE is
essential for the recognition of persistent seizures. Early recognition
and treatment of non-convulsive SE is advocated because it may
influence outcome.
Recognition of cardiac arrest sequence of PBLS duty
cycle bystander CPR
Although the ILCOR BLS taskforce advised in favour of commenc-
ing CPR with compressions (CAB), the paediatric taskforce
maintained clinical equipoise. In a separate COSTR the PLS
387 353
taskforce had already suggested that bystanders provide CPR with
ventilation for infants and children younger than 18 years with OHCA
(weak recommendation, very low quality evidence) and that if
bystanders can’t provide rescue breaths as part of CPR for infants
and children younger than 18 years with OHCA (Good Practice
statement), they should at least provide chest compressions.4 The
ILCOR PLS taskforce also recommended that emergency dis-
patchers provide CPR instructions for paediatric CA when no
bystander CPR is in progress (strong recommendation, low
certainty evidence).143 The ILCOR BLS taskforce further recom-
mended that lay persons initiate CPR in children or adults for
presumed CA without concerns of harm to patients not in CA (strong
recommendation, very low certainty evidence).557 A Cochrane
review on continuous chest compressions for non-asphyxial OHCA
identified only one paediatric study.558 Our RR additionally included
some manikin studies as ‘indirect’ evidence (appendix RR
19.1,19.4, and 19.5).559 563 We also refer to the RR on pulse
check RR 19.7 and RR 25 on CPR for bradycardia.
The majority of paediatric cardiac arrests are caused by
hypoxaemia or ischaemia and oxygen reserves are most often
depleted by the time arrest occurs. The added value of ventilation in
this context has been advocated repeatedly.564 The PLS 2020
COSTR recommends bystanders provide CPR with ventilation for
paediatric OHCA.143 The taskforce identified in a subsequent search
two additional papers (very-low certainty evidence) that found no
difference in survival and neurological outcomes with compression-
only CPR in children (older than infants), but did not consider this
sufficient evidence to change their recommendation.565,566 In a
multicenter cohort study, higher ventilation rates during CPR were
associated with improved outcome.567
Unconscious children with an obstructed airway might experience
ventilatory arrest. Spontaneous breathing may be restored with simple
airway opening and a few positive pressure breaths. Such children
have an excellent outcome but might not be captured in CA registries,
unless chest compressions are started before airway opening.
In making these recommendations we also considered that:
 Mobile phones are ubiquitous and most emergency calls are
currently by mobile phone. Limited evidence suggests about 60%
of callers can put their mobile phone on speaker.
 For adult CPR, the ILCOR BLS taskforce recommends that the
lone bystander with a mobile phone first dials the EMS, activates
the speaker or other hands-free option on the mobile phone, and
then immediately begins CPR (strong recommendation, very-low-
certainty of evidence).557
 Removing clothes did not seem to influence quality of CPR in two
simulation studies but induced a delay of about 30 s.
 The identification of ‘abnormal breathing’ is not always easy in
case of dispatcher-assisted CPR and adding specific word
descriptors might improve recognition. Some groups suggest in
adults the use of the ‘hand on belly’ method.568 These methods are
especially relevant in cases where there are issues of safety in
approaching the victim's mouth and nose (e.g. viral transmission).
The standard ‘look, listen, feel’ method should be avoided in these
cases.7
 There is no evidence to support nor refute the existing guideline
advocating five initial rescue breaths. Considering the impact on
education and implementation, we therefore continue to recom-
mend this approach.
 Adequate ventilation demands a sufficient long inspiratory time
(1 s) and an adequate tidal volume (chest rise). To do so, there must
354 RESUSCITATION 161 (2021) 327
be a good seal between mouth of the rescuer (or mask) and the
mouth/mouth-nose of the child (if needed, closing nose or lips to
avoid air escape). When available, competent providers should use
(2- person) BMV preferably with oxygen instead of expired air
ventilation. In larger children when BMV is not available, competent
providers can also use a pocket mask for rescue breaths.
All three discriminants of the formula of survival (science, education,
and implementation) are important and we recommend that only those
trained specifically in paediatric BLS use the paediatric specific
guidelines. The duty cycle advocated in the 2015 guidelines for
children was 15:2 and there is no reason to change this. Short pauses
for rhythm check and a switch of the rescuer performing compressions
to minimise fatigue should be scheduled every 2 min. In cases where
there is a risk of earlier fatigue (e.g. when wearing full PPE for COVID-
19) more rapid switching might be reasonable.569
BLS in traumatic cardiac arrest
Most of the evidence found on this topic was indirect (appendix RR
19.6). We identified four observational studies and refer to the ILCOR
first aid COSTR on external bleeding and spinal motion restric-
tion.497,570 573 Paediatric traumatic cardiac arrest [TCA] is rare and
has a poor outcome. Of 21,710 children in the UK TARN database,
0.6% sustained TCA.571 Overall, 30-day survival was 5.4% ((95% CI
2.6 to 10.8%), n = 7). In one TCA cohort initial recorded rhythms were
shockable in only 3.5%.570 Most TCAs were unwitnessed (49.5%),
and less than 20% of children received chest compressions by
bystanders. 19.5% achieved ROSC in the field, 9.8% survived the first
24 h, and 5.7% survived to discharge. Unlike those sustaining blunt
trauma or strangulation, most TCA patients who survived the first 24 h
after penetrating trauma or drowning were discharged alive. We could
not find studies investigating a relationship between a specific
sequence of BLS actions and outcome for TCA. Dispatcher-assisted
CPR (DA-CPR) seemed not to be associated with achieving sustained
ROSC.574 TCA cases were less likely to have dispatcher recognition
of cardiac arrest, dispatcher initiation of bystander CPR or any
dispatcher delivery of CPR instructions. Improved DA-CPR protocols
for TCA should be studied and validated.
Overall, bystander CPR was performed in 20 35% of paediatric
TCAs.572 Bystander interventions varied greatly, mainly depending on
situational factors and the type of medical emergency. In one cohort
survivors had triple the rate of bystander CPR than non-survivors.570
This survival advantage for bystander CPR may be even greater for
trauma victims in low- and middle-income countries where posture
change and airway opening by bystanders reduces mortality.575 We
advise performing bystander CPR for paediatric TCA provided it is
safe to do so. The bystander should minimise spinal movement as far
as possible without hampering the process of resuscitation.
There are no data exploring the individual components of CPR.
Among 424 adults with TCA, there was no significant difference in
sustained ROSC between AED and non-AED groups.576 Shockable
rhythms are rare in paediatric TCA. Adult TCA guidelines also de-
emphasise the importance of defibrillation. Therefore, we do not
encourage the routine use of AEDs at the scene of paediatric TCA
unless there is a high likelihood of a shockable underlying rhythm.
Massive haemorrhage is one cause of TCA. The initial treatment
for external massive bleeding is direct pressure - if possible, using
haemostatic dressings. The ILCOR first aid taskforce suggested that if
life-threatening external bleeding is amenable to the application of a
387
tourniquet, first aid providers should use a tourniquet in preference to
direct manual pressure alone.497 A manufactured tourniquet is
preferred to an improvised tourniquet (weak recommendations, very
low certainty of evidence).
Pulse check
We identified two observational studies and refer to RR 32.3 on the
use of ultrasound during CPR.577,578 No studies compared manual
pulse check with ‘signs of life’ in a RCT design (appendix RR 19.7).
‘Signs of life’ were implemented as part of the guidelines because of
concern about false negatives and thus not providing CPR where it
was needed. Starting CPR in those not needing it is off less concern
not least because CPR-induced injury is rare in infants and children.
Some data indicate that providing CPR to children with ‘non-
pulseless’ bradycardia and severely impaired perfusion improves
outcome.579
The identification of pulseless CA and ROSC in advanced life
support relies on evaluation of circulation, including the manual
palpation of pulses. Although experienced health care providers
perform better than inexperienced providers, the risk of both type 1
and type 2 error and prolonged CPR pauses is still significant. The
detection of circulation therefore should also include other intra-arrest
parameters such as ETCO2, blood pressure and SpO2 (or possibly
ultrasound).
Chest compressions: rate depth recoil
The 2020 COSTR PLS 1605 on chest compression depth
identified insufficient evidence to change existing recommenda-
tions.143 In addition to a related scoping review,580 we also report
on six RCTs581 586 and 15 observational studies (appendix RR
21.1).587 601
Evidence suggests that outcome is related to the quality of chest
compressions, including hands-off time. Several factors should be
considered, ideally in an integrated way. Instead of considering the
average of each factor, focus on consistent good quality compres-
sions meaning a high percentage of compressions that are good:
 Rate: the 2015 guidelines recommended a rate of 100 120 min 1
for all infants and children. Excessive rates are not uncommon in
children and might impact outcome.602,603 Very low certainty
evidence suggests slightly slower rates (80 100) are associated
with a higher rate of survival to hospital discharge and survival with
favourable neurological outcome.588 The current guideline is
unchanged.
 Depth: a certain depth is needed to generate blood pressure and
perfusion, but over-compression might worsen outcome. The
2015 guidelines recommended depressing the lower sternum by
at least one third of the anterior posterior (AP) dimension of the
chest (infant 4 cm, child 5 cm). In older, larger children however,
this 1/3 of the AP dimension might often generate a compression
depth of more than 6 cm (adult limit). Also, the 2015 target is often
not reached and there is a risk that compression will be too shallow
if there is too much concern about over-compression.595 Visually
determining depth in cm is near impossible (and so only
informative for feedback devices). We therefore continue to
recommend depressing the lower sternum by one third of the AP
dimension of the chest. For larger children, compressions should
never be deeper than the adult 6 cm limit (approx. an adult thumb's
length). Positioning the arm 90 to the chest and using a step stool
 RESUSCITATION 161 (2021) 327
are modifiable factors facilitating improved chest compression
depth.604
 Recoil and leaning: this might impact outcome by hampering
venous return. There is no evidence to suggest a relation between
rate, depth and recoil but be aware of the risk of insufficient recoil
when performing CPR.
 Hands-off time: indirect evidence from adults suggests that it is
important to limit the hands-off time as much as possible.
Visual feedback helps to keep compression rates within the correct
range, but applied force remains widely variable. Feedback devices
might positively influence the quality of CPR, but current evidence is
still equivocal. Until further data (from e.g. the multicenter PediResQ
study) become available, we align our advice with the ILCOR BLS
COSTR which suggests against routine implementation of real-time
CPR feedback devices as a stand-alone measure to improve
resuscitation outcome, without more comprehensive quality improve-
ment initiatives (weak recommendation, very low quality of evi-
dence).557 In systems currently using real-time CPR feedback
devices, they suggest these devices may continue to be used given
that there is no evidence suggesting significant harm (weak
recommendation, very low quality of evidence).
The ILCOR BLS taskforce also evaluated the impact of a firm
surface for chest compressions.557 They made the following recom-
mendation: “We suggest performing chest compressions on a firm
surface when possible (weak recommendation, very low certainty
evidence). During in-hospital cardiac arrest, we suggest, where a bed
has a CPR mode which increases mattress stiffness, it should be
activated (weak recommendation, very low certainty of evidence).
During in-hospital cardiac arrest, we suggest against moving a patient
from a bed to floor, to improve chest compression depth (weak
recommendation, very low certainty of evidence). During in-hospital
cardiac arrest, we suggest in favour of either a backboard (when
already implemented in routine practice) or no-backboard strategy (if
not yet part of current practice), to improve chest compression depth,
(Conditional recommendation, very low certainty of evidence).”
There is a lack of studies in OHCA and in children. Providers
should avoid inadequate compression depth due to soft surfaces and
either change the surface or adjust the compression force. In general,
children can be more easily moved to improve CPR quality (firm
surface, accessibility to the victim). Moving the child should be
balanced against the risk of injury, delay, more confined space (if
moved to the floor) or losing monitoring or IV access.
Chest compressions: method
We identified three SRs,605 607 four observational studies608 611 and
24 (randomised) manikin studies (appendix RR 21.2).599,603,612 631
The method of chest compression influences the attainment of set
goals for rate, depth and recoil. The level of certainty of the available
evidence for different compression methods is very limited.
For infants, previous guidelines advised using two fingers (TF) for
a single and a two-thumb encircling technique (TTET) for two
rescuers. Compression location should be the lower half of the
sternum. However, the standard TF technique is associated with
suboptimal compression quality and early fatigue. The TTET
consistently performs better, even for the single rescuer, and
hands-off times are little different compare to the TF technique,
although there is an identified risk of incomplete recoil (to be
considered when teaching). The TF technique should only be
387 355
considered for untrained rescuers (supported by dispatcher CPR or
those only trained in adult BLS), where a TTET might be too difficult to
explain ad hoc.
The 2015 paediatric ERC guidelines advised that the thumbs
should be side by side and non-overlapping when using the TTET.
This differed from the 2015 neonatal guidelines that advised placing
one thumb on top of the other (superimposed). We advise using the
latter method, if possible, based on weak evidence suggesting the
superimposed thumb technique to generate a higher perfusion
pressure and less liver compression.
New techniques to improve the quality of CPR have recently been
explored. None of these have been validated in children. Preliminary
results from manikin studies suggest these methods are at least as
effective as standard techniques.632 The modified vertical two-thumb
technique might be especially useful for providers with smaller
hands.633 These new methods should be considered only as ‘rescue’
alternatives for providers trained in their use when standard methods
become too tiring or are difficult to perform.
The optimal compression position for infants was set in the 2015
guidelines at the lower half of the sternum. To avoid compression of
other organs, it was advised to stay one-finger width above the
xiphisternum. Recent data from CT studies suggest that this advice
still holds. One study highlighted the value of position aids (marker
stickers) to improve quality of CPR.613
For children older than 1 year, rescuers can use either one-handed
or two-handed CPR. There is insufficient evidence to change the 2015
guideline and advise one technique over another. The attainment of
the set goals should define which technique is used. If the one-handed
technique is used the other hand can be positioned to maintain an
open airway throughout or to stabilise the compression arm at the
elbow.
Standard guidelines advise changing the person doing compres-
sions every 2 min. However, regardless of the technique fatigue and
decreasing quality can occur after just 60 to 90 s. Rescuers should be
alert to fatigue and switch hands, technique or rescuer when
necessary to maintain optimal compressions.
The use of an automated external defibrillator [AED] as part of
PBLS
We identified one guideline,634 one SR,635 one narrative review636
and 11 observational studies (appendix RR 22).14,637 646
Early defibrillation in patients with CA and a shockable rhythm
increases the high likelihood of ROSC and a subsequent good
neurological outcome in children and adults. However, in children with
a primary non-shockable rhythm, the use of the AED might increase
no-flow time and divert attention from other interventions which
influence outcome.
During BLS it is impossible to determine the underlying rhythm
before attaching an AED or other monitor, thus rescuers must rely on
contextual evidence for the decision to use an AED. Alternatively, an
AED can be attached in all children. The likelihood of a shockable
rhythm is much higher in older children, children with specific medical
conditions or a sudden witnessed collapse; but shockable rhythms
can also occur in other cases, even in the very young. A small
proportion of children with an initial non-shockable rhythm will have a
subsequent shockable rhythm (0.5 2%). There is insufficient
evidence to change existing recommendations. For treatment of
out-of-hospital VF/pulseless VT in children under 8 years of age the
recommended method of shock delivery is, in order of preference: (1)
356 RESUSCITATION 161 (2021) 327
manual defibrillator, (2) AED with dose attenuator and (3) AED without
dose attenuator. If there is any delay in the availability of the preferred
device, use the device that is available. The majority of existing AEDs
deliver a standard dose of 120 200 J (biphasic) and with a paediatric
attenuator the dose is usually 50 J. The algorithm of an AED used for
small children should have demonstrated high specificity and
sensitivity for detecting shockable rhythms in infants.
While continuing to emphasise the importance of rescue breaths
and high-quality chest compressions we advise the use of AEDs in all
children if feasible (i.e. more than one rescuer, AED accessible). Lone
rescuers should not interrupt CPR to collect an AED unless there is a
high likelihood of a primary shockable rhythm (such as in sudden
witnessed collapse) and the AED directly available.
These recommendations are for trained providers. CPR provided
by untrained bystanders is typically guided by EMS dispatchers. The
risk of prolonged no-flow time and suboptimal CPR quality is higher
when untrained bystanders use an AED even with dispatcher
assistance. Although there is no specific literature supporting this
recommendation, it is our opinion that an AED should primarily be
advised as part of dispatcher-assisted CPR in those cases where the
likelihood of a primary shockable rhythm is very high (as in sudden
witnessed collapse or when there are specific ‘cardiac’ antecedents),
and there is an AED nearby and accessible.
Recovery position
In making our recommendation, we considered the ILCOR First Aid
COSTR on the topic,497 as well as one guideline647 three SRs,648 650
two RCTs,651,652 and five observational studies (appendix RR 23).653
657
The recovery position has been advised for use in unconscious
non-trauma patients without advanced airway support, who are not in
cardiac arrest. If performed properly, it improves airway patency and
reduces the risk of aspiration compared to the supine position. In one
cohort study, the recovery position was associated with a significant
decrease in hospital admission.656 In cardiopulmonary arrest,
children almost immediately lose consciousness but can have
breathing movements for up to 2 min after arrest. The lateral recovery
position might hinder the early detection of abnormal breathing. To
prevent this, rescuers should be taught to repeatedly assess
breathing. Changing the recommendation of re-evaluating the victim
from ‘regularly’ to ‘every minute’ significantly increased the likelihood
of detecting CA.652 In the case of untrained lay people, EMS
dispatchers should therefore stay in contact with rescuers until the
EMS arrives.
The overall evidence is very limited, and it remains unclear
whether this advice applies to all situations and types of rescuer. In
cases of pregnancy and in intoxicated children, a left lateral position is
preferable.648 In situations where there is a high risk of hypoxic
respiratory arrest or impending CA, it is probably advisable to just
continue head tilt chin lift or jaw thrust in the supine position. For the
specific case of unconscious trauma victims, one must also balance
the harm of decreased airway patency against the risk of secondary
spinal injury. The evidence is equivocal about the potential for harm of
lateral rotation in trauma. Mandatory in-line stabilisation requires
several rescuers to place and maintain the child in a recovery position.
Foreign body airway obstruction [FBAO]
FBAO causes thousands of deaths yearly, particularly in vulnerable
populations that have difficulty protecting their airway, such as
387
children.658 Rapid bystander interventions can significantly improve
survival. Age-specific manoeuvres for FBAO have been part of
resuscitation guidelines for more than 25 years. However, despite
FBAO being an important health problem, and many anecdotal reports
of successful airway clearance, the evidence supporting these
guidelines is conflicting and of very low certainty (appendix RR
24).659 663 A dedicated 2020 COSTR BLS368 provided treatment
recommendations.557
We do not recommend the use of existing anti-choking devices in the
first aid of a choking child. The immediate use of such a device might
distract bystanders from performing the recommended steps of the
current algorithm in a timely way. In the absence of evidence of safety,
certain risks to children cannot be ruled out. Such devices could
interfere with the ability to cough in conscious children and might cause
damage to upper airway structures or encourage aspiration of gastric
contents. There will also be a considerable cost associated with
widespread implementation of such devices. We acknowledge the lack
of evidence and the need for additional research, especially in victims
who are no longer coughing efficiently or are unconscious.664 In
situations where conventional manoeuvres have failed, an anti-choking
device might be an adjunct to standard treatment. However, at present,
this should be in the context of formal evaluation in a study setting.
Chest compression for children not in cardiac arrest
Despite a lack of evidence, previous guidelines recommended that
bradycardia with signs of poor perfusion, even with a palpable pulse,
should be treated by immediate CPR (appendix RR 25).665 667 In one
study, in 18% of children who received CPR, compressions were
started at the early stage of non-pulseless bradycardia before the child
became pulseless, whereas this only applied to 2% of adults receiving
CPR.668 Survival to discharge after pulseless non-shockable events
was better in children (24%) than in adults (11%) and this might have
been attributable to an early aggressive approach in children with
bradycardia with poor perfusion.
Outcomes from hypoxic cardiac arrest are clearly worse than those
of arrests of primary cardiac origin. It is likely that children with an
hypoxic cardiac arrest have already suffered severe hypoxic brain
damage by the time of circulatory arrest. In arrested heart organ
donors, after withdrawal of life-sustaining care, the first observed
physiological steps are desaturation and hypoperfusion.669 This
phase preceding terminal bradycardia may last between a few
minutes and 3 h. After the onset of bradycardia somatic death usually
occurs in a few minutes.
Several recent studies showed that children who received CPR for
bradycardia with pulses and poor perfusion had better outcomes than
children who suffered immediate asystole or PEA.579,670,671 Altogeth-
er, outcomes were the best in the population of children who became
bradycardic, received CPR but never became pulseless. The longer
the time between the initiation of CPR for bradycardia with pulse and
poor perfusion and the actual loss of pulse, the lower the chance of
survival.
We put higher value on the potential for improved outcome by early
CPR than the low potential risk of harm of inadvertent CPR. It is often
impossible to identify the point at which the pulse is truly lost and
waiting for pulselessness (or loss of SpO2 trace, blood pressure
values etc.) will only cause delay.
There are currently no studies on the impact of chest compres-
sions on survival in children with very low-flow shock states without
bradycardia (e.g. supraventricular tachycardia).
 RESUSCITATION 161 (2021) 327
Pads versus paddles for defibrillation
The ILCOR COSTR EvUp (PLS 378 426) did not identify sufficient
evidence to change the current guidelines (appendix RR 26.1).143,672
675
In those settings where self- adhesive pads are unavailable,
paddles are an acceptable alternative. Paddles might also be used for
the first defibrillation if the application of self-adhesive pads is taking
too long. As in 2015, defibrillation paddles can be used to determine a
rhythm if monitor leads or self-adhesive pads are not immediately
available.
We could not identify any high-certainty evidence favouring either
the anterio-posterior (AP) or the antero-lateral (AL) position. The
previous GL suggested ‘If the paddles are too large and there is a
danger of charge arcing across the paddles, one should be placed on
the upper back, below the left scapula and the other on the front, to the
left of the sternum’.667 However, other sources suggest a slightly
different position, based on anatomy and pathophysiology. Acknowl-
edging this and in view of consistency, for the AP position we advise
placing the anterior pad mid-chest immediately next to the sternum and
the posterior pad mid-back between the scapulae. Very low certainty
evidence suggests that the AP position might be at least as effective as
the AL position. The AP position is difficult to use with paddles. In case of
shock-resistant VF/pVT and an initial AL position of self-adhesive pads,
consider changing these to an AP position.
Stacked shocks
The PWG did not identify any new evidence to change the existing
recommendations that favour a single-shock strategy followed by
immediate CPR (appendix RR 26.2). However, in a setting with
monitoring attached and a defibrillator immediately ready for use,
immediate defibrillation before starting CPR following the
witnessed onset of VF/pVT is possible and potentially beneficial.
The heart is believed to be more readily defibrillated in this phase.676 If
an immediate defibrillation attempt is unsuccessful, outcome may be
improved by a second and if needed third attempt before commencing
CPR. Considering this and the relatively limited time delay of a ‘3
shocks first’ approach despite very limited evidence we advise
using a ‘stacked’ shock approach for those children who are monitored
and have a defibrillator immediately ready for use at the moment of a
‘witnessed’ VF/pVT.677,678 This ‘stacked shock’ approach has also
been advised during ALS for patients with COVID 19 where rescuers
are not yet wearing appropriate personal protection.7 In case of a
stacked shock approach, IV amiodarone is given immediately after the
3 initial shocks, whilst adrenaline will only be given after 4 min.
Dose and timing of defibrillation
Shockable rhythms are not infrequent in children (4 10%) and their
prognosis is better than other rhythms (appendix RR 26.3).679 The
primary determinant of survival from VF/pVT CA is the time to
defibrillation. Secondary VF is present at some point in up to 27% of in-
hospital resuscitation events and has a much poorer prognosis than
primary VF.
Energy dose: There are inconsistent data about the optimal
energy dose for shockable rhythms in children. The ILCOR PLS 405
scoping review did not identify sufficient new evidence to alter their
recommendation.143 In the SR of Mercier et al. ROSC was frequently
achieved (85%) with energy dose ranging from 2 to 7 J/kg.680 The
ideal energy dose for safe and effective defibrillation remains
387 357
unknown. The defibrillation threshold in children varies according to
body weight and appears to be higher in infants. A recent registry-
based study suggested better outcome for first shock energy doses of
around 2 J/kg in paediatric IHCA with primary shockable rhythms.681
However, this study did not report on many important co-variables
which might have affected the outcome such as reasons for protocol
violations, CPR quality, duration, no-flow time and number of shocks.
Sample sizes were also too small for strong conclusions.
Doses higher than 4 J/kg have defibrillated children effectively with
negligible side effects.680 Animal studies suggest myocardial damage
and subsequent reduced myocardial function with doses above
10 J/Kg. Adult data and guidelines suggest a first dose of 120 200 J
(depending on the type of waveform) with escalating doses for
refractory or recurrent VF. Adult guidelines also suggest attempting
defibrillation in any VF regardless of amplitude, even if this is judged to
be ‘fine’ or close to asystole.678
Given the lack of evidence and taking into consideration issues of
implementation and education we continue to recommend 4 J/kg as
standard energy dose. It seems reasonable not to use doses above
those suggested for adults and to consider stepwise escalating doses
for refractory VF/pVT (i.e. failure to respond to initial defibrillation and
antiarrhythmic medications).682 A lower energy dose for the first shock
(2 J/kg) might be a reasonable alternative for primary shockable
rhythms. If no manual defibrillator is available, use an AED that can
recognise paediatric shockable rhythms (appendix RR22).
Timing of charging and rhythm checks: it is unclear in adults
whether immediate defibrillation or a short period of CPR before
defibrillation is superior.683 The ILCOR BLS taskforce suggests a
short period of CPR until the defibrillator is ready for analysis and/or
defibrillation in unmonitored CA (weak recommendation, low-certainty
evidence).557 They also suggest immediate resumption of chest
compressions after shock delivery (weak recommendation, very-low-
certainty evidence). If there is alternative physiological evidence of
ROSC, chest compressions can be paused briefly for rhythm analysis.
The interval between defibrillation attempts is set at 2 min, as in the
2015 guidelines.667 This is based on expert opinion. There are studies
that show improved outcome with a more rapid second attempt, but
this is insufficient evidence to change the current guideline, especially
when considering the impact on education and implementation.684,685
Hypothermic cardiac arrest
The standard paediatric ALS actions should be adapted to adjust for
the hypothermic state of the victim. For details, we refer to the chapter
on special circumstances within these guidelines.405 We considered
the BLS 2020 COSTR on drowning,557 as well as one guideline,686
four SRs,687 690 two narrative reviews,691,692 and two observational
studies (appendix RR 27).693,694 Estimating the potential for survival
with good neurological outcome in children after hypothermic arrest is
difficult. No single parameter has sufficient test performance to do so.
The adage ‘no child can be declared dead if not warm’ does not
necessarily apply for those children with prolonged submersion/burial
times, a lethal injury, a fully frozen body, or an unmanageable airway.
However, none of these alone was 100% predictive and specifically in
children prolonged submersion times in ice cold water have been
associated with survival. Importantly, the presented evidence
suggests a far worse prognosis for those children with preceding or
associated asphyxia. Although not always easy to identify in the pre-
hospital environment, one should carefully consider the mechanism
and circumstances, and the first measured core body temperature
358 RESUSCITATION 161 (2021) 327
(<24  C is more likely primary hypothermic). Additionally, the team
should also consider the potential risks for the rescuers, the expected
use of resources and the potential for harm to the victim.695
Any child with severe hypothermia who is considered to have any
chance of favourable outcome (whether in CA or not) should ideally be
transported as soon as possible to a centre with ECLS or CPB capacity
for children. In hypothermic children emergency median sternotomy
seems the preferable technique for vascular access. If not accessible
continuous veno-venous haemofiltration or peritoneal lavage might be
alternatives but seem to be associated with far less favourable
outcomes.
FiO2 during CPR
The ILCOR 2020 COSTR PLS 396 did not identify sufficient evidence
to change their 2005 recommendation to use 100% oxygen.143
Although there is increasing evidence of a detrimental effect of
hyperoxia on survival in critically ill adults, including those admitted
with ROSC after CPR, clear evidence for an effect of oxygen titration
during CRP in patients of any age is lacking (appendix RR 28).
Hyperoxia during CPR is not clearly associated with increased
mortality.696
Advanced airway during ALS
Considering the published 2019 COSTR and two additional recent
observational studies,697 699 we advise the standard use of BMV
during OHCA (appendix RR 29.1). Intubation or SGA placement might
be performed once ROSC has been achieved. Competent airway
operators might consider placement of an advanced airway in cases
where CPR during transport or prolonged resuscitation is anticipated.
Despite the lack of evidence, for consistency, we advise a similar
approach for IHCA. However, when a competent professional attends
an IHCA, early placement of an advanced airway might be considered.
Ventilation strategy during ALS
In addition to the related ILCOR 2020 EvUp,143 we included four
observational studies and several papers with indirect evidence
(appendix RR 29.3).588,699 701
Overall, the evidence base in favour of ‘sub- physiological’
ventilation rates is weak and suffers from severe indirectness. Early
papers highlighted the potential harm caused by over-ventilation
during CPR in adults.702,703 However, the rates used to define
hyperventilation in adult research and guidelines might not be
applicable to children.
The importance of ventilation as part of the paediatric CPR
algorithm is discussed in RR 19.4 and RR 29.3. Furthermore, one
observational study be it with only 47 subjects suggests that low
respiratory rates may be associated with less favourable outcomes
especially for those children with bradycardia and poor perfusion.567
One paediatric animal study found no differences in ROSC rates
between ventilation rates of 10, 20 and 30 min 1 but the highest rate
was associated with higher PaO2 levels.700 This paper raised a
concern that lower PaCO2 values may result in reduced cerebral
oxygen delivery, as the NIRS values tended to be lower in the 30
breaths per minute group. From a pathophysiological perspective,
there is a fear that positive pressure breaths would inhibit passive
venous return into the thorax due to increased intrathoracic pressure,
and/or inadvertent PEEP. However, it is not known at what rate for age
387
this might become an issue in children. A recent paper using a porcine
infant asphyxia model of CA demonstrated that pressure-controlled
ventilation at a rate of 20/min with an FIO2 of 1.0 provided adequate
oxygenation and restored normocapnia.704
Given the above and considering issues of education and
implementation, we advise using minute volumes that are closer to
those used for ventilation of any critically ill child.
There are no studies in children on the optimum ventilation
strategy. What evidence there is, is derived from animal studies,
manikin simulations and questionnaire surveys. Animal studies
mainly used a porcine model of VF cardiac arrest and so did not
address the asphyxial pathophysiology of paediatric resuscitation.
One study showed that apnoeic oxygenation was equivalent to
positive pressure ventilation with a mechanical ventilator in main-
taining oxygenation in a VF arrest model.705 A further study examined
the effect of ventilator settings on blood gases and coronary perfusion
pressure during CPR and demonstrated that trigger settings should be
disabled.706 Three adult studies examined chest compression
synchronised ventilation modes and concluded that they offer
advantages during CPR, but it is unclear how this translates into
paediatric practice.707 709 More relevant to paediatric resuscitation, is
a newborn piglet study which demonstrated that the use of a self-
inflating bag, a T-piece resuscitator or a mechanical ventilator all had
similar effects on gas exchange.710 The same group highlighted the
leak around an uncuffed TT during CPR, which increased with
PEEP.711 Various manikin studies showed how the use of ventilator
systems during adult CPR freed up hands for other necessary
tasks.712 714
There are no data to inform the use of PEEP. It is known that
intrathoracic airway closure occurs during CPR and that PEEP could
potentially reverse this.715 However, there is also concern that PEEP
would raise the intrathoracic pressure and inhibit venous return during
compressions. Low PEEP is likely to reduce oxygenation in children
already requiring high PEEP before CA.
Finally, there might not be a need for five initial rescue breaths in
children already ventilated before cardiac arrest, but providers should
check that ventilations before cardiac arrest were adequate -and for
instance not themselves the reason for cardiac arrest- before deciding
to omit the first rescue breaths.
Adrenaline during ALS
We considered the 2020 PLS COSTR 1541,143 as well as some
additional non-RCTs for our RR (appendix RR 30).716 726 A shorter
time to first administration of adrenaline is associated with more
favourable outcomes in children for both IHCA and OHCA, a time to
first dose of adrenaline of less than 3 min being the most favourable.
No subgroup analyses between shockable and non-shockable CA
rhythms could be performed. A cut-off of 5 min for the interval between
adrenaline doses in paediatric IHCA was favourable for ROSC,
survival to hospital discharge, and 12-month survival. However, if the
cut-off interval was set as 3 min, more frequent administration of
adrenaline tended to be harmful for 12-month survival.
Similar to adult data, the time to first adrenaline dose in
traumatic CA seems to have different effects: a shorter time
(<15 min) to first dose compared with a longer time was associated
with significantly higher ROSC, but not with improved survival at
discharge or better neurological outcome. Furthermore, early
adrenaline administration was a risk factor for mortality in an
haemorrhagic shock subgroup.
 RESUSCITATION 161 (2021) 327
In line with the PLS COSTR 1541, we recommend administering
the first dose of adrenaline for non-shockable rhythms as early as
possible after collapse if possible, within 3 min. Given the lack of
evidence concerning dose interval, we continue to advise an interval
of 3 5 min. Avoid an interval shorter than 3 min. In case of trauma, we
put less emphasis on early adrenaline and advice rescuers to first
consider treatment for reversible causes. In shockable rhythms, in line
with the 2015 paediatric guidelines, we recommend giving a first dose
of adrenaline after the third shock (about 4 5 min after start of
CPR).667 Although rare, avoid adrenaline in catecholaminergic
polymorphic VT as this will aggravate the arrhythmia and worsen
outcome.727
Finally, other vasoactive drugs (like vasopressin, terlipressin,
milrinone or noradrenaline) have all been used in CA both in studies
and in reports of clinical practice. The evidence for or against their use
remains very weak and we would currently only advise their use in
research settings.
The use of amiodarone or lidocaine during ALS
This was topic of a 2018 ILCOR COSTR PLS 825 and published in the
ERC 2018 update.728 The 2015 recommendations about the use of
amiodarone or lidocaine remained unchanged. Either amiodarone or
lidocaine can be used in the treatment of paediatric shock- refractory
VF/pVT. Clinicians should use the drug with which they are familiar. A
recent retrospective comparative cohort study (GWTG-R) did not find
any difference in outcome for either drug (appendix RR 30.2).729
Atropine during ALS
We did not identify any relevant paediatric studies or recent indirect
evidence supporting the use of atropine in children in CA (appendix
RR 31.1). For other use and dosing we refer to the related RR.
Magnesium
We did not identify any relevant paediatric studies or recent indirect
evidence supporting an alteration in the 2015 ERC guideline which
advised that magnesium should not be given routinely during CA
(appendix RR 31.2).667 Magnesium treatment is indicated in the child
with documented hypomagnesaemia or with torsade de pointes VT
regardless of the cause.
Calcium
We identified two observational studies,730,731 that gave no reason to
alter the recommendations made in 2010: the routine use of calcium
for infants and children with cardiopulmonary arrest is not recom-
mended in the absence of hypocalcemia, calcium channel blocker
overdose, hypermagnesaemia, or hyperkalaemia. (appendix RR
31.3).143
Bicarbonate
Since 2010, one narrative review732 and nine observational trials were
published describing the association between the administration of
sodium bicarbonate (or THAM) and outcomes in paediatric CA
(appendix RR 31.4).14,730,733 738 Whilst these studies are likely to be
confounded by the association between administration of sodium
bicarbonate and longer CPR duration, none provide any evidence to
387 359
change the recommendation that bicarbonate should not be given
routinely in paediatric CA.
The previous guidelines recommended that bicarbonate may be
considered in cases of prolonged CA, severe metabolic acidosis,
haemodynamic instability, co-existing hyperkalaemia and tricyclic
antidepressant drug overdose. We however did not find any evidence
to support the use of sodium bicarbonate in prolonged CA beyond the
latter two indications.
Intra-arrest parameters to guide CPR
Recommendations were primarily based on the related 2020 ILCOR
PLS scoping reviews.143 Given the limited evidence found, these
reviews also considered adult and animal data, taking into account the
serious indirectness of these (appendix 32.1, 32.2, 32.3, 32.4 and
32.6).
ETCO2
The 2020 ILCOR PLS scoping review identified two observational
studies.739,740 ETCO2 is thought to relate to cardiac output and
perfusion. However, in one study it was not associated with diastolic
blood pressure nor with any pre-defined outcomes.739 This might be
because ETCO2 is also affected by minute volume and ventilation:
perfusion matching. This study was only descriptive in nature, in a very
selected population and at no point evaluated the outcomes
associated with ETCO2-directed CPR.
The level of certainty of the available paediatric evidence is too low
to make any recommendation for or against the use of ETCO2 to guide
resuscitation efforts in children with CA. More specifically, there is no
single ETCO2 value that can be used as an indicator to terminate CPR,
nor is there a single value that can be used as a target during CPR or as
an indicator to continue or discontinue CPR.
Blood pressure
The 2020 ILCOR PLS scoping review identified three observational
studies.735,741,742 Adequate myocardial and brain tissue perfusion is
fundamental to outcome and blood pressure could be useful as a
clinically measurable surrogate for this. The current evidence is of
very low certainty due to study design, sample size and selection
bias, but suggests a possible relation between diastolic BP and the
child's outcome. Only IHCA events were studied because of the
need for invasive BP monitoring. Although one study identified
optimal ROC curve thresholds for test performance, and thresholds
below which no child survived,742 the evidence is too limited to
consider diastolic BP on its own sufficient to identify CPR futility or to
predict favourable outcome. The level of certainty of the available
evidence is too low to make any recommendation for or against the
use of diastolic blood pressure to guide resuscitation efforts in
children with cardiac arrest. However, for those children with IHCA
where an arterial line is already in place and within settings that
allow for proper implementation, haemodynamic-directed CPR
might be considered.
POCUS
In their 2020 scoping review PLS 814 the ILCOR paediatric Taskforce
warned against rapid implementation of POCUS in paediatric practice
without sufficient evidence, despite its great potential and widespread
acceptance. Acquisition and interpretation of images in children is
more complex, especially in children with pre-existing heart disease.
Furthermore, there are significant material and training costs which
360 RESUSCITATION 161 (2021) 327
might be important in low-resource settings. We suggest the use of
POCUS by competent healthcare providers, when feasible, to identify
reversible causes of cardiac arrest (4H4T). POCUS may also have
role in identifying the presence of perfusion, but currently this should
be only in the context of research. POCUS should currently not be
used for prognostication.
Near-infrared spectroscopy NIRS
The related 2020 ILCOR PLS identified two small observational
studies.743,744 The adult literature is more extensive, but the level of
certainty is still low (serious indirectness presumed). At present, there
is no consensus on a cut-off threshold of regional cerebral oxygen
saturation (rSO2) that can be used as an indicator of futility, nor is there
a single rSO2 value that can be used as a target during CPR or an
argument to continue CPR. Adult literature suggests that a trend in
rSO2 is the most useful prognostic indicator, although this has not yet
been validated in adults or children.
Lactate or potassium
We identified two SRs,687,688 one guideline 686 and seven relevant
non-RCT studies.694,745 750
Intra-arrest potassium measurement is indicated for the exclusion
of hyperkalaemia as a potential reversible cause of CA. However,
there is insufficient evidence for making a statement about its use as a
prognostication factor in children with CA. Even extreme hyper-
kalaemia should not impede CPR and ECLS in children.
Elevated lactate values are associated with worse short- and long-
term outcomes in critically ill children, children with IHCA as well as in
children treated with ECLS; they do not alone enable early
prognostication. It should be noted that IO lactate samples might
be higher during CA than in arterial and venous samples (evidence
from animal studies only).
Reversible causes of paediatric cardiac arrest: 4H4T
For most topics we refer to the dedicated RR within this document. In
this paragraph, we highlight the potential reversibility and/or treatment
options of certain pathologies. To do so we identified two guide-
lines,677,751 one SR,752 eight observational studies and several
background papers (appendix RR 33.1).485 487,738,753 756
Although there might be other causes of CA that could be
considered reversible some sources propose 5 or even 6 Hs and Ts
we prefer to keep the ‘4H4T’ mnemonic, in view of both consistency
with the adult guidelines and ease of education.678 We added
hyperthermia (see RR 17.1) and hypoglycaemia (see RR 15) and
deleted acidosis as reversible cause (see RR 31.4). Specific
conditions such as cardiac surgery, neurosurgery, trauma, sepsis,
and pulmonary hypertension demand a specific approach and
importantly, the more widespread use of eCPR changes the concept
of reversibility (see RR 33.3).
Institutions performing cardiothoracic surgery in children should
establish institution-specific algorithms for CA in paediatric patients
after cardiothoracic surgery. It is highly probable that this very specific
group of patients will benefit from a different sequence of actions.
There are two recent guidelines that can serve as an example for the
development of such an algorithm from The Society of Thoracic
Surgeons and the European Association for Cardio-Thoracic
Surgery.677
387
Cardiac arrest in septic children
We considered one SR757 and 10 non-RCT studies (appendix RR
33.2).734,758 764 Severe sepsis and septic shock are known risk
factors for paediatric CA. Sepsis-associated IHCA has a bad outcome
and prevention is the most crucial step. Different strategies can be
used to prevent sepsis associated IHCA including the use of ECMO in
refractory septic shock. No recommendations to deviate from the
standard PALS algorithm can be made based on the currently
available evidence. Early consideration and treatment of possible
reversible causes is highly encouraged. IHCA occurring shortly before
or during ECMO cannulation should not preclude ECMO initiation in
paediatric patients with refractory septic shock as studies suggests
that these children possibly benefit most from ECLS. Using high flows
(greater than 150 mL/kg/min) might improve outcomes. Should ECPR
be considered as a rescue therapy for septic IHCA the ECMO team
must be activated early after initiation of PALS based on institution-
specific protocols.
Traumatic cardiac arrest
Our RR identified two guidelines,765,766 10 SRs,767 776 17 observa-
tional studies,450,571,777 790 and a lot of papers with indirect evidence
(appendix RR 34).
Paediatric TCA has a poor prognosis. Children with TCA who
arrest after ED admission have better outcomes than those who arrest
in the field. Strategies for improving early resuscitation can potentially
change outcome. In case of paediatric TCA, resuscitation should be
initiated in the absence of signs of irreversible death. Prolonged
resuscitative efforts in children after blunt injury in whom CPR was
ongoing for more than 15 min before arrival at the ED (or pre-hospital
initiation of advanced CPR techniques) and who have fixed pupils are
probably not beneficial and termination of resuscitation may be
considered.
There is insufficient evidence to recommend for or against any
specific sequence of actions in paediatric TCA. However, the early
reversal of some of the reversible causes might yield more ROSC
during pre-hospital care. Given this and the dire prognosis of
paediatric TCA with standard care, we advise the pre-hospital near-
immediate use of a bundle of interventions aimed specifically at
reversible causes. Chest compressions should, if possible, be
performed simultaneously with other interventions depending on
the available personnel. Treatment of assumed reversible causes,
based on mechanism of injury, might precede adrenaline
administration.
Consider ED thoracotomy in paediatric TCA patients with
penetrating trauma with or without signs of life on arrival to ED as
this may improve survival of these children. Highly competent
professionals in settings where the procedure has already been
implemented might also consider pre-hospital thoracotomy for these
children.
Current evidence shows no benefit (or even worse outcome) of
thoracotomy in children after blunt injuries and this intervention is
not generally recommended. In very selected blunt injury patients,
based on thorough assessment, highly competent professionals
might nevertheless identify an indication for emergency thoracot-
omy. Children with TCA should preferably be transported directly
to a major trauma centre designated for children (or both children
and adults) based on the local trauma system policy (expert
consensus).
 RESUSCITATION 161 (2021) 327
Pulmonary hypertension
We refer to the ILCOR 2020 EvUp PLS 56143 and the high-quality
scientific statement by the American Heart Association on CPR in
children with cardiac disease, as well as the specific guideline on
intensive care treatment of PHT in children by the European Paediatric
Pulmonary Vascular disease Network (appendix RR 35).791,792
Consider the possibility of PHT in children with IHCA, who have a
predefined risk for it.793 Once cardiac arrest develops in a child with
PHT, chest compressions and resuscitation drugs might be ineffective
in generating pulmonary blood flow, left ventricular filling, and cardiac
output. It is extremely important to search for and treat possible
reversible causes of increased pulmonary vascular resistance,
including inadvertent interruption in PHT therapy, hypercarbia,
hypoxia, arrhythmia, cardiac tamponade, or drug toxicity. Maintain
normocarbia and ensure adequate oxygenation. For the initial
treatment of pulmonary hypertensive crises, oxygen administration
and induction of alkalosis through hyperventilation or alkali adminis-
tration can be useful while pulmonary- specific vasodilators are
administered. There is no high-certainty evidence that alkali
administration improves outcome, and excessive ventilation during
resuscitation might also be harmful positive-pressure ventilation will
decrease systemic venous return, right ventricular filling, and cardiac
output generated during chest compressions. If high-quality CPR
remains ineffective despite provision of specific therapy, including
pulmonary vasodilators, rapid consideration of ECLS might offer a
chance of survival, either as a bridge to heart/lung transplantation or to
permit recovery from the inciting factor.
Extracorporeal eCPR
In line with the ILCOR 2019 COSTR update on the use of eCPR in
children, we advise considering eCPR for children with ED- or IHCA
with a presumed or confirmed reversible cause where conventional
ALS does not promptly lead to ROSC (weak recommendation, very
low certainty evidence).697 An essential precondition is the organisa-
tional setting i.e. with a strong institution-based commitment to
sustaining a resuscitation system that includes eCPR with appropriate
quality improvement systems. To make a realistic choice about the use
of eCPR, systems should also consider the evidence on cost-
efficiency (see chapter on ethics).695 Given the high resources
needed and the fact that outcome is related to time to initiation and
quality of CPR before initiation, the indications for eCPR in OHCA are
very limited (appendix RR 33.3).794 798
Management post-ROSC
Evidence on the impact of treating centre characteristics (or more
broadly regional healthcare organisation) on outcome of children with
ROSC after IHCA or OHCA is conflicting and difficult to interpret
because of many confounders.129,799 801 This should be a research
priority. Pending further data, it is preferable to admit children who
have been resuscitated from CA to a facility with the necessary
competences and resources for proper post-ROSC neuroprotective
care, organ- and/or life supporting treatments, comprehensive
neurological assessment and psychosocial support.802
Blood pressure
The ILCOR paediatric taskforce performed an EvUp (PLS 820) on this
topic.143 The authors identified five observational studies supporting
the conclusion that post-CA hypotension less than the 5th percentile
387 361
for age is associated with worse outcomes (appendix RR 36.1).803 807
One paper demonstrated that hypertension immediately after CA is
associated with improved survival. However, children who require
higher doses of vasopressor support have lower rates of survival to
hospital discharge.
Oxygenation & ventilation
The paediatric ILCOR taskforce performed a SR on oxygenation
and ventilation targets after ROSC (appendix RR 36.2).143 They
suggest that rescuers measure PaO2 after ROSC and target a
value appropriate to the specific condition of the child. In the
absence of specific patient data, rescuers should target normox-
emia after ROSC (weak recommendation, very-low-quality evi-
dence). Rescuers should also measure PaCO2 after ROSC and
target normocapnia (weak recommendation, very-low-certainty
evidence). Adjustments to the target PaCO2 should be considered
for specific populations where normocapnia may not desirable (e.g.
chronic lung disease with chronic hypercapnia, single ventricle
physiology). It is unclear if a strategy of permissive mild
hypercapnia could be beneficial in ventilated children with
respiratory failure.
Targeted temperature management
In line with the ILCOR 2019 COSTR update on targeted
temperature management (TTM) in children after ROSC,697 TTM
should be used for children who achieve ROSC (appendix RR
36.3). Although potentially of benefit, lower goals for TTM (e.g.
34  C) demand appropriate systems of paediatric neurocritical care
and should only be used in settings where these are in place.
Whether certain temperature goals are more appropriate for certain
subgroups is not supported by evidence and thus at the discretion
of the attending team. This is also the case for the duration of TTM
(24 to 72 h).
Prognostication
An ILCOR 2020 EvUp evaluated the role of EEG in neuro-
prognostication.143 Although EEG background patterns seem
associated with neurological outcomes, the authors concluded that
neither the presence or absence of any single factor predicts with
high accuracy survival or survival with favourable neurological
outcome. Biological markers measured within the first 24 h such as
elevated blood lactate, or blood pH, or base excess may be
indicative, but cut-off values remain unknown. Neuroimaging using
CT, EEG, or biological markers may be promising in the future
(appendix RR 36.6).
Conflict of interest
FH reports speaker honorarium from ZOLL.
IM reports his role as Associate editor BMJ Open Paediatrics.
Acknowledgments
We thank Alexander Moylan, Imperial College London, UK for his
assistance in preparation of some of the evidence sheets, as well
as Nele Pauwels, information specialist at Ghent University,
Belgium for her support in developing the necessary search
strategies.
362 RESUSCITATION 161 (2021) 327
We also thank Sophie Skellett, Great Ormond Street Hospital
London, UK for her critical revision and suggestions to the near final
draft.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.resuscitation.2021.02.015.
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Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Education for resuscitation

Robert Greif a, * , Andrew Lockey b , Jan Breckwoldt c, Francesc Carmona d ,

Patricia Conaghan e , Artem Kuzovlev f , Lucas Pflanzl-Knizacek g , Ferenc Sari h,
Salma Shammet i , Andrea Scapigliati j , Nigel Turner k , Joyce Yeung l ,
Koenraad G. Monsieurs m
a
Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland; School of Medicine, Sigmund
Freud University Vienna, Vienna, Austria
b
Emergency Department, Calderdale Royal Hospital, Halifax, UK
c
Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
d
Sistema d’Emergències Mèdiques, Barcelona, Spain
e
Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
f
Negovsky Research Institute of General Reanimatology of the Federal Research and Clinical Center of Intensive Care Medicine and
Rehabilitology, Moscow, Russia
g
Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
h
Emergency Department, Skellefteå Hospital, Sweden
i
Karary University, Medical College, Khartoum, Sudan
j
Institute of Anaesthesia and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, IRCCS,
Rome, Italy
k
Department of Pediatric Anesthesia, Division of Vital Functions, Wilhelmina Children’s Hospital at the University Medical Center, Utrecht, The
Netherlands
l
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
m
Emergency Department, Antwerp University Hospital and University of Antwerp, Edegem, Belgium

Abstract
These European Resuscitation Council education guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation
Science with Treatment Recommendations. This section provides guidance to citizens and healthcare professionals with regard to teaching and
learning the knowledge, skills and attitudes of resuscitation with the ultimate aim of improving patient survival after cardiac arrest.
Keywords: Resuscitation, Education, Simulation, Faculty development, Technology enhanced learning, Basic and advanced life support

Introduction and scope
This chapter provides evidence-based guidance to citizens and
healthcare professionals (HCPs) with regard to teaching and learning
the knowledge, skills and attitudes of resuscitation with the ultimate
aim of improving patient survival after cardiac arrest. The guidance
addresses the second key component of the Utstein formula of
survival, namely ‘educational efficiency’ (Fig. 1).1 As educational
approaches are the critical links between scientific findings and their
implementation into practice, we present the components of education
in resuscitation in more detail, based upon the original formula of
survival (Fig. 2). The effects of educational interventions in

* Corresponding author.
E-mail address: robert.greif@insel.ch (R. Greif).
https://doi.org/10.1016/j.resuscitation.2021.02.016

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
 RESUSCITATION 161 (2021) 388 407 389

Fig. 1 – The Utstein formula of survival.

resuscitation are maximised by incorporating educational theory. This
chapter addresses education in all settings where people may teach
and learn resuscitation, including every level from basic to advanced
life support and for all ages of learners as well as all ages of cardiac
arrest victims. Key stakeholders to be targeted include governmental
(healthcare, education, etc.) and political authorities who manage
national and/or regional healthcare systems.
The basic principles of medical education adopted for the ERC
resuscitation courses encapsulate learning theories and teaching
strategies to build an educational framework for the different types of
learners and approaches to teach resuscitation. These guidelines
address the teaching of different target groups, as well as the learning
of skills to provide high-quality resuscitation. Over the last decade,
technology and simulation to educate resuscitation have gained

Fig. 2 – ERC educational approach to best practice and improved patient survival.
390 RESUSCITATION 161 (2021) 388 407

increasing importance promoting changes in the way ERC courses
are taught. Therefore, this chapter highlights faculty development
which needs to be implemented by each teaching institution. The
chapter ends with a view on the outcome of resuscitation education,
encountered research gaps, and future direction of resuscitation
education. A summary of the educational strategies referred to in this
chapter is presented in Fig. 2. The recently published ERC COVID-19
Resuscitation guidelines include recommendations for resuscitation
education during the pandemic.2 These COVID-19 guidelines are
constantly updated, based on evolving knowledge and experience
with the disease. These changes and guidance on restarting ERC
courses are accessible via the ERC web page (www.erc.edu).
For the purpose of this chapter, the term CPR relates to the specific
technical skills of cardiopulmonary resuscitation (e.g. performance
metrics of CPR), whilst resuscitation is used as a generic term
covering the broader range of skills and interventions. The term
bystander is used to describe rescuers who happen to be at the scene
to provide help, and the term first responder is used for those who have
additional training and are alerted to attend the scene of a
resuscitation. Healthcare Professionals (HCP) are defined as those
who work in any healthcare sector. Finally, any form of resuscitation
education beyond BLS (defined as initiating the chain of survival,
chest compression, ventilation, use of an AED) is described
generically as advanced life support (neonatal, paediatric and adult

Fig. 3 – Education summary infographic.

 RESUSCITATION 161 (2021) 388
Fig. 4 – Approaches to educate resuscitation.
life support). Where the term ‘ALS’ is used, this refers specifically to
the ERC Advanced Life Support course.
These guidelines were drafted and agreed by the Education
Writing Group members. The methodology used for guideline
development is presented in the Executive summary.2a The guide-
lines were posted for public comment in October 2020. The feedback
was reviewed by the writing group and the guidelines was updated
where relevant. The Guideline was presented to and approved by the
ERC General Assembly on 10th December 2020.
Key messages from these guidelines are presented in Fig. 3.
Concise guideline for educational practice
The principles of medical education applied to resuscitation
The ERC, as a scientific based organisation, grounds its guidelines on
current medical evidence. The same applies for the ERC education
guidelines for resuscitation. The ERC approach to education can be
grouped into 4 themes (4 ‘I's): (1) Ideas (theories of education and how
we learn), (2) Inquiry (research which both develops from and informs
the ideas mentioned), (3) Implementation (approaches based on the
research), and (4) Impact (outcome of these educational approaches
both for learning and clinical practice) (Fig. 4).
Resuscitation education for different target groups
Every citizen should learn to provide the basic skills to save a life.
Those with a duty to respond to emergencies need to be competent to
perform resuscitation, depending on the level of rescue they provide,
from BLS to advanced life support, for children and/or adults,
407 391
according to the current ERC guidelines. Resuscitation competencies
are best maintained if training and retraining is distributed over time,
and frequent retraining is suggested between two and twelve months.
For HCPs, accredited advanced life support training is recommended,
as well as the use of cognitive aids and feedback devices during
resuscitation training. Specific team membership and team leadership
training should be a part of advanced life support courses, and data-
driven, performance-focused debriefing needs to be taught.
Key points in resuscitation education for bystanders and first
responders are:
 enhance willingness to perform CPR;
 reinforce the chain of survival;
 teach resuscitation using feedback devices;
 distribute resuscitation training over time (spaced education);
 maintain resuscitation competencies by frequent retraining.
Key points in resuscitation education for HCPs are:
 teach every HCP high-quality CPR (from BLS to advanced life
support level, children and/or adults, special circumstances
depending on the workplace and patient mix);
 teach accredited advanced life support courses and include team
and leadership training in such courses;
 use cognitive aids;
 teach and use debriefing.
Teaching the skills to perform high-quality resuscitation
Teaching the technical skills to perform resuscitation on every given
level is very important. Equally important, however, is the teaching of
human factors: e.g. communication, collaboration in teams and with
different professions, awareness of the critical situation, etc. Human
392 RESUSCITATION 161 (2021) 388
factors are crucial to achieving high-quality CPR and good clinical
practice. Teaching these factors will increase the willingness of trained
responders to help victims in a life-threatening situation, improve the
initiation of the chain of survival by starting BLS and gives participants
of CPR courses the confidence to attempt resuscitation whenever
needed.
Technology enhanced education to teach resuscitation
Learning CPR can be supported by the use of smartphones, tablets,
etc. by using apps and social media, as well as feedback devices.
These learning modalities may be teacher independent. They improve
retention and facilitate competency assessment in CPR. Gamified
learning, (e.g. virtual and augmented reality, tablet apps simulating
monitors, etc.) may engage many learners. Virtual learning environ-
ments are recommended to be used for pre-course e-learning, as part
of a blended learning approach, or for self-learning options of learning
independent of time and location for all levels of CPR courses.
Simulation to educate resuscitation
High as well as low fidelity simulation in resuscitation education
facilitates contextualised learning for a variety of learners. It integrates
technical and non-technical skills and considers the environment or
context of specific learner groups and the different levels of expertise.
Hence, simulation provides the opportunity to learn to deal with human
factors in critical situations. Specific team or leadership training should
be included in advanced life support simulation. Profound learning
occurs during the reflection phase in the debriefing of a simulated
resuscitation.
Faculty development to improve education
In many areas of education, the quality of the teacher has a major
impact on learning, and this can be improved by training and ongoing
faculty development. The evidence for these effects in resuscitation
training is scarce and many recommendations on faculty development
are therefore extrapolated from other areas. Three aspects of faculty
development are important: selection of suitable instructors, initial
instructor training, and maintenance and regular update of their
teaching quality.
Effect of resuscitation education on outcome
Accredited ALS training and accredited neonatal resuscitation training
(NRT) for HCPs improve the outcome of patients. The effect of other
life support courses on patient outcome is less clear, but it is
reasonable to recommend other accredited life support courses.
Further research is needed to quantify their actual impact on patient
outcomes.
Research gaps and future directions in educational research
There is a lack of high-quality research in resuscitation education to
demonstrate whether CPR training improves process quality (e.g.
compression rate, depth or fraction) and patient outcomes (e.g. return
of spontaneous circulation, survival to discharge or survival with
favourable neurological outcome). Successful strategies to improve
educational efficiency from the wider medical education literature
should be considered to study their value for resuscitation education.
407
Contextualised and tailored CPR training can prevent the decay of
resuscitation competency. There is a potential for resuscitation
courses to become less generic and to focus more on individual needs
of the learner. Future research areas include investigating optimal
training and support provided to resuscitation trainers and the role of
education in reducing emotional and psychological trauma to the
rescuer.
Evidence informing the guidelines
The principles of medical education applied to resuscitation
The Utstein formula of survival in resuscitation demands that
educators “create learning experiences highly likely to result in
acquisition and retention of skills, knowledge and attitudes needed for
good performance.”1 The ERC Education for Resuscitation guidelines
use a framework which draws on four components (idea, inquiry,
implementation, impact) to achieve this objective.
1. Idea the theories of education and how we learn
Many educational theories arise from sociology, psychology,
anthropology, neuroscience, and more recently the growth of new
technologies. All these theories attempt to explain how we learn and
therefore how we should teach.3 There is no single theory which
encapsulates the many disciplines involved in education. However,
there is a commonality among the theories which can arguably be
encapsulated in five main paradigms (Fig. 4).
a. Behaviourism assumes that learners are like a piece of blank
paper, with learning occurring as response to the application of a
stimulus. Learning is an externally driven activity resulting in a
change in the individual's behaviour. It results from the repeated
application of the stimulus or reinforcement whether positive or
negative i.e. punishment or reward. There is no consideration of
the individual's mental state or ability. The main proponent of
behaviourism is Skinner.4
b. Cognitivism argues that learning is more than a response to a
stimulus and focuses on the mental activities which enable
learning. These processes govern how knowledge is received,
organised, stored and retrieved. Memory, attitudes and beliefs
play an important role in cognitive theory. Internal processing in
the brain is the main focus of cognitivism, not so much the
response. Cognitivist approaches emphasise the need to make
learning meaningful and to relate new knowledge to previous
existing knowledge.5 7 Cognitive Load Theory is based on how
we acquire and store different types of knowledge. It distinguishes
between biologically primary knowledge (that which we have
evolved to learn), and biologically secondary knowledge (which is
more recently required by society for cultural reasons). Secondary
knowledge is harder to acquire. Because of the way in which
information is processed, the working memory can become
overloaded and instructional design should therefore be based on
managing the cognitive load.8
c. Constructivism focuses on the individual's experience of the world
and how they construct meaning from reflecting on this.
Constructivism calls for real life experiences to enable the learner
to construct new competencies building on their own prior
experiences. Learners are active participants in their learning.
An example is Bruner's Discovery Learning.9 Students are placed
in problem solving situations where they must construct meaning
 RESUSCITATION 161 (2021) 388
Fig. 5 – Educational theories and approaches.
by drawing on past experience and knowledge to create new
knowledge. Vygotsky argued that the social context surrounding the
learner impacts on their learning as they learn from their interaction
with others.10 This ‘social constructivism’ is the key to what we can
learn on our own and what we can learn when guided and
supported by a knowledgeable partner, the difference between
the two is referred to as the “Zone of Proximal” development.
Bruner developed Vygotsky's ideas describing the support and
help from the skilled partner as scaffolding, initially used to
support the learner through the zone of proximal development,
but gradually withdrawn as the student progresses.
d. Humanism sees learning as a personal act to achieve fulfilment.
Learning is student centred and personalised, it is not just about
intellect but about the whole person, their needs and journey to
self-actualisation. Attention should be paid to the dignity and
emotions of the learner more than the intellect.11,12
e. Connectivism is a 21st century learning theory based on the idea
of learning through communities and networks. Heavily influenced
by the rise of the internet and digital platforms, connectivism sees
learning as no longer about the individual but about connections
with technology and others. It moves away from the cognitive view
of internal processing and instead relies on a network of people or
technology to store, access and retrieve knowledge.13
The application of these theories to advanced life support courses
in particular have been described in a narrative review (Fig. 5).14
Beside these theories three concepts describe how people learn:
pedagogy, androgogy, and heutagogy.15,16 These concepts focus on
407 393
the relationship between learner and teacher, which has been
described as a continuum17 :
 Pedagogy involves teacher-centred learning: the student is the
recipient of what the teacher wants the student to learn.
 Androgogy involves student-centred learning: the student and
teacher negotiate the learning.18
 Heutagogy means self-discovery and therefore involves student-
led learning: the student determines what they want to learn.19
Peer-to-peer learning, referred to as paragogy has been described in
recent years.159 Initially the peer-to-peer learning theory came from
connectivists’ on-line education and has developed beyond online to any
peer-to-peer education and also successfully in resuscitation training.20
The ERC's approach to education demonstrates the move along
this continuum, with the introduction of the virtual learning environment
(CoSy https://cosy.erc.edu/), modular education (standardisation vs.
individualisation of CPR training), life-long learning, blended learning
and hands-on face-to-face courses, feedback methods to support CPR
teaching and learning, coaching, and recertification. The ERC is moving
from didactic teaching and utilising approaches based on research
culminating into a connected system where the individual learners
determine what and when they wish to learn.
2. Inquiry the research which both develops from and
informs the ideas mentioned
The ERC education guidelines use the existing evidence from
educational research to inform the approach to education. It is
important that all aspects of educational delivery are subjected to the
394 RESUSCITATION 161 (2021) 388
same academic scrutiny as the clinical scientific guidelines. This
guidance is produced following a series of systematic and narrative
reviews of the international literature to inform best educational
practice. For more detailed information consult the ILCOR Consensus
of Science and Treatment Recommendation (CoSTR) publication for
2020.21
3. Implementation the approaches based on the research
This guideline on education for resuscitation discusses a number of
approaches based on the fundamental theories of education (Fig. 4).
The specifics with regard to implementation are also covered in more
detail in the Chapter Systems Saving Lives of these ERC guidelines.22
4. Impact the outcome of these educational approaches
both for learning and clinical practice
Research has revealed that almost any approach to learning may
work.23 It is important to move away from merely identifying the
effect of different approaches to identifying the impact each
approach has relative to another. Hattie compared this approach
to clinical practice where treatments are constantly monitored to
ensure they are leading to success and evidence is the key to
adaptive professional decision making.23 Following a meta-analysis
of 800 studies, he identified the ten most effective factors that
influence learning: (1) student self-reporting grades, (2) formative
evaluation, (3) teacher clarity, (4) reciprocal teaching (where
students become the teacher in a small group), (5) feedback, (6)
teacher student relationships, (7) meta-cognitive strategies (to
help students understand the way they learn), (8) self-verbalisation/
questioning, (9) teacher professional development, and (10)
problem-solving teaching. A consequence is that learning becomes
visible when teachers see the learning through the eyes of their
students.24 The teachers develop an approach to their teaching
which encompasses having the right mindset, being a cooperative
and critical planner, being an adaptive learning expert and a
receiver of feedback. In the end, the role of teachers is to know their
impact and to help students become their own teachers.
Resuscitation education for different target groups
Initially CPR was taught to HCPs and to first responders such as first
aiders and rescue organisations. Subsequently, evidence emerged
about the importance of system intervention to foster early
resuscitation attempts as a key to increasing survival after cardiac
arrest. This has led to the expansion of CPR education to larger
population groups: from children and their teachers, from citizens and
bystanders, from organised First Responder programmes, to HCPs at
different levels of response and duty (e.g. prehospital Emergency
Medical Services (EMS) personnel and dispatchers, as well as in-
hospital ward staff, intensive care unit and emergency department
physicians and nurses). The specific educational needs of these
groups lie on a continuum depending on individual and organisational
CPR competency needs (e.g. from basic to advanced levels). The
required competency level determines the CPR training interval,
frequency, duration, and need for retraining, along with the required
teaching equipment for the level of training and assessment.
Bystanders and first responders
The primary goals of resuscitation training for non-HCPs (ranging from
children in different age groups to bystanders and first responders) are
to increase CPR rates, effective BLS and AED use, and timely EMS
407
activation for out-of-hospital cardiac arrest. Enhancing willingness to
perform CPR as part of the CPR teaching programme in this
population may have a direct impact on survival rates for out-of-
hospital cardiac arrest.21 Furthermore, an essential part of bystander
CPR education is the recognition of cardiac arrest (unresponsiveness,
not breathing normally), alerting the EMS, and the performance of BLS
(which includes the use of an AED) according to the ERC Guidelines
2020.25
The evidence identified in the ILCOR CoSTR suggests that the use
of feedback devices that provide directive feedback on compression
rate, depth, release, and hand position can be of benefit during
bystander and professional CPR training (weak recommendation,
low-certainty evidence). In the absence of such devices, tonal
guidance including music or metronomes may be used but they only
improve compression rate.21 The ILCOR CoSTR for spaced learning
(education or retraining separated by longer periods of time) identified
17 studies (13 randomised studies, 4 cohort studies). A narrative
synthesis of these findings showed that spaced learning seems to be
more effective than massed learning (education provided close
together in time) leading to a weak recommendation, based on very-
low-certainty evidence supporting the use of spaced learning.21,26 The
recommendation for increased use of spaced learning in resuscitation
education is valid for non-HCPs as well as for HCPs. The ILCOR
systematic review found insufficient data to suggest for or against the
use of cognitive aids in non-HCP training.21 A further ILCOR CoSTR
found insufficient evidence to recommend an optimum interval or
method for BLS retraining for non-HCPs. BLS skills decay within 3 12
months after initial CPR education but evidence suggests that more
frequent (re)-training improves CPR skills (weak recommendation,
very-low-certainty evidence), responder confidence, and willingness
to perform CPR leading to a weak recommendation, based on very-
low-quality evidence supporting frequent re-training.21
The KIDS SAVE LIVES programme initiated by the ERC has a key
strategic aim to target as many children as possible worldwide with
CPR education in schools.27,28 The CPR competencies should be
adapted to the age of the students from preschool to university level
due to their differing abilities to perform the skill and understand the
underpinning theory.29 33 Teachers are very supportive about BLS
training, but often lack proper content knowledge.34,35 Teachers only
need to learn the specific skills of resuscitation that they will
subsequently teach to their students as they are already experts in
teaching.36 Including such resuscitation teaching into curricula of
teachers’ education is highly recommended.33 No evidence exists
about which educational strategy to teach school children is the most
effective.37 Therefore, the format of teaching CPR will vary depending
upon local requirements and circumstances. One example of a
successful approach to teaching school children is of medical students
acting as resuscitation teachers. This is very effective for both
schoolchildren and the medical students themselves.38 40 The
medical students improved their own resuscitation competencies,
they learned at the same time how to act as future CPR instructors,
and they improved community CPR education.
Healthcare professionals at different levels of response and
duty
High-quality resuscitation education is mandatory for HCPs at all
levels from BLS to advanced life support, for children and/or adult
resuscitation, depending on their workplace requirements for CPR
competencies. BLS education for HCPs is, in principle, no different
from teaching resuscitation to non-HCPs, but in special
 RESUSCITATION 161 (2021) 388
circumstances specific competencies need to be added to the
standard BLS teaching (e.g. neonates, COVID-19, specific in-
hospital settings such as operating rooms, etc.). The ILCOR CoSTR
identified that the provision of accredited adult ALS education for
HCPs is recommended as such courses improve patient outcome
(weak recommendation, very-low-certainty evidence).21,41 An evi-
dence update in the ILCOR CoSTR supports that low-fidelity
manikins are suggested as acceptable for standard advanced life
support training in an educational setting.21 High-fidelity manikins
might also be used for resuscitation education if the infrastructure,
trained personnel, and resources to maintain the programme are
available. The ILCOR systematic review on specific team and
leadership training suggests bases on a very-low-certainty evidence
to include such training as part of advanced life support training for
HCPs.21 In contrast an ILCOR systematic review on the use of
cognitive aid did not find evidence for its use in bystanders or first
responders resuscitation education, indirect evidence from clinical
trauma care and from full-scale simulation suggests that cognitive
aids (e.g. checklist, flow-charts, mnemonics, etc.) should be used
during resuscitation training of HCPs.21 An ILCOR CoSTR weak
recommendation based on very-low-certainty evidence suggests
that data-driven, performance-focused debriefing should be used by
rescuers after every resuscitation. Therefore, we suggest such
debriefing needs to be integrated into advanced life support
education for HCPs during training and as a teaching goal to be
applied during real resuscitation of cardiac arrest victims.21,42
Dispatcher education to provide high-quality CPR
To identify a cardiac arrest situation by means of a phone call is not
always easy. Dispatchers accurately identify cardiac arrest in about
70% of cases.43,44 If the suspected diagnosis of cardiac arrest is
wrong, patients will receive inappropriate chest compressions or
CPR is not started.45 Other significant challenges for dispatchers
are the identification of agonal breathing,46 how to engage
bystanders to deliver CPR and increase their willingness to perform
CPR, and how to shorten the time to initiation of chest
compressions.43,44 Programmes that improve the quality of
telephone-assisted CPR and the feedback from physicians to
dispatchers have improved the outcome of cardiac arrest patients.47
Specific training of dispatchers on how to deliver telephone-assisted
CPR can lead to improved cardiac arrest recognition, reduction of
misinterpretation of agonal breathing, increased rate of patients
receiving chest compressions, and a shorter time until the first
compression is delivered.48 Even short simulation-based training
sessions can improve cardiac arrest recognition rates, and the
speed with which CPR is started.49
No structured course to educate dispatchers exists, and EMSs
tend to teach their dispatchers via in-house training programmes. It
is suggested that any dispatcher education needs to cover the most
challenging tasks for dispatchers when confronted on the phone
with a possible cardiac arrest situation: (1) recognition of the
cardiac arrest, (2) enhance the willingness of rescuers to perform
CPR and warn rescuers about their safety, (3) provide instructions
to perform chest-compression-only CPR, (4) make rescuers aware
when an AED might be available and to use the AED when it
arrives, and (5) how to help the EMS to reach the location of the
incident. Finally, the value of debriefing of dispatchers after such
telephone instructions and how to receive feedback from the EMS
personnel attending the cardiac arrest should be included in
dispatcher education.
407 395
Teaching the skills to perform high quality resuscitation
To improve patient survival from cardiac arrest, essential core skills in
resuscitation need to be defined and learned. The learning goals for
advanced life support education include all defined BLS competences
and advanced competencies such as airway management and
vascular access. Over the past few years, the importance of human
factors has been increasingly recognised.
Educational goals in BLS
Independent of the background of the rescuer (e.g. bystander, first
responder, HCP), BLS education needs to teach effective chest
compressions and the safe use of an AED. In paediatric BLS,
ventilation skills should be taught together with chest compressions.
Studies show that chest compressions can be taught from childhood
but the effectiveness of chest compressions depends on the physical
abilities of the rescuer, which should be taken into account when
teaching children.30,31 Evidence exists that the use of feedback
devices during CPR education can improve the quality of chest
compressions during training,21 but unfortunately this does not lead to
improved patient outcomes.50 Because of their user-oriented design,
even an untrained user including children can follow the instructions to
use an AED safely.51 Rescuer safety is a key point for AED training.
Traditionally BLS courses teach mouth-to-mouth/nose and mouth-
to-mask ventilation for every rescuer, and ventilating the lungs is an
important skill to be learnt particularly in certain circumstances (e.g.
children, drowning, or asphyxia). In some patients (e.g. infection risk)
bag-mask ventilation is preferable, and this situation introduces a new
skill set to be learnt for many non-HCPs and most HCPs. They may not
be as competent as those HCP who use bag-mask ventilation in daily
clinical practice. With that we emphasis the value of potentially
providing some degree of ventilation of the lungs which in turns is
better than no ventilation.
Performing two-person ventilation, one holding the mask with two
hands (two-hand mask ventilation), and the other squeezing the bag
may improve the seal of the mask and the chance of effective
oxygenation and ventilation and therefore is the recommended
technique.2,52 It is reasonable to recommend teaching this relatively
simple technique of bag-mask ventilation to first responders and
HCPs who normally provide BLS, especially when there is a risk of
spreading infection (e.g. during a COVID pandemic). In contrast to
mouth-to-mouth ventilation, the practice of bag-mask ventilation
during training on manikin carries no risk of infection. Learners of BLS
and advanced life support courses need to understand how to avoid
injury and which measures should be applied to minimise infection
risk.2 BLS courses should include teaching potential rescuers how to
communicate effectively with the EMS dispatcher providing and
receiving adequate information to avoid unnecessary delay in
initiating resuscitation. First responders might obtain insights in
how to conduct structured hand-over communication to EMS or to
other HCPs.
Education about communication during BLS is important in order
to overcome barriers that rescuers might experience in performing
CPR.53 There are three main barriers: personal factors (emotional
barriers, most often “panic”, but also socio-economic factors, and
physical factors like “ability to place the patient flat”); CPR knowledge
(skill deficits, fear of causing injury or doing something wrong); and
procedural issues (communication and language barriers, and
recognition of cardiac arrest).21,54 A narrative synthesis summarised
the following factors that increase rescuers’ willingness to perform
396 RESUSCITATION 161 (2021) 388
CPR (despite dispatcher instructions, community initiatives, and
social media technologies): prior CPR training, community CPR
awareness programmes, chest compression only programmes in
mass training, and CPR-trained rescuers with a higher educational
degree. Mouth-to-mouth ventilation was not a barrier for bystanders to
perform CPR, although this study pre-dated the COVID-19 pandem-
ic.21 Addressing these barriers and enablers to starting CPR might
increase the willingness to help those in a life-threatening situation.
Finally, BLS education has an important role to play in encouraging the
broader participation of rescuers in community programmes that aim
to provide help for people in life-threatening situations (e.g. first aid,
first responder resuscitation, public AED programmes, schoolchildren
CPR programmes) which was summarised in a ILCOR CoSTR
narrative review.21,55
The duration of BLS courses is a matter of debate. There is no one
duration that fits all learners, as this depends on the previous
resuscitation education of the rescuers, the specific learning goals for
a given group of learners, and local social and cultural educational
factors. Examples range from very short BLS introductory sessions to
2-h courses and traditional BLS courses for non-HCPs of 4 h.56,57
Some of the theory in these courses could be taught online as part of a
blended learning approach to save the face-to-face time for hands-on
training.
Educational goals in advanced life support
All of the aforementioned BLS skills are an integral part of advanced
life support education and need to be adapted to the target group of
patients (e.g. neonatal, children, adults, trauma). Specific learning
goals for advanced life support are airway management, manual
defibrillation, vascular access, a structured approach to managing the
critically ill patient, application of advanced resuscitation approaches
for special situations and circumstances, as well as the treatment of
peri-arrest arrhythmias and immediate post-resuscitation care. The
teaching of these competencies can take more time and effort
depending on the learners’ profession and clinical duties and need to
be adapted to their learning needs and level of previous competen-
cies. For this reason, the ERC advanced life support courses have
implemented a modular approach to adapt to the needs of the course
participants.
A specific characteristic of ERC ALS courses is the integration of
leadership and team training as detailed described in an ILOCT
CoSTR systematic review, which includes the importance of human
factors during resuscitation.21,58,59 Theoretical and practical human
factors competencies in resuscitation can be taught in scenario-based
simulation sessions highlighting the importance of these human
factors such as situation awareness, team and task management, and
decision-making.
There is no evidence about the best way to teach these non-
technical skills. Teaching approaches need to consider local social
and cultural factors as well as the previous awareness of the ALS
course participants. The use of briefing and debriefing was addressed
in an ILCOR CoSTR systematic review encouraging the application of
supportive, correcting and constructive feedback during ALS educa-
tion.21 Based on very low-certainty of evidence a weak recommenda-
tion was issued to use data-driven performance-focused debriefing of
rescuers in- and out of hospital. The application of closed-loop
communication in a team is a suitable way for the learners to integrate
these behaviours into their clinical practice.60 The increased
application of human factors during patient care may reduce medical
errors and improve patient safety.
407
How to teach these skills?
There are a variety of ways to learn the theory of the resuscitation
skills behind the aforementioned competencies. Examples include
reading a manual, following an interactive e-learning pro-
gramme,61,62 or participating in a workshop or an internet-based
webinar.63 A blended learning approach has become common for
resuscitation training.64 No specific didactic approach is superior to
another in teaching skills. The factors that influence skills teaching
the most are the degree of instructor engagement with the content
and with the learners, and the degree of truthful feedback on the
performance.65 Hands-on workshops on CPR skills using low- or
high-fidelity manikins, interactive video-based self-learning,66
internet-based e-learning, scenario simulation and reflection on
practice during case discussions are all ways to teach and learn
these competencies. The different ERC courses put the concept of
blended learning into practice by using all of these different
educational modalities. For more details please visit the ERC
website and the ERC virtual learning environment CoSy (www.erc.
edu or https://cosy.erc.edu/en/login)
The use of cardiac arrest scenario simulation seems to be a
suitable strategy for the education of human factors.67 Instructors
need to appreciate the value of the debriefing as learning happens
during the phases of reflection on the experience. At the same time
cardiac arrest simulation may provide opportunities for learners to
develop and apply new strategies to improve on earlier
performance.
Traditionally, resuscitation education is commonly delivered
during teaching events or courses at a single period of time and
without interruption, also called massed learning.68 Evidence from
an ILCOR CoSTR suggests that spaced learning (training or
retraining distributed over time) can improve CPR skill performance
between course conclusion and 1 year after a course compared to
massed learning (very-low certainty of evidence).21,26 Moreover,
‘rapid cycle deliberate practice’ has been shown to be a very
effective educational strategy to improve team performance in
simulated resuscitation education.69 71 Rapid cycle deliberate
practice divides complex parts into easier individual skills. These
skills are repeated as often as needed with corrective feedback
‘rapid cycles’ until the expected level of performance is obtained,
and the next level of skill difficulty is approached. This allows
individualised feedback on improvements adjusted to the level of the
learner's competency.
These educational strategies move resuscitation education away
from single course events to learning distributed over time. Following
these principles, the ERC has developed a life-long-learning (LLL)
strategy enabling all persons educated in resuscitation to maintain
their resuscitation competencies as long as they pass recertification
modules every 6 12 months (Fig. 6).
Formative assessment with corrective feedback is needed to
provide an external view of the given performance to the learner
beyond self-assessment of competencies. Training and assessing the
competencies of a rescuer to provide high-quality CPR guarantees
that adequate help will be provided whenever needed.
An ILCOR CoSTR systematic review issued a weak recom-
mendation based on very low-certainty of evidence to provide
standardised ALS courses with properly trained instructors as
such ALS courses have been shown to improve patient out-
comes.21,41 Peer-teaching was also reported as a highly effective
educational strategy for BLS20,72,73 as well as for advanced
resuscitation programmes.74
 RESUSCITATION 161 (2021) 388
Fig. 6 – Life Long Learning (VR = virtual reality, AR = augmented reality).
Technology-enhanced education to teach resuscitation
Over the past few years, many new technologies have become
available to teach CPR but their actual impact on teaching and
learning is less clear. Access to medical content has never been easier
because of the ubiquitous availability of the internet. Virtual learning
environments (VLE) support medical education and, since 2015,
CoSy has been established as the virtual learning environment of the
ERC and as part of all the ERC courses. Smartphones and tablets can
perform multiple tasks and they change how we teach and learn CPR:
they can be turned into a compression feedback device or become a
simulated monitor. An ILCOR CoSTR systematic review based on
low-certainty evidence suggests that real-time feedback from apps
provided during CPR teaching improves skill performance with visual
and/or audio prompts.21 Serious games on mobile devices engage
CPR learners differently than traditional class room teaching (e.g.
https://life-saver.org.uk Resuscitation Council UK; http://sauveune-
vie.be University of Liege, Belgium; www.ircouncil.it/relive/Relive and
www.ircouncil.it/picnic both Italian Resuscitation Council, or https://
www.erc.edu/news/a-breathtaking-picnic-app via the ERC website).
32,75 77
Therefore, such devices and programmes should be included
in future CPR educational approaches and combined with face-to-
face education.
The easily accessible and large variety of social media platforms
have the potential to teach large audiences in a variety of settings,
times and remote areas. Social media enable the instantaneous
addition of comments or content and promote immediate communi-
cation and learning,78 but little is known about the effect of social
407 397
media on the teaching and learning of resuscitation. A small study
reported the usefulness of an instant messaging app (Telegram) in
maintaining BLS theory amongst medical students.79 Twitter was
reported to promote learning during courses and was able to track
CPR training barriers.80 YouTube contains many videos about CPR
education, but these videos provide insufficient information about BLS
and advanced life support in adults and children according to current
CPR guidelines.81,82 In a systematic review of freely available mobile
phone applications (Apps) giving instructions to perform adult CPR,
only 15% adhered to current AHA or ERC guidelines.83
Free open access medical education (FOAMed) is a dynamic
collection of resources.84 FOAMed (e.g. Twitter, blogs, etc.) promotes
clinical concepts, evidence-based medicine, and circulates confer-
ence material, but erroneous content can be spread rapidly and
widely, even after a fast correction.85 VLEs give learners the flexibility
to adapt their time and location for learning and most participants have
a positive attitude towards their use.86 The evidence about the use of
e-learning to teach BLS is not overwhelming. Most studies compare
standard courses with e-learning. In a randomised controlled trial
Castillo et al. compared an ERC standard 4-h BLS-course with
blended learning (2-h virtual training and 2-h in-person instruction)
and found no difference in high-quality CPR or BLS-knowledge 9
months later.87 Others implemented blended learning in their BLS
courses for bystanders and HCPs using a virtual reality headset and
quality CPR real-time feedback and BLS-manikin practice.88 Adding
e-learning to paediatric BLS improved outcomes of practical skill
acquisition in medical students at the end of the course.64 There is
insufficient evidence to suggest for or against blended BLS learning.
398 RESUSCITATION 161 (2021) 388
A blended learning approach including e-learning and reduced
face-to-face teaching time for the ALS course was found to be as
successful as standard face-to-face courses, especially for those
participants who liked the teaching format of e-learning.89 91 An
ILCOR CoSTR systematic review strongly recommends based on
very-low- to low-certainty evidence the provision of e-learning as part
of a blended learning approach to reduce face-to-face training time in
ALS courses (Fig. 6).21
Simulation to teach resuscitation
Simulation in resuscitation education is widely used and is a well-
established educational strategy. It facilitates contextualised learning
relating to each learner's real-world setting from first responder to
complex resuscitation teams. Simulation includes the teaching of
technical skills (e.g. airway management, defibrillation, etc.) and
human factors (e.g. non-technical interpersonal and cognitive skills).
Advanced life support teaching includes simulation of peri-arrest and
cardiac arrest situations. Simulation enables crisis resource manage-
ment targeting specific team or leadership behaviour during CPR.
Simulation equipment encompasses part task trainers for BLS and
complex high-fidelity technology in advanced life support education.
Taking into account these characteristics, learning objectives need to
be defined for the participating individuals or teams, as well as
choosing the adequate equipment. An ILCOR CoSTR evidence
update supports that simulation-based education of resuscitation in
situ (directly at the workplace of individuals) or in a dedicated
simulation centre might be included within the continuous education
programmes of life support courses.21 The learning from a simulation
experience is greatly enhanced during the cognitive reflective
debriefing of a simulated resuscitation.
Fidelity of simulation
The fidelity of simulation manikins, compared to real humans, can be
scored from low to high. Low-fidelity manikins or part-task trainers,
provide training opportunities for basic procedures and skills (e.g.
airway management using heads, chest compressions and ventila-
tions using BLS torsos) without any further technologically advanced
features. High-fidelity manikins comprise computer-controlled simu-
lators offering different features (e.g. physical findings, displaying vital
signs, specific sounds, procedural realism to interventions like airway
management or vascular access) resembling actual patients. The use
of high-fidelity manikins can provide more intense engagement with
the learner and improve the consistency of the learning experience.
Furthermore, regardless of the fidelity of the manikin, the relevance of
the simulation setting is of critical importance to engage learners and
promote learning.92,93
A systematic review compared the use of high versus low-fidelity
manikins during resuscitation training on patient outcomes, skill
performance or cognitive knowledge.94 An ILCOR CoSTR evidence
update in 2020 found that the high-fidelity group demonstrated
moderately improved skills immediately following course completion
and improved knowledge retention 6 months later.21,94,95 There was
no benefit for high-fidelity manikin use for knowledge at course
completion, skill performance at 1 year or between course conclusion
and 1 year. Therefore, the selection of adequate equipment remains a
question of simulation objectives and resources, taking into account
first the educational purpose and second the level of competencies of
the participating individuals. Bases on very-low certainty of evidence
the ILCOR CoSTR 2020 issued a weak recommendation to use high-
407
fidelity manikins when the training site has the infrastructure, trained
personnel, and resources to maintain the programme.21 In cases
where high-fidelity manikins are not available, it is suggested that the
use of low-fidelity manikins is acceptable for advanced life support
training in an educational setting (weak recommendation based on
low-quality certainty of evidence). Additionally, modern tablet-based
simulation apps combined with the use of low-fidelity manikins may be
a suitable alternative at reasonable cost for simulation during
resuscitation education.
Teaching of human factors
Simulation provides the opportunity to experience the effect of
human factors on performance and to learn how to improve specific
non-technical skills in a simulated critical situation of a cardiac
arrest. Human factors include interpersonal and cognitive factors,
such as effective communication, situational awareness, leadership
and team collaboration, task management, and decision making.
Teamwork and leadership are increasingly recognised as important
factors contributing to patient safety and outcome in healthcare.96
Moreover, leadership during resuscitation is associated with better
team performance.97 Additionally, an observational study of video-
recorded in-hospital ALS situations suggests that good non-
technical skills may be associated with improved performance of
technical skills such as chest compression quality, ventilation
quality, and defibrillation quality.98 Leadership and team training can
be taught using various methods, such as e-learning, video-based
training, instruction, demonstration using role models, or by means
of simulation with or without specific checklists (e.g. Team
Emergency Assessment Measure (TEAM-tool)).99 However, the
use of checklists and assessment tools need to be validated before
use in order to be capable of specifically targeting the respective
skill sets corresponding to the learning objectives.100 Leadership
and team training, as well as human factors education, may be
delivered in dedicated sessions as an add-on to courses, as well as
incorporated as a longitudinal theme throughout. However, an
ILCOR CoSTR systematic review identified a lack of evidence in
terms of effectiveness and efficiency of team and leadership training
when comparing different teaching modalities.21 In the absence of
randomised controlled trials, the effect of specific leadership and
team training on patient outcomes remains unclear. Studies have so
far mainly focused on HCPs, but human factors training as well as
team and leadership training should extend to include first
responders or bystanders as well. In summary, it is suggested that
specific team and leadership training should be integrated as part of
advanced life support courses for HCPs (very low certainty of
evidence). Hence, team and leadership should be addressed as a
core competency alongside technical skills when educating
resuscitation.
Briefing and debriefing of resuscitation performance
Briefing and debriefing represent two vital aspects relating to
simulation training and to actual resuscitation practice. Briefing is
defined as a review and communication of pertinent facts about the
resuscitation before the event.101 It sets out a framework for
professional resuscitation teams to prepare the roles and tasks
within the resuscitation team and before patient contact and
performance. Debriefing is a discussion, reflection and analysis of
a performance between individuals after resuscitation or training with
the aim of improving future performance.102,103 Specifically, the
critical insights and reflection on the performance after a simulation or
 RESUSCITATION 161 (2021) 388
real cardiac arrest are critically reviewed and this is a crucial aspect in
the learning process.
The characteristics of debriefing include: (1) a facilitator (who
may or may not have been a member of the resuscitation team, and
with or without dedicated training on how to perform a debriefing)
and the participants (individuals up to an entire team or care unit);
(2) the format (individual feedback, or involving parts of or a whole
group session); (3) the content (quality of care, e.g. guideline,
protocol or process adherence; objective CPR quality metrics such
as chest compression rate and depth, flow fraction; human factors
and emotional aspects); (4) the timing (immediately after the event
hot debriefing; later in time cold debriefing); (5) the duration
(from a few minutes up to a longer extent).104 107 Due to difficulties
in self-assessment and recall of events, the use of objective
recorded CPR data may contribute to an unprejudiced review
during the debriefing and many defibrillators/monitors already offer
such options.108 110
A systematic review of the impact of briefing and debriefing on
resuscitation performance compared to no briefing or debriefing
revealed, firstly, that no evidence was identified relating to briefing
before cardiac arrest. Secondly, CPR quality metrics on debriefing
after in-hospital cardiac arrest in adults111,112 and children,113 and
after adult out-of-hospital cardiac arrest could be analysed.114 All
studies included data-driven performance-focused recordings of
different sources in the debriefing. The meta-analysis demonstrated
significant effects of data-driven debriefing on survival to discharge,
return of spontaneous circulation, and chest compression depth.
There was no significant effect demonstrated on survival with
favourable neurological outcome, chest compression rate and chest
compression fraction in the ILCOR systematic review.21 It is
suggested that data-driven, performance-focused debriefing of
rescuers after in- and out of hospital cardiac arrest should be the
standard of care for both adults and children (based on very-low
certainty of evidence).
Faculty development to improve education
For general education, the work of Hattie (using a meta-analysis of 800
studies) related the strongest effect sizes for learning achievement to
the individual instructional quality of the teacher.24 Another systematic
review of 38 meta-analyses evaluated factors correlating with
achievement in higher education and emphasises the importance
of teacher training.115 The authors found strong associations of
learners’ achievement with social interaction within courses and
stimulation of meaningful learning by setting learning tasks which
require the students to actively process the content.115 The review
concluded that it was much more important how a method was applied
than what format of instruction was used. Teachers whose students
showed high achievement after being taught invested much effort in
designing the microstructure of their courses, establishing clear
learning goals, and employing feedback practices.115
Although these are strong arguments for faculty development in
general, there is much less evidence on faculty development
specifically in medical education and very little in the field of
resuscitation education.116 The outcome of interventions in faculty
development can be assessed at various levels looking at the effect on
the faculty trained (e.g. the acquisition of teaching skills), on the
learners (encompassing both the acquisition and the implementation
of the taught skills) and on the outcomes learners achieve when they
applied the learned skills in practice.
407 399
Low quality evidence is available in relation to outcomes at the
level of the faculty trained117,118 and at the level of learners trained by
trained faculty.119 For instance, one randomised controlled study on
CPR training for medical students found little difference between
those instructed by trained instructors and those trained by untrained
instructors.119
When looking for evidence for resuscitation training, observational
studies have shown that BLS courses for laypersons had deficits in
instructor quality, and in the way content was delivered. These
findings call for improved strategies to train BLS instructors.120 123 No
data are available for faculty development interventions related to
patient outcomes.
In this section, three aspects of faculty development will be
discussed: the selection of instructors, the initial instructor training,
and the maintenance of skills.
Selection of instructors
Resuscitation education aims to teach the management of cardiac
arrest, an uncommon event for many HCPs and which most non-
HCPs who learn CPR will rarely encounter. Various target groups of
learners have to be educated including clinicians in acute care
specialties, first responders, HCPs with various levels of resuscita-
tion practice and bystanders, including children. For these
purposes, instructors with different expertise and with different
backgrounds have to be recruited. Many instructors for BLS courses
will not have a professional background in healthcare (e.g.
schoolteachers, lifeguards, volunteer members of First Aid or
charity organisations).
Only one randomised controlled trial on CPR training for school-
children looked into CPR trainer selection and found that school-
teachers were superior to HCPs in transferring knowledge while being
equally successful in teaching skills.124
Since resources for faculty training are limited, it is important to
select individuals who already show supportive attitudes, intrinsic
motivation, appropriate communication skills, and enthusiasm for
the content to be taught. The availability of instructors differs
according to the type of courses. BLS instructors teach relatively
simple “basic” but lifesaving skills. These lifesaving skills can be
learnt from an engaged person, who can enthusiastically teach
these competencies, with relatively little content expertise. For
teaching children (e.g. in the KIDS SAVE LIVES programmes)
schoolteachers are suggested to be most appropriate. Besides their
teaching competencies, instructors should also be aware of being
role models and change agents. They need to have an appreciation
of affective learning and motivational skills as well as being aware of
the educational outcomes most relevant to their learners (i.e. in
which situations learners will have to apply the learned content), as
well as its impact on patient outcome.
Within the ERC advanced life support courses, the faculty
recognises instructor potential based upon specific criteria to
suitable course candidates who show excellent knowledge, skills
and personality traits believed to be conductive for facilitating
learning.
Instructor training
No study addressed specific formats about how to teach a CPR
instructor. A recent systematic review on faculty development
programmes in medicine found various approaches to teacher
training to be effective including seminars, workshops, series of
400 RESUSCITATION 161 (2021) 388
teaching sessions, and fellowships.116 Most of the studies only
addressed observed teaching performance and not the effect of the
teacher training on the learning achievement of their students. An
effective approach emerging from this review was to utilise practical
learning formats coupled with constructive feedback, commonly
referred to as experiential learning.125 128 Instructor training should
cover all the teaching methods applied in the courses for which the
instructors are being educated. First of all, instructors should have
appropriate content knowledge to sufficiently explain the details and
the evidence behind the taught CPR competencies to the level
appropriate for their learners. Initial training programmes for
resuscitation instructors should utilise formats based on evidence
from educational theory, applying outcome-based, meaningful
teaching and learning activities. Essential educational elements of
resuscitation instructor training should be the teaching of practical
CPR skills, the facilitation of interactive small group learning and the
use of basic presentation skills. Instructors should be able to provide a
structured teaching session which builds on the pre-existing
knowledge of the learners. In addition, instructors should develop
an understanding of which learner outcomes have the strongest
impact on patient outcomes (e.g. initiating CPR, chest compression
quality, etc.).
Educational content of the training should cover how to establish
competency-(outcome)-based teaching and learning settings, to
provide constructive feedback, and to conduct valid assessments to
guide teaching and for certification.
Advanced life support instructors should also have appropriate
content knowledge to explain all the details and the evidence behind
the taught resuscitation competencies. Not only for the more complex
teaching contexts (e.g. training of HCP teams, who routinely deal with
resuscitation), competencies of future instructors should include how
to support the development of human factors (non-technical skills,
communication and interprofessional team collaboration), how to
debrief effectively and how to use feedback devices during
resuscitation training.21,129,130. Many different strategies to provide
feedback, to debrief and to teach teamwork have been described,
however it is not known which method works best for resuscitation
instructor training.
Resuscitation instructors for non-HCPs need to be able to educate
learners to be motivated to help and to be able to perform BLS to a level
that improves patient outcomes. As large numbers of such BLS
instructors are required to teach whole populations, these instructors
are often non-HCPs themselves and a high level of content expertise
cannot be expected. These BLS instructors should be able to
demonstrate and perform the actions and skills of CPR according to
the current guidelines perfectly and answer questions relating to the
information provided in the teaching materials. Studies indicate that
instructors delivering courses for non-HCPs may have deficits in key
content knowledge and are therefore unable to assess the compe-
tence of their learners reliably.121,123 As they are not content experts
they need to use national or international checklists as the basis for the
assessment. Effective learning is important to increase self-efficacy
and motivation to intervene promptly in an emergency.131 All these
aspects need to be addressed specifically during the education of BLS
instructors for non-HCPs.
Teaching resuscitation skills to children may require a specific set
of teaching competencies and there is evidence that schoolteachers
are as effective as HCPs in teaching CPR skills whilst potentially
achieving better transfer of knowledge to their students.28,124 A
potential solution could be that both HCPs as content experts and
407
qualified schoolteachers as teaching experts could be involved in
faculty development programmes for CPR instructors who teach
schoolchildren.
Finally, formative assessment of instructor competence is
necessary before teaching on actual courses. When starting to
teach, a valuable step is that of instructor-candidate status, when the
future instructor teaches on courses under supervision with
immediately available peer support and feedback.
Maintenance of competencies/continuous professional
development
Once instructors have been trained, it is essential for them to maintain
their competencies and to keep up with the developments in
resuscitation and education science. The aim is to promote self-
directed, continuous professional development, and to avoid
individuals “doing their own thing”. Continuous Professional Devel-
opment is equally important for ERC instructors, course directors and
educators.
No study addressed the question how competencies of instructors
might best be maintained over time. To promote self-directed, lifelong
professional development, a number of strategies have been
proposed based on limited evidence including reflective practice,
peer coaching and establishing communities of practice.68
Deliberate reflective practice describes the process of self-reflection
on one's own performance with the intention to further improve
performance.132 There are important obstacles to the development of
reflective practice in medicine. Foremost is the difficulty some HCPs
have with self-assessment.133 There is also confusion about the
concept of reflective practice and a dearth of experienced reflective
practitioners to act as role models.134 All of these problems need to be
addressed if reflective practice is to be implemented effectively into
faculty development for resuscitation training.135 Structured faculty
evaluation tools might be useful for this.
Peer coaching provides a valuable perspective from outside,
promotes mutual learning between peers and strengthens commu-
nities of practice.42,136 Peer coaching may be encouraged within
instructor teams and therefore easily performed, and this is a
common situation in advanced life support courses. It can also be
done as a mutually planned observation of two instructors. This
requires a climate of mutual trust between instructors and may be
the first step towards the development of communities of practice.
Communities of practice may influence the practice of teaching by
sharing aims and views on teaching.137 Collaborations may be
established, e.g. to share teaching material, or to establish peer
coaching. Also, new information may be spread more quickly, and in
a standardised manner. For communities of practice, organisational
support is essential; one example of a supporting tool is the ERC
VLE ‘CoSy’. Other approaches to establish communities of practice
are ‘instructor groups’ or the organisation of ‘instructor days’ to
support ongoing continuous professional development. Instructors,
course directors and educators should view themselves as
members of a community of practice. Web-based formats for
interaction and networking may be helpful to avoid individuals ‘doing
their own thing’ (Fig. 7).
Effect of resuscitation education on outcome
Adult ALS training
The ERC has a long history of delivering accredited life support
training covering the care of neonatal, paediatric, and adult patients.
 RESUSCITATION 161 (2021) 388
Fig. 7 – Resuscitation Competences a continuum from BLS to ALS.
The delivery of these courses requires resources and depends on the
available time for instructors and candidates to attend. It is therefore
important to demonstrate the effect of these courses on patient
outcomes.
A systematic review looked at whether prior participation of one or
more members of the resuscitation team on an ALS course affected
patient outcomes.41 All studies of any language looking specifically at
the American Heart Association Advanced Cardiac Life Support,
Resuscitation Council UK ALS, ERC ALS and Australian Resuscita-
tion Council ALS courses were included in the review. Eight
observational studies were included in a meta-analysis.138 145
An ILCOR CoSTR systematic review found very-low quality
evidence showing an association between advanced cardiac life
support training and return of spontaneous circulation.21,140 145
There is very-low quality evidence showing an association between
advanced cardiac life support training and survival to hospital
discharge or survival to 30 days.138 140,142 145 There is very-low
quality evidence showing no association between advanced cardiac
life support training and survival to one year.142,143 It can therefore be
concluded that the prior participation of HCPs on an accredited ALS
course has a positive impact upon patient outcomes.
Neonatal life support training
A systematic review and meta-analysis of the impact of neonatal
resuscitation training on neonatal and perinatal mortality identified
20 trials with 1,653,805 births.146 The authors concluded that
neonatal resuscitation training versus control decreased the risk of
407 401
stillbirths, 7-day neonatal mortality, 28-day neonatal mortality, and
perinatal mortality. These analyses were based upon two random-
ised controlled trials.147,148 In addition, the systematic review
analysed 18 pre and post intervention studies and concluded that
after neonatal resuscitation training there was a decrease in the risk
of all stillbirths, fresh stillbirths, 1-day neonatal mortality, 7-day
neonatal mortality, 28-day neonatal mortality, and perinatal
mortality. The quality of evidence was deemed to be high for 7-
day and 28-day neonatal mortality in the neonatal resuscitation
training versus control analyses and moderate for perinatal mortality
in the same analysis. All other analyses were stated to be based
upon very-low quality evidence. The implications for practice from
this review are that neonatal resuscitation training promotes better
ante and peri-natal care leading to a reduced rate of stillbirths and
improves the survival of new-born patients.
Other life support courses
The evidence from similar life support courses is also important. A
systematic review of the impact of Advanced Trauma Life Support
(ATLS) courses concluded that there was positive educational value
for the course.149,150 Unfortunately, high certainty evidence that the
training reduced trauma mortality was lacking. This review identified
only one prospective cohort study and six retrospective studies. Five
studies showed no effect, one showed significant improvement, whilst
one showed worse outcomes for trauma patients managed by ATLS
certified doctors. A Cochrane review on ATLS training was unable to
identify any controlled trials for this topic and claimed further
402 RESUSCITATION 161 (2021) 388
research.151 Whilst the limited evidence for ATLS is neutral, it does not
conflict with the evidence for ALS and neonatal resuscitation training.
In conclusion, the provision of accredited adult ALS training and
neonatal resuscitation training is recommended for healthcare
professionals.21 In the absence of data to demonstrate harm, it is
reasonable to recommend other similar accredited life support
courses for healthcare professionals, such as advanced paediatric
life support training, although further research is needed to quantify
their actual impact on patient outcomes.
Research gaps and future directions in educational research
The aim of international resuscitation evidence evaluation is to
critically appraise the most up to date science in education and
implementation across all levels of providers.152 The significance of
educational research in resuscitation lies in implementing best
educational practices for learners and instructors that leads to
improved patient outcomes after cardiac arrest, which remains the
utmost priority.
The American Heart Association expanded upon the Formula for
Survival1 in its resuscitation education science scientific statement,
introducing new concepts from the wider medical education literature,
and providing new strategies to improve educational efficiency in
resuscitation training.68
There remains a lack of high-quality research in resuscitation
education to demonstrate that training can improve process quality
(e.g. compression rate, depth and fraction) and patient outcomes (e.g.
return of spontaneous circulation, survival to discharge or survival with
favourable neurological outcome). The optimal mode of delivery and
frequency of retraining to maintain and prevent skill decay is not
known.21 Other knowledge gaps include the feasibility, learner
preference, self-efficacy and cost-effectiveness of refresher training
and spaced learning.26,153
There is a lack of research to support the most effective and
efficient method to teach leadership and team performance, how to
best integrate human factors and non-technical skills in medical
education, choosing the most effective assessment tool based on the
learning objectives, as well as finally exploring the value of simulation
training on improving patient outcomes.
Strategies to improve educational efficiency may include rede-
signing resuscitation training courses with the learner in mind, as well
as how to make the best use of new modalities of teaching using digital
media, but there is insufficient evidence to guide us. More research is
needed to identify the potential benefits of a blended learning
approach across all course modalities for laypeople and healthcare
professionals. Such research should not be limited to educational
outcomes (e.g. knowledge, skills and participant satisfaction) but also
outcomes such as cost-effectiveness and reduction in face-to-face
time.
Recommendations for education research
Further research is needed to examine the impact of medical
emergencies and resuscitation attempts on the emotional and
psychological well-being of bystanders, first responders with a duty
to respond, and HCPs. Education and training help reducing stress
and cognitive load around resuscitation but this has not been fully
explored.154 The impact of interprofessional learning and gender
differences in leading CPR teams are still not very well
understood.155,156
407
Train-the-trainer programmes disseminate resuscitation educa-
tion around the world improving instructor education.157 Despite
this, the development of existing instructors and educators involved
in resuscitation training is an area in need of research, ranging from
basic to advanced life support education. Feedback and debriefing
form an important part of resuscitation training but effective
feedback must be fit for purpose to be effective. There is an
evident lack of research to guide and train instructors in delivering
the most effective feedback.158 Specific attention is required to
develop a competent teaching faculty able to deliver a curriculum to
learners effectively and in a contextualised manner.68 Faculty
development will also need to tackle the wide variability in instructor
expertise and background.
Collaborators
The writing group like to thank Jasmeet Soar for his input on this
educational chapter.
Conflicts of interest
RG declares his role as Editor of the journal Trends in Anaesthesia and
Critical Care, associate editor European Journal of Anaesthesiology.
He reports institutional research funding.
JB declares his role of Associate editor BMC and
Notfall&Rettungsmedizin.
JY declares research grants from National Institute for Health
Research and Resuscitation Council UK.
AL reports his role of Medical advisor for First on Scene training
company.
AS declares Research funding EU for “I procure security project”.
LP-K is shareholder of Patientensicherheit.at OG.
FC declares partial ownership of a company of CPR training and
simulation materials.
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Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Ethics of resuscitation and end of life decisions

Spyros D. Mentzelopoulos a, * , Keith Couper b,c , Patrick Van de Voorde d,e ,

Patrick Druwé f , Marieke Blom g , Gavin D. Perkins b , Ileana Lulic h, Jana Djakow i,j ,
Violetta Raffay k,l , Gisela Lilja m, Leo Bossaert n
a
National and Kapodistrian University of Athens Medical School, Athens, Greece
b
UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
c
Warwick Medical School, University of Warwick, Coventry, UK
d
University Hospital and University Ghent, Belgium
e
Federal Department Health, Belgium
f
Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
g
Amsterdam University Medical Center, Amsterdam, The Netherlands
h
Clinical Hospital Merkur, Zagreb, Croatia
i
Paediatric Intensive Care Unit, NH Hospital, Horovice, Czech Republic
j
Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno,
Czech Republic
k
European University Cyprus, School of Medicine, Nicosia, Cyprus
l
Serbian Resuscitation Council, Novi Sad, Serbia
m
Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
n
University of Antwerp, Antwerp, Belgium

Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and
end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care
planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the
application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Introduction and scope
The purpose of the current European Resuscitation Council Guideline
chapter is to provide evidence-based recommendations for the
ethical, routine practice of resuscitation and end-of-life care of adults
and children. This means maximising the benefit of life-sustaining
treatments, while concurrently preventing pertinent harm, and
promoting equitable access to best-quality resuscitation care. The
chapter should be read in conjunction with other chapters that focus on
specific relevant topics; information on e.g. epidemiology, education,
post-resuscitation care and on the ethics of resuscitation of newly born
babies (transition at birth), can be found in the dedicated chapters
within these guidelines.
We primarily focus on major ethical practice interventions (i.e.
advance directives, advance care planning, and shared decision
making), decision making regarding resuscitation, education, and
research. These areas are tightly related to the application of the
principles of bioethics in the practice of resuscitation and end-of-life
care. Consensus definitions of core bioethical principles and relevant
key terms are included in the online supplement.

* Corresponding author at: Department of Intensive Care Medicine University of Athens Medical School, Evaggelismos General Hospital, 45-47
Ipsilandou Street, GR-10675 Athens, Greece.
E-mail addresses: sdmentzelopoulos@yahoo.com, sdmentzelopoulos@gmail.com (S.D. Mentzelopoulos).
https://doi.org/10.1016/j.resuscitation.2021.02.017

0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
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We also refer to emerging ethical challenges that resulted from
the societal and legal changes associated with the coronavirus
disease-19 (COVID-19) pandemic.1 These changes include new
social norms (e.g. social distancing), potential exacerbation of
healthcare inequalities, and dissemination of public health
misinformation.1,2
The chapter content is based on scoping reviews of 22 research
questions, and expert opinion. Reviews were originally completed in
2019. Due to the COVID-19 crisis and the postponement of the
publication of the 2020 guidelines, we updated each scoping review in
mid-2020. Full details of each scoping review, including search
strategies, included studies, and study findings are included in the
electronic supplement.
Key messages from this chapter are summarised in Fig. 1.
These guidelines were drafted and agreed by the Ethics Writing
Group members. The methodology used for guideline development is
presented in the Executive summary.2a The guidelines were posted
for public comment in October 2020. The feedback was reviewed by
Fig. 1 – Key messages relating to ethics in Guidelines 2021.
409
the writing group and the guidelines was updated where relevant. The
Guidelines were presented to and approved by the ERC General
Assembly on 10th December 2020.
Concise guidelines for clinical practice
Major interventions aimed at safeguarding autonomy
Patient preferences and treatment decisions
Clinicians should:
 Use advance care planning that incorporates shared decision
making to improve consistency between patient wishes and
treatment.
 Offer advance care planning to all patients at increased risk of
cardiac arrest or poor outcome in the event of cardiac arrest.
 Support advance care planning in all cases where it is requested
by the patient.
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Record advance care plans in a consistent manner (e.g. electronic
registries, documentation templates etc.).
 Integrate resuscitation decisions with other treatment decisions,
such as invasive mechanical ventilation, in overarching advance
emergency care treatment plans to increase clarity of treatment
goals and prevent inadvertent deprivation of other indicated
treatments.
 Clinicians should not offer CPR in cases where resuscitation
would be futile.
Improving communication
 Clinicians should use evidence-based communication interven-
tions to improve end-of-life discussions and support completion of
advance directives/advance care plans.
 Clinicians should combine structured end-of-life discussions with
video decision aids for shared decision making about end-of-life
hospital transfer from nursing homes in systems where this
technology is available.
 Clinicians should consider inviting a communication facilitator to
join discussions with patients and/or their family when making
advance care plans about the appropriateness of life sustaining
treatments. This refers to systems where communication
facilitators are available.
 Healthcare systems should provide clinicians with communication
skills training interventions to improve clinicians’ skill and comfort
in delivering bad news or supporting patients to define care goals.
 Clinicians should integrate the following patient/family support
elements with shared decision making:
1. Provide information about the patient's status and prognosis in
a clear and honest manner. This may be supported by use of a
video-support tool.
2. Seek information about the patient's goals, values, and
treatment preferences.
3. Involve patients/family members in discussions about advance
care plans.
4. Provide empathic statements assuring non-abandonment,
symptom control, and decision-making support.
5. Provide the option of spiritual support.
6. Where appropriate, explain and apply protocolised patient-
centred procedures for treatment withdrawal with concurrent
symptom control and patient/family psychological support.
7. Consider recording meetings with family for the purpose of
audit/quality improvement.
Deciding when to start and when to stop cardiopulmonary
resuscitation (CPR)
Withholding and Withdrawing CPR
 Systems, clinicians, and the public should consider cardiopulmo-
nary resuscitation (CPR) a conditional therapy.
 Systems should implement criteria for the withholding and
termination of CPR for both in-hospital cardiac arrest (IHCA)
and out-of-hospital cardiac arrest (OHCA), taking into consider-
ation the specific local legal, organisational, and cultural context.
 Systems should define criteria for the withholding and termination
of CPR, and ensure criteria are validated locally. The following
criteria may be considered:
 Unequivocal criteria:
 When the safety of the provider cannot be adequately
assured
 When there is obvious mortal injury or irreversible death
 When a valid and relevant advance directive becomes
available that recommends against the provision of CPR.
 Further criteria to inform decision making:
 Persistent asystole despite 20 minutes of advanced life
support (ALS) in the absence of any reversible cause.
 Unwitnessed cardiac arrest with an initial non-shockable
rhythm where the risk of harm to the patient from ongoing
CPR likely outweighs any benefit e.g. absence of return of
spontaneous circulation (ROSC), severe chronic co-mor-
bidity, very poor quality of life prior to cardiac arrest.
 Other strong evidence that further CPR would not be
consistent with the patient's values and preferences, or in
their best interests.
 Criteria that should not alone inform decision-making e.g.

Pupil size
 CPR duration
 End-tidal carbon dioxide (CO2) value
 Co-morbid state
 Initial lactate value
 Suicide attempt
 Clinicians should clearly document reasons for the
withholding or termination of CPR, and systems should audit
this documentation.
 Systems should implement criteria for early transport to hospital in
cases of OHCA, taking into account the local context, if there are
no criteria for withholding/terminating CPR. Transfer should be
considered early in the CPR attempt and incorporate patient,
event (e.g. distance to hospital, risk of high-priority transport for
those involved), and treatment (e.g. risk of suboptimal CPR)
factors. Patients who may particularly benefit from early transport
include emergency medical services (EMS) witnessed arrest [or
by bystander performing high quality basic life support (BLS)] with
either ROSC at any moment or ventricular fibrillation/tachycardia
(VT/VF) as presenting rhythm and a presumed reversible cause
(e.g. cardiac, toxic, hypothermia).
 Systems should implement criteria for inter-hospital transfer of
IHCA patients in hospitals where advanced CPR techniques are
not offered.
 Clinicians should start CPR in patients who do not meet local
criteria for withholding CPR. Treatments may then be tailored as
more information becomes available.
 Clinicians should not partake in ‘slow codes’.
 During a pandemic, resource demand (e.g. critical care beds,
ventilators, staffing, drugs) may significantly exceed resource
availability. Healthcare teams should carefully assess each
patient's likelihood of survival and/or good long-term outcome
and their expected resource use to optimise allocation of
resources. Clinicians should not use categorical or blanket criteria
(e.g. age thresholds) to determine the eligibility of a patient to
receive treatment.
 In systems that offer uncontrolled donation after circulatory death
and other systems of organ donation, transparent criteria should
be developed for the identification of candidates and process for
obtaining consent and organ preservation.
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Bystander CPR
Systems should:
 Recognise the importance of bystander CPR as a core component
of the community response to OHCA.
 Recognise bystander CPR as a voluntary act, with no perceived
moral or legal obligation to act.
 Support bystanders in minimising the impact on their own health of
performing bystander CPR. In the context of transmissible disease
(such as COVID-19), bystanders also have a responsibility of
preventing further disease transmission to other individuals in the
immediate vicinity and the wider community.
 Aim to identify cases where bystander CPR is likely to be beneficial
and cases where it is unlikely to be beneficial.
 Never evaluate the value of (bystander) CPR in isolation but as
part of the whole system of healthcare within their region.
(Bystander) CPR seems feasible in settings where resources and
organisation support the integrity of the chain of survival.
Family presence during resuscitation
Resuscitation teams should offer family members of cardiac arrest
patients the opportunity to be present during the resuscitation attempt
in cases where this opportunity can be provided safely, and a member
of the team can be allocated to provide support to the patient's family.
Systems should provide clinicians with training on how best to provide
information and support to family members during resuscitation
attempts.
Patient outcomes and ethical considerations
 When making decisions about CPR, clinicians should explore and
understand the value that a patient places on specific outcomes.
 Health systems should monitor outcomes following cardiac arrest,
and identify opportunities to implement evidence-based inter-
ventions to reduce variability in patient outcome.
 Cardiac arrest research should collect core outcomes, as
described in the cardiac arrest core outcome set.
Ethics and emergency research
 Systems should support the delivery of high-quality emergency,
interventional and non-interventional research, as an essential
component of optimising cardiac arrest outcomes.
 Researchers should involve patients and members of the public
throughout the research process, including design, delivery and
dissemination of the research.
 For observational research (e.g. in the context of registry data
collection and/or DNA biobank data sampling and analyses)
we suggest consideration of a deferred and broad consent
model, with concurrent implementation of appropriate safe-
guards aimed at preventing data breaches and patient re-
identification.
 Communities or population in which research is undertaken and
who bear the risk of research-related adverse events, should be
given the opportunity to benefit from its results.
 Researchers must ensure that research has been reviewed and
approved by an independent ethical review committee, in line with
local law, prior to it being commenced.
 Researchers must respect the dignity and privacy of research
subjects and their families.
411
 Researchers should comply with best practice guidance to ensure
transparency of research, including study protocol registration,
prompt reporting of results, and data sharing.
 Systems should ensure that funding for cardiac arrest research is
proportionate to the societal burden caused by cardiac arrest-
associated morbidity and mortality.
Evidence informing the guidelines
For ethics in relation to the COVID-19 pandemic see 00 Ethical
considerations on resuscitation during the COVID-19 pandemic00 .3
Major interventions aimed at safeguarding autonomy
The key interventions for safeguarding patient autonomy are advance
directives and advance care planning. These interventions should be
underpinned by a shared decision-making process.
Variability in terminology, definitions, type and delivery of
interventions, and outcome choice makes it challenging to identify
and assimilate research evidence in this area.4,5 In view of this, the
writing group developed consensus definitions and statements for
advance directives, advance care planning, and shared decision
making, which are summarised in Tables 1
3 and the online
supplement.
In developing treatment guidelines, we drew on core ethical
principles, 29 systematic/scoping reviews, and 49 recent primary
research papers. Key systematic reviews and studies are summarised
in the supplementary text and Tables S2 and S3. The corresponding
rapid reviews 1.1
1.4 are summarised in the respective appendices.
Advance directives
Effective use of advance directives relies on the accurate and efficient
exchange of information about patient values, goals, and preferences,
and available treatment options.4 Consequently, several, structured
communication tools (e.g. paper, video, or computer decision aids,
and educational interventions) have been developed to facilitate end-
of-life decision-making.4 Evidence from meta-analyses of randomised
controlled trials (RCTs), systematic reviews, and recent studies
suggests that structured communication tools aid in the completion of
advance directives and may increase concordance of end-of-life care
with the care desired by the patient.4,6
12
Do not attempt CPR (DNACPR) decisions seek to protect patients
from receiving invasive treatments they have declined, they have
considered futile, or from treatments that are not aligned with the
patient's values and preferences.13 Evidence from 13 RCTs and from
8 nonrandomised studies included in 3 systematic reviews suggests
associations of communication interventions with an increased
frequency of DNACPR orders.4,7,8,10
Four systematic reviews reported mixed findings regarding the
impact of advance directives on the documentation of patient's wishes
about treatment escalation and resuscitation decision-making.5,9,10,14
These reviews also highlighted that, in some studies, the making of a
DNACPR decision may confer benefit as regards the patient's quality
of care through, for example, more adequate pain relief and hydration,
and improved response of healthcare providers to clinical
deterioration.
Recent evidence from RCTs supports the use of informational
video decision support tools in both the nursing home and the in-
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Table 1 – Consensus definition and statements for advance directives.

Advance directives *
 An advance directive is an instrument that relays information concerning an individual's preferences and goals regarding medical procedures and treatments,
especially those used for end-of-life care.
 Advance directives intend to extend the patient's autonomy to situations in which he/she is unable to express his/her preferences regarding treatment decisions.
They reflect a patient's individual moral, cultural, and religious attitudes. They are represented in three formats: Living Will (or instruction directive), Appointment of
a Healthcare Proxy (or proxy directive), and Legal Status of Preferences.
 In principle, advance directives (ADs) must fulfil the following 3 criteria: Existence, Validity (partly realised through periodic review), and Applicability.
 Health care professionals should determine whether their patients have ADs.
 Physicians should respect their patient's ADs and incorporate them into their decision making.
 Physicians should discuss advance directives with their patients.
 Attempts should be made to ascertain patient's wishes (especially patients with terminal diseases) concerning life-sustaining treatments when they are capable of
making decisions or, alternatively, from their surrogates when they are not capable of making decisions.
 There are times when advance directives should not be followed. These include situations when the advance directive calls for an action that is prohibited by the
country's laws and/or regulations, where there is compelling evidence that the patient may have changed his/her mind since completing the advance directive,
when there is compelling evidence suggesting that the patient did not understand the nature of the advance directive he/she completed, or when there is evidence
that the patient did not have freedom of choice at the time of drafting.
 If advance directives concern the refusal of a specific treatment, careful interpretation should be made as to whether this should concern similar (but still
alternative) treatments or not. For example, a patient may refuse a specific medical or surgical treatment due to certain rare but severe side effects. In such a case, it
may not be appropriate to exclude alternative treatments that may exhibit a more favourable safety profile and comparable efficacy relative to the refused treatment.
 Reasons for refusal of standard treatments of a specific disease may not apply after the introduction of new interventions with more favourable safety profiles and
increased efficacy. Given the fact of the continuous and rapid progress in clinical practice, old (e.g. >5 years) and non-updated advance directives should be
cautiously interpreted in the context of availability of new, safer, and potentially more effective therapies.
 Nonstandard advance directives (e.g. tatoos indicating do-not-attempt cardiopulmonary resuscitation - DNACPR) should not be immediately perceived as legally
valid, unless designated so by local law. In countries where the presence of nonstandard advance directives is considered legally valid, CPR administered in
conditions where resuscitation is likely to be futile can lead to legal prosecution of the healthcare professional. Concurrently, every effort should be promptly
undertaken to clarify whether a valid, pertinent advance directive exists.

*, Consensus definitions and statements were based on 7 references.5a
5g

Table 2 – Consensus definition and statements for advance care planning.

Advance care planning *
 A process that enables individuals to define goals and preferences for future medical treatment and care, to thoroughly discuss these goals and preferences with
family and health-care professionals, and to record and review these preferences if appropriate. The main objective of advance care planning is to help ensure that
people receive medical care that is consistent with their values, goals and preferences during serious, chronic and/or acute/life-threatening illness.
 Advance care planning elements may include communication interventions such as information brochures or pamphlets, and video decision support tools.
 Regarding specific population subgroups with morbidity-related decisional incapacity (e.g. patients with dementia, or children with intellectual disability and a life-
limiting illness): due to very limited or even completely lacking, relevant evidence, it is still unclear whether advance care planning (based on surrogate decision-
making) can positively impact their health-related quality of end-of-life, and also ameliorate the surrogates’ psychological burden, symptoms, and distress. In the
meantime, advance care planning should still be considered for such patients.
 Advance care plans that are not updated or re-reviewed should be cautiously interpreted in the context of availability of new and improved therapies that might
potentially affect patient preferences; patient preferences may also evolve with time independently of available treatment options.
 Patient's cultural background, religious beliefs/religiosity, and associated, possible spiritual needs, should be taken into account/respected in the course of
development and reviewing of advance care planning.
 Regarding treatment limitation directives, a recent multicenter observational study suggested that end-of-life treatment limitation practices may be affected both
by patients and physician religion.

*, Consensus definitions and statements were based on 3 references.5a,5g,64

hospital setting by reducing the frequency of delivery of interventions
that are unlikely to be beneficial.15
18 Four recent retrospective
studies and a point-prevalence review suggest that advance
directives and/or DNACPR decisions are associated with reduced
use of life-sustaining treatments.19
24
Evidence from two systematic reviews suggests that the use of
advance directives is associated with reductions in emergency room
visits, hospital admissions, health care costs, and more preference for
comfort care as opposed to life-sustaining treatments.4,8 The effect on
outcomes such as hospital/ICU length of stay, and patient preference
for end-of-life care is less clear. These mixed findings may be partly
attributed to heterogeneity across studies in relation to population,
interventions, and the comparator group. Despite study limitations,
findings of studies of advance directives generally support the use of
structured communication tools.4
Symptom control is key to improving the end-of-life experi-
ences of a dying patient.25 However, 15 RCTs included in a
systematic review failed to determine any advance directive
benefit on patients’ anxiety, depression, pain, psychological well-
being and health.8
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Table 3 – Consensus definition and statements for shared decision making.

Shared decision making *
 Shared decision making is a collaborative process that allows patients, or their surrogates, and a possibly/preferably multidisciplinary team of healthcare
professionals to reach consensus on which treatment strategies and interventions - including life-support limitation and palliative care- accord with the patient's
values, goals, and preferences. Healthcare decisions should take the best available scientific evidence into account. Honest exchange of information should foster
the development of trust/partnership between patient/surrogate(s) and clinician(s). Clinicians should be trained in communication skills. Shared decision making
practices should be evaluated by research using patient-/surrogate-reported outcomes.
 The shared decision making process should include information exchange, deliberation, and decisions relating to a treatment.
 Shared decision making should preferably be part of the application of current guidelines on family-centred care.
 Shared decision making should take into account any pre-existing, documented patient goals, values, and preferences in the form of either 00 isolated00 advance
directives, or advance directives completed in the context of advance care planning.

*, Consensus definitions and statements were based on 3 references.4a,5h,64

In recent guidelines, patient/family satisfaction was considered as
a core outcome.26 Data from eight RCTs included in three systematic
reviews indicated that communication interventions aiding the
completion of advance directives had no significant effect on
patient/family satisfaction with end-of-life care.4,7,8 However, another
4 RCTs included in one of these reviews, reported an increase in
patient/family satisfaction with care associated with a communication
intervention.8
Advance care planning
Advance care planning may be regarded as the state-of-the art
procedure for ensuring respect for patient autonomy. It is a dynamic
process based on effective and honest communication between the
patient and their family, and healthcare professionals (Table 2).
Most studies support the use of advance care planning as a
strategy to ensure that end-of-life care is in line with the patient's
values and preferences, although there is some inconsistency across
the available evidence.9,27
32 Video-based information and other
types of interventions may support the development of advance care
plans and thereby increase the concordance between care desired
and care received. How effective interventions are in achieving
concordance may depend on their nature and on the context in which
they are used.33
36
Documenting a person's or a patient's updated preferences about
end-of-life treatments (including life-sustaining treatments and CPR)
is a major objective of advance care planning (Table 2); documented
preferences may then be accessed by healthcare professionals to
potentially inform treatment decisions. Evidence from six systematic
reviews indicates that advance care planning increases documenta-
tion of patient preferences.27,30,32,37
39 Recent studies also reported
positive results.40
42
We identified mainly positive results on the effect of advance care
planning (with or without the aid of communication tools) on the
preference for and/or actual use of life-sustaining treatments at the
end-of-life. In a meta-analysis of seven RCTs, a video intervention
reduced the likelihood of indicating a preference for CPR relative to
control.43 Another systematic review concluded that advance care
planning was associated with a reduction in the use of life-sustaining
treatments.9 In contrast, two RCTs and four observational studies
included in another systematic review did not report any significant
association between communication tools for end-of-life decision
making and DNACPR status.44 Nevertheless, four recent RCTs45
48
and a cross-sectional survey49 suggest that advance care planning is
associated with less frequent preferences for CPR and/or use of life-
sustaining treatments at the end-of-life.
We identified limited supporting evidence for the use of
communication tools in the context of advance care planning, to
reduce hospitalisations, ICU admissions, and hospital/ICU utilisation
among patients who are unlikely to obtain any benefit. Indeed, in meta-
analyses that included five RCTs and eight observational studies,
communication tools had no effect on ICU length of stay.44 In addition,
although a meta-analysis of three observational studies suggested
that communication tools are associated with reduced ICU length of
stay of non-survivors, this was not confirmed in one RCT.44 A meta-
analysis of five observational studies suggested that communication
tools may be associated with reduced hospital costs. However, one
RCT and another two observational studies did not report any effect of
communication tools on hospital costs in ICU non-survivors. One RCT
reported a reduction in the duration of mechanical ventilation with the
use of communication tools, but another two RCTs and two
observational studies failed to confirm such benefit.44
The effects of advance care planning on hospital/ICU admissions,
healthcare resource utilisation, death at preferred location, hospice
use, palliative care referrals, healthcare costs, and quality of dying and
death are inconsistent between studies.9,27,30,31,36,38,43,49
58
Evidence from systematic reviews suggests that advance care
planning is associated with improvements in symptom control and
quality of life.9,30,31,37,38,50,59 However, three recent RCTs found no
benefit with respect to patients’ health-related quality-of-life, physical/
functional outcomes, and anxiety or depression.53,60,61
A recent cluster RCT in nursing homes reported an advance care
planning-associated decrease in family carers’ decisional conflict.62 A
cross-sectional survey,49 and a historically controlled, prospective
study57 reported associations of advance care planning with good
quality of end-of-life and decreased suffering in children/adoles-
cents,49,57 or adults49 with complex chronic conditions; advance care
planning was also associated with reduced parental decisional regret,
or lower caregiver burden.
Evidence from five systematic reviews suggests that advance care
planning may improve patient/family satisfaction with care.9,31,37,38,44
However, a recent, multicenter RCT of advanced cancer patients
reported that consultation plus early palliative care did not affect family
satisfaction with care.53
Specific and adequate training of healthcare professionals is key to
improving the quality of end-of-life care.63 The results of 21 studies
(RCT, n = 3) included in a systematic review suggested that
communication skills training interventions increase comfort, self-
efficacy, and preparedness of healthcare professionals in the delivery
of end-of-life care.37 In an interview-based study included in a
systematic review, advance care planning discussions increased
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healthcare professionals’ confidence in their dealings with the
patient.29
Shared decision making
Shared decision making is an individualised, collaborative, multistep
process aimed at reaching major and preference-sensitive treatment
decisions (Table 3).64 The concept underpins all patient-focused
healthcare decision-making.
Effective communication about end-of-life care relies on a shared
decision-making process. Its use has been shown to improve end-of-
life care, particularly in relation to concordance between care desired
and care received, in a systematic review65 and most recent studies.
60,66
70
However, studies reporting the effect on quality of care and
symptom control have produced conflicting findings.65
From a health service perspective, shared decision-making
may support the appropriate allocation of resources by ensuring
that patient treatment aligns with their values and preferences.
Use of interventions based on the concept of effective shared
decision-making may be associated with shorter ICU/hospital
length-of-stay, selection of palliative care pathways in nursing
homes, and reduced health care costs and fewer in-hospital deaths,
although evidence from systematic reviews and recent studies is
inconsistent.65,67,69,71
79
Family members of patients may be impacted by the illness of their
loved ones. Up to 50% of family members of critically ill patients
experience psychological symptoms, such as acute stress, post-
traumatic stress disorder, anxiety, depression, and decisional conflict/
regret.26,80
82 Family support interventions may help to reduce these
psychological impacts, as suggested by four systematic re-
views,37,71,72,83 and two recent studies.84,85 However, some recent
studies found that family support interventions did not reduce
psychological symptoms in family members.66,67,75,79
Patient and family satisfaction is a key objective of patient- and
family centred communication and care. Communication in the
context of shared decision-making is associated with higher patient/
family satisfaction and increased decisional confidence, as suggested
by four systematic reviews.65,71,72,74 Key components of this
approach include open, honest, clear, and frequent communication
and inclusion of family members in discussions with healthcare
professionals.83 Recordings of clinician-family conferences suggest
that communication is often sub-optimal, such that the patient's values
and preferences are infrequently elicited.86 The use of structured
communication tools may help to improve communication with
families, as suggested by two systematic reviews.37,44 Furthermore,
according to recent studies, communication supported by other
strategies such as video decision aids may be associated with
improved family satisfaction.67,75,78
Major interventions aimed at safeguarding autonomy and
COVID-19
During periods of public health disaster, such as the COVID-19
pandemic, the importance of pre-existing documentation of patient's
wishes regarding life-sustaining treatments, including mechanical
ventilation and CPR, may increase, especially for overstretched
healthcare systems with limited resources.87
89 In the absence of
advance directives, healthcare professionals should actively seek to
engage in treatment escalation decisions with patients, especially those
at high-risk of death.90 Ideally, this should apply to all healthcare settings,
using digital communications as appropriate and feasible.87
89
Discussions should focus on eliciting an individual's values and
preferences, rather than asking them to choose a treatment option.91
Treatment escalation decision-making, such as DNACPR, should be
based on an individualised patient assessment that draws upon clinical
and scientific evidence,92 the patient's values and preferences, and the
local context, such as resource availability. Decision-making based on
single factors such as age, sex, race, religion/ethnicity, intellectual
disability, and socioeconomic status is not ethically justifiable.87,88,92,93
Discrimination according to a patient's COVID-19 status must also be
avoided.94
Structured advance care planning interventions may include face-
to-face conversations between the patient and a healthcare
professional over a specified time interval, often with family members
present.46 Clearly, such interventions may be hindered by the need for
physical distancing due to healthcare catastrophes like the COVID-19
pandemic. Although digital telecommunication technology may
obviate the need for physical presence during a discussion, its
availability and the patient's/proxy's capability of adequate use should
not always be taken for granted. Concurrently, there may be a
perceived need for augmented dissemination and even acceleration
of the advance care planning processes to prevent the waste of
potentially scarce resources on disproportionate and/or unwanted,
aggressive end-of-life treatments.89 Such upscaling process should
be achieved solely through improvements in system organisation and
infrastructure, public communication and education, and effective
suppression of health misinformation.1,2 Any form of psychological
pressure in the context of categorical discrimination of frail people
should be regarded as ethically unacceptable.92 For emergency
department patients at high risk of severe COVID-19 and without
advance care plans, a viable alternative may comprise the
implementation of an emergency department-based palliative care
team committed to high-quality goals of care discussions with the
patient and/or proxy. Such interventions may increase the rates of
time-sensitive decisions about CPR and other life-sustaining treat-
ments, and comfort care.95
Shared decision-making becomes more challenging in situations
where face-to-face communication is not feasible. In the context of
COVID-19, visiting has been limited in many hospitals and the burden
on hospital services may have limited the time available to healthcare
professionals to engage in detailed discussions with patients and their
families. In these circumstances, use of teleconferences may be an
acceptable and feasible approach to maintain patient-centred
communication with families and integrate shared decision-making
in routine clinical practice.
Deciding when to start and when to stop CPR
The corresponding rapid reviews 2.1
2.7 are summarised in the
respective appendices (pages 167
310 of the online supplement).
Termination of resuscitation
The 2020 International Liaison Committee on Resuscitation (ILCOR)
Consensus on Science and Treatment Recommendation condition-
ally supported the use of termination of resuscitation (ToR) rules (very-
low certainty evidence).96 In making the recommendation, the ILCOR
Education Implementation and Teams task force acknowledged
variation in patient values, resources available, and performance of
ToR rules across settings. The task force sought to balance the risk
that implementation might result in missed survivors, against current
variation in practice and improve termination decisions more
generally. ToR may also reduce demand on hospital resources and
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increase rescuer safety by reducing the number of patients trans-
ported to hospital in cardiac arrest.
It is generally agreed that CPR should not be provided to all
patients. This viewpoint reflects both medical and ethical perspec-
tives, including the potential harm of CPR (in terms of dignity, victim
awareness, deception of relatives, etc.), and the risks of unfavourable
outcome in survivors (and likewise burden for caregivers, risks to
healthcare providers, medical costs, and preservation of medical
resources). Many authors strongly defend the individual's right to die in
a society where more and more advanced medical techniques can
lengthen life at the potential cost of quality of life and palliative
comfort.97,98 Prolongation of an inevitable dying process should be
considered harm (dysthanasia). In practice, it is often challenging to
reliably identify which individuals will have a poor outcome in the event
of cardiac arrest.99
103
Futility has traditionally been described as a likelihood of survival
of less than 1%.104 More recently, this concept has been challenged
for not considering either neurological and functional outcome of
survivors or broader societal considerations opinions (e.g. utility
trade-off).104
106 Importantly, Van Norman et al. posed relevant
questions about fairness of the concept when there is a potential for
unconscious bias based on socioeconomic and demographic
factors like social status, fear of litigation or the patient gestalt.107

109
The appreciation of futility is timely and contextual in nature
and often also incorporating religious or spiritual beliefs.110,111
Patients and families may define futility very differently than medical
providers. Marked differences are also observed between different
providers. Many clinicians lack confidence in making ToR decisions
and some report using non-validated or controversial factors as a
single reason for terminating CPR.106,107,112
122 Decision-making
becomes even more complex in the context of newer advanced
resuscitation technologies.
Defining an unfavourable outcome is challenging. The cut-off of a
cerebral performance category (CPC) of 2 may translate to a spectrum
of functional outcomes. Moreover, the value of an outcome to an
individual will likely be specific to that person.105 Defining
as a
society, healthcare provider or even as a relative
that a certain life no
longer is worth living, especially when this becomes balanced against
cost or societal interaction, should only be done with the greatest
caution as it incorporates a great inherent risk of quickly crossing
acceptable ethical boundaries.123,124 As such, there has been a shift
from futility to considering the broader concept of best interests, which
rather evaluates burden versus benefit.
Decision-making regarding the withholding or termination of
resuscitation exists in a legal framework, which will have primacy
over ethical concepts.125 The ILCOR Education, Implementation, and
Teams (EIT) taskforce in their insights highlighted the need to
consider local legislation.96
There are important differences between the withholding or
termination of resuscitation between the in-hospital and out-of-
hospital setting. In the out-of-hospital setting, EMS teams often arrive
at a scene where CPR is in progress, and then can only decide to
withdraw (not withhold) resuscitation efforts. They often have limited
information on the patient's previous medical history and their values
and preferences, and may be unable to discuss treatment options with
family members. As such, where there is uncertainty about the
appropriateness of terminating resuscitation, the focus should be on
patient treatment with a view to reconsidering the appropriate
treatment once the patient's values and preferences, and clinical
trajectory are known.98,102
415
The ILCOR COSTR recommends that none of the existing ToR
rules should be the sole determinant of when to discontinue
resuscitation.96 ToR rules will inevitably introduce a self-fulfilling
prophecy and should be reviewed periodically as new treatments
evolve. Intra-arrest factors are not sufficiently reliable to be used in
isolation for terminating resuscitation.126
135 Examples of factors that
should not be used alone include serum potassium, end-tidal CO2,
cardiac standstill on ultrasound, pupillary response/size, temperature,
co-morbid status, cause of arrest, no-flow time, low-flow time, and
absence of ROSC.
The ILCOR CoSTR summarises several ToR rules.136,137 Some
factors are consistent across tools, such as whether the arrest was
witnessed. A key challenge in operationalising these rules stems from
uncertainty as to the applicability of rules to other healthcare settings
and the challenge in reliably estimating the number of missed potential
survivors when applying the rule.103,104,138
144
There are specific guidelines for specific subpopulations, such as
children.145 Despite differences in pathophysiology and aetiology, the
ethical framework in paediatric cardiac arrest is otherwise similar,
although many clinicians may be more cautious in terminating the
resuscitation of a child.99,146,147
Typical, but not only important for children, is the mandate and role
of surrogate decision makers. Time is often limited to come to shared
decision-making during cardiac arrest. Moreover, the likelihood of
truly informed unbiased consent is low, and it is unclear whether the
best interest of the patient might not conflict with the rights and
interests of the relatives.148 Importantly, putting for instance parents in
the position to forgo CPR may intensify parental grief and
helplessness.148 Therefore, clinicians should carry the primary
professional and moral responsibility for the decision and use a
model of informed assent from parents, allowing for respectful
disagreement. Nevertheless, local regulation and laws might demand
actual guardian's consent.
Slow code
A ‘slow code’ is slang for the deceptive practice of purposely delivering
sub-optimal CPR with the pretence of attempting to save the patient's
life. There is evidence that slow codes continue to be performed both
in IHCA and OHCA, even when CPR is considered of no benefit to the
patient.149
151
Use of the slow code is extremely ethically problematic, although
some have advocated for it in certain circumstances.152,153 Several
alternatives have been described that are ethically more acceptable,
such as informed non-dissent, tailored code or early advance care
planning with open communication. More education on ethics in
resuscitation might positively affect this.
Extracorporeal (E)-CPR
The European Resuscitation Council (ERC) ethics writing group
acknowledges the ALS and paediatric life support 2020 ILCOR
COSTRs that support the use of E-CPR as a rescue therapy for
selected cardiac arrest patients when conventional CPR has failed in
settings where E-CPR can be implemented (weak recommendation,
very-low certainty of evidence).154,155 To inform our insights, we
further identified 6 systematic reviews,156
161 four narrative reviews
162
165
and 13 observational studies68,140,160,166
175 on this topic.
Other sources, such as commentaries and ethical dissertations, were
considered as indirect information.
The evidence base for the cost-effectiveness and ethical
framework of E-CPR is limited. For IHCA, E-CPR may be cost-
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effective, provided the programme is limited to specific patient groups.
The incremental cost-effectiveness ratio is mainly influenced by the
probability of survival, although large variations in in-hospital cost
estimates have been reported. Physicians involved should be
knowledgeable and provide proper stewardship of available resour-
ces. Across 224 North American hospitals that participate in the
American Heart Association (AHA) Get-with-the-Guidelines-Resus-
citation-registry, fewer than 1% patients received E-CPR between
2000 and 2018, indicating a further need for optimised patient
selection and E-CPR implementation strategies.170,171 One system-
atic review examined E-CPR in refractory adult OHCA of cardiac
origin.157 They suggested that it is feasible and may increase both
neurologically intact survival and organ donation in non-survivors.
Implementation in existing EMS systems is challenging and requires
detailed protocols for patient selection and transportation.160,173
175
The Ethics writing group identified an urgent need for more research
on patient selection, modifiable outcome variables, risk-benefit, and
cost-effectiveness of E-CPR. Such data are crucial for E-CPR
programme implementation.
Organ donation
Patients who sustain a cardiac arrest are an important source of donor
organs, mainly because severe neurological injury is a common mode
of death.176
178 There are three pathways by which cardiac arrest
patients might donate organs: following confirmation of brainstem
death, following withdrawal of life-sustaining treatment leading to
circulatory death (controlled donation after circulatory death) or
donation where resuscitation attempts to achieve ROSC have been
unsuccessful (uncontrolled donation after circulatory death). The
Post-Resuscitation Care and ALS sections of the guidelines provide
further details on these pathways. This section focuses on the ethics of
organ donation.
We included two systematic reviews,178,179 four narrative
reviews,180
183 five observational studies184
188 and some addi-
tional editorials and ethical dissertations.
Across Europe, there is variability in organ donor rates, availability
of organ donation pathways, and law and policy regulating organ
donation (World Health Organization Collaborating Centre on Organ
Donation and Transplantation 2019). Shortage of available donor
organs is an ongoing challenge across Europe and contributes to
premature morbidity and mortality in individuals with organ failure.
Organ donation provides an opportunity following a tragic event to
respect the donor's wish to benefit wider society. For relatives of the
donor, consenting to organ donation may provide comfort that their
grief has given life to others.188 Organ donation is generally supported
by society, although levels of support vary by cultural group and
between individuals.181,186
A key issue is the need for both family members and society to
maintain trust that donation is considered only when ongoing
treatment will not achieve an outcome important to the patient.
Examples of safeguards to maintain this trust include respect for the
dead-donor rule, a clear division between the clinical and transplan-
tation team, and transparent communication with family members
before organ retrieval. A review of attitudes towards organ donation
concluded that both general and ethical education may serve to guide
policy and to facilitate family member requests and informed consent
dialogues.180 Helping families to understand and accept not only
medical and legal criteria for determining death, but also ethical
criteria for withdrawing life support, may help them be more
comfortable with their decisions.
Uncontrolled donation after circulatory death raises ethical
challenges.185,189 In particular, the time-critical nature of the process
usually requires the initiation of organ preservation processes prior to
family consultation to maintain organ viability.186,190,191 Cardiac arrest
patients may meet criteria for both uncontrolled donation and E-CPR
programmes.157,159,179 In centres that offer both modalities, uncon-
trolled donation should be considered only in patients who do not meet
clinical criteria for E-CPR, in order to prevent the loss of potentially
saveable life.163 For a more in-depth discussion see the supplement
(pages 255
259).
Importantly, several authors suggest that organ-preserving CPR
should be considered only for patients who are brain-dead, or in those
with evidence of futility, a known wish for organ donation and a specific
informed consent from a next of kin.163,190,192,193
Family presence during resuscitation
In our literature search we did not specifically address parental
presence during the resuscitation of a child as this is expected to be
topic of a specific COSTR from the ILCOR paediatric Taskforce;
however, our findings apply equally to this context and we also refer to
the 2015 ERC guidelines.194,195 For family presence during
resuscitation, we identified one guideline,196 two systematic re-
views,197,198 five narrative reviews,199
203 one RCT,204 and three
observational studies,205
207 as well as several ethical dissertations
and opinion pieces.
The available evidence indicates that family presence during
resuscitation does not affect patient outcome but may improve family
member psychological outcomes. On this basis, teams should offer
family members the option to be present during resuscitation in
situations where it is safe, and when the family can be adequately
supported.
CPR after attempted suicide
This guidance is based on one narrative review208 and on an
observational study,209 with other sources included as indirect
evidence.
The 2015 ERC ethics chapter highlighted the challenge of
determining whether the patient who has attempted suicide had
mental capacity at the time of the suicide attempt.195 On this basis,
the guidance recommended that treatment be started because of
the risk of harm if treatment is delayed. Crucial to the decision
making is the appreciation of mental capacity. This is defined as
sufficient understanding of the nature, purpose and effects of the
proffered treatment, and able to comprehend and retain the
treatment information; believe the information; and weigh it among
other factors to reach a decision.210 The patient must also be able to
communicate and substantiate the decision (see also supplement
for our consensus definition of decisional incapacity). Sufficiency of
capacity is seen as a spectrum, and the more profound the
consequences of the decision, the higher the level of capacity that
must be demonstrated.210
A specific complex situation is when the patient is not considered
competent but has a valid advance directive.211 A decision to withhold
treatment might be viewed as abetting a suicide attempt, but it is
reasonable to continue to honour a valid and applicable advance
directive. This is because the test of capacity is based on when the
advance directive was made, rather than at the time of the suicide
attempt.212 An alternative perspective is that there are competing
rights that are sufficient to override a competent decision to refuse
treatment. These may include the state's interests in preventing
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suicide and the need to protect innocent third parties, such as
dependent children and even foetuses.
If the treating healthcare professional is uncertain about the
patient's capacity or validity of an advance directive, it is reasonable to
provide lifesaving treatment and simultaneously seek urgent ethical or
legal advice. Sufficient time should be taken to consider contextual
evidence relating to the suicidal behaviour, the nature of the treatment
decision and the verification of any documentation.208
It is difficult to rapidly judge the context of an attempted suicide and
it is suggested that the default should be to initiate life
sustaining
treatment.213 Surrogate decision makers may be unable to represent
the views of patients, especially in the setting of attempted suicide. If
the patient is stabilised, the quality of ongoing life may not be in line
with their values and preferences. The response to the clinical
situation should not be dogmatic but proportional to the individual
case.214
Some authors have suggested that a suicide attempt is not as
important as the underlying (disease) process that led to the attempt.
In other words, it may be ethical to withhold or withdraw life
sustaining
treatment in case of suicide when there is an underlying serious
medical condition.215
The ethical framework of bystander CPR
Early bystander CPR improves patient outcomes in OHCA.216
221
In many countries, systems of trained volunteers and/or first
responders, in addition to dispatcher-assisted CPR by lay people,
have been implemented. The crucial role of this community
response to OHCA is incorporated in the chain of survival and in
the ERC guidelines.222 There are important differences in rates of
bystander CPR between countries, regions and even in circum-
stances or victim characteristics.217,223
226
A 2020 ILCOR scoping review explored the individual's
willingness to perform bystander CPR.227 Factors influencing
bystander willingness or actual delivery of bystander CPR include
emotional factors, patient status (e.g. vomiting), socioeconomic
status of the patient, patient sex, physical challenges (e.g. patient
positioning, bystander age), and lack of knowledge or confi-
dence.228,229 Rescuers are more willing to perform compression-
only CPR compared to CPR with rescue breaths. Some authors also
identified fear of legal consequences as a potential barrier.230,231
Older bystanders are less likely to start CPR, despite a higher
chance of being bystanders to cardiac arrest. Important facilitators
include prior knowledge and training, and feeling a moral obligation
to act.232
235
There are ethical aspects concerning the ILCOR-supported
use of smartphone-apps or text- messaging to alert trained lay
rescuers to OHCA (strong recommendation, very low-certainty
evidence).236 Regional systems of alerting lay volunteers and/or
first responders have many common characteristics but still may
vary depending on the local context. 224,225,237
256 Some systems
a priori exclude (young) children, traumatic cardiac arrest,
intoxication, drowning and/or suicide, unsafe or inaccessible
settings and/or nursing homes. Such exclusions are most often not
further explained and/or defined. The low sensitivity and specificity
of current dispatcher protocols for cardiac arrest recognition
results in a high percentage of false positive and false negatives.
We identify this as a major issue and consider better case
selection a priority. In up to 30% of OHCAs, the attending EMS
team will not start CPR. A priori identifying these cases is very
417
difficult but might limit a subsequent ethical conflict between the
lay rescuers and the arriving EMS team.
Further key ethical issues in relation to the establishment of these
systems include the potential psychological impact on the bystander
of attending a cardiac arrest, the potential variability in the skills and
competence of volunteers dispatched to OHCA, and the potential
impact on the patient's privacy of treatment by a non-professional
rescuer. Most authors put higher value on the potential of saving a life
than on the possible breach of privacy associated. A survey of North
Americans found that most did not object to the implementation of an
app-alerted volunteer system in their community nor to receiving
crowdsourced help.249
An ILCOR review identified only limited evidence of harm to
rescuers of performing CPR and/or using an AED. However, in the
context of the COVID-19 pandemic, there is a risk of infection
transmission to the rescuer. Whilst not performing CPR (or with
substantial delay) will reduce the likelihood of a good outcome for
many victims, bystanders should try to limit the associated risk of
disease transmission by doing CPR.3,257 The specific risk-benefit will
be a function of factors such as the current regional COVID-19
prevalence, the victim's presentation (presumed COVID-19 status),
the likelihood that CPR would be effective, the availability of personal
protective equipment, and whether the bystander already had
previous contact with the victim.
CPR training should better prepare lay rescuers for the various
logistical, conceptual, and emotional challenges of resuscita-
tion.105,258,259 This includes limiting self-doubt, improving knowledge
of the exact impact of performing or not performing certain actions and
correcting certain misbeliefs.
CPR is promoted as a highly effective treatment both in the popular
press and in dedicated media campaigns.260 Only recently, more
discussion about indications and limitations of CPR has started to take
place in the public domain.106 Such discussions, although from a
patient and healthcare provider perspective very relevant, are difficult
to appreciate for the lay rescuer. The Ethics writing group continues to
support the emphasis on bystander CPR as a key link in the chain of
survival.
Improved public information about the situations where CPR has a
reasonable likelihood of providing clinical benefit and those where not,
may be helpful.105 EMS dispatch centre protocols should seek to
better identify patients for whom bystander CPR might be beneficial
but also try to identify those for whom it is not. Bystander CPR should
never be considered a moral or judicial obligation.
Providing CPR is emotionally challenging for lay rescuers and
first responder and, for some, has consequences in terms of family
and work life.253,261,262 The role undertaken by the lay bystander
should be acknowledged by both the EMS dispatch centre and the
EMS team.263
Finally, the ILCOR EIT Taskforce looked at OHCA in resource-
limited environments, as many of the statements related to CPR might
not be applicable in resource-limited settings.264 They acknowledged
that the feasibility and cost-effectiveness of CPR in OHCA in these
settings can be challenged. One could argue that CPR is only ethically
acceptable in settings where resources are such that other
fundamental parts of the healthcare system are already sufficiently
developed. CPR, as with many other healthcare choices, should never
be evaluated in isolation but as part of the whole system of healthcare
within a country or region. The role and remit of bystander CPR within
such a context is obviously far less clear.
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Education, communication and system organisation
Education of lay persons, persons at risk of cardiac arrest
and family
Education about patient’s right of autonomy
Advance care planning discussions led by trained nurse facilitators or
social workers are associated with an increase in patient knowledge
about advance care planning, significantly more advance care planning
discussions with physicians and a higher likelihood to agree to a
DNACPR decision.10,265
268 A patient-centred advance care planning
approach increases the congruence in decision-making for future
medical treatment between patients and their surrogate, improves
satisfaction with the decision-making process and decreases the
decisional conflict.269 A pilot RCT addressing specific cultural factors by
a tailored intervention using a bilingual, bicultural patient navigator
suggests improved palliative care outcomes for minority groups facing
advanced medical illness.270 A controlled randomised intervention
study in the US exploring peer mentoring by patients trained to help
other patients with end-of-life planning had a significant influence on the
completion of advance directives and the effect was also most
prominent among African Americans.271
Education about CPR indications, procedures and outcome
Video decision support tools depicting CPR, resuscitation preference
options and different levels of care are associated with higher rates of
understanding of the purpose of CPR and resuscitation op-
tions.4,17,272 Educational CPR videos and structured patient-centred
interviews can be helpful in decision making with more patients likely
to forgo CPR and focus on comfort.4,45,70,273,274
Education of healthcare professionals
DNACPR orders and advance care planning
More complex interventions involving education of healthcare
professionals, education of patients and their caregivers as well as
involvement of special teams seem to have greater impact at least on
the effectiveness of DNACPR discussions. It is preferable to have
these discussions as part of a broader approach such as advance care
planning.275 Some of the background evidence suggests that
discrepant interpretations of DNACPR discussion occur with a
concerning frequency between physicians and their hospitalised
patients.276 However, there is no direct evidence whether education
(and in what form) changes this phenomenon.
Family presence during resuscitation
A presentation reviewing the literature supporting family presence
during resuscitation, open discussion about family presence and a
script that could be used to support families during resuscitation are all
effective at improving attitudes of nurses and physicians towards
family presence.277
279 The presence of a trained support person may
further increase staff comfort with family presence during
resuscitation.196
Communication
Advance care planning
Advance care planning discussions with a trained nurse facilitator,
structured nurse-led advance care planning discussions with long-
term care residents of a nursing home and their proxies, and a
physician and clinical nurse specialist team processing medical
information of the primary physician all improved the consensus about
care between patients, their families and the healthcare
professionals.37,265,267,280
Termination of resuscitation and breaking bad news
Ambulance personnel feel particularly concerned about the skills
required to deliver death notification and communicate with family and
bystanders. This unpreparedness is associated with avoidance and
distress. Ambulance personnel use distancing and detachment as a
coping mechanism and focus on rational or structured behaviours of
resuscitation to avoid interaction or empathetic engagement with
family and bystanders.281
Patient outcomes and ethical considerations
The outcome of a cardiac arrest can be defined in several ways.
Outcomes may be measured at multiple time points from during the
cardiac arrest (e.g. end-tidal CO2) to hospital discharge (e.g. survival,
neurological outcome) and beyond (e.g. survival, neurological
outcome, health-related quality of life).282 A successful resuscitation
may be characterised as survival with an acceptable quality of life. This
means that long-term outcomes are of particular interest to patients
and the resuscitation community.283,284
Valuing outcomes
Traditionally, cardiac arrest outcomes have been clinician-reported,
and often dichotomised as good or poor.283 This dichotomisation often
attempts to separate individuals that are functionally independent
from those with ongoing dependency or death.
Today, it is understood that cardiac arrest outcome is
multifactorial and may include long-term changes in functional,
emotional, physical, cognitive and social domains, all associated
with health-related quality of life.283 To make patient-centred
decisions about the appropriateness of resuscitation requires
clinicians and patients to have a shared understanding of how
the patient defines a good outcome. The patient's perspective on
outcome may be influenced by factors such as age, religion, societal
values, and personal experiences. This should inform decisions
about treatments, such as CPR.
Epidemiological data provides information on outcome at the
population level.217,285,286 Outcome for an individual is influenced by
patient-level factors such as age, co-morbid status, and aetiology of
cardiac arrest. As such, predicting outcome at an individual patient
level is challenging. Key challenges for clinicians are effective
communication of uncertainty about the likely outcome if an individual
has a cardiac arrest, and to ensure that their personal values and
preferences do not influence the patient.
Individual autonomy gives individuals the right to decline a
treatment but does not obligate a health system to provide a treatment
that is either futile or not cost-effective. Publicly funded healthcare
systems have limited resources with an expectation that systems use
funding in the most effective way. Treatments that do not meet pre-
defined cost-effectiveness thresholds may not be made available. To
date, few cardiac arrest interventions have been subjected to a health
economic evaluation.287
289
In recent years organ donation has been highlighted as an
important outcome following cardiac arrest.290 Organ donation
provides benefit to the wider health system and society as a clinical
and cost-effective treatment for organ failure.
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In some cases, eliciting how an individual values a particular
outcome may not be possible, such as in the context of young children
or individuals with severe cognitive dysfunction. In these circum-
stances, clinicians should discuss treatment decisions with those
close to the individual. Society often places particular value on the life
of a child. Clinicians must take care to ensure that any decision is in the
individual's best interests. In rare cases where the clinical team and
other parties hold discordant views that cannot be reconciled, parties
may need to defer decision-making to the legal system.
Variability in outcome
Variability in outcome following cardiac arrest has been described in
both IHCA and OHCA.217,285,286,291,292 This variability may be
between locality, EMS systems, hospitals, regions, and countries.
Variation may reflect differences at several levels, including data
collection methods, case-mix, and treatment.293,294 From an ethical
perspective, the key concern occurs when variability is caused by
differences in treatment or processes of care.
Observational data suggest that females and individuals from
socially deprived and ethnic minority groups are less likely to receive
bystander CPR and key post-arrest interventions.295,296 Survey data
indicates that both in-hospital systems of care and long-term follow up
and rehabilitation differ markedly between hospitals.291,297
299
One strategy proposed to improve patient outcomes is central-
isation of hospital services across a range of conditions including
cardiac arrest.300,301 This enables the development of clinical
expertise and facilitates delivery of specialist interventions, such as
primary percutaneous coronary intervention and extracorporeal CPR.
There is a concern that centralisation may disadvantage individuals
that live in rural areas.
Research and registry outcomes
Utstein statements describe the outcomes that should be collected by
registries. Core outcomes are identified as ROSC, survival at hospital
discharge/30-days, and neurological outcome at hospital dis-
charge.302,303 The inclusion of health-related quality of life and 12-
month survival as supplementary outcomes reflects the balance
between the importance of these outcomes, and the challenges of
collection, such as the associated resource requirement.
In the context of research, differences in the way that outcomes are
measured or reported by studies may preclude comparison of results
between studies, and limit opportunities for meta-analysis.304 A
systematic review of cardiac arrest literature identified variability in the
outcomes reported, differences in outcome definitions, and differ-
ences in the timepoint and method used to record outcomes.282 The
patient's perspective on outcome was rarely included.
To address this issue, ILCOR developed a cardiac arrest core
outcome set (COSCA) in a process that involved patients, their
partners, clinicians and researchers.305 Core outcome sets describe
the key outcomes that should be reported in all clinical trials, thereby
ensuring consistency in outcome reporting.306,307 COSCA identified
three outcomes: survival at discharge/30-days; modified Rankin score
at discharge/30-days; and health-related quality of life at 180-days/1-
year. COSCA supports the collection of detailed measures of specific
problems experienced by cardiac arrest survivors, such as fatigue,
anxiety and societal participation. These data may improve our
knowledge of cardiac arrest survivorship and patient support and
rehabilitation in the post-acute phase.
An important challenge for both registries and clinical trials is
ensuring a high level of data completeness for outcomes that rely on
419
patient or proxy engagement, such as health-related quality of life.
Response rates vary markedly across trials.288,308,309 A key concern
is that respondents may be systematically different to non-respond-
ents.310 In cardiac arrest research, survivors with poor outcome are
less likely to respond, leading to bias.311
313 The SPIIRT (Standard
Protocol Items: Recommendations for Interventional Trials) PRO
(Patient-reported outcome) extension guidelines provide information
on including patient reported outcomes in clinical trials.310
Ethics and emergency research
Right to self-determination vs. scientific progress
The prognosis after cardiac arrest remains poor.314
316 Therefore,
there is a need for interventional, multicentre, randomised, controlled
clinical research aimed at reliably assessing the effects of new and
potentially beneficial treatments or validating empirical routine
practice treatments of uncertain efficacy.63,195,317,318 Striking the
best balance between respect for autonomy (i.e. the right to self-
determination) and beneficence (i.e. improving patient outcomes) or
even non-maleficence (i.e. avoiding patient exposure to unproven
treatments) has been recognised as one of the greatest challenges of
emergency research conduct.63,195,317,319
The new European Union Clinical Trials Regulation No. 536/2014.
permits the use of deferred consent in drug trials under clearly
specified conditions. Tested interventions should be considered of
minimal risk/burden for the subject in comparison with the standard
treatment for the subject's condition.317 Thus, the new regulation
enables potentially beneficial, low-risk, multicentre, and multinational
cardiac arrest research.195,317,320 Nevertheless, regulatory improve-
ments are still needed as the new regulation does not concern clinical
trials evaluating devices.317 Notably, device-related emergency
research may confer considerable benefit in terms of leading to
improvements in clinical practice and patient outcomes.321
Deferred consent (i.e. obtaining consent from a surrogate and/or
patient as soon as possible after enrolment) may be necessary
because the therapeutic window is too narrow to obtain a valid pre-
enrolment consent.63,317,322
324 This is considered as an ethically
acceptable alternative for low-risk research, ensuring both the
possibility of research benefit and respect for patient/family autono-
my.325,326 In contrast, a strict requirement for pre-enrolment consent
may delay the initiation of an experimental intervention, thereby
hampering its potential benefit to the patient.327 Another ethically
acceptable and legally supported consent model comprises exception
to informed consent (EIC) with prior community consultation (and a
possibility of prospective opt out for community members).328
335 The
EIC model also mandates obtaining post-enrolment consent.317
Both deferred consent and EIC models are limited by the patient's
and or next-of-kin's right for consent withdrawal later on, as this may
introduce bias in trial results by excluding the data from patients with a
more complicated clinical course.63 This might be partly addressed by
regulatory provisions aimed at preventing the exclusion of patient data
recorded until the time point of consent revocation.63
A recent pragmatic trial of adrenaline (epinephrine) in OHCA
used a combination of a deferred consent model with informative
press releases before and throughout the study period, a constantly
updated trial website during the study period, an electronically
supported opt-out option (which requires further evaluation), a pre-
specified and realistic approach to inform the patient and request
their consent after regaining their decisional capacity, a pre-
specified and clear definition of personal and professional legal
420 R E S U S C I T A T I O N 1 6 1 ( 2 0 2 1 ) 4 0 8
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representative for patients lacking decisional capacity, a pre-
specified method of approach and communication with the legal
representative, a clearly specified procedure for consent refusal or
revocation, and a pre-specified approach for passive provision of
trial information (e.g. through websites or newsletters) to the families
of patients who died before their relatives could be contacted.318
Future research should compare the relative potential benefits (i.e.
less emotional stress) and harms (i.e. limited or no knowledge of the
patient's trial participation details) of passive versus active provision
of information (i.e. more stress but also more knowledge about the
patient's trial participation).
During the design phase of the pragmatic adrenaline trial, the main
outcomes were specified in collaboration with patient and public
representatives.318 Involvement of all major stakeholders (including
patients and representatives of the public) in the iterative development
of core outcome sets during study design, as well as conduct and
delivery of the research and dissemination of its results is an emerging
and promising practice. Indeed, this practice has already been
adopted in several fields of research and may comprise patient-centric
initiatives such as advocacy group support and involvement, patient
advisory panels, and focus groups, interviews with trial participants
and staff, questionnaires and Delphi surveys/consensus processes,
and consensus meetings.336
344
The EIC model is based on the 1996 United States Food and Drug
Administration regulation 21 CFR 50.24.345 Although this regulation
seems to provide clearly defined guidance for the conduct of
emergency research, several authors have previously attributed to
it significant procedural impediments.346,347 For instance, if a family
member is present in an emergency, it may not be feasible for the
researcher to explain to them the research protocol, or even the
concept of informed consent.348 Furthermore, a survey with 530
respondents from a community participating in EIC research projects
revealed that only 5% of the respondents were aware of ongoing
research protocols despite pre-study community consultation. This
casts doubt upon the feasibility of adequate dissemination of research
information among research-participating communities.349
A worrying reduction of cardiac arrest trials of 15% per year
between 1992 and 2002 was documented in the United States.350
Similar worries were articulated for steep reductions of 30
50% in
European trials submitted for grants or ethical approval by the end of
2005351
353; at that time, European Union Directive 2001/20/EC was
in force and its strict interpretation mandated pre-enrolment consent
for all types of drug clinical trials.63,354
The literature cited above highlights the inherent perplexity of
respecting autonomy of patients lacking decisional capacity when
enrolling them in emergency clinical research protocols aimed at
improving their outcomes. This ongoing ethical dilemma could be partly
addressable by advance care planning specifically pertaining to
participation in emergency research. However, such care plans should
also be immediately accessible by emergency healthcare staff and
researchers, even in the setting of OHCA; this may still prove electronic
resource-demanding or even impossible in many situations/settings.355
Large, national and international registries enable the recording of
general population data on the incidence, presumed cause, and
outcomes of cardiac arrest. Information about whether a patient
collapse was witnessed or not, cardiac arrest location, certain aspects
of emergency care organisation (e.g. availability of dispatcher-
assisted bystander CPR), patient characteristics (e.g. age, sex, race,
and comorbidities), treating hospital characteristics (e.g. bed size and
teaching status), downtimes (e.g. time from collapse to first shock),
and treatments administered may also be collected.356,357 Registry
data can be analysed to (1) study regional variation, temporal trends,
and predictors of patient outcomes; (2) compare propensity score
matched patient subgroups receiving different treatments; and (3)
gain insights into the implementation of published evidence and
guidelines in routine clinical practice.316,356,358
361 In addition, DNA
biobanks have been established for DNA sequencing in the context of
genomic research in sudden cardiac arrest.362
Big observational registry/biobank data originate from multiple
sources. Such data may have to be linked for the detection of
associations between potential predictor variables and patient
outcomes.363 The resulting production of high-quality evidence
informing personalised prevention and treatment may contribute to
improved outcomes and reduction of healthcare costs.364 However,
these beneficial processes are not free of ethical issues pertaining to
privacy (i.e. risk of patient re-identification), genetic discrimination,
and moral obligation for disclosure of findings to high-risk patients who
decline becoming aware of their genetic test results. There are also
challenges around observational data quality and potentially biased
results leading to creation of incorrect risk profiles, obtaining consent
for data use in an emergency research setting, and use of appropriate
safeguards for data protection.362,365
374
The current European Union General Data Protection Regulation
(GDPR) 2016/680 mandates that specific appropriate safeguards
(e.g. safe data storage and encryption, access logging, data enclaves,
etc.) be in place for the scientific processing of the data of a natural
person. Records of processing activities must be kept by data
controllers. A data protection impact assessment may be required to
determine and confirm the risks relative to the subject's rights. GDPR
compliance of research institutions must be monitored by a
designated data protection officer.362
The GDPR does not concern anonymous data and data from
deceased persons. Nevertheless, there are also stronger conditions
concerning consent for the inclusion of personal patient data in
research. Notably, a strict requirement for prospective (or pre-
collection) informed consent would exclude collection of data from
most sudden cardiac arrest patients. This would result in consent bias,
skewing of the data, and compromised reliability of research results,
with consequent societal harm. Furthermore, excluding collection of
data from some incapacitated patients could potentially violate their
preference to act in favour of the common good.362 Therefore, for
observational emergency research we suggest that local/regional
supervising authorities consider allowing deferred and broad (i.e. for
the overall research topic) consent, while concurrently ensuring the
implementation of safeguards aimed at preventing data breaches and
patient re-identification.362,375
377 Lastly, and regarding both obser-
vational and interventional research, sometimes, it may not be
possible to obtain even deferred consent, e.g. the patient dies and no
surrogate decision maker can be located, or two surrogates of equal
legal standing disagree. In such cases, we suggest consideration of
permitting the use of the data collected until the time point of
confirmation of the inability to obtain the consent.
Equal distribution of research benefits and risks
Whenever certain communities or societal groups bear the burden of
the risk of research-associated adverse events, they should also have
the possibility of enjoying any benefits arising from the research
results.63 Indeed, the use of relevant scientific achievements should
not be confined to other privileged populations not participating in the
research protocol(s).63
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Access to best possible care and respect for patient/family
dignity
Enrolment in a research protocol should in no way be linked to the
quality or intensity of care. For instance, obtainment of deferred
surrogate consent for a given patient's continued participation in a
cardiac arrest trial evaluating therapeutic hypothermia should not
result in preferential ICU admission of that patient over another patient
whose proxy has refused consent.63
Researchers should also ensure that the dignity and privacy of the
research participant and their family are respected. For example,
enrolees in a cardiac arrest trial should be referred to as post cardiac
arrest patients rather than cardiac arrests or cardiac arrest victims.63
Study design issues, and transparency of study conduct and
reporting of results
Previously identified ethical issues concerning mainly commercial
research have prompted the requirement for pre-enrolment registra-
tion of trial protocols,63,378 reporting of any protocol and trial status
changes (e.g., temporary suspension) throughout the period of trial
conduct, and posting of main results to the trial registry within 12
months of study completion and publication in a peer-reviewed journal
after another 12 months.63,379 At the time of paper submission to a
peer-reviewed journal, authors are normally obliged to report on the
sponsor's role as well as on their own contributions to the study, and
also approve the submission.63 Furthermore, data sharing policies
could be adopted to further enhance research transparency.63,380
Another concern pertains to the substantially disproportionate
funding favouring commercial research evaluating the efficacy of high-
cost, patent protected drugs or devices over the undoubtedly
necessary, non-commercial, academic resuscitation research on
patent-unprotected, low-cost, widely used drugs of potentially
uncertain efficacy, such as adrenaline (epinephrine), or antiarrhyth-
mics.63,318,381,382 This may partly explain the fact that BLS/ALS
guidelines are based on 35
53-fold fewer RCTs/10,000 deaths/year
relative to guidelines for acute cardiovascular events and heart
failure.63,381 Governmental, or non-profit organisation, or even mixed
public and private/industrial funding of resuscitation research needs
therefore to be increased.63,383 Furthermore, such funding should be
fairly and proportionately distributed between studies of in-hospital
and pre-hospital interventions, preferably also according to their
estimated effect(s) on patient outcomes.384
Emergency research and the COVID-19 mass casualty crisis.
COVID-19 case surges may cause disruption over a wide spectrum of
societal and healthcare system activities.1,385
387 Accordingly,
processes and procedures primarily related to interventional research
may be hindered or halted. The need for physical distancing may
cause cancellation of face-to-face meetings concerning study design
(see also above), study protocol approval, and evaluation of the
progress of study conduct (by investigators, and data monitoring
committees); nevertheless, physical meeting issues can be at least
partly addressed by using digital telecommunication technology.
Delays in CPR initiation due to donning of personal protective
equipment may impact patient outcomes,385,386,388 and thereby
modify the measured effect of concurrent or subsequent, investiga-
tional, resuscitative interventions, such as new drug therapies, or
temperature/ventilatory management during and/or after resuscita-
tion. In OHCA, increases in the volume of emergency calls in the
context of a saturated healthcare system may prolong arrival times of
emergency medical services, whereas the potential risk of contracting
421
the disease while performing chest compressions may reduce
bystander CPR rates.3,389 Again, both latter factors may impact
patient outcomes, and ultimately, the results of any ongoing
emergency research. Fear of contracting the infection and/or
excessive workload may discourage healthcare professionals from
participating in research teams or initiating and leading a research
project.89,390
392 Lastly, increases in DNACPR decisions and
especially use of blanket CPR exclusion criteria such as
age87,88,385,390,393 may introduce selection bias and hamper the
generalisability of the research results, as well as their applicability to
normal conditions. Such challenges may be addressable solely
through effective governmental policies limiting viral spread and
preventing healthcare system overload.
Future directions
The evidence supporting autonomy-safeguarding interventions ex-
hibits several limitations, such as diversity/variability in definitions of
key terms (see also Tables 1
3 and online supplement), evaluated
intervention type/design, geographical distribution of studies and
characteristics of participating populations (e.g. type of life-limiting
illness, religion/religiosity, ethnicity, etc.) specified outcomes and
methods of their determination, and reliability of reported results
(further details provided in the supplement).
These weaknesses have either precluded the conduct of meta-
analyses or increased the heterogeneity of reported meta-analyses
results. Accordingly, the certainty of existing evidence has been
judged most frequently as low to very low by authors of systematic
reviews.7
10,28,38,39,43,44,72
As a result, scientific gaps exist regarding the actual effects of
advance directives, advance care planning, and shared decision
making on patient outcomes. These gaps range from uncertainty
about the effect estimates of meta-analyses (in the presence of
substantial pertinent literature), to very limited data from nonrandom-
ised studies, and/or even the absence of relevant studies (e.g. the
case of healthcare-related quality of life after cardiac arrest; see also
online supplement).
Therefore, new, high-quality, and preferably multinational
RCTs, based on clear and wide consensus-based definitions of
interventions and outcomes are warranted. Observational big data
potentially matching the strength of RCT data394,395 and qualita-
tive research identifying key issues that need to be addressed are
also needed.28,29,59,71,83,396 Further study is also warranted to
establish the effectiveness of inter-professional shared decision
making, which has been recently recommended by experts for
important clinical decisions. Inter-professional shared decision
making takes into account the available evidence, the expertise of
involved clinicians, and the patient's values goals, and
preferences.397
Despite the limitations of the currently available, substantial but still
heterogenous, body of evidence, the presence of either positive or
neutral RCTs on structured communication tools aimed at facilitating
the completion of advance care directives and plans suggests a class
effect and increased likelihood of benefit compared with usual care.4,7
Structured, complex, multifaceted interventions in the context of
advance care planning and shared decision making may effectively
prevent disproportionate/unwanted end-of-life care and accordingly
reduce use of healthcare resources.4,7,44,72,355,398 Future pertinent
research should primarily be guided by scientific evidence.
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4 3 2
Potentially successful, organisational interventions include: (1)
structural educational initiatives of the public (e.g. informational videos,
media coverage, and patient-public involvement workshops); (2)
systematic training of healthcare professionals in ethics and communi-
cation skills355; (3) infrastructural initiatives enabling emergency health-
care providers to instantly access and honour the patient's recorded
wishes (e.g. establishment of electronic registries/health records and
appropriate regulatory provisions355,398; (4) public involvement to ensure
clarity and acceptability of electronic documents used for the recording of
treatment options; (5) immediate availability of adequate palliative care
services upon patient/family request
this pertains to paediatric
palliative care as well399; and (6) continuous monitoring of the quality
of care supporting relevant improvement efforts/initiatives.
During a pandemic such as COVID-19, patient/family engagement
in advance care planning and shared decision-making should still be
feasible as part of remote clinical monitoring and care models
(ClinicalTrials.gov NCT04425720).
The Ethics writing group emphasises the importance of thorough
societal consultation and debate to provide a context-specific ethical
framework for many of the complex resuscitation decisions such as use
of extracorporeal CPR or uncontrolled donation after circulatory death.
Systems should continue to evaluate the performance of their
decision making with regard to withdrawing or withholding life support,
including the potential use of specific ToR rules, the degree of
implementation of advance directives, and the number of advanced
CPR cases. As technology progresses, it is likely that these concepts
will evolve as well.
Systems should try and better define the place and remit of
bystanders and first responders, as well as the ethical challenges
around bystander CPR particularly in respect of the balance between
benefit for the victim and harm to the rescuer.
There is a need to measure and track outcomes that are meaningful
to both patients generally and the specific patient being treated.
Future, high-quality research should identify the optimal educa-
tional method for healthcare professionals on standardised patient
outcome sets, and also evaluate its effect on healthcare professional's
understanding of patient's preferences.
Systems should consider educational interventions to introduce
the concept of family presence during resuscitation. Future research
projects should consider the identification of healthcare personnel
best suited to guide families through the resuscitation, and also being
able to provide comfort, recognise family distress and participate in
debriefing sessions after resuscitation.
More research is needed to determine how best to prepare and
support ambulance personnel for the challenges of resuscitation
decision-making and patient death, acknowledging the unique
contextual demands of the prehospital setting.
We suggest the broadest possible/multinational establishment of
harmonised regulations for emergency research aimed at fostering
interventional drug and device trials as well as observational studies,
while concurrently safeguarding participants’ autonomy and protec-
tion/integrity of their personal data.
Conclusions
The Ethics writing group has provided sets of simple and clear
recommendations supported by a wealth of systematic reviews,
recent RCTs and nonrandomised studies. Despite the generally low
certainty about the precision of the effect estimates of several
evaluated meta-analyses, the directions of the effects on patient
outcomes clearly favour the use of interventions such as advance care
planning, shared decision making, and ToR rules. The writing group
also produced three narrative reviews to summarise the existing key
evidence/knowledge/issues on education/system organisation, pa-
tient outcomes, and ethics of emergency research. Lastly, the writing
group has provided a set of consensus definitions of key terms, which
could potentially prove useful in both routine clinical practice and the
design of future research protocols.
Conflict of interest
MB declares her role of co-coordinator EU project ESCAPE-NET.
GDP reports funding from Elsevier for his role as an editor of the
journal Resuscitation. He reports research funding from the National
Institute for Health Research (NIHR) in relation to the PARAMEDIC2
trial and the RESPECT project.
Acknowledgments
The writing group thanks Nele Pauwels, information specialist at
Ghent University, Belgium for her support in developing the necessary
search strategies. GDP is supported by the NIHR Applied Research
Collaboration West Midlands. The views expressed are those of the
author(s) and not necessarily those of the NIHR or the Department of
Health and Social Care.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.resuscitation.2021.02.017.
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BASIC LIFE SUPPORT

Unresponsive with absent

or abnormal breathing

Call emergency services

Give 30 chest compressions

Give 2 rescue breaths

Continue CPR 30:2

As soon as AED arrives –

switch it on and follow
instructions
BASIC LIFE SUPPORT
STEP-BY-STEP
SEQUENCE/ACTION TECHNICAL DESCRIPTION
SAFETY
• Make sure that you, the victim and any bystanders
are safe

RESPONSE
Check for a response Hello! • Shake the victim gently by the shoulders and ask
loudly: “Are you all right?"

AIRWAY
• If there is no response, position the victim on their
Open the airway
back
• With your hand on the forehead and your fingertips
under the point of the chin, gently tilt the victim’s
head backwards, lifting the chin to open the airway

BREATHING • Look, listen and feel for breathing for no more than
Look, listen and feel 10 seconds
for breathing
• A victim who is barely breathing, or taking
infrequent, slow and noisy gasps, is not breathing
normally

ABSENT OR
ABNORMAL BREATHING
Alert emergency services
• If breathing is absent or abnormal, ask a helper to
112 call the emergency services or call them yourself
• Stay with the victim if possible
• Activate the speaker function or hands-free option
on the telephone so that you can start CPR whilst
talking to the dispatcher

SEND FOR AED

• Send someone to find and bring back an AED if
Send someone to get an AED
available
• If you are on your own, DO NOT leave the victim,
but start CPR

CIRCULATION
• Kneel by the side of the victim
Start chest compressions
• Place the heel of one hand in the centre of the
victim’s chest - this is the lower half of the victim’s
breastbone (sternum)
• Place the heel of your other hand on top of the first
hand and interlock your fingers
• Keep your arms straight
• Position yourself vertically above the victim’s chest
and press down on the sternum at least 5 cm (but
not more than 6 cm)
• After each compression, release all the pressure
on the chest without losing contact between your
hands and the sternum
• Repeat at a rate of 100-120 min-1
BASIC LIFE SUPPORT
STEP-BY-STEP
SEQUENCE/ACTION
COMBINE RESCUE BREATHING WITH
CHEST COMPRESSIONS
COMPRESSION-ONLY CPR
WHEN AED ARRIVES
Switch on the AED and
attach the electrode pads
FOLLOW THE SPOKEN/
VISUAL DIRECTIONS
TECHNICAL DESCRIPTION
• If you are trained to do so, after 30 compressions,
open the airway again, using head tilt and chin lift
• Pinch the soft part of the nose closed, using the
index finger and thumb of your hand on the
forehead
• Allow the victim’s mouth to open, but maintain chin
lift
• Take a normal breath and place your lips around the
victim’s mouth, making sure that you have an airtight
seal
• Blow steadily into the mouth whilst watching for the
chest to rise, taking about 1 second as in normal
breathing. This is an effective rescue breath
• Maintaining head tilt and chin lift, take your mouth
away from the victim and watch for the chest to fall
as air comes out
• Take another normal breath and blow into the
victim’s mouth once more to achieve a total of two
rescue breaths
• Do not interrupt compressions by more than 10
seconds to deliver the two breaths even if one or
both are not effective
• Then return your hands without delay to the correct
position on the sternum and give a further 30 chest
compressions
• Continue with chest compressions and rescue
breaths in a ratio of 30:2
• If you are untrained, or unable to give rescue
breathes, give chest-compression-only CPR
(continuous compressions at a rate of 100-120 min-1)
• As soon as the AED arrives switch it on and attach
the electrode pads to the victim’s bare chest
• If more than one rescuer is present, CPR should
be continued whilst the electrode pads are being
attached to the chest
• Follow the spoken and visual directions given by the
AED
• If a shock is advised, ensure that neither you nor
anyone else is touching the victim
• Push the shock button as directed
• Then immediately resume CPR and continue as
directed by the AED
BASIC LIFE SUPPORT
STEP-BY-STEP
SEQUENCE/ACTION
IF NO SHOCK IS ADVISED
Continue CPR
IF NO AED IS AVAILABLE
Continue CPR
IF UNRESPONSIVE BUT BREATHING
NORMALLY
Place in the Recovery Position
TECHNICAL DESCRIPTION
• If no shock is advised, immediately resume CPR
and continue as directed by the AED
• If no AED is available, OR whilst waiting for one to
arrive, continue CPR
• Do not interrupt resuscitation until:
• A health professional tells you to stop OR
• The victim is definitely waking up, moving,
opening eyes, and breathing normally
• OR
• You become exhausted
• It is rare for CPR alone to restart the heart. Unless
you are certain that the victim has recovered
continue CPR
• Signs that the victim has recovered
• Waking-up
• Moving
• Opening eyes
• Breathing normally
• If you are certain that the victim is breathing
normally but still unresponsive, place them in the
recovery position SEE FIRST AID SECTION
• Be prepared to restart CPR immediately if the victim
becomes unresponsive, with absent or abnormal
breathing
ADVANCED LIFE SUPPORT
Unresponsive with absent
or abnormal breathing

Call EMS/Resuscitation team

CPR 30:2
Attach defibrillator/monitor

Assess rhythm

Shockable Non-shockable
(VF/PULSELESS VT) (PEA/ASYSTOLE)

1 shock

Immediately resume chest Return of spontaneous Immediately resume chest

compressions for 2 minutes circulation (ROSC) compressions for 2 minutes

Give high-quality chest compressions and Identify and treat reversible causes
• Hypoxia
• Give oxygen
• Use waveform capnography • Hypovolaemia
• Hypo-/hyperkalemia/metabolic
• Continuous compressions if advanced airway
• Hypo-/hyperthermia
• Minimise interruptions to compressions • Thrombosis – coronary or pulmonary
• Intravenous or intraosseous access • Tension pneumothorax
• Give adrenaline every 3-5 min • Tamponade- cardiac
• Give amiodarone after 3 shocks • Toxins
Consider ultrasound imaging to identify
• Identify and treat reversible causes
reversible causes
Consider
• Coronary angiography/percutaneous coronary
intervention
• Mechanical chest compressions to facilitate transfer/treatment
• Extracorporeal CPR
After ROSC
• Use an ABCDE approach
• Aim for SpO2 of 94-98% and normal PaCO2
• 12 Lead ECG
• Identify and treat cause
• Targeted temperature management
IN-HOSPITAL RESUSCITATION

Collapsed/ sick patient

MAINTAIN
PERSONAL
SAFETY
Shout for help and assess patient

Signs of life?
Check for responsiveness
and normal breathing
Experienced ALS providers should
simultaneously check for carotid pulse

No or if any doubt Yes

(Cardiac arrest) (Medical emergency)

Call and collect* Call and collect*

Call resuscitation /
Call resuscitation team medical emergency team if needed
Collect resuscitation equipment Collect resuscitation equipment

High-quality CPR* Assess*

Give high-quality CPR with oxygen ABCDE assessment- recognise and treat
and airway adjuncts* Give high-flow oxygen
Switch compressor at every (titrate to SpO2 when able)
rhythm assessment Attach monitoring
Obtain IV access
Consider call for resuscitation/ medical
emergency team (if not already called)

Defibrillation*
Apply pads/ turn on AED
Attempt defibrillation if indicated**
Handover
Handover to resuscitation/ medical
emergency team using SBAR format

Advanced life support

When sufficient skilled personnel
are present

Handover
Handover to resuscitation team
using SBAR format

* Undertake actions concurrently if sufficient staff available

**Use a manual defibrillator if trained and device available
TACHYCARDIA
Synchronised shock up to 3 attempts
ASSESS with ABCDE approach
Life-threatening features? • Sedation, anaesthesia if conscious
• Give oxygen if SpO2 < 94% and obtain IV access
1. Shock YES If unsuccessful:
• Monitor ECG, BP, SpO2. Record 12 lead ECG
2. Syncope
• Identify and treat reversible causes
• Amiodarone 300 mg IV over 10-20 min,
or procainamide 10-15 mg/kg IV over 20
UNSTABLE
3. Myocardial ischaemia
(e.g. electrolyte abnormalities, hypovolaemia min;
4. Severe heart failure
causing sinus tachycardia) • Repeat synchronised shock

NO

STABLE
Is QRS narrow (<0.12 s)? SEEK EXPERT HELP

Broad
BroadQRS
QRS Narrow QRS
IsIsrhythm regular?
QRS regular? Is QRS regular?

Irregular Regular Regular Irregular

Possibilities include:
• Atrial fibrillation with bundle
branch block — treat as for irregu-
lar narrow complex
• Polymorphic VT
(e.g. torsades de pointes) — give
magnesium 2 g over 10 min
Vagal manoeuvres Probable atrial fibrillation:
If VT (or uncertain rhythm):
• Procainamide 10-15 mg/kg IV over 20 • Control rate with beta-blocker or
min diltiazem
or If ineffective: • Consider digoxin or amiodarone if
• Amiodarine 300 mg IV over 10-60 min Adenosine (if no pre-excitation) evidence of heart failure
• 6 mg rapid IV bolus; • Anticoagulate if duration > 48h
• If unsuccessful give 12 mg
If previous certain diagnosis of SVT
• If unsuccessful give IV 18 mg
with bundle branch block/
aberrant conduction:
• Treat as for regular narrow complex
tachycardia If ineffective:
• Verapamil or beta-blocker

If ineffective:
• Synchronised DC shock
up to 3 attempts
• Sedation, anaesthesia
if conscious
 BRADYCARDIA

ASSESS with ABCDE approach

ABCDE approach • Give oxygen if SpO2 < 94% and obtain IV access
oxygen if hypoxic
• Monitor ECG, BP, SpO2 Record 12 lead ECG
nd record 12-lead ECG
• Identify and treat reversible causes
(e.g. electrolyte abnormalities, hypovolaemia)
ible causes
alities)

Life-threatening features?
1. Shock
2. Syncope
3. Myocardial ischaemia
4. Severe heart failure

YES

NO
Atropine 500 mcg IV

YES
Satisfactory response? Risk of asystole?
• Recent asystole
NO • Mobitz II AV block
• Complete heart block
YES with broad QRS
Consider interim measures: • Ventricular pause > 3 s
• Atropine 500 mcg IV repeat to
maximum of 3 mg
• Isoprenaline 5 mcg min-1 IV
• Adrenaline 2-10 mcg min-1 IV NO
• Alternative drugs*
and / or
• Transcutaneous pacing

Seek expert help

Observe
Arrange transvenous pacing

* Alternatives include:
• Aminophylline
• Dopamine
• Glucagon (if bradycardia is caused by beta-blocker or calcium channel blocker)
• Glycopyrrolate (may be used instead of atropine)
TRAUMATIC CARDIAC ARREST/
PERI-ARREST ALGORITHM

Trauma Patient in Arrest/ Peri-Arrest

Non-traumatic arrest likely ? YES ALS

NO

Hypoxaemia Address reversible causes START

Hypovolaemia simultaneously: CPR
Tension pneumothorax
1. Control external catastrophic
Tamponade
haemorrhage
2. Secure airway and maximise
oxygenation
3. Bilateral chest decompression
(thoracostomies) Expertise?
4. Relieve tamponade Equipment?
(penetrating chest injury)
Environment ?
5. Proximal vascular control Elapsed time
(REBOA/manual aortic compression)
since loss of vital
6. Pelvic splint signs < 15 min?

7. Blood products / Massive

Haemorrhage Protocol

Resuscitative
ROSC Thoracotomy

YES NO

Pre-hospital: immediate Consider termination

transport to of resuscitation
appropriate hospital
In-hospital: damage control
surgery / resuscitation
ACCIDENTAL HYPOTHERMIA
Core temperature <35°C or cold to touch

Vital signs present

YES NO

• Obvious signs off irreversible death (1)

Impaired consciousness YES TO ANY Consider
• Valid DNR order withholding
NO YES • Conditions unsafe for rescuer or termination
• Avalanche burial >60 min, airway packed of CPR
with snow and asystole

Prehospital cardiac instability Witnessed NO TO ALL

Transport to nearest hospital hypothermic
if injured; consider onsite or • SBP <90 mm Hg (2) cardiac arrest - • Start CPR, do not delay transport
hospital treatment if uninjured • Cardiocirculatory instability Start CPR • If continuous CPR is not possible, consider intermittent
• Core temperature <32°C in old and or delayed CPR in difficult or dangerous rescue
multimorbid or <30°C in young and healthy • Airway management
• Core temperature <30°C max 3 defibrillations,
HT I (3) no epinephrine
NO TO ALL YES TO ANY
• Warm environment and dry clothing • Gather information of mechanism of accident
• Warm sweet drinks
• Active movement
YES
Transport to nearest
Cardiac arrest from alternative appropriate hospital or
cause prior to cooling manage as per
Transport to nearest Transport to hospital
• Avalanche burial <60 min supervising MD
appropriate hospital with ECLS (4)

NO

Transport to hospital with ECLS

HT II or III (3) (4); do NOT terminate CPR
• Minimal and cautious movements to avoid rescue
collapse
• Prevent further heat loss Consider prognostication to NO TO ANY
• Active external and minimally invasive rewarming determine benefit of ECLS (6)
techniques (5) • HOPE survival probability ≥10
• Airway management as required • ICE score <12

YES TO ANY
Cardiac
instability HT IV (3)
• Prepare for multi-organ failure and resolved No ROSC Consider
need for ECLS respiratory support • Rewarm with ECLS termination
• Post-resuscitation care • If ECLS not available within 6 hrs, CPR and of CPR
non-ECLS rewarming in peripheral hospital
• Rewarm to core temperature ≥32°C
12/10/2020
EMERGENCY TREATMENT
OF HYPERKALAEMIA
• Assess using ABCDE approach
• 12-lead ECG and monitor cardiac rhythm if serum potassium (K+) ≥ 6.5 mmol/L
• Exclude pseudohyperkalaemia
• Give empirical treatment for arrhythmia if hyperkalaemia suspected

Mild Moderate Severe

K 5.5 - 5.9 mmol/L
+ K+ 6.0 - 6.4 mmol/L K+ ≥ 6.5 mmol/L
Consider cause and need Treatment guided by clinical Emergency treatment
for treatment condition, ECG and rate of rise indicated

Seek expert help

ECG Changes?
Peaked T waves Broad QRS Bradycardia
Flat/ absent P waves Sine wave VT

NO YES

IV Calcium
10ml 10% Calcium Chloride IV OR
Protect the 30ml 10% Calcium Gluconate IV
heart • Use large IV access and give over 5 min
• Repeat ECG
• Consider further dose after 5 min if ECG changes persist

Insulin–Glucose IV Infusion
Glucose 25g with 10 units soluble insulin over 15 - 30 min IV
(25g = 50ml 50% glucose; 125ml 20% glucose, 250ml 10% glucose)
If pre-treatment BG < 7.0 mmol/L:
Shift K+ Start 10% glucose infusion at 50ml/ hour for 5 hours (25g)
into cells
Risk of
Consider
hypoglycaemia

Salbutamol 10 – 20 mg nebulised
Consider Life-threatening
hyperkalaemia

*Sodium zirconium cyclosilicate *Sodium zirconium cyclosilicate

10g X3/day oral for 72 HRS OR 10g X3/day oral for 72 HRS OR
Remove K+ *Patiromer *Patiromer
from body 8.4G /day oral OR 8.4G /day oral
*Calcium resonium
15g X3/day oral
Consider Dialysis
*Follow local practice
Seek expert help

Monitor K+
and blood Monitor serum K+ and blood glucose
glucose K+ ≥ 6.5 mmol/L
despite medical
therapy

Prevention Consider cause of hyperkalaemia and prevent recurrence

Emergency treatment of hyperkalaemia. ECG – electrocardiogram; VT ventricular tachycardia. BG Blood Glucose

CORONARY THROMBOSIS

1. Prevent and be prepared

• Encourage cardiovascular prevention to reduce the risk of acute events
• Promote health education to reduce delay to first medical contact
• Promote laypeople BLS to increase the chance of bystander CPR
• Ensure adequate resources for better management
• Improve quality management systems & indicators for better quality monitoring

2. Detect parameters suggesting coronary thrombosis &

Activate STEMI network
• Chest pain prior to arrest
• Known coronary artery disease
• Initial rhythm VF or pVT
• Post-resuscitation ECG: ST elevation

3. Resuscitate and treat possible causes

Sustained ROSC No Sustained ROSC

STEMI patients No STEMI patients Assess setting & patient

Time from conditions and available
Individualise decisions
diagnosis to PCI resources
considering patient
< 120 min characteristics, OHCA If futility:
setting, ECG findings
Activate PCI Consider stopping CPR
laboratory Quick diagnostic work up
Discard non-coronary If no futility:
Transfer for
immediate PCI causes Consider transfer to PCI
Chest patient condition centre with on-going CPR
> 120 min
If there is on Consider mechanical
Perform pre-hospital going ischaemia compressions and extra-
fibrinolysis or haemodynamic corporeal CPR
Transfer to PCI compromise?
centre Consider PCI
Yes – immediate PCI
No - consider delayed PCI
 Management of acute asthma in adults in hospital
Features of acute severe asthma
• Peak expiratory flow (PEF) 33–50% of
best (use % predicted if recent best
unknown)
• Can’t complete sentences in one breath
• Respiration ≥25 breaths/min
• Pulse ≥110 beats/min
IMMEDIATE TREATMENT
• Oxygen to maintain SpO2 94–98%
• β2 bronchodilator (salbutamol 5 mg) via an oxygen-driven nebuliser
• Ipratropium bromide 0.5 mg via an oxygen-driven nebuliser
• Prednisolone tablets 40–50 mg or IV hydrocortisone 100 mg
• No sedatives of any kind
• Chest X-ray if pneumothorax or consolidation are suspected or patient
requires mechanical ventilation

Life-threatening features IF LIFE-THREATENING FEATURES ARE PRESENT:

• Discuss with senior clinician and ICU team
• PEF <33% of best or predicted • Consider IV magnesium sulphate 1.2–2 g infusion over 20 minutes (unless already
• SpO2 <92% given)
• Silent chest, cyanosis, or poor • Give nebulised β2 bronchodilator more frequently eg salbutamol 5 mg up to every
respiratory effort 15-30 minutes or 10 mg per hour via continuous nebulisation (requires special nebuliser)
• Arrhythmia or hypotension
• Exhaustion, altered consciousness
SUBSEQUENT MANAGEMENT
IF PATIENT IS IMPROVING continue:
If a patient has any life-threatening feature,
• Oxygen to maintain SpO2 94–98%
measure arterial blood gases. No other
• Prednisolone 40–50mg daily or IV hydrocortisone 100 mg 6 hourly
investigations are needed for immediate
• Nebulised β2 bronchodilator with ipratropium 4–6 hourly
management.
IF PATIENT NOT IMPROVING AFTER 15–30 MINUTES:
Blood gas markers of a life-threatening
• Continue oxygen and steroids
attack:
• Use continuous nebulisation of salbutamol at 5–10 mg/hour if an appropriate
• ‘Normal’ (4.6–6 kPa, 35–45 mmHg) PaCO2
nebuliser is available. Otherwise give nebulised salbutamol 5 mg every 15–30
• Severe hypoxia: PaO2 <8 kPa
minutes
(60 mmHg) irrespective of treatment with
• Continue ipratropium 0.5 mg 4–6 hourly until patient is improving
oxygen
• A low pH (or high H+)
IF PATIENT IS STILL NOT IMPROVING:
• Discuss patient with senior clinician and ICU team
Caution: Patients with severe or life-
• Consider IV magnesium sulphate 1.2–2 g over 20 minutes (unless already given)
threatening attacks may not be distressed
• Senior clinician may consider use of IV β2 bronchodilator or IV aminophylline or
and may not have all these abnormalities.
progression to mechanical ventilation
The presence of any should alert the doctor.

Near-fatal asthma MONITORING

• Raised PaCO2
• Requiring mechanical ventilation with • Repeat measurement of PEF 15–30 minutes after starting treatment
raised inflation pressures • Oximetry: maintain SpO2 >94–98%
• Repeat blood gas measurements within 1 hour of starting treatment if:
- initial PaO2 <8 kPa (60 mmHg) unless subsequent SpO2 >92% or
Peak Expiratory Flow Rate - Normal Values
- PaCO2 normal or raised or
680 - patient deteriorates
660 • Chart PEF before and after giving β2 bronchodilator and at least 4 times daily
640 throughout hospital stay
620

600 Transfer to ICU accompanied by a doctor prepared to intubate if:

580 • Deteriorating PEF, worsening or persisting hypoxia, or hypercapnia
560 • Exhaustion, altered consciousness
540 • Poor respiratory effort or respiratory arrest
PEF (l/min) EU Scale

520

500

480 Height
DISCHARGE
Men
460
190 cm (75 in) When discharged from hospital, patients should have:
183 cm (72 in)
440
175 cm (69 in) • Been on discharge medication for 12–24 hours and have had inhaler technique
167 cm (66 in)
420
160 cm (63 in) checked and recorded
400
• PEF >75% of best or predicted and PEF diurnal variability <25% unless discharge is
380
agreed with respiratory physician
360
Height • Treatment with oral steroids (prednisolone 40–50 mg until recovery - minimum 5
Women
340
183 cm (72 in) days) and inhaled steroids in addition to bronchodilators
320 175 cm (69 in)
167 cm (66 in)
• Own PEF meter and written asthma action plan
300 160 cm (63 in)
15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 152 cm (60 in)
• GP follow up arranged within 2 working days
Age (years) • Follow-up appointment in respiratory clinic within 4 weeks
Adapted by Clement Clarke for use with EN13826 / EU scale peak flow meters
from Nunn AJ Gregg I, Br Med J 1989:298;1068-70
Patients with severe asthma (indicated by need for admission) and adverse behavioural
or psychosocial features are at risk of further severe or fatal attacks.
• Determine reason(s) for exacerbation and admission
• Send details of admission, discharge and potential best PEF to GP
TOXIC EXPOSURE

Toxic exposure

NO Risk of contamination? YES PPE1

Cardiac arrest/peri arrest? Universal ALS

YES algorithm
NO

Poison centre

If indicated:
• Avoid mouth-to-mouth breathing
Decontamination
• Continue resuscitation
Enhanced elimination
• Higher dose of medication
Antidote

• Try to identify the poison

• Consider hypo- or hyperthermia
• Exclude all reversible causes
CARDIAC SURGERY

1. Prevent and be prepared

• Ensure adequate training of the staff in technical skills and ALS

• Ensure availability and well-functioning of emergency equipment

• Use safety checklists

2. Detect cardiac arrest and activate cardiac arrest protocol

• Identify and manage deterioration in the post-operative cardiac patient
• Consider echocardiography
• Confirm cardiac arrest by clinical signs and pulseless waveforms
• Shout for help and activate cardiac arrest protocol

3. Resuscitate and treat possible causes

Asystole / extreme
VF/pVT PEA
bradycardia

Correct potentially
Defibrillate
reversible causes
(apply up to 3 Apply early pacing
consecutive shocks) Turn off pacing to
exclude VF

No ROSC
• Initiate compressions and ventilation
• Perform early resteronotomy (<5 min)
• Consider circulatory support devices and extracorporeal-CPR
ICPR DELAYED AND INTERMITTENT CPR IN HYPOTHERMIC PATIENTS WHEN
CONTINUOUS CPR IS NOT POSSIBLE DURING DIFFICULT RESCUE MISSIONS

Cardiac arrest confirmed

Mechanical chest compression device available?

YES NO

Mechanical CPR Manual CPR

Necessity to transport and inability for continuous CPR

Core temp <28°C

Core temp >28°C , Confirmed core
or unknown, unequivocal
patient warm temperature <20°C
hypothermic CA

Strongly consider HEMS or Alternating 5 min CPR and Alternating 5 min CPR and
wait for mechanical CPR ≤5 min without CPR ≤10 min without CPR
CARDIAC CATHETERISATION
LABORATORY

1. Prevent and be prepared

• Ensure adequate training of the staff in technical skills and ALS
• Ensure availability and that equipment is functioning
• Use safety checklists

2. Detect cardiac arrest and activate cardiac arrest protocol

• Check patient’s status and monitored vital signs regularly
• Consider cardiac echocardiogram in case of haemodynamic instability or
suspected complication
• Shout for help and activate cardiac arrest protocol

3. Resuscitate and treat possible causes

VF / pVT cardiac arrest Asystole / PEA

Defibrillate
(apply up to 3
consecutive shocks)

No ROSC

• Resuscitate according to ALS algorithm

• Check and correct potentially reversible causes including echocardiography
and angiography
• Consider mechanical chest compression and circulatory support devices
(including extracorporeal-CPR)
ICPR DELAYED AND INTERMITTENT CPR IN HYPOTHERMIC PATIENTS WHEN
CONTINUOUS CPR IS NOT POSSIBLE DURING DIFFICULT RESCUE MISSIONS

Cardiac arrest confirmed

Mechanical chest compression device available?

YES NO

Mechanical CPR Manual CPR

Necessity to transport and inability for continuous CPR

Core temp <28°C

Core temp >28°C , Confirmed core
or unknown, unequivocal
patient warm temperature <20°C
hypothermic CA

Strongly consider HEMS or Alternating 5 min CPR and Alternating 5 min CPR and
wait for mechanical CPR ≤5 min without CPR ≤10 min without CPR
 AVALANCHE RESCUE

Assess patient at extrication

Lethal injuries or Do not

YES
whole body frozen start CPR

NO

Duration of burial Universal ALS

≤60 MIN (≥30°C)
(core temperature)1 Algorithm2

>60 MIN (<30°C)

Minimally
Vital signs3 YES invasive
ECG4 rewarming 5

Witnessed cardiac arrest

NO

VF, pVT, PEA or any vital signs

Universal ALS 6

ASYSTOLE

YES or Consider Hospital

Patent airway7 HOPE survival ≥10%
uncertain with ECLS
probability8

NO

<10%
Consider termination
of CPR

1. Core temperature may substitute if duration of burial is unknown.

2. Transport patient with injuries or potential complications (e.g. pulmonary oedema) to the most appropriate hospital.
3. Check for spontaneous breathing, pulse and any other movements for up to 60 seconds.
4. Use additional tools for detection of vital signs (end-tidal CO2, arterial oxygen saturation (SaO2), ultrasound) if available.
5. Transport patients with core temperature <30°C, systolic blood pressure <90mmHg or any other cardiocirculatory
instability to a hospital with ECLS.
6. With deeply hypothermic patient (<28°C) consider delayed CPR if rescue is too dangerous and intermittent CPR with
difficult transport.
7. If airway is patent, the additional presence of an air pocket is a strong predictor for survival.
8. If HOPE is not possible, serum potassium and core temperature (cut-offs 7 mmol/L and 30°C) can be used but may be
less reliable.
Abbreviations: ALS Advanced life support, CPR cardiopulmonary resuscitation, ECLS extracorporeal life support, PEA
pulseless electrical activity, pVT pulseless ventricular tachycardia, SaO2 arterial oxygen saturation, VF ventricular fibrillation
HYPERTHERMIA
YES
Universal ALS
Require CPR?
algorithm TIME IS KEY: COOL AND RUN APPROACH

NO • Cool first, transfer to hospital after

Bathtub, ½ to ¾ filled • Immediate cooling
water & ice, 1-17°C, • Rapidly cool to <39°C until symptoms resolve
stirred or circulated
Use a YES
Core temperature
temperature
>40.5ºC
probe Continue monitoring for at least
15 min after cooling
NO Rapid cooling (cold Stop cooling at core
water immerssion) temperature <39°C • Rehydrate as required
• Check for improved mental status
Core temperature
≤40.5ºC, & confused/ • Avoid accidental hypothermia
desoriented YES (<35°C)

NO

If abnormal mental state initiate IV

YES 100ml bolus of 3% saline at 10 min
Blood sodium Hyponatraemia
intervals, 2nd and 3rd bolus only
<130 mEq/L if required. If normal mental state
algorithm
administer oral sodium
NO

If abnormal mental state administer

YES IV normal saline or Ringer’s lactated.
Severely
dehydrated? If normal mental state provide oral
rehydration and sodium
NO

NO YES
Release with exercise Appropriate algorithm
Other symptoms
restrictions e.g. Hypoglycaemia
POST-RESUSCITATION CARE

Airway and breathing

• Maintain SpO2 94 – 98%
• Insert advanced airway
IMMEDIATE TREATMENT

• Waveform capnography
• Ventilate lungs to normocapnia

Circulation
• 12-lead ECG
• Obtain reliable intravenous access
• Aim for SBP > 100 mmHg
• Fluid (crystalloid) – restore normovolaemia
• Intra-arterial blood pressure monitoring
• Consider vasopressor/ inotrope to maintain SBP

Control temperature
• Constant temperature 32°C – 36°C
• Sedation; control shivering

NO Likely cardiac cause? YES

DIAGNOSIS

YES 12-lead ECG ST elevation?

Coronary angiography ± PCI NO

Consider CT brain Cause for cardiac Consider Coronary

and/or CTPA NO
arrest identified? angiography ± PCI

YES

Treat non-cardiac
Admit to ICU
cause of cardiac arrest

ICU management
• Temperature control: constant temperature 32°C – 36°C for ≥ 24h;
OPTIMISING RECOVERY

prevent fever for at least 72h

• Maintain normoxia and normocapnia; protective ventilation
• Avoid hypotension
• Echocardiography
• Maintain normoglycaemia
• Diagnose/treat seizures (EEG, sedation, anti-epileptic drugs)
• Delay prognostication for at least 72h

Secondary prevention Functional assessments

e.g. ICD, screen for inherited before hospital discharge
disorders, risk factor management Rehabilitation
Structured follow up after
hospital discharge
NEUROPROGNOSTICATION FOR THE
COMATOSE PATIENT AFTER RESUSCITATION
FROM CARDIAC ARREST

Targeted temperature
management and rewarming

Unconscious patient,
M≤3 at ≥72h without confounders (1)

YES

At least TWO of:

• No pupillary (2) and corneal reflexes at ≥72h
• Bilaterally absent N20 SSEP wave YES Poor
• Highly malignant (3) EEG at >24h outcome
likely (*)
• NSE >60 µg/L (4) at 48h and/or 72h
• Status myoclonus (5) ≤72h
• Diffuse and extensive anoxic injury on brain CT/MRI

NO

Observe and re-evaluate

1
Major confounders may include analgo-sedation, neuromuscular blockade, hypothermia,
severe hypotension, hypoglycaemia, sepsis, and metabolic and respiratory derangements
2
Use an automated pupillometer, when available, to assess pupillary light reflex
3
Suppressed background ± periodic discharges or burst-suppression, according to American Clinical
Neurophysiology Society
4
Increasing NSE levels between 24h-48h or 24/48 and 72h further support a likely poor outcome
5
Defined as a continuous and generalised myoclonus persisting for 30 minutes or more
* Caution in case of discordant signs indicating a potentially good outcome (see text for details).
RECOMMENDATIONS FOR IN-HOSPITAL
FUNCTIONAL ASSESSMENTS, FOLLOW-UP
AND REHABILITATION AFTER CARDIAC
ARREST

BEFORE HOSPITAL DISCHARGE

Perform functional assessments of

physical and non-physical impairments

Refer to rehabilitation
if necessary

AT FOLLOW UP
Within 3 months from
hospital discharge

Perform Provide information

Perform
screening for and support to
screeening for
emotional problems the survivor and
cognitive problems
and fatigue their family

Consider referral to
further specialised
care if indicated
 Unresponsive patient after ROSC

YES Severe cerebral oedema

Suspected neurological cause of arrest? Brain CT and brainstem herniation?

}
NO Signs of brain death?
• Fixed dilated pupils YES
TTM • Diabetes insipidus
• Cardiovascular changes
suggesting herniation

Unresponsive patient after rewarming

Exclude confounders, particularly Follow World Brain Death Project
residual sedation recommendations for brain
death determination*

All brainstem reflexes absent? YES

(Pupillary, corneal,
oculocephalic, cough)

NO

Neuroprognostication Brain death confirmed

(see algorithm) According to local legislation

WLST at any time

Evaluate for organ donation

*Includes a 24-hour observation period after rewarming to 36oC before clinical testing for brain death/death by neurological criteria
World Brain Death Project - Greer DM et al. JAMA 2020;324:1078–1097
Circulatory death at any time Adapted from Sandroni C, D’Arrigo S, Callaway CW, Carious A, Dragancea I, Taccone FS, Antonelli M. The rate of brain death and organ
donation in patients resuscitated from cardiac arrest: a systematic review and meta-analysis. Intensive Care Med 2016;42:1661–1671.
 (Antenatal counselling)
Team briefing & equipment check

Birth
Preterm < 32 weeks Delay cord clamping if possible

Place undried in plastic Start the clock or note the time

wrap + radiant heat Dry/wrap, stimulate, keep warm

Approx 60 seconds
Assess tone, breathing, heart rate

Inspired oxygen If inadequate breathing:

(≥ 32 weeks 21%) Open the airway
28-31 weeks 21-30%
Preterm - Consider CPAP
<28 weeks 30%

If gasping or not breathing:

AT ALL TIMES ASK - DO YOU NEED HELP?

Start with 25 cm H2O Give 5 inflations (30 cm H2O)
Apply SpO2 +/-ECG

MAINTAIN TEMPERATURE
Reassess
If no increase in heart rate,
look for chest movement
Acceptable
pre-ductal SpO2
2 min 65% If the chest is not moving
5 min 85% Check mask, head and jaw position
10 min 90% 2-person support
(Suction/Laryngeal Mask/Tracheal tube)
Consider increasing the inflation pressure
Repeat 5 inflations
TITRATE OXYGEN TO ACHIEVE TARGET SATURATIONS

Reassess
If no increase in heart rate,
look for chest movement

When the chest is moving

continue ventilation

If the heart rate is absent/very slow (<60min-1)

after 30 seconds of ventilation
Co-ordinate
Co-ordinate 3 chest compressions to 1 ventilation
Increase oxygen to 100%
Consider intubation if not done already
(or laryngeal mask if intubation not possible)

Reassess
Check heart rate every 30 seconds

If the heart rate is absent/very slow:

Vascular access and drugs
Consider other factors
eg: pneumothorax, hypovolaemia,
congenital abnormality

Update parents and debrief team

Complete records
PAEDIATRIC
BASIC LIFE SUPPORT

SAFE? - SHOUT ‘HELP’

SECOND RESCUER:
Unresponsive? • Call EMS / ALS team (speaker function)
• Collect & apply AED (if accessible)

Open airway

• If competent, use
Absent or abnormal breathing bag-mask ventilation
(2-person), with oxygen
• If unable to ventilate,
perform continuous
compressions;
add rescue breaths as
soon as possible
5 rescue breaths

Unless clear signs of life SINGLE RESCUER:

• Call EMS / ALS team
(speaker function)
• Collect & apply AED in
case of sudden witnessed
collapse (if accessible)
15 chest compressions

2 breaths
further alternating
15 compressions : 2 breaths
PAEDIATRIC
ADVANCED LIFE SUPPORT
SAFE? - SHOUT ‘HELP’

Cardiac arrest recognised?

(including bradycardia due to hypoxia or ischemia)

Commence / continue PBLS

Minimise interruptions
Ensure the EMS /ALS team is alerted
Attach defibrillator / monitor

Assess rhythm

Shockable Non-shockable

Return of Termination Give adrenaline IV/IO

One Shock 4J/KG 10 mcg/kg (max 1mg)
spontaneous of
circulation Resuscitation as soon as possible

Immediately resume CPR for 2 min Immediately resume

Minimise interruptions CPR for 2 min
After the third shock: Minimise interruptions
IV/IO amiodarone 5 mg/kg (max 300 mg)
IV/IO adrenaline 10 mcg/kg (max 1mg)

DURING CPR CORRECT REVERSIBLE CAUSES IMMEDIATE POST ROSC

• Ensure high-quality CPR: rate, depth, recoil • Hypoxia • ABCDE approach
• Provide bag-mask ventilation with 100% oxygen • Hypovolaemia • Controlled oxygenation
(2-person approach) • Hyper/hypokalaemia, -calcaemia, (Sp02 94-98%) &
• Avoid hyperventilation -magnesemia; Hypoglycaemia ventilation (normocapnia)
• Vascular access (intravenous, intraosseous) • Hypothermia - hyperthermia • Avoid hypotension
• Once started, give adrenaline every 3-5 min • Toxic agents • Treat precipitating causes
• Flush after each drug • Tension pneumothorax
• Repeat amiodarone 5 mg/kg (max 150mg) after • Tamponade (cardiac)
the 5th shock • Thrombosis (coronary or
• Consider an advanced airway and capnography pulmonary)
(if competent) ADJUST ALGORITHM IN SPECIFIC
• Provide continuous compressions when a SETTINGS (E.G. TRAUMA, E-CPR)
tracheal tube is in place. Ventilate at a rate of
25 (infants) – 20 (1-8y) – 15 (8-12y) or 10 (>12y)
per minute
• Consider stepwise escalating shock dose (max
8J/kg – max 360J) for refractory VF/pVT (≥6
shocks)
PAEDIATRIC FOREIGN BODY
AIRWAY OBSTRUCTION

SAFE? - SHOUT ‘HELP’

Suspect foreign body

airway obstruction

CALL EMS
Effective Ineffective (Second rescuer /
Cough cough speaker function)

Encourage cough CONSCIOUS UNCONSCIOUS

Continue to check Infant: 5 back blows Open airway and try
for deterioration 5 chest thrusts 5 rescue breaths;
alternating continue with PBLS
Child: 5 back blows No repeated or blind
5 abdominal thrusts finger sweeps
alternating

If obstruction relieved: urgent medical follow-up

EDUCATION
X X = Survival
Medical Education Local
Science Efficiency Implementation
EDUCATION
ence & Knowle
tific Evid d g e
Scien Gaps
Teaching & Learning
Technology enhanced learning Repetition reading – e-Learning – Podcast
e.g. online-webinars, gamification,
Interdisciplinary/interprofessional education
virtual/augmented reality
Assessment/ testing effect
Reducing cognitive load
Checklist during training
Blended learning
Mentoring/coaching
Flipped classroom Implementation
Small group teaching
Briefing/Debriefing Just in time support by dispatchers
Faculty Development
Spaced learning Logistics & technology (e.g. drones)
Mobile phone applications Deliberate practice
Feedback
Checklists (for real life ALS) Mastery Learning
Simulation
Lecturing
Best Practice
Improved Patient Survival
EDUCATION
Educational Research
Theories “both develops from
“attempt to explain and inform ideas”
how we learn”
Idea Inquiry
Impact Implement
Outcomes Approaches
“approaches to teaching
influence on learning “recommendations
& clinical practice” of research”
EDUCATIONAL THEORIES AND APPROACHES
Pedagogy Heutagogy
Behaviourism
Connectivism
Skinner, Thorndyke,
Siemens, Downes
Pavlov
Skills teaching Technology enhanced education
Mastery Learning Interdisciplinary & interprofessional education
Instructor led learning Ideal group size
Checklists (in training and real CPR) Gamified learning
Social learning in groups Just in time instruction
Self-learning
Androgogy
Constructivism Cognitivism Humanism
Bruner, Vygotsky, Ausabel, Piaget, Maslow, Rogers,
Kolb, Piaget, Gagne Bloom Lyon
Feedback Cognitive load theory Feedback
Briefing & debriefing Feedback Mastery Learning
Blended learning Assessment/ testing effect Self-learning
Flipped classroom Spaced learning Non-instructor-led learning
Simulation
EDUCATION
Pre-course phase Course Post-Course Real life
(individual) (physical attendance) (individual: (cardiac arrest)
refresher/recertify
Pre-course Clarification Just-in-time support
reading material of questions
• Alerting SMS /
(consolidation of
mobile app
knowledge) Refresher:
• Dispatcher
Interactive interactive
CPR instructions
e-learning e-learning,
Skills training video demos, • Feedback
(with meaningful mobile apps by devices
Video demo / instructor feedback) (e.g. metronome,
self-learning video CC depth)
Pre-course
knowledge test Improved patient
End-of-course Self
(passing may be outcome
practical test assessment /
mandatory prior to (plus debriefing)
(to be passed) recertification
practice training)
Modified from: Breckwoldt J. E-Learning: [New Technologies for Resuscitation Training] in German.
in: Neumayr A, Baubin M, Schinnerl A (Edit.). Herausforderung Notfallmedizin: Innovation, Vision, Zukunft. Heidelberg 2018 (Springer) pp 163-172.
LIFE LONG LEARNING CYCLE
(SUPPORTED BY VIRTUAL LEARNING ENVIRONMENT)
Recertification
Life Repeat
Support cycle
Course if needed
Practice & Practice &
assessment Practice & Practice & assessment
assessment assessment
Educational Approaches
• e-Learning • Workshops
• Manual reading • Cardiac arrest simulation
• Self-learning programs • Competence assessment
• Hands-on skills session • Recertification
• Gamification (VR & AR) • Self-assessment