Basic Life Support

Advanced Cardiac Life Support

Automated External Defibrillator

Advanced Cardiac Life Support step 1 check for responsiveness tap &
Overview and Protocol - ACLS Shout are you alright then scan the chest for
movement here you're looking for absent or
AHA
abnormal breathing this can be no
cardiovascular disease strikes in every
breathing or only gasping he's not
nation around the world from sudden
responding and he doesn't he's not
cardiac arrest to the disabling effects of
breathing activate the emergency response
acute coronary syndromes and acute
system and get an AED if the patient is
ischemic stroke cardiovascular disease
unresponsive then move
remains a leading cause of disability and
to step two activate the emergency
death in many parts of the world
response system and get an AED step 3
understanding and activating the systems of
circulation check the carotid pulse do not
care developed by the American Heart
spend more than 10 seconds checking for a
Association can help improve survival rates
pulse if you cannot feel
and may even prevent cardiac arrest you
a pulse within 10 seconds start CPR
play a pivotal role in
immediately give cycles of 30 chest
providing high quality cardiovascular care
compressions followed by 2 ventilations
what you do matters what you learn can
step 4 defibrillation as soon as possible
save lives welcome to the American Heart
attach an AED or defibrillator and if
Association's BLS and ACLs surveys video
indicated deliver a shock if you've had any
will be demonstrating the latest life-saving
training on BLS you'll notice the sequence
interventions and the skills necessary to
of steps has changed you no longer look
successfully manage arrest peri-arrest acs
listen and feel for breathing before
and stroke patients most of the instruction
delivering two breaths the ABCD sequence
will take place here in the American Heart
often delayed chest compressions as the
Association's training lab where we can
healthcare provider tried to open the airway
successfully demonstrate and practice
and deliver ventilations by changing the
those important skills you of course will
sequence and giving chest compressions
have the chance to practice skills in learning
first more patients may achieve return of
stations in your classroom in this segment
spontaneous circulation or roske however if
of the course you'll be learning to systematic
you determine that the patient is not
approaches developed by the American
breathing normally but has a pulse bypass
Heart Association for treating patients the
chest compressions and support the patient
basic life support or BLS survey and the
with rescue breathing delivering one breath
advanced cardiovascular life support or
every five to six seconds the critical
ACLs survey by adhering to these steps you
concepts for high quality BLS are push hard
can better manage patients when deciding
and push fast allow complete chest recoil
which survey to use to treat a patient start
after each compression minimize
with a step we all do automatically visually
interruptions in chest compressions switch
assess if the patient is conscious or
providers about every two minutes to avoid
unconscious if the patient is conscious
fatigue and avoid excessive ventilations let's
move to the ACLs survey which we'll review
take a look at how the BLS steps come
in a
together in an arrest situation morning
moment for unconscious patients you'll use
gentlemen don't want a joke good morning
the BLS survey which has four steps
sorry it's so early yes thank you so much all
right now if you look at the
graphs you'll see that the new programs
have implemented haven't really kicked
in yet a 57 year old man is experiencing
many of the warning signs of acute
coronary syndromes or ACS with chest
discomfort indigestion and feeling faint
Daniel are you okay you don't look so
good
I'm fine probably gonna go home early
though oh that is your scenario now
begin sir are you all right
he's unresponsive and not breathing
activate the emergency response system
and get an AED 1 2 3 4 5 6 7 8 9 10 11
12 13 14 15 16 17 18 19 20 21 to 23 24
25 26 seven twenty eight twenty nine
thirty one two three
the co team is on the way I've got the
AED 8 9 10 11 12 13 14 15 16 17 attach
pads to patients bare chest 25 26 27 28
29 plug in pads connector 1 2 3 4 5 6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21
a two analyzing heart rhythm do not
touch the patient shock needed one two
charging 4 5 6 7 8
stay clear of patient deliver shock now
to the patient press the flashing button
shot down 3 1 2 3
shocking jaw are never delivered begin
CPR start with compressions high-quality
BLS is the foundation for saving lives
following sudden cardiac arrest if these
steps are performed rapidly and well the
patient's chance of survival increases
the effectiveness of advanced life
support measures depends on high quality
BLS there's a reason that these steps
are called life support when a patient
goes into cardiac arrest one of the
common presenting rhythms is ventricular
fibrillation or VF the heart is
quivering but not effectively pumping
blood to vital organs high quality chest
compressions maintain blood flow to
vital organs especially the heart chest
compressions are the highest priority in
the first minutes of cardiac arrest
one way to measure the effectiveness of
chest compression is with coronary
perfusion pressure coronary perfusion
pressure during CPR must reach at least
10 millimeters of mercury
to be 10
achieved the return of spontaneous
circulation or Ross as chest
compressions begin it takes several
compressions to raise the coronary
perfusion pressure to a level adequate
to supply blood to the heart the higher
the coronary perfusion pressure during
CPR the better the survival rate for the
patient when health care providers
interrupt chest compressions perfusion
pressure Falls dramatically and remains
very low until compressions are
restarted because coronary perfusion
pressure measurements are not readily
available during a resuscitation attempt
health care providers can monitor CPR
quality with wave form capnography and
intra-arterial relaxation pressures will
discuss the details of wave form
capnography later in this course
specific patients with an end tidal co2
reading of less than 10 millimeters of
mercury may not achieve roske for
intra-arterial relaxation pressures a
reading of less than 20 millimeters of
mercury indicates ineffective
compressions to perform high quality
chest compressions you should push hard
and push fast push hard means that you
should compress the chest at least two
inches and allow complete chest recoil
after each compression if the chest is
not completely recoil coronary perfusion
will remain low push fast means to
deliver at a rate of at least 100
compressions per minute scientific
studies show that the number of chest
compressions delivered is an important
direct determinant of Ross and
neurologically intact survival it can be
difficult to maintain such a vigorous
pace which is why the American Heart
Association recommends that rescuers
switch roles after 2 minutes or 5 cycles
of 30 compressions and 2 ventilations
high-quality CPR minimizes interruptions
and chest compressions so more chest
compressions are delivered resulting in
better perfusion studies show that even
health care providers interrupt
compressions far too often and for too
long in some cases spending 25 to 50
percent of a code without delivering
chest compressions the circular BLS
algorithm emphasizes the two-minute
period of compressions and ventilations
punctuated by a break of no more than 10
seconds to assess the patient and to
defibrillation another key step in BLS
is providing rapid defibrillation if
indicated although CPR can provide vital
oxygen and blood circulation
defibrillation is essential to
establishing a normal rhythm in patients
with a lethal shockable rhythm the
delivery of an electrical shock from a
defibrillator briefly stops all
electrical activity in the heart if the
heart is still viable its normal
pacemakers may resume electrical
activity that ultimately results in a
perfusing rhythm or roske
survival rates are highest when rescuers
provide CPR immediately and
defibrillation for initial shockable
rhythm occurs within 3 to 5 minutes for
a patient with the shockable rhythm
every minute that ticks by without a
shock reduces the chance of survival
let's review the four steps of the BLS
survey step one check responsiveness tap
and shout and scan the chest for
movement step 2 activate the emergency
response system and get an AED step 3
circulation check for a carotid pulse if
you cannot feel a pulse within 10
seconds support circulation by giving
cycles of 30 chest compressions followed
by two ventilations step four
defibrillation as soon as possible
connect an AED or defibrillator and if
indicated deliver a shock the best
chance of a patient surviving an episode
of cardiac arrest depends on high
quality BLS in some cases BLS results in
roske but sometimes cardiac arrest
persists requiring you to continue with
more advanced invasive measures that's
the time to use the ACLs survey another
time to use the ACLs survey is if a
patient is conscious but needing
treatment for ACS you can easily
remember the steps of the ACLs survey by
thinking ABCD a stands for airway for
unconscious patients healthcare
providers should maintain a patent
airway and consider inserting an
advanced airway device the resuscitation
team must ensure proper placement of an
advanced airway if the team chooses an
endotracheal tube insertion is the
method of airway control
a form capnography should be used
conscious patients can often maintain
the integrity of their own airway and
health care providers need only ensure
patency by providing suctioning if
needed
B represents breathing for patients
experiencing cardiac arrest health care
providers should provide two
ventilations with the bag mask after
every 30 chest compressions
after inserting an advanced airway
health care providers should continue
ventilations by providing one breath
every six to eight seconds or eight to
ten breaths per minute if the patient is
not in cardiac arrest health care
providers should assist ventilation is
needed at a rate of one breath every
five to six seconds or 10 to 12 breaths
per minute if the patient does not
require assisted ventilation health care
providers can support the patient by
administering oxygen as needed c
involves supporting the patient's
circulatory status attached ECG leads
obtain intravenous or IV access or
interosseous or IO access and give
appropriate drugs to manage rhythms
finally D stands for differential
diagnosis search foreign treat
reversible causes or symptoms by
reviewing the h's and t's although these
steps are listed in progressive order
the resuscitation team often performs
them simultaneously with ACLs patient
care is organized around two minute
periods of high-quality CPR when the two
minutes have ended that's the time to
quickly assess the patient with a rhythm
or pulse check and provide
defibrillation if necessary the pause
should also be used to rotate
compressors preparing as a team for
these pauses and choreographing your
movements improves patient care
remember
iha wants these pauses in CPR to be 10
seconds or less let's return to our case
in the training lab to watch how
providers incorporate the ACLs survey
into a scenario where a patient is
suffering from persistent VF the case
progresses with the arrival of a team of
advanced health care providers
seven eight nine ten eleven twelve
thirteen fourteen fifteen okay what have
we got the patient suddenly collapsed
during a meeting we started CPR
immediately and we've shocked the
patient once one minute 48 seconds ago
followed by immediate CPR we've got the
ECG monitoring attached now it's now 2
minutes from our last shock
okay let's analyze this rhythm stand
back everyone hold chest compressions
okay we've got persistent VF resuming
compressions one two let's deliver a
second shock at 150 joules Dana let's
establish IV access and be prepared to
administer one milligram of epinephrine
IV charging clear the patient shocking
on three one two three shocking shock
delivered
resuming compressions one two three what
do we know about the possible causes
first responder said that the patient
complained of chest pain before he
collapsed houses airway I was getting in
chest rise with a bag mask but now I'm
getting significant resistance okay
let's go ahead and insert an advanced
airway
Dana once that IV is established you
have one milligram of epinephrine and
flush with a 20 milliliters saline bolus
okay one milligram epinephrine with a 20
milliliter saline bolus the idea started
and one milligram epinephrine and the IV
is flushed okay thank you let's go ahead
and prepare 300 milligrams of amiodarone
I'll let you know if and when to give it
okay drawing 300 milligrams of
amiodarone the laryngeal tube is in fine
I've got good bilateral breath sounds
wave poem capnography is reading 20
millimeters of mercury okay great we're
gonna continue chest compressions at a
rate of at least 100 beats per minute
let's give one breath every six to eight
seconds and avoid excessive ventilation
how long since our last shot it's almost
two minutes okay let's get ready to
switch compressors we're gonna stop and
analyze two minutes okay let's analyze
okay we have an organized rhythm with
regular complexes do we have a pulse
we've got a week but palpable pulse in
tidal co2 is now up to 50 millimeters of
mercury okay great job everyone we're
gonna start post cardiac arrest care
I'll need a blood pressure a set of labs
pulse ox and let's get a 12-lead ECG
successful resuscitation following
cardiac arrest requires an integrated
set of coordinated actions which are
represented by the links in the adult
chain of survival these links include
the immediate recognition of cardiac
arrest and activation of the emergency
response system early CPR rapid
defibrillation effective advanced life
support an integrated immediate post
cardiac arrest care healthcare providers
implement this chain of survival through
BLS and ACLs surveys the BLS survey
stresses activation of the emergency
response system early CPR and rapid
defibrillation the ACLs survey airway
breathing circulation and differential
diagnosis integrates advanced techniques
such as advanced Airways quantitative
waveform capnography appropriate drug
delivery and the diagnosis and treatment
of reversible causes successfully
following the American Heart Association
systematic approach to assessing and
treating patients with the BLS and ACLs
surveys can make a difference what you
learn can save lives
How to Conduct Hands only to maintain the level of quality of reviving
Cardiopulmonary Resuscitation or the patient.
CPR? Remember, when giving chest
compressions
If you are a bystander to an accident it should be “not too hard, not too fast."
and one of your relatives may be a casualty Continue giving CPR until a rescue team
immediately determine if the patient is still arrives
breathing or until you see signs of consciousness
By looking at his or her chest if it is going up such as coughing, opening eyes, speaking,
and down. and starting to breathe normally.
If a person is not breathing As mentioned earlier
We must be prepared to perform hands-only the level of quality in reviving the patient
CPR. must be the same
This situation is very critical If you get tired, there should be an
because within just a few minutes alternative to revive the patient.
The patient may die if CPR will not be In giving hands-only CPR here are the
provided. things to remember:
If you are not alone in the scene Place the heel of your right hand on the
ask someone to immediately call for help patient’s chest.
From an emergency medical service like On top of the abdomen.
911-UNTV. Perform 100-120 compressions
Kneel beside the patient Not too hard and not too fast
cover the left hand with the heel of your Continue giving CPR, until the patient is
other hand revived or until a rescue team arrives.
then place it at the center of the chest on
top of his abdomen.
Make sure that your back, shoulders, and
elbows are straight
As you provide compression to the patient.
Press down on the patient’s chest
for about 2 to 2.4 inches
to make sure that there is blood flowing to
the brain
Perform 100-120 compressions per minute.
In case that you have no formal CPR
training
and just learned it here on Lifesaver’s
program
it is not necessary to try rescue breathing
and instead, continue to perform chest
compression procedures on the patient.
Preferably, it is better to have and alternate
in providing chest compressions
CPR & COVID-19 (Phil. Heart
Association Guidelines)
Out of hospital cardiac arrest
PPE- N95, goggles, double gloves, face
shield, gown
Casual- gloves, mask, face shield
Call help, if not sure what to do.
If untrained, perform hands only CPR
Push hard and fast.
Q- Humihinga is CHEST RISE
Call for Help
Shoulders are parallel to the victim
Elbows locked
100-120 compressions per minute
If untrained perform Hands only CPR
Push hard and fast
Signs of life
Perform high quality CPR
Ask if the patient is conscious. Tap.
Ask for help
LLF- look, listen, and feel.
Check pulse. (full ppe. Do not come close if
there's none. FIRST PRIORITY IS YOUR
OWN HEALTH.)
Feel your throat, find Laryngeal prominence
or ADAM’s apple. Feel through the pulse.
Either pulse has stopped or is weak. See if
there's chest rise. If there’s no pulse,
perform CPR. CHest compression. If there’s
no barrier. Ambu bag?? Is not used
anymore unless there's a filter because it’s
not disposable. Secretions. Endotracheal
intubation is used in the hospital instead.
MTMR is not allowed. Mouth-to mouth
resus.
Shockable- automated external defibrillator
(AED)
Remove the patient's clothes. Shave if hairy.
On device. Apply pads on chest. Plug pads
to AED. let it analyze. No touchy touchy.
Wait for ambulance. Higher survival rate if
CPR is alternated.
Sudden cardiac arrest- patient is w/o
symptoms. Kuryente sa puso problem. AED
stops heart to reset contraction. Supply
oxygenated blood. Ventricular fibrillation is
only managed by a defibrillator??? Huaw.
Di naman laging may AED. Thus CPR is
important whenever you are waiting for AED
and ambulance.
Chest compression- pinapatagal yung
panginginig. Aanhin mo yung puso kung
tumigil na.
FLatline- heart has stopped. Anumang
kuryente, waley na. Heart will not respond.
But there’s still a possibility.
Thus CPR increases survival rate.
AED knows if what you’re doing is right.
“Good compression. Push harder. Push
faster.” AED guides you on what to do.
IF not shockable, check pulse. Either pulse
is normal or it has stopped (ASYSTOLE).
Q-
You see one of the reason to stop CPR is
when you defibrillate
HQCPR is minimizing interruptions
There is a law which requires places with
sick populations like Pharmacies will be
required to install their own AEDs
Survival rate of CPR is just 8-10%
Asystole is absence of electrical impulse so
NO DEFIBRILLATION
Defibrillation ORGANIZES a disorganized
rhythm like VF, pulseless VTach which are
shockable rhythms
2-2.4 DEPTH for blood to reach into the
brain and vital organs. POssibility that
there’s survival. Wag sa beach. Recoil is
maintained.
PAG TUMIGIL TAYO, TITIGIL NA DIN ANG
PUSO, THUS CONTINUOUS ANG CPR
CHEST COMPRESSION.
Epinephrine is given. Out of hospital, the
only thing you can do is chest compre.
of rescuers to achieve a CCF greater than
80%.
5. • Ventilation: 2 breaths after 30
compressions without an advanced airway;
1 breath every 6 seconds with an advanced
airway.

After resus, all the PPE is to be thrown MTMR is not allowed. An Ambu bag is used
away. Be extra careful. Wag mong galawin with a mouthpiece. No actual MTM even
pag wala kang equipment. Baka mahawa ka before COVID. Not during COVID, it is
pa. Pakielamera. preferred to do hands-only CPR with a
barrier: N95. Cover patient with plastic chest
upto head. Protect yo self. Need not rush
What are the 5 components of high quality chest compre, allowable time to gear up
CPR? prior to starting or resuming ALS/BLS.
Five main components of high-performance Ambu bags are not used unless there’s a
CPR have been identified: viral filter. Even though it is a closed
chest compression fraction (less than 80% mechanism, it still is needed to use viral
CCF), filters. A brand of a bag valve. Bag valves
chest compression rate (100-120 are generic. Tube in a viral chuchu.
compressions per minute),
chest compression depth (2-2.4 inches or
5-6cm depth),
allow for chest recoil on a flat surface
(residual leaning),
and ventilation.
Minimize interruptions.
These CPR components were identified
because of their contribution to blood flow
and outcome.

PHA- push hard and fast.

AHA- nah. Contrary

1. • Depth: 2–2.4 inches (5–6 centimeters)

2. • Compression rate: 100–120/minute
3. • Recoil: Allow for full recoil after each
compression. No leaning.
4. • Minimize pauses. Get the chest
compression fraction (CCF), the percentage
of time CPR is being delivered, as high as
possible, with a target of at least 60%. It
may be reasonable with a sufficient number
MegaCode and Team management
- ACLS AHA
team dynamics are critical during a
resuscitation attempt the interaction
among team members has a profound
impact
on the effectiveness of each individual
as well as the patient's overall
survival the better you work as a team
the better the potential outcome for
your patient that's why it's so
important that you understand not just
what to do in a resuscitation attempt
but how to communicate and perform as an
effective team regardless of your role
as team member or team leader welcome to
the American Heart Association's
megacode and team resuscitation video in
this video we're going to demonstrate
and model an effective resuscitation
team in a case scenario our simulation
will have six team members you may have
fewer members depending on the situation
so be prepared to adjust your roles
accordingly our case study begins in a
local emergency department where a 65
year old woman has been brought in
complaining of epigastric and back
discomfort hello I'm dr. Jackson what's
bothering you today doctor I don't feel
good I feel really bad I'm dizzy and I'm
sick of my stomach my son was really
worried about me what me in ok are you
having chest pain right now
no but I'm party started in my stomach
and now it's in my back okay we're gonna
see if we can find out what's going on
okay
joette do we have a set of vitals from
this Fernandez yeah blood pressure is 70
over 40 heart rate is 45 beats per
minute respiratory rate is 16 breasts
for a minute and pulse ox is 92 percent
okay let's go ahead and start her on 2
liters of o2 miss Fernandez we've got
you hooked up to a monitor so we can
take a look at your heart rhythm okay
and we've started you on oxygen so you
can breathe a little easier if pulse ox
reading is 95% with 2 liters of o2
dr. right okay it looks like we have
sinus bradycardia Dana let's go ahead
and get an IV started right now miss
Fernandez mrs. Fernandez can you hear
me
mrs. Fernandez she's unresponsive you
feel a pulse okay let's call a code the
patient's gone into v-fib start chest
compressions three compressions Mandell
you'll be on defibrillator Shelley
you'll be recording recording Sam you'll
manage the airway Dana have you been
able to establish an IV access yet I've
tried several times but it's failed okay
let's move on to IO access please let me
try oh access six twenty seven twenty
eight twenty nine thirty one two three
four five six seven eight nine ten
charging at 200 joules shock Witte clear
the patient shocking on three one two
three shocking shock delivered
I have IO access now great we'll
continue CPR for two minutes and
evaluate the need for additional
defibrillation Shelley I'll rely on you
to monitor the quality of the chest
compressions Dana you'll need to draw
the drugs up before each rhythm check so
if the arrest persists we can move
quickly to drug therapy let's begin with
one milligram of epinephrine all right
one milligram epinephrine three two
minutes
okay let's analyze switch roles
okay the patient remains in v-fib the
protocol for this biphasic device is
escalated dosing let's shock again at
300 joules shocking at 300 joules
charging clear the patient shocking on
three
one two three shocking shock delivered
continue CPR continue compressions one
two Dana please give one milligram of
epinephrine
one milligram epinephrine and the Iowa
squished great
we've given two shocks and given one
milligram of epinephrine the next
medication to consider is amiodarone
they know please prepare 300 milligrams
of amiodarone trying 300 milligrams of
amiodarone Sam are you getting good
chest rise yes
and I'm being careful not to deliver
ventilations too quickly or porcelain
okay great let's continue there two
Minutes
Q- Roles have been specified
Perform BLS Ventricular fibrillation
Patient is V fib
Shocked defibrillated
Dana is the medication Nurse
2 shocks delivered
Epinephrine given 1 mg
Amiodarone 300mg prepared
Epinephrine given 1 mg
Amiodarone 300mg prepared
2 minutes switch roles, analyze rhythm still
at Vfib
Amiodarione given
Reversible cause of cardiac arrest consider
6H and 5Ts
Sinus Bradycardia without pulse continue
compressions
In the 2021 guidelines Vasopressin is NO
LONGER advised
Rapi weak pulse ROSC or return of
spontaneous circulation
Therapeutic hypothermia protects the brain
after ROSC
Cold NSS is used
Check vital signs during ROSC
ECG is STEMI PCI will be done
Team debriefing
Offer affirmation
Supra glottic airway
Alternative to ET tube as advanced airway
Confusion at the start
Good communication skills like a closed
loop communication
No horsing around during a code
Assigning roles again
IO is intraosseous
Location of IO is at the left tibia
Biphasic devise 200
Epinephrine 1 mg
Shock delivered then
Anti arrhythmic given
Vasopressin is only given inlace of the first
or second epinephrine
From Peter Quilala to Everyone 10:19 AM
5H and 6Ts
The role of the Chinese girl is the
pharmacist’s role
ET inserted
Hooked to BV and ventilation resumed
Post Cardiac Care Algorithm after ROSC
okay let's analyze switch roles okay the
patient is in persistent VF let's shock
again at 360 joules charging at 360
joules shock ready clear the patient
shocking on three one two three shocking
shock delivered
continue CPR continuing CPR f1 shoot we
can't give amiodarone now thanks Shelley
Dana please give 300 milligrams of
amiodarone hey senator milligrams of
amiodarone given and the IO is flushed
we've given three shocks after the
second shock we administered one
milligram of epinephrine and we've just
given 300 milligrams of amiodarone our
next drug will be vasopressin Dana
please prepare 40 units of vasopressin
trying 40 units of vasopressin
let's review any reversible causes by
considering the hsm TS
what about hypervolemia that's a good
thought we have IO access established
but no obvious signs of internal or
external bleeding anybody else have any
other suggestions have we considered
hypoxia is the airway still patent still
getting good test ride she came in with
epigastric discomfort and symptomatic
bradycardia have we considered coronary
thrombosis that's a great point
everything seems to suggest a STEMI two
minutes okay let's analyze switch roles
okay the monitor shows sinus bradycardia
do we have a pulse I don't feel a pulse
continue chest compressions dictate you
a taste compressions one two three
Shelly how long has it been since our
last dose of epinephrine three minutes
okay
Dana let's go ahead and give 40 units of
vasopressin 40 units of vasopressin
given and the IO is flushed Mandel your
compressions are slowing down can you
pick up the pace of it two minutes
let's analyze switch roles
okay the monitor shows sinus tachycardia
Sam do we have a pulse
I can feel a rapid weak pulse okay great
let's initiate immediate post cardiac
arrest care Dana let's get a blood
pressure a complete set of vital signs
pulse ox and labs Mandel let's start a
12-lead ECG please can we check to see
if this patient is breathing and
responsive ma'am can you squeeze my
fingers she's still unresponsive still
not breathing
okay let's insert an advanced airway and
prepare for therapeutic hypothermia your
patient's blood pressure is 82 over 40
with a heart rate of 130 and a rhythm of
signs tachycardia okay the patient is
hypotensive let's start with a liter of
saline since we've started with
hypothermia let's use cold saline for
the bolus yeah we'll switch out for cold
saline tubes in
oK we've got good breath sounds let's
establish waveform capnography the o2
saturation is 96% here's a 12-lead okay
she has a STEMI Mandel please call the
cath lab and tell them that we have a
STEMI patient PCI and hypothermia can be
safely combined after cardiac arrest the
return of spontaneous circulation or
roske is no longer the end of the
cardiac arrest protocol more scientific
studies show that survival rates improve
significantly with the comprehensive
system of post cardiac arrest care it is
important to know your local systems
plan for the management of post cardiac
arrest patients hypothermia is the only
intervention that has been shown to
improve neurologic recovery the
resuscitation team should consider
inducing hypothermia for any patient who
remains comatose after Ross several
studies show improved outcomes for
patients whose bodies were cooled to 32
to 34 degrees Celsius for 12 to 24 hours
a new recommendation in the 2010
guidelines is the introduction of a
structured team debriefing studies show
teams who debrief together perform
better on subsequent codes here's how
team debriefing differs from simple
feedback feedback is geared toward
correcting actions effective debriefing
focuses on correcting the thought
process that leads to the action while
debriefing takes longer than simple
feedback it results in deeper
understanding the hallmark of structured
debriefing is a learner centered self
analysis and active participation in
discussion the goal is to gather
information on how the code progressed
to analyze the information to create an
accurate record and to summarize the
goals for future improvement
thanks team nice job I made a few notes
during my evaluation so let's talk about
what went well and why you made the
decisions that you made well from my
perspective I thought the code went very
well Shelly did a good job monitoring
the quality of chest compressions Shelly
did we have any prolonged pauses or
interruptions in the chest compressions
no Joette Mandel both switched positions
quickly and resume compressions
even as the defibrillator was charging
Mandel did you get tired or have any
trouble with the pace of compressions at
the end of the code I was starting to
slow down but Shelly was able to correct
the rate of compression so I was able to
pick up the pace it is easy to lose
track of how fast you should be
compressing so having someone pacing
you
through the code is helpful yeah maybe
we should use a metronome to help keep
pace or make it standard practice to do
compression checks at points during the
code that's a good idea let's try that
next time Sam what do you think of
managing the arrest without an advanced
airway we were getting good chest rising
entire time so we didn't need to
interrupt chest compressions to insert
an endotracheal tube you know we could
have inserted a supraglottic airway that
could have been done without
interrupting the chest compressions you
know that could have been an option
especially if ventilations became too
difficult one benefit of using a
bag-mask ventilation is that
ventilations are at regular intervals
and it kept me from ventilating too much
however because she wasn't intubated we
didn't have in tidal co2 readings to
monitor CPR quality or detector Oscar
yeah that's a good observation it is a
trade-off when to consider inserting an
advanced airway Dana how did you feel
about your treatment especially moving
to IO access early in the code IO access
and adults is new to me but I found that
it was easy to push drugs through so
what are the take-home messages I
thought it was great that we assigned
code team roles early in the day because
when the code was called I knew exactly
what I supposed to do yeah because
before we did that we'd walk into a room
and there'd be some confusion good
anything else okay again nice job
successful teams not only have medical
expertise and mastery of resuscitation
skills they also practice good
communication skills and adhere to the
key elements of effective team dynamics
these elements help teams work together
in the most efficient way possible let's
review those now closed loop
communication this is important for both
the team leader and team members when
the team leader gives an order the team
member should confirm that he or she
heard and understood the order the team
leader should make sure the team
member understood the order before
assigning additional tasks clear messages
Using concise clear language helps prevent
misunderstandings speaking in a tone of
voice that is loud enough to understand
but also calm and confident helps keep
all team members focused on the task at
hand clear roles and responsibilities
when everyone knows their job and
responsibilities during a code the team
functions smoothly the team leader
should clearly define and delegate tasks
according to each team members area of
competence know your limitations every
member on the team should know his or
her limitations and the team leader
should be aware of them ask for
assistance and advice early not when the
situation deteriorates knowledge sharing
this is a critical component of
effective team performance team leaders
should ask for good ideas for a
differential diagnosis and frequently
ask for observations from team members
about possible oversights constructive
intervention sometimes a team member or
the team leader may correct actions that
are incorrect or inappropriate it's
important to be tactful especially if
you have to correct a colleague who is
about to make a mistake whether it's a
drug dosage or intervention summarizing
and re-evaluation summarizing
information out loud is a good way to
maintain an ongoing record of treatment
and acts as a way to reevaluate the
patient's status the interventions
performed and where the team is within
the algorithm of care this technique can
also help team members respond to
the patient's changing condition finally
all team members should display mutual
respect in a professional attitude to
other team members regardless of their
personal expertise or training it's
important that the team leaders speak in
a friendly controlled voice avoiding
shouting or unnecessary aggression not
only is it important to know what to do
during a megacode event it's as
important to know how to work together
as a team during the code reviewing how
a code went not only helps individual
team members perform better and
subsequent codes but may also bring
system deficiencies to light now we'll
play the mega code resuscitation case
study again this time as you watch look
for the key elements of effective team
dynamics closed loop communication:
clear messages, clear roles and
responsibilities, knowing one's
limitations, knowledge sharing,
constructive intervention, summarizing
and re-evaluation, and mutual respect
the
patient's gone into v-fib start chest
compressions any compressions
Mandell you'll be on defibrillator
shellie you'll be recording recording
Sam you'll manage the airway Dana have
you been able to establish an IV access
yet I've tried several times but it's
failed okay let's move on to IO access
please let me tayo access 6 27 28 29 30
two three four five six seven eight nine
ten
charging at 200 joules shock ready clear
the patient shocking on three one two
three shocking shock delivered
I have i/o access now great we'll
continue CPR for two minutes and
evaluate the need for additional
defibrillation Shelly I'll rely on you
to monitor the quality of the chest
compressions Dana you'll need to draw
the drugs up before each rhythm check so
if the arrest persists we can move
quickly to drug therapy let's begin with
one milligram of epinephrine all right
one milligram epinephrine three two
minutes
okay let's analyze switch roles okay the
patient remains in v-fib the protocol
for this biphasic device is escalated
dosing let's shock again at 300 joules
shocking at 300 joules charging clear
the patient shocking on three one two
three
shocking shock delivered continue CPR
configure compressions one Dana please
give one milligram of epinephrine one
milligram epinephrine and the iowa's
pushed
great we've given two shocks and given
one milligram of epinephrine the next
medication to consider is amiodarone
they know please prepare 300 milligrams
of amiodarone trying 300 milligrams of
amiodarone Sam are you getting good
chest rise yes
and I'm being careful not to deliver
ventilations too quickly or forcefully
okay great let's continue there two
minutes
okay let's analyze switch roles okay the
patient is in persistent VF let's shock
again at 360 joules charging at 360
joules shock ready clear the patient
shocking on three one two three shocking
shock delivered
continue CPR continuing CPR one two
three we can give amiodarone now thanks
Shelley Dana please give 300 milligrams
of amiodarone Hey Center milligrams of
amiodarone given and the IO is flushed
we've given three shocks after the
second shock we administered one
milligram of epinephrine and we've just
given 300 milligrams of amiodarone our
next drug will be vasopressin Dana
please prepare 40 units of vasopressin
on 40 units of vasopressin
let's review any reversible causes by
considering the hsm TS
what about hypervolemia that's a good
thought we have IO access established
but no obvious signs of internal or
external bleeding anybody else have any
other suggestions have we considered
hypoxia is the airway still patent still
good and good test ride
she came in with epigastric discomfort
and symptomatic bradycardia probably
considered a coronary thrombosis that's
a great point everything seems to
suggest a STEMI two minutes
okay let's analyze switch roles okay the
monitor shows sinus bradycardia do we
have a pulse I don't feel a pulse
continue chest compressions picked on
you at chest compressions one two three
Shelly how long has it been since our
last dose of epinephrine three minutes
okay Dana let's go ahead and give 40
units of vasopressin 40 units of
vasopressin given and the IO is flushed
Mandel your compressions are slowing
down can you pick up the pace a bit two
minutes
let's analyze switch roles
okay the monitor shows sinus tachycardia
Sam do we have a pulse
I can feel a rapid weak pulse okay great
let's initiate immediate post cardiac
arrest care Dana let's get a blood
pressure a complete set of vital signs
pulse ox and labs Mandel let's start a
12-lead ECG please can we check to see
if this patient is breathing and
unresponsive ma'am can you squeeze my
fingers she's still unresponsive
still not breathing okay let's insert an
advanced airway and prepare for
therapeutic hypothermia the patient's
blood pressure has 82 over 40 with a
heart rate of 130 in a rhythm of science
tech a cardio okay the patient is
hypotensive let's start with a liter of
saline
since we've started with hypothermia
let's use cold saline for the bolus yeah
we'll switch out for cold saline
tubes in
oK we've got good breath sounds let's
establish waveform capnography the o2
saturation is 96% here's a 12-lead okay
she has a STEMI Mandel please call the
cath lab and tell them that we have a
STEMI patient PCI and hypothermia can be
safely combined after cardiac arrest in
this section of the course we've shown
you the key steps involved in the adult
cardiac arrest algorithm as well as the
post cardiac care algorithm to promote a
positive patient outcome in the event of
the return of spontaneous circulation
you've also evaluated the megacode
scenario with the key elements of
effective team dynamics and structured
team debriefing combining your knowledge
of essential arrest skills with
effective team dynamics can give your
team a better chance of success with
every resuscitation attempt
 Topics

Adult Pediatric
Basic and Basic and Resuscitation
Neonatal Life Systems of
Advanced Advanced Education
Support Care
Life Support Life Support Science

Introduction
These Highlights summarize the key issues and changes in the 2020 American Heart Association (AHA) Guidelines for
Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). The 2020 Guidelines are a comprehensive
revision of the AHA’s guidelines for adult, pediatric, neonatal, resuscitation education science, and systems of care topics.
They have been developed for resuscitation providers and AHA instructors to focus on the resuscitation science and guide-
lines recommendations that are most significant or controversial, or those that will result in changes in resuscitation training
and practice, and to provide the rationale for the recommendations.
Because this publication is a summary, it does not reference the supporting published studies and does not list Classes
of Recommendation (COR) or Levels of Evidence (LOE). For more detailed information and references, please read the 2020
AHA Guidelines for CPR and ECC, including the Executive Summary,1 published in Circulation in October 2020, and the
detailed summary of resuscitation science in the 2020 International Consensus on CPR and ECC Science With Treatment
Recommendations, developed by the International Liaison Committee on Resuscitation (ILCOR) and published simultaneously
in Circulation2 and Resuscitation3 in October 2020. The methods used by ILCOR to perform evidence evaluations4 and by the
AHA to translate these evidence evaluations into resuscitation guidelines5 have been published in detail.
The 2020 Guidelines use the most recent version of the AHA definitions for the COR and LOE (Figure 1). Overall, 491
specific recommendations are made for adult, pediatric, and neonatal life support; resuscitation education science; and
systems of care. Of these recommendations, 161 are class 1 and 293 are class 2 recommendations (Figure 2). Additionally, 37
recommendations are class 3, including 19 for evidence of no benefit and 18 for evidence of harm.

The American Heart Association thanks the following people for their contributions to the development of this publication: Eric J. Lavonas,
MD, MS; David J. Magid, MD, MPH; Khalid Aziz, MBBS, BA, MA, MEd(IT); Katherine M. Berg, MD; Adam Cheng, MD; Amber V.
Hoover, RN, MSN; Melissa Mahgoub, PhD; Ashish R. Panchal, MD, PhD; Amber J. Rodriguez, PhD; Alexis A. Topjian, MD, MSCE;
Comilla Sasson, MD, PhD; and the AHA Guidelines Highlights Project Team.
© 2020 American Heart Association

eccguidelines.heart.org 1
Figure 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic
Testing in Patient Care (Updated May 2019)*

2 American Heart Association

Figure 2. Distribution of COR and LOE as percent of 491 total recommendations in the 2020 AHA Guidelines for CPR and ECC.*

*Results are percent of 491 recommendations in Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life
Support, Resuscitation Education Science, and Systems of Care.
Abbreviations: COR, Classes of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, Randomized.

About the Recommendations

The fact that only 6 of these 491 recommendations (1.2%) are based on Level A evidence (at least 1 high-quality randomized
clinical trial [RCT], corroborated by a second high-quality trial or registry study) testifies to the ongoing challenges in perform-
ing high-quality resuscitation research. A concerted national and international effort is needed to fund and otherwise support
resuscitation research.
Both the ILCOR evidence-evaluation process and the AHA guidelines-development process are governed by strict AHA
disclosure policies designed to make relationships with industry and other conflicts of interest fully transparent and to
protect these processes from undue influence. The AHA staff processed conflict-of-interest disclosures from all participants.
All guidelines writing group chairs and at least 50% of guidelines writing group members are required to be free of all
conflicts of interest, and all relevant relationships are disclosed in the respective Consensus on Science With Treatment
Recommendations and Guidelines publications.

eccguidelines.heart.org 3
Adult Basic and Advanced Life Support
Summary of Key Issues and Major Changes
In 2015, approximately 350 000 adults in the United States
experienced nontraumatic out-of-hospital cardiac arrest
(OHCA) attended by emergency medical services (EMS)
personnel. Despite recent gains, less than 40% of adults
receive layperson-initiated CPR, and fewer than 12% have
an automated external defibrillator (AED) applied before EMS
arrival. After significant improvements, survival from OHCA
has plateaued since 2012.
In addition, approximately 1.2% of adults admitted to US
hospitals suffer in-hospital cardiac arrest (IHCA). Outcomes
from IHCA are significantly better than outcomes from OHCA,
and IHCA outcomes continue to improve.
Recommendations for adult basic life support (BLS) and
advanced cardiovascular life support (ACLS) are combined
in the 2020 Guidelines. Major new changes include the
following:
• Enhanced algorithms and visual aids provide easy-to-
remember guidance for BLS and ACLS resuscitation
scenarios.
• The importance of early initiation of CPR by lay rescuers
has been re-emphasized.
• Previous recommendations about epinephrine
administration have been reaffirmed, with emphasis on
early epinephrine administration.
• Use of real-time audiovisual feedback is suggested as a
means to maintain CPR quality.
• Continuously measuring arterial blood pressure and end-
tidal carbon dioxide (ETCO2) during ACLS resuscitation
may be useful to improve CPR quality.
• On the basis of the most recent evidence, routine use of
double sequential defibrillation is not recommended.
• Intravenous (IV) access is the preferred route of medication
administration during ACLS resuscitation. Intraosseous (IO)
access is acceptable if IV access is not available.
• Care of the patient after return of spontaneous circulation
(ROSC) requires close attention to oxygenation, blood
4 American Heart Association
pressure control, evaluation for percutaneous coronary
intervention, targeted temperature management, and
multimodal neuroprognostication.
• Because recovery from cardiac arrest continues long
after the initial hospitalization, patients should have formal
assessment and support for their physical, cognitive, and
psychosocial needs.
• After a resuscitation, debriefing for lay rescuers, EMS
providers, and hospital-based healthcare workers may be
beneficial to support their mental health and well-being.
• Management of cardiac arrest in pregnancy focuses on
maternal resuscitation, with preparation for early perimortem
cesarean delivery if necessary to save the infant and
improve the chances of successful resuscitation of
the mother.
Algorithms and Visual Aids
The writing group reviewed all algorithms and made focused
improvements to visual training aids to ensure their utility as
point-of-care tools and reflect the latest science. The major
changes to algorithms and other performance aids include
the following:
• A sixth link, Recovery, was added to the IHCA and OHCA
Chains of Survival (Figure 3).
• The universal Adult Cardiac Arrest Algorithm was modified
to emphasize the role of early epinephrine administration for
patients with nonshockable rhythms (Figure 4).
• Two new Opioid-Associated Emergency Algorithms have
been added for lay rescuers and trained rescuers
(Figures 5 and 6).
• The Post–Cardiac Arrest Care Algorithm was updated to
emphasize the need to prevent hyperoxia, hypoxemia, and
hypotension (Figure 7).
• A new diagram has been added to guide and inform
neuroprognostication (Figure 8).
• A new Cardiac Arrest in Pregnancy Algorithm has been
added to address these special cases (Figure 9).
 Adult Basic and Advanced Life Support

Despite recent gains, less than 40%

of adults receive layperson-initiated
CPR, and fewer than 12% have an
AED applied before EMS arrival.

Figure 3. AHA Chains of Survival for adult IHCA and OHCA.

eccguidelines.heart.org 5
Figure 4. Adult Cardiac Arrest Algorithm.

6 American Heart Association

 Adult Basic and Advanced Life Support

Figure 5. Opioid-Associated Emergency for Lay Responders Algorithm.

eccguidelines.heart.org 7
Figure 6. Opioid-Associated Emergency for Healthcare Providers Algorithm.

8 American Heart Association

 Adult Basic and Advanced Life Support

Figure 7. Adult Post–Cardiac Arrest Care Algorithm.

eccguidelines.heart.org 9
Figure 8. Recommended approach to multimodal neuroprognostication in adult patients after cardiac arrest.

10 American Heart Association

 Adult Basic and Advanced Life Support

Figure 9. Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm.

eccguidelines.heart.org 11
Major New and Updated
Recommendations
Early Initiation of CPR by Lay Rescuers
2020 (Updated): We recommend that
laypersons initiate CPR for presumed
cardiac arrest because the risk of harm
to the patient is low if the patient is not
in cardiac arrest.
2010 (Old): The lay rescuer should not
check for a pulse and should assume
that cardiac arrest is present if an adult
suddenly collapses or an unrespon-
sive victim is not breathing normally.
The healthcare provider should take
no more than 10 seconds to check for
a pulse and, if the rescuer does not
definitely feel a pulse within that time
period, the rescuer should start chest
compressions.
Why: New evidence shows that the risk
of harm to a victim who receives chest
compressions when not in cardiac
arrest is low. Lay rescuers are not able
to determine with accuracy whether
a victim has a pulse, and the risk of
withholding CPR from a pulseless victim
exceeds the harm from unneeded chest
compressions.
Early Administration of Epinephrine
2020 (Unchanged/Reaffirmed): With
respect to timing, for cardiac arrest
with a nonshockable rhythm, it is
reasonable to administer epinephrine
as soon as feasible.
2020 (Unchanged/Reaffirmed): With
respect to timing, for cardiac arrest with
a shockable rhythm, it may be reason-
able to administer epinephrine after
initial defibrillation attempts have failed.
Why: The suggestion to administer
epinephrine early was strengthened
to a recommendation on the basis of a
systematic review and meta-analysis,
which included results of 2 randomized
trials of epinephrine enrolling more than
8500 patients with OHCA, showing
that epinephrine increased ROSC and
survival. At 3 months, the time point felt
to be most meaningful for neurologic
recovery, there was a nonsignificant in-
crease in survivors with both favorable
12 American Heart Association
and unfavorable neurologic outcome in
the epinephrine group.
Of 16 observational studies on
timing in the recent systematic review,
all found an association between
earlier epinephrine and ROSC for
patients with nonshockable rhythms,
although improvements in survival
were not universally seen. For patients
with shockable rhythm, the literature
supports prioritizing defibrillation and
CPR initially and giving epinephrine
if initial attempts with CPR and
defibrillation are not successful.
Any drug that increases the rate
of ROSC and survival but is given
after several minutes of downtime
will likely increase both favorable and
unfavorable neurologic outcome.
Therefore, the most beneficial
approach seems to be continuing
to use a drug that has been shown
to increase survival while focusing
broader efforts on shortening time
to drug for all patients; by doing so,
more survivors will have a favorable
neurologic outcome.
Real-Time Audiovisual Feedback
2020 (Unchanged/Reaffirmed): It may be
reasonable to use audiovisual feedback
devices during CPR for real-time
optimization of CPR performance.
Why: A recent RCT reported a 25%
increase in survival to hospital dis-
charge from IHCA with audio feedback
on compression depth and recoil.
Physiologic Monitoring of CPR Quality
2020 (Updated): It may be reasonable to
use physiologic parameters such as
arterial blood pressure or ETCO2 when
feasible to monitor and optimize
CPR quality.
2015 (Old): Although no clinical study has
examined whether titrating resuscita-
tive efforts to physiologic parameters
during CPR improves outcome, it may
be reasonable to use physiologic
parameters (quantitative waveform cap-
nography, arterial relaxation diastolic
pressure, arterial pressure monitoring,
and central venous oxygen saturation)
when feasible to monitor and optimize
CPR quality, guide vasopressor therapy,
and detect ROSC.
Why: Although the use of physiologic
monitoring such as arterial blood
pressure and ETCO2 to monitor CPR
quality is an established concept,
new data support its inclusion in the
guidelines. Data from the AHA’s Get
With The Guidelines®-Resuscitation
registry show higher likelihood of
ROSC when CPR quality is monitored
using either ETCO2 or diastolic blood
pressure.
This monitoring depends on the
presence of an endotracheal tube (ETT)
or arterial line, respectively. Targeting
compressions to an ETCO2 value of at
least 10 mm Hg, and ideally 20 mm Hg
or greater, may be useful as a marker
of CPR quality. An ideal target has not
been identified.
Double Sequential Defibrillation
Not Supported
2020 (New): The usefulness of double
sequential defibrillation for refractory
shockable rhythm has not been
established.
Why: Double sequential defibrillation
is the practice of applying near-
simultaneous shocks using 2
defibrillators. Although some case
reports have shown good outcomes,
a 2020 ILCOR systematic review found
no evidence to support double sequen-
tial defibrillation and recommended
against its routine use. Existing studies
are subject to multiple forms of bias,
and observational studies do not show
improvements in outcome.
A recent pilot RCT suggests that
changing the direction of defibrillation
current by repositioning the pads may
be as effective as double sequential
defibrillation while avoiding the risks
of harm from increased energy and
damage to defibrillators. On the basis
of current evidence, it is not known
whether double sequential defibrillation
is beneficial.

IV Access Preferred Over IO
2020 (New): It is reasonable for providers
to first attempt establishing IV access
for drug administration in cardiac arrest.
2020 (Updated): IO access may be
considered if attempts at IV access are
unsuccessful or not feasible.
2010 (Old): It is reasonable for providers
to establish intraosseous (IO) access
if intravenous (IV) access is not readily
available.
Why: A 2020 ILCOR systematic review
comparing IV versus IO (principally
pretibial placement) drug administra-
tion during cardiac arrest found that
the IV route was associated with better
clinical outcomes in 5 retrospective
studies; subgroup analyses of RCTs
that focused on other clinical questions
found comparable outcomes when IV
or IO were used for drug administration.
Although IV access is preferred, for
situations in which IV access is difficult,
IO access is a reasonable option.
Post–Cardiac Arrest Care and
Neuroprognostication
The 2020 Guidelines contain signifi-
cant new clinical data about optimal
care in the days after cardiac arrest.
Recommendations from the 2015
AHA Guidelines Update for CPR and
ECC about treatment of hypotension,
titrating oxygen to avoid both hypoxia
and hyperoxia, detection and treatment
of seizures, and targeted temperature
management were reaffirmed with new
supporting evidence.
In some cases, the LOE was
upgraded to reflect the availability of
new data from RCTs and high-quality
observational studies, and the post–
cardiac arrest care algorithm has
been updated to emphasize these
important components of care. To be
reliable, neuroprognostication should
be performed no sooner than 72
hours after return to normothermia,
and prognostic decisions should be
based on multiple modes of patient
assessment.
Adult Basic and Advanced Life Support
The 2020 Guidelines evaluate 19
different modalities and specific
findings and present the evidence
for each. A new diagram presents
this multimodal approach to
neuroprognostication.
Care and Support During Recovery
2020 (New): We recommend that cardiac
arrest survivors have multimodal reha-
bilitation assessment and treatment for
physical, neurologic, cardiopulmonary,
and cognitive impairments before
discharge from the hospital.
2020 (New): We recommend that cardiac
arrest survivors and their caregivers
receive comprehensive, multidisci-
plinary discharge planning, to include
medical and rehabilitative treatment
recommendations and return to
activity/work expectations.
2020 (New): We recommend structured
assessment for anxiety, depression,
posttraumatic stress, and fatigue for
cardiac arrest survivors and their
caregivers.
Why: The process of recovering from
cardiac arrest extends long after the
initial hospitalization. Support is needed
during recovery to ensure optimal
physical, cognitive, and emotional
well-being and return to social/role
functioning. This process should be
initiated during the initial hospitalization
and continue as long as needed. These
themes are explored in greater detail in
a 2020 AHA scientific statement.6
Debriefings for Rescuers
2020 (New): Debriefings and referral for
follow up for emotional support for
lay rescuers, EMS providers, and
hospital-based healthcare workers
after a cardiac arrest event may be
beneficial.
Why: Rescuers may experience anxiety
or posttraumatic stress about providing
or not providing BLS. Hospital-based
care providers may also experience
emotional or psychological effects of
caring for a patient with cardiac arrest.
Team debriefings may allow a review of
team performance (education, quality
improvement) as well as recognition of
the natural stressors associated with
caring for a patient near death. An AHA
scientific statement devoted to this
topic is expected in early 2021.
Cardiac Arrest in Pregnancy
2020 (New): Because pregnant patients
are more prone to hypoxia, oxygenation
and airway management should be
prioritized during resuscitation from
cardiac arrest in pregnancy.
2020 (New): Because of potential
interference with maternal resusci-
tation, fetal monitoring should not be
undertaken during cardiac arrest in
pregnancy.
2020 (New): We recommend targeted
temperature management for pregnant
women who remain comatose after
resuscitation from cardiac arrest.
2020 (New): During targeted tempera-
ture management of the pregnant
patient, it is recommended that the
fetus be continuously monitored for
bradycardia as a potential complication,
and obstetric and neonatal consultation
should be sought.
Why: Recommendations for manag-
ing cardiac arrest in pregnancy were
reviewed in the 2015 Guidelines Update
and a 2015 AHA scientific statement.7
Airway, ventilation, and oxygenation
are particularly important in the setting
of pregnancy because of an increase
in maternal metabolism, a decrease in
functional reserve capacity due to the
gravid uterus, and the risk of fetal brain
injury from hypoxemia.
Evaluation of the fetal heart is not
helpful during maternal cardiac arrest,
and it may distract from necessary
resuscitation elements. In the absence
of data to the contrary, pregnant
women who survive cardiac arrest
should receive targeted temperature
management just as any other survivors
would, with consideration for the status
of the fetus that may remain in utero.
eccguidelines.heart.org 13
Pediatric Basic and Advanced Life Support
Summary of Key Issues and Major Changes
More than 20 000 infants and children have a cardiac arrest
each year in the United States. Despite increases in survival
and comparatively good rates of good neurologic outcome
after pediatric IHCA, survival rates from pediatric OHCA
remain poor, particularly in infants. Recommendations
for pediatric basic life support (PBLS) and CPR in infants,
children, and adolescents have been combined with rec-
ommendations for pediatric advanced life support (PALS)
in a single document in the 2020 Guidelines. The causes
of cardiac arrest in infants and children differ from cardiac
arrest in adults, and a growing body of pediatric-specif-
ic evidence supports these recommendations. Key issues,
major changes, and enhancements in the 2020 Guidelines
include the following:
• Algorithms and visual aids were revised to incorporate
the best science and improve clarity for PBLS and PALS
resuscitation providers.
• Based on newly available data from pediatric resuscitations,
the recommended assisted ventilation rate has been
increased to 1 breath every 2 to 3 seconds (20-30 breaths
per minute) for all pediatric resuscitation scenarios.
• Cuffed ETTs are suggested to reduce air leak and the need
for tube exchanges for patients of any age who require
intubation.
• The routine use of cricoid pressure during intubation is no
longer recommended.
• To maximize the chance of good resuscitation outcomes,
epinephrine should be administered as early as possible,
ideally within 5 minutes of the start of cardiac arrest from
a nonshockable rhythm (asystole and pulseless
electrical activity).
• For patients with arterial lines in place, using feedback from
continuous measurement of arterial blood pressure may
improve CPR quality.
• After ROSC, patients should be evaluated for seizures; status
epilepticus and any convulsive seizures should be treated.
• Because recovery from cardiac arrest continues long
after the initial hospitalization, patients should have formal
assessment and support for their physical, cognitive, and
psychosocial needs.
• A titrated approach to fluid management, with epinephrine
14 American Heart Association
or norepinephrine infusions if vasopressors are needed,
is appropriate in resuscitation from septic shock.
• On the basis largely of extrapolation from adult data,
balanced blood component resuscitation is reasonable
for infants and children with hemorrhagic shock.
• Opioid overdose management includes CPR and the timely
administration of naloxone by either lay rescuers or trained
rescuers.
• Children with acute myocarditis who have arrhythmias, heart
block, ST-segment changes, or low cardiac output are at
high risk of cardiac arrest. Early transfer to an intensive care
unit is important, and some patients may require mechanical
circulatory support or extracorporeal life support (ECLS).
• Infants and children with congenital heart disease and
single ventricle physiology who are in the process of staged
reconstruction require special considerations in PALS
management.
• Management of pulmonary hypertension may include the
use of inhaled nitric oxide, prostacyclin, analgesia, sedation,
neuromuscular blockade, the induction of alkalosis, or
rescue therapy with ECLS.
Algorithms and Visual Aids
The writing group updated all algorithms to reflect the latest
science and made several major changes to improve the
visual training and performance aids:
• A new pediatric Chain of Survival was created for IHCA in
infants, children, and adolescents (Figure 10).
• A sixth link, Recovery, was added to the pediatric OHCA
Chain of Survival and is included in the new pediatric IHCA
Chain of Survival (Figure 10).
• The Pediatric Cardiac Arrest Algorithm and the Pediatric
Bradycardia With a Pulse Algorithm have been updated to
reflect the latest science (Figures 11 and 12).
• The single Pediatric Tachycardia With a Pulse Algorithm
now covers both narrow- and wide-complex tachycardias in
pediatric patients (Figure 13).
• Two new Opioid-Associated Emergency Algorithms have
been added for lay rescuers and trained rescuers (Figures 5
and 6).
• A new checklist is provided for pediatric post–cardiac arrest
care (Figure 14).
 Pediatric Basic and Advanced Life Support

The causes of cardiac arrest in infants

and children differ from cardiac
arrest in adults, and a growing body of
pediatric-specific evidence supports
these recommendations.

Figure 10. AHA Chains of Survival for pediatric IHCA and OHCA.

eccguidelines.heart.org 15
Figure 11. Pediatric Cardiac Arrest Algorithm.

16 American Heart Association

 Pediatric Basic and Advanced Life Support

Figure 12.  Pediatric Bradycardia With a Pulse Algorithm.

eccguidelines.heart.org 17
Figure 13.  Pediatric Tachycardia With a Pulse Algorithm.

18 American Heart Association

 Pediatric Basic and Advanced Life Support

Figure 14. Pediatric Post–Cardiac Arrest Care Checklist.

eccguidelines.heart.org 19
Major New and Updated
Recommendations
Changes to the Assisted Ventilation
Rate: Rescue Breathing
2020 (Updated): (PBLS) For infants and
children with a pulse but absent or
inadequate respiratory effort, it is rea-
sonable to give 1 breath every
2 to 3 seconds (20-30 breaths/min).
2010 (Old): (PBLS) If there is a palpa-
ble pulse 60/min or greater but there
is inadequate breathing, give rescue
breaths at a rate of about 12 to 20/min
(1 breath every 3-5 seconds) until
spontaneous breathing resumes.
Changes to the Assisted Ventilation
Rate: Ventilation Rate During CPR
With an Advanced Airway
2020 (Updated): (PALS) When perform-
ing CPR in infants and children with an
advanced airway, it may be reasonable
to target a respiratory rate range of
1 breath every 2 to 3 seconds
(20-30/min), accounting for age and
clinical condition. Rates exceeding
these recommendations may
compromise hemodynamics.
2010 (Old): (PALS) If the infant or child is
intubated, ventilate at a rate of about
1 breath every 6 seconds (10/min)
without interrupting chest
compressions.
Why: New data show that higher
ventilation rates (at least 30/min in
infants [younger than 1 year] and at
least 25/min in children) are associated
with improved rates of ROSC and
survival in pediatric IHCA. Although
there are no data about the ideal
ventilation rate during CPR without
an advanced airway, or for children in
respiratory arrest with or without an ad-
vanced airway, for simplicity of training,
the respiratory arrest recommendation
was standardized for both situations.
20 American Heart Association
Cuffed ETTs
2020 (Updated): It is reasonable to
choose cuffed ETTs over uncuffed
ETTs for intubating infants and children.
When a cuffed ETT is used, attention
should be paid to ETT size, position,
and cuff inflation pressure (usually
<20-25 cm H2O).
2010 (Old): Both cuffed and uncuffed
ETTs are acceptable for intubating
infants and children. In certain circum-
stances (eg, poor lung compliance, high
airway resistance, or a large glottic air
leak) a cuffed ETT may be preferable to
an uncuffed tube, provided that atten-
tion is paid to [ensuring appropriate]
ETT size, position, and cuff inflation
pressure.
Why: Several studies and systematic
reviews support the safety of cuffed
ETTs and demonstrate decreased need
for tube changes and reintubation.
Cuffed tubes may decrease the risk of
aspiration. Subglottic stenosis is rare
when cuffed ETTs are used in children
and careful technique is followed.
Cricoid Pressure During Intubation
2020 (Updated): Routine use of cricoid
pressure is not recommended during
endotracheal intubation of pediatric
patients.
2010 (Old): There is insufficient evidence
to recommend routine application of
cricoid pressure to prevent aspiration
during endotracheal intubation in
children.
Why: New studies have shown that
routine use of cricoid pressure reduces
intubation success rates and does not
reduce the rate of regurgitation. The
writing group has reaffirmed previous
recommendations to discontinue
cricoid pressure if it interferes with
ventilation or the speed or ease of
intubation.
Emphasis on Early
Epinephrine Administration
2020 (Updated): For pediatric patients in
any setting, it is reasonable to admin-
ister the initial dose of epinephrine
within 5 minutes from the start of chest
compressions.
2015 (Old): It is reasonable to administer
epinephrine in pediatric cardiac arrest.
Why: A study of children with IHCA
who received epinephrine for an initial
nonshockable rhythm (asystole and
pulseless electrical activity) demon-
strated that, for every minute of delay
in administration of epinephrine, there
was a significant decrease in ROSC,
survival at 24 hours, survival to dis-
charge, and survival with favorable
neurological outcome.
Patients who received epinephrine
within 5 minutes of CPR initiation
compared with those who received
epinephrine more than 5 minutes
after CPR initiation were more likely
to survive to discharge. Studies of
pediatric OHCA demonstrated that
earlier epinephrine administration
increases rates of ROSC, survival to
intensive care unit admission, survival
to discharge, and 30-day survival.
In the 2018 version of the Pediatric
Cardiac Arrest Algorithm, patients
with nonshockable rhythms received
epinephrine every 3 to 5 minutes, but
early administration of epinephrine
was not emphasized. Although
the sequence of resuscitation has
not changed, the algorithm and
recommendation language have been
updated to emphasize the importance
of giving epinephrine as early as
possible, particularly when the rhythm
is nonshockable.
Invasive Blood Pressure Monitoring to
Assess CPR Quality
2020 (Updated): For patients with
continuous invasive arterial blood
pressure monitoring in place at the
time of cardiac arrest, it is reasonable
for providers to use diastolic blood
pressure to assess CPR quality.

2015 (Old): For patients with invasive
hemodynamic monitoring in place at
the time of cardiac arrest, it may be
reasonable for rescuers to use blood
pressure to guide CPR quality.
Why: Providing high-quality chest
compressions is critical to successful
resuscitation. A new study shows that,
among pediatric patients receiving
CPR with an arterial line in place,
rates of survival with favorable neu-
rologic outcome were improved if the
diastolic blood pressure was at least
25 mm Hg in infants and at least
30 mm Hg in children.8
Detecting and Treating
Seizures After ROSC
2020 (Updated): When resources are
available, continuous electroencepha-
lography monitoring is recommended
for the detection of seizures following
cardiac arrest in patients with
persistent encephalopathy.
2020 (Updated): It is recommended to
treat clinical seizures following
cardiac arrest.
2020 (Updated): It is reasonable to treat
nonconvulsive status epilepticus
following cardiac arrest in consultation
with experts.
2015 (Old): An electroencephalography
for the diagnosis of seizure should be
promptly performed and interpreted
and then should be monitored frequent-
ly or continuously in comatose patients
after ROSC.
2015 (Old): The same anticonvulsant
regimens for the treatment of status
epilepticus caused by other etiologies
may be considered after cardiac arrest.
Why: For the first time, the Guidelines
provide pediatric-specific recommen-
dations for managing seizures after
cardiac arrest. Nonconvulsive sei-
zures, including nonconvulsive status
epilepticus, are common and cannot
be detected without electroenceph-
alography. Although outcome data
from the post–cardiac arrest popula-
tion are lacking, both convulsive and
nonconvulsive status epilepticus are
associated with poor outcome, and
Pediatric Basic and Advanced Life Support
treatment of status epilepticus is
beneficial in pediatric patients in
general.
Evaluation and Support for
Cardiac Arrest Survivors
2020 (New): It is recommended that
pediatric cardiac arrest survivors be
evaluated for rehabilitation services.
2020 (New): It is reasonable to refer
pediatric cardiac arrest survivors for
ongoing neurologic evaluation for at
least the first year after cardiac arrest.
Why: There is growing recognition that
recovery from cardiac arrest continues
long after the initial hospitalization.
Survivors may require ongoing integrat-
ed medical, rehabilitative, caregiver, and
community support in the months to
years after their cardiac arrest. A recent
AHA scientific statement highlights the
importance of supporting patients and
families during this time to achieve the
best possible long-term outcome.6
Septic Shock
Fluid Boluses
2020 (Updated): In patients with septic
shock, it is reasonable to administer
fluid in 10 mL/kg or 20 mL/kg aliquots
with frequent reassessment.
2015 (Old): Administration of an initial
fluid bolus of 20 mL/kg to infants and
children with shock is reasonable,
including those with conditions such
as severe sepsis, severe malaria, and
dengue.
Choice of Vasopressor
2020 (New): In infants and children with
fluid-refractory septic shock, it is rea-
sonable to use either epinephrine or
norepinephrine as an initial vasoactive
infusion.
2020 (New): In infants and children
with fluid-refractory septic shock, if
epinephrine or norepinephrine are un-
available, dopamine may be considered.
Corticosteroid Administration
2020 (New): For infants and children with
septic shock unresponsive to fluids and
requiring vasoactive support, it may be
reasonable to consider stress-dose
corticosteroids.
Why: Although fluids remain the main-
stay of initial therapy for infants and
children in shock, especially in hypovo-
lemic and septic shock, fluid overload
can lead to increased morbidity. In
recent trials of patients with septic
shock, those who received higher fluid
volumes or faster fluid resuscitation
were more likely to develop clinically
significant fluid overload and require
mechanical ventilation. The writing
group reaffirmed previous recommen-
dations to reassess patients after each
fluid bolus and to use either crystalloid
or colloid fluids for septic shock resus-
citation.
Previous versions of the Guidelines
did not provide recommendations
about choice of vasopressor or the
use of corticosteroids in septic shock.
Two RCTs suggest that epinephrine
is superior to dopamine as the initial
vasopressor in pediatric septic shock,
and norepinephrine is also appropriate.
Recent clinical trials suggest a benefit
from corticosteroid administration in
some pediatric patients with refractory
septic shock.
Hemorrhagic Shock
2020 (New): Among infants and children
with hypotensive hemorrhagic shock
following trauma, it is reasonable to
administer blood products, when avail-
able, instead of crystalloid for ongoing
volume resuscitation.
Why: Previous versions of the
Guidelines did not differentiate the
treatment of hemorrhagic shock from
other causes of hypovolemic shock. A
growing body of evidence (largely from
adults but with some pediatric data)
suggests a benefit to early, balanced
resuscitation using packed red blood
cells, fresh frozen plasma, and platelets.
Balanced resuscitation is supported by
recommendations from the several US
and international trauma societies.
eccguidelines.heart.org 21
Opioid Overdose
2020 (Updated): For patients in
respiratory arrest, rescue breathing
or bag-mask ventilation should be
maintained until spontaneous breathing
returns, and standard PBLS or PALS
measures should continue if return of
spontaneous breathing does not occur.
2020 (Updated): For a patient with
suspected opioid overdose who has a
definite pulse but no normal breathing
or only gasping (ie, a respiratory arrest),
in addition to providing standard PBLS
or PALS, it is reasonable for responders
to administer intramuscular or intrana-
sal naloxone.
2020 (Updated): For patients known or
suspected to be in cardiac arrest, in the
absence of a proven benefit from the
use of naloxone, standard resuscitative
measures should take priority over
naloxone administration, with a focus
on high-quality CPR (compressions plus
ventilation).
2015 (Old): Empiric administration of
intramuscular or intranasal naloxone
to all unresponsive opioid-associated
life-threatening emergency patients
may be reasonable as an adjunct to
standard first aid and non–healthcare
provider BLS protocols.
2015 (Old): ACLS providers should
support ventilation and administer
naloxone to patients with a perfusing
cardiac rhythm and opioid-associated
respiratory arrest or severe respiratory
depression. Bag-mask ventilation
should be maintained until spontaneous
breathing returns, and standard ACLS
measures should continue if return of
spontaneous breathing does not occur.
2015 (Old): We can make no
recommendation regarding the
administration of naloxone in confirmed
opioid-associated cardiac arrest.
Why: The opioid epidemic has not
spared children. In the United States
in 2018, opioid overdose caused 65
deaths in children younger than 15
years and 3618 deaths in people 15 to
24 years old,9 and many more children
required resuscitation. The 2020 Guide-
lines contain new recommendations
22 American Heart Association
for managing children with respiratory
arrest or cardiac arrest from opioid
overdose.
These recommendations are
identical for adults and children, except
that compression-ventilation CPR is
recommended for all pediatric victims
of suspected cardiac arrest. Naloxone
can be administered by trained
providers, laypersons with focused
training, and untrained laypersons.
Separate treatment algorithms
are provided for managing opioid-
associated resuscitation emergencies
by laypersons, who cannot reliably
check for a pulse (Figure 5), and by
trained rescuers (Figure 6). Opioid-
associated OHCA is the subject of a
2020 AHA scientific statement.10
Myocarditis
2020 (New): Given the high risk of cardiac
arrest in children with acute myocarditis
who demonstrate arrhythmias, heart
block, ST-segment changes, and/or low
cardiac output, early consideration of
transfer to ICU monitoring and therapy
is recommended.
2020 (New): For children with myocarditis
or cardiomyopathy and refractory low
cardiac output, prearrest use of ECLS
or mechanical circulatory support can
be beneficial to provide end-organ
support and prevent cardiac arrest.
2020 (New): Given the challenges to
successful resuscitation of children
with myocarditis and cardiomyopathy,
once cardiac arrest occurs, early
consideration of extracorporeal
CPR may be beneficial.
Why: Although myocarditis accounts
for about 2% of sudden cardiovascular
deaths in infants,11 5% of sudden car-
diovascular deaths in children,11 and 6%
to 20% of sudden cardiac death in ath-
letes, previous12,13 PALS guidelines did
not contain specific recommendations
for management. These recommenda-
tions are consistent with the 2018 AHA
scientific statement on CPR in infants
and children with cardiac disease.14
Single Ventricle: Recommendations
for the Treatment of Preoperative
and Postoperative Stage I Palliation
(Norwood/Blalock-Tausig Shunt) Patients
2020 (New): Direct (superior vena cava
catheter) and/or indirect (near infrared
spectroscopy) oxygen saturation
monitoring can be beneficial to trend
and direct management in the critically
ill neonate after stage I Norwood
palliation or shunt placement.
2020 (New): In the patient with an appro-
priately restrictive shunt, manipulation
of pulmonary vascular resistance
may have little effect, whereas low-
ering systemic vascular resistance
with the use of systemic vasodilators
(alpha-adrenergic antagonists and/or
phosphodiesterase type III inhibitors),
with or without the use of oxygen, can
be useful to increase systemic delivery
of oxygen (DO2.)
2020 (New): ECLS after stage I Norwood
palliation can be useful to treat low
systemic DO2.
2020 (New): In the situation of known
or suspected shunt obstruction, it
is reasonable to administer oxygen,
vasoactive agents to increase shunt
perfusion pressure, and heparin
(50-100 units/kg bolus) while preparing
for catheter-based or surgical
intervention.
2020 (Updated): For neonates prior to
stage I repair with pulmonary over-
circulation and symptomatic low
systemic cardiac output and DO2, it is
reasonable to target a Paco2 of 50 to
60 mm Hg. This can be achieved during
mechanical ventilation by reducing
minute ventilation or by administering
analgesia/sedation with or without neu-
romuscular blockade.
2010 (Old): Neonates in a prearrest
state due to elevated pulmonary-
to-systemic flow ratio prior to Stage I
repair might benefit from a Paco2 of
50 to 60 mm Hg, which can be achieved
during mechanical ventilation by reduc-
ing minute ventilation, increasing the
inspired fraction of CO2, or administer-
ing opioids with or without chemical
paralysis.

Single Ventricle: Recommendations for
the Treatment of Postoperative Stage II
(Bidirectional Glenn/Hemi-Fontan) and
Stage III (Fontan) Palliation Patients
2020 (New): For patients in a prearrest
state with superior cavopulmonary
anastomosis physiology and severe
hypoxemia due to inadequate pul-
monary blood flow (Qp), ventilatory
strategies that target a mild respiratory
acidosis and a minimum mean airway
pressure without atelectasis can be
useful to increase cerebral and system-
ic arterial oxygenation.
2020 (New): ECLS in patients with su-
perior cavopulmonary anastomosis or
Fontan circulation may be considered
to treat low DO2 from reversible causes
or as a bridge to a ventricular assist
device or surgical revision.
Why: Approximately 1 in 600 infants and
children are born with critical con-
genital heart disease. Staged surgery
for children born with single ventricle
physiology, such as hypoplastic left
heart syndrome, spans the first several
years of life.15 Resuscitation of these
infants and children is complex and
differs in important ways from standard
Neonatal Life Support
There are over 4 million births every
year in the United States and Canada.
Up to 1 of every 10 of these newborns
will need help to transition from the
fluid-filled environment of the womb
to the air-filled room. It is essential
that every newborn have a caregiver
dedicated to facilitating that transition
and for that caregiver to be trained and
equipped for the role. Also, a signifi-
cant proportion of newborns who need
facilitated transition are at risk for com-
plications that require additional trained
personnel. All perinatal settings should
be ready for this scenario.
PALS care. Previous PALS guidelines
did not contain recommendations for
this specialized patient population.
These recommendations are con-
sistent with the 2018 AHA scientific
statement on CPR in infants and
children with cardiac disease.14
Pulmonary Hypertension
2020 (Updated): Inhaled nitric oxide or
prostacyclin should be used as the
initial therapy to treat pulmonary hyper-
tensive crises or acute right-sided heart
failure secondary to increased pulmo-
nary vascular resistance.
2020 (New): Provide careful respiratory
management and monitoring to avoid
hypoxia and acidosis in the postoper-
ative care of the child with pulmonary
hypertension.
2020 (New): For pediatric patients
who are at high risk for pulmonary
hypertensive crises, provide adequate
analgesics, sedatives, and neuromus-
cular blocking agents.
2020 (New): For the initial treatment of
pulmonary hypertensive crises, oxygen
administration and induction of alka-
losis through hyperventilation or alkali
The process of facilitating
transition is described in the Neonatal
Resuscitation Algorithm that starts
with the needs of every newborn
and proceeds to steps that address
the needs of at-risk newborns. In
the 2020 Guidelines, we provide
recommendations on how to follow
the algorithm, including anticipation
and preparation, umbilical cord
management at delivery, initial actions,
heart rate monitoring, respiratory
support, chest compressions,
intravascular access and therapies,
withholding and discontinuing
resuscitation, postresuscitation care,
and human factors and performance.
Here, we highlight new and updated
recommendations that we believe will
have a significant impact on outcomes
from cardiac arrest.
Neonatal Life Support
administration can be useful while
pulmonary-specific vasodilators are
administered.
2020 (New): For children who develop
refractory pulmonary hypertension,
including signs of low cardiac output
or profound respiratory failure despite
optimal medical therapy, ECLS may
be considered.
2010 (Old): Consider administering
inhaled nitric oxide or aerosolized
prostacyclin or analogue to reduce
pulmonary vascular resistance.
Why: Pulmonary hypertension, a rare
disease in infants and children, is
associated with significant morbidity
and mortality and requires specialized
management. Previous PALS guidelines
did not provide recommendations for
managing pulmonary hypertension in
infants and children. These recommen-
dations are consistent with guidelines
on pediatric pulmonary hypertension
published by the AHA and the
American Thoracic Society in 2015,16
and with recommendations contained
in a 2020 AHA scientific statement on
CPR in infants and children with
cardiac disease.14
Summary of Key Issues
and Major Changes
• Newborn resuscitation requires
anticipation and preparation by
providers who train individually and
as teams.
• Most newly born infants do not
require immediate cord clamping or
resuscitation and can be evaluated
and monitored during skin-to-skin
contact with their mothers after birth.
• Prevention of hypothermia is
an important focus for neonatal
resuscitation. The importance of
skin-to-skin care in healthy babies is
reinforced as a means of promoting
parental bonding, breastfeeding, and
normothermia.
eccguidelines.heart.org 23
• Inflation and ventilation of the lungs
are the priority in newly born infants
who need support after birth.
• A rise in heart rate is the most
important indicator of effective
ventilation and response to
resuscitative interventions.
• Pulse oximetry is used to guide
oxygen therapy and meet oxygen
saturation goals.
• Routine endotracheal suctioning for
both vigorous and nonvigorous infants
born with meconium-stained amniotic
fluid (MSAF) is not recommended.
Endotracheal suctioning is indicated
only if airway obstruction is suspected
after providing positive-pressure
ventilation (PPV).
• Chest compressions are provided if
there is a poor heart rate response
to ventilation after appropriate
ventilation-corrective steps, which
preferably include endotracheal
intubation.
• The heart rate response to
chest compressions and
medications should be monitored
electrocardiographically.
• When vascular access is required
in newly born infants, the umbilical
venous route is preferred. When IV
access is not feasible, the IO route
may be considered.
• If the response to chest
compressions is poor, it may be
reasonable to provide epinephrine,
preferably via the intravascular route.
• Newborns who fail to respond to
epinephrine and have a history or an
exam consistent with blood loss may
require volume expansion.
• If all these steps of resuscitation
are effectively completed and there
is no heart rate response by 20
minutes, redirection of care should be
discussed with the team and family.
24 American Heart Association
Major New and Updated
Recommendations
Anticipation of Resuscitation Need
2020 (New): Every birth should be at-
tended by at least 1 person who can
perform the initial steps of newborn
resuscitation and initiate PPV and
whose only responsibility is the care of
the newborn.
Why: To support a smooth and safe
newborn transition from being in the
womb to breathing air, every birth
should be attended by at least 1 person
whose primary responsibility is to the
newly born and who is trained and
equipped to begin PPV without delay.
Observational and quality-improvement
studies indicate that this approach
enables identification of at-risk
newborns, promotes use of checklists
to prepare equipment, and facilitates
team briefing. A systematic review of
neonatal resuscitation training in low-
resourced settings showed a reduction
in both stillbirth and 7-day mortality.
Temperature Management for
Newly Born Infants
2020 (New): Placing healthy newborn
infants who do not require resuscitation
skin-to-skin after birth can be effective
in improving breastfeeding, tempera-
ture control, and blood glucose stability.
Why: Evidence from a Cochrane
systematic review showed that
early skin-to-skin contact promotes
normothermia in healthy newborns. In
addition, 2 meta-analyses of RCTs and
observational studies of extended skin-
to-skin care after initial resuscitation
and/or stabilization showed reduced
mortality, improved breastfeeding,
shortened length of stay, and improved
weight gain in preterm and low-birth-
weight babies.
Clearing the Airway When
Meconium Is Present
2020 (Updated): For nonvigorous new-
borns (presenting with apnea or
ineffective breathing effort) delivered
through MSAF, routine laryngoscopy
with or without tracheal suctioning is
not recommended.
2020 (Updated): For nonvigorous new-
borns delivered through MSAF who
have evidence of airway obstruction
during PPV, intubation and tracheal
suction can be beneficial.
2015 (Old): When meconium is present,
routine intubation for tracheal suction
in this setting is not suggested because
there is insufficient evidence to
continue recommending this practice.
Why: In newly born infants with MSAF
who are not vigorous at birth, initial
steps and PPV may be provided. Endo-
tracheal suctioning is indicated only if
airway obstruction is suspected after
providing PPV. Evidence from RCTs
suggests that nonvigorous newborns
delivered through MSAF have the same
outcomes (survival, need for respiratory
support) whether they are suctioned
before or after the initiation of PPV.
Direct laryngoscopy and endotracheal
suctioning are not routinely required for
newborns delivered through MSAF, but
they can be beneficial in newborns who
have evidence of airway obstruction
while receiving PPV.
Vascular Access
2020 (New): For babies requiring vascular
access at the time of delivery, the um-
bilical vein is the recommended route.
If IV access is not feasible, it may be
reasonable to use the IO route.
Why: Newborns who have failed to respond
to PPV and chest compressions require
vascular access to infuse epinephrine and/
or volume expanders. Umbilical venous
catheterization is the preferred technique in
the delivery room. IO access is an alter-
native if umbilical venous access is not
feasible or care is being provided outside
of the delivery room. Several case reports
have described local complications associ-
ated with IO needle placement.

Termination of Resuscitation
2020 (Updated): In newly born babies
receiving resuscitation, if there is no
heart rate and all the steps of resusci-
tation have been performed, cessation
of resuscitation efforts should be
discussed with the healthcare team and
the family. A reasonable time frame for
this change in goals of care is around
20 minutes after birth.
2010 (Old): In a newly born baby with no
detectable heart rate, it is appropriate
to consider stopping resuscitation if the
heart rate remains undetectable for
10 minutes.
Why: Newborns who have failed to
respond to resuscitative efforts by
approximately 20 minutes of age have
a low likelihood of survival. For this
Resuscitation Education Science
Effective education is a key variable
in improving survival outcomes from
cardiac arrest. Without effective
education, lay rescuers and
healthcare providers would struggle
to consistently apply the science
supporting the evidence-based
treatment of cardiac arrest. Evidence-
based instructional design is critical to
improving provider performance and
patient-related outcomes from cardiac
arrest. Instructional design features are
the active ingredients, the key elements
of resuscitation training programs that
determine how and when content is
delivered to students.
In the 2020 Guidelines, we provide
recommendations about various
instructional design features in
resuscitation training and describe
how specific provider considerations
influence resuscitation education.
Here, we highlight new and updated
recommendations in education that we
believe will have a significant impact on
outcomes from cardiac arrest.
Summary of Key Issues
and Major Changes
• The use of deliberate practice
and mastery learning during life
Resuscitation Education Science
reason, a time frame for decisions
about discontinuing resuscitation
efforts is suggested, emphasizing
engagement of parents and the resus-
citation team before redirecting care.
Human and System Performance
2020 (Updated): For participants who
have been trained in neonatal resus-
citation, individual or team booster
training should occur more frequently
than every 2 years at a frequency that
supports retention of knowledge, skills,
and behaviors.
2015 (Old): Studies that explored how
frequently healthcare providers or
healthcare students should train
showed no differences in patient
outcomes but were able to show some
support training, and incorporating
repetition with feedback and minimum
passing standards, can improve skill
acquisition.
• Booster training (ie, brief retraining
sessions) should be added to massed
learning (ie, traditional course based)
to assist with retention of CPR skills.
Provided that individual students can
attend all sessions, separating training
into multiple sessions (ie, spaced
learning) is preferable to massed
learning.
• For laypersons, self-directed training,
either alone or in combination
with instructor-led training, is
recommended to improve willingness
and ability to perform CPR. Greater
use of self-directed training may
remove an obstacle to more
widespread training of laypersons in
CPR.
• Middle school– and high school–age
children should be trained to provide
high-quality CPR.
• In situ training (ie, resuscitation
education in actual clinical spaces)
can be used to enhance learning
outcomes and improve resuscitation
performance.
advantages in psychomotor perfor-
mance and knowledge and confidence
when focused training occurred every
6 months or more frequently. It is
therefore suggested that neonatal
resuscitation task training occur more
frequently than the current 2-year
interval.
Why: Educational studies suggest that
cardiopulmonary resuscitation knowl-
edge and skills decay within 3 to 12
months after training. Short, frequent
booster training has been shown to
improve performance in simulation
studies and reduce neonatal mortality
in low-resource settings. To anticipate
and prepare effectively, providers and
teams may improve their performance
with frequent practice.
• Virtual reality, which is the use of
a computer interface to create
an immersive environment, and
gamified learning, which is play and
competition with other students, can
be incorporated into resuscitation
training for laypersons and healthcare
providers.
• Laypersons should receive training in
how to respond to victims of opioid
overdose, including the administration
of naloxone.
• Bystander CPR training should target
specific socioeconomic, racial,
and ethnic populations who have
historically exhibited lower rates of
bystander CPR. CPR training should
address gender-related barriers to
improve rates of bystander CPR
performed on women.
• EMS systems should monitor how
much exposure their providers
receive in treating cardiac arrest
victims. Variability in exposure among
providers in a given EMS system
may be supported by implementing
targeted strategies of supplementary
training and/or staffing adjustments.
• All healthcare providers should complete
an adult ACLS course or its equivalent.
eccguidelines.heart.org 25
• Use of CPR training, mass training,
CPR awareness campaigns, and
hands-only CPR promotion should
continue on a widespread basis to
improve willingness to provide CPR
to cardiac arrest victims, increase the
prevalence of bystander CPR, and
improve outcomes from OHCA.
Major New and Updated
Recommendations
Deliberate Practice and
Mastery Learning
2020 (New): Incorporating a deliberate
practice and mastery learning model
into basic or advanced life support
courses may be considered for improv-
ing skill acquisition and performance.
Why: Deliberate practice is a training
approach where students are given a
discrete goal to achieve, immediate
feedback on their performance, and
ample time for repetition to improve
performance. Mastery learning is
defined as the use of deliberate
practice training and testing that
includes a set of criteria to define
a specific passing standard, which
implies mastery of the tasks being
learned.
Evidence suggests that incorporating
a deliberate practice and mastery
learning model into basic or advanced
life support courses improves multiple
learning outcomes.
Booster Training and
Spaced Learning
2020 (New): It is recommended to imple-
ment booster sessions when utilizing a
massed-learning approach for resusci-
tation training.
2020 (New): It is reasonable to use a
spaced-learning approach in place of a
massed-learning approach for resusci-
tation training.
Why: The addition of booster training
sessions, which are brief, frequent
sessions focused on repetition of prior
content, to resuscitation courses im-
proves the retention of CPR skills.
26 American Heart Association
The frequency of booster sessions
should be balanced against student
availability and the provision of
resources that support implementation
of booster training. Studies show that
spaced-learning courses, or training
that is separated into multiple sessions,
are of equal or greater effectiveness
when compared with courses delivered
as a single training event. Student
attendance across all sessions is
required to ensure course completion
because new content is presented at
each session.
Lay Rescuer Training
2020 (Updated): A combination of
self-instruction and instructor-led
teaching with hands-on training is
recommended as an alternative to
instructor-led courses for lay rescuers.
If instructor-led training is not available,
self-directed training is recommended
for lay rescuers.
2020 (New): It is recommended to train
middle school– and high school–age
children in how to perform high-quality
CPR.
2015 (Old): A combination of self-
instruction and instructor-led
teaching with hands-on training can
be considered as an alternative to
traditional instructor-led courses for lay
providers. If instructor-led training is not
available, self-directed training may be
considered for lay providers learning
AED skills.
Why: Studies have found that self-
instruction or video-based instruction
is as effective as instructor-led training
for lay rescuer CPR training. A shift
to more self-directed training may
lead to a higher proportion of trained
lay rescuers, thus increasing the
chances that a trained lay rescuer
will be available to provide CPR when
needed. Training school-age children
to perform CPR instills confidence and
a positive attitude toward providing
CPR. Targeting this population with CPR
training helps build the future cadre of
community-based, trained lay rescuers.
In Situ Education
2020 (New): It is reasonable to conduct
in situ simulation-based resuscitation
training in addition to traditional train-
ing.
2020 (New): It may be reasonable to
conduct in situ simulation-based resus-
citation training in place of traditional
training.
Why: In situ simulation refers to train-
ing activities that are conducted in
actual patient care areas, which has the
advantage of providing a more realistic
training environment. New evidence
shows that training in the in situ envi-
ronment, either alone or in combination
with traditional training, can have a
positive impact on learning outcomes
(eg, faster time to perform critical tasks
and team performance) and patient
outcomes (eg, improved survival, neu-
rological outcomes).
When conducting in situ simulation,
instructors should be wary of potential
risks, such as mixing training supplies
with real medical supplies.
Gamified Learning and Virtual Reality
2020 (New): The use of gamified learning
and virtual reality may be considered for
basic or advanced life support train-
ing for lay rescuers and/or healthcare
providers.
Why: Gamified learning incorporates
competition or play around the topic of
resuscitation, and virtual reality uses a
computer interface that allows the user
to interact within a virtual environment.
Some studies have demonstrated
positive benefits on learning outcomes
(eg, improved knowledge acquisition,
knowledge retention, and CPR skills)
with these modalities. Programs
looking to implement gamified learning
or virtual reality should consider
high start-up costs associated with
purchasing equipment and software.
 Resuscitation Education Science

Bystander CPR training should target

specific socioeconomic, racial,
and ethnic populations who have
historically exhibited lower rates of
bystander CPR. CPR training should
address gender-related barriers
to improve rates of bystander CPR
performed on women.

Opioid Overdose Training for
Lay Rescuers
2020 (New): It is reasonable for lay rescu-
ers to receive training in responding to
opioid overdose, including provision of
naloxone.
Why: Deaths from opioid overdose in the
United States have more than doubled
in the past decade. Multiple studies
have found that targeted resuscita-
tion training for opioid users and their
families and friends is associated with
higher rates of naloxone administration
in witnessed overdoses.
Disparities in Education
2020 (New): It is recommended to target
and tailor layperson CPR training to
specific racial and ethnic populations
and neighborhoods in the United
States.
2020 (New): It is reasonable to address
barriers to bystander CPR for female
victims through educational training
and public awareness efforts.
Why: Communities with low socio-
economic status and those with
predominantly Black and Hispanic
populations have lower rates of by-
stander CPR and CPR training. Women
are also less likely to receive bystander
CPR, which may be because bystand-
ers fear injuring female victims or being
accused of inappropriate touching.
Targeting specific racial, ethnic,
and low-socioeconomic populations
for CPR education and modifying
education to address gender
differences could eliminate disparities
in CPR training and bystander CPR,
potentially enhancing outcomes from
cardiac arrest in these populations.
EMS Practitioner Experience
and Exposure to Out-of-Hospital
Cardiac Arrest
2020 (New): It is reasonable for EMS
systems to monitor clinical personnel’s
exposure to resuscitation to ensure
treating teams have members com-
petent in managing cardiac arrest
cases. Competence of teams may be
supported through staffing or training
strategies.
Why: A recent systematic review found
that EMS provider exposure to cardiac
arrest cases is associated with im-
proved patient outcomes, including
rates of ROSC and survival. Because
exposure can be variable, we rec-
ommend that EMS systems monitor
provider exposure and develop strate-
gies to address low exposure.
ACLS Course Participation
2020 (New): It is reasonable for health-
care professionals to take an adult
ACLS course or equivalent training.
Why: For more than 3 decades, the
ACLS course has been recognized as
an essential component of resuscita-
tion training for acute care providers.
Studies show that resuscitation teams
with 1 or more team members trained in
ACLS have better patient outcomes.
Willingness to Perform Bystander CPR
2020 (New): It is reasonable to increase
bystander willingness to perform
CPR through CPR training, mass CPR
training, CPR awareness initiatives, and
promotion of Hands-Only CPR.
Why: Prompt delivery of bystander CPR
doubles a victim’s chances of survival
from cardiac arrest. CPR training, mass
CPR training, CPR awareness initiatives,
and promotion of Hands-Only CPR are
all associated with increased rates of
bystander CPR.

eccguidelines.heart.org 27
Systems of Care
Survival after cardiac arrest requires an
integrated system of people, training,
equipment, and organizations. Willing
bystanders, property owners who
maintain AEDs, emergency service
telecommunicators, and BLS and ALS
providers working within EMS systems
all contribute to successful resuscita-
tion from OHCA. Within hospitals, the
work of physicians, nurses, respirato-
ry therapists, pharmacists, and other
professionals supports resuscitation
outcomes.
Successful resuscitation also
depends on the contributions
of equipment manufacturers,
pharmaceutical companies,
resuscitation instructors, guidelines
developers, and many others. Long-
term survivorship requires support
from family and professional caregivers,
including experts in cognitive, physical,
and psychological rehabilitation and
recovery. A systems-wide commitment
to quality improvement at every
level of care is essential to achieving
successful outcomes.
Summary of Key Issues
and Major Changes
• Recovery continues long after the
initial hospitalization and is a critical
component of the resuscitation
Chains of Survival.
• Efforts to support the ability and
willingness of the members of the
general public to perform CPR and
use an AED improve resuscitation
outcomes in communities.
• Novel methods to use mobile phone
technology to alert trained lay
rescuers of events that require
CPR are promising and deserve
more study.
• Emergency system telecommunica-
tors can instruct bystanders to per-
form hands-only CPR for adults and
children. The No-No-Go framework is
effective.
28 American Heart Association
• Early warning scoring systems and
rapid response teams can prevent
cardiac arrest in both pediatric and
adult hospitals, but the literature
is too varied to understand what
components of these systems are
associated with benefit.
• Cognitive aids may improve
resuscitation performance by
untrained laypersons, but in simulation
settings, their use delays the start of
CPR. More development and study are
needed before these systems can be
fully endorsed.
• Surprisingly little is known about
the effect of cognitive aids on the
performance of EMS or hospital-
based resuscitation teams.
• Although specialized cardiac
arrest centers offer protocols and
technology not available at all
hospitals, the available literature
about their impact on resuscitation
outcomes is mixed.
• Team feedback matters. Structured
debriefing protocols improve the
performance of resuscitation teams in
subsequent resuscitation.
• System-wide feedback matters.
Implementing structured data
collection and review improves
resuscitation processes and survival
both inside and outside the hospital.
Major New and Updated
Recommendations
Using Mobile Devices to
Summon Rescuers
New (2020): The use of mobile phone
technology by emergency dispatch
systems to alert willing bystanders to
nearby events that may require CPR or
AED use is reasonable.
Why: Despite the recognized role of lay
first responders in improving OHCA
outcomes, most communities experi-
ence low rates of bystander CPR and
AED use. A recent ILCOR systematic
review found that notification of lay
rescuers via a smartphone app or
text message alert is associated with
shorter bystander response times,
higher bystander CPR rates, shorter
time to defibrillation, and higher rates of
survival to hospital discharge for people
who experience OHCA. The differences
in clinical outcomes were seen only
in the observational data. The use of
mobile phone technology has yet to be
studied in a North American setting, but
the suggestion of benefit in other coun-
tries makes this a high priority for future
research, including the impact of these
alerts on cardiac arrest outcomes in
diverse patient, community, and geo-
graphic contexts.
Data Registries to Improve
System Performance
New (2020): It is reasonable for organiza-
tions that treat cardiac arrest patients
to collect processes-of-care data and
outcomes.
Why: Many industries, including health-
care, collect and assess performance
data to measure quality and identify
opportunities for improvement. This
can be done at the local, regional, or
national level through participation in
data registries that collect informa-
tion on processes of care (eg, CPR
performance data, defibrillation times,
adherence to guidelines) and outcomes
of care (eg, ROSC, survival) associated
with cardiac arrest.
Three such initiatives are the AHA’s
Get With The Guidelines-Resuscitation
registry (for IHCA), the Cardiac Arrest
Registry to Enhance Survival registry (for
OHCA), and the Resuscitation
Outcomes Consortium Cardiac Epistry
(for OHCA), and many regional
databases exist. A 2020 ILCOR
systematic review found that most
studies assessing the impact of data
registries, with or without public
reporting, demonstrate improvement in
cardiac arrest survival in organizations
and communities that participated in
cardiac arrest registries.
References
1. Merchant RM, Topjian AA, Panchal AR, et al. Part 1: executive summary: 2020 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):In press.
2. International Liaison Committee on Resuscitation. 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):In press.
3. International Liaison Committee on Resuscitation. 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science with Treatment Recommendations. Resuscitation. 2020:In press.
4. Morley P, Atkins D, Finn JM, et al. 2: Evidence-evaluation process and management of potential conflicts of interest: 2020 International Consensus on
Cardiopulmonary Resuscitation Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):In press.
5. Magid DJ, Aziz K, Cheng A, et al. Part 2: evidence evaluation and guidelines development: 2020 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):In press.
6. Sawyer KN, Camp-Rogers TR, Kotini-Shah P, et al; for the American Heart Association Emergency Cardiovascular Care Committee; Council on
Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; Council on Quality of Care and Outcomes Research; and Stroke
Council. Sudden cardiac arrest survivorship: a scientific statement from the American Heart Association. Circulation. 2020;141:e654-e685. doi:
10.1161/CIR.0000000000000747
7. Jeejeebhoy FM, Zelop CM, Lipman S, et al; for the American Heart Association Emergency Cardiovascular Care Committee, Council on
Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, and Council on Clinical Cardiology.
Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. Circulation. 2015;132(18):1747-1773. doi: 10.1161/
CIR.0000000000000300
8. Berg RA, Sutton RM, Reeder RW, et al; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative
Pediatric Intensive Care Quality of Cardio-Pulmonary Resuscitation Investigators. Association between diastolic blood pressure during pediatric in-
hospital cardiopulmonary resuscitation and survival. Circulation. 2018;137(17):1784-1795. doi: 10.1161/CIRCULATIONAHA.117.032270
9. Wilson N, Kariisa M, Seth P, Smith H IV, Davis NL. Drug and opioid-involved overdose deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep.
2020;69(11):290-297. doi: 10.15585/mmwr.mm6911a4
10. Dezfulian, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for healthcare and public responses: a
scientific statement from the American Heart Association. Circulation. 2020:In press.
11. Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities:
task force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a
scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e273-e280. doi: 10.1161/
cir.0000000000000239
12. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States,
1980-2006. Circulation. 2009;119(8):1085-1092. doi: 10.1161/CIRCULATIONAHA.108.804617
13. Fung G, Luo H, Qiu Y, Yang D, McManus B. Myocarditis. Circ Res. 2016;118(3):496-514. doi: 10.1161/CIRCRESAHA.115.306573
14. Marino BS, Tabbutt S, MacLaren G, et al; for the American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular
Disease in the Young; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and
Anesthesia; and Emergency Cardiovascular Care Committee. Cardiopulmonary resuscitation in infants and children with cardiac disease: a scientific
statement from the American Heart Association. Circulation. 2018;137(22):e691-e782. doi: 10.1161/CIR.0000000000000524
15. Oster ME, Lee KA, Honein MA, Riehle-Colarusso T, Shin M, Correa A. Temporal trends in survival among infants with critical congenital heart defects.
Pediatrics. 2013;131(5):e1502-e1508. doi: 10.1542/peds.2012-3435
16. Abman SH, Hansmann G, Archer SL, et al; for the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and
Resuscitation; Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; Council on Cardiovascular Radiology and Intervention;
Council on Cardiovascular Surgery and Anesthesia; and the American Thoracic Society. Pediatric pulmonary hypertension: guidelines from the
American Heart Association and American Thoracic Society. Circulation. 2015;132(21):2037-2099. doi: 10.1161/CIR.0000000000000329

eccguidelines.heart.org 29
30 American Heart Association