BJA Education Advance Access published September 27, 2016
BJA Education, 2016, 1–6
Matrix reference
1B04, 1I02, 2CO4
Current recommendations on adult resuscitation
S Williams MBChB FRCA1 and R Bacon MBBS FRCA FFICM2, *
1
Consultant in Anaesthesia, Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK and 2Consultant
in Anaesthesia, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12
0HS, UK
*To whom correspondence should be addressed. Tel: +44 20 3313 3143; Fax: +44 20 3313 5373; E-mail: rosalind.bacon@imperial.nhs.uk
Key points
• Chest compressions must be of high quality with
minimal interruptions. If necessary for specific in-
terventions, interruptions should be <5 s duration.
• A stepwise approach to airway management is
recommended.
• Capnography should be used to confirm and con-
tinually monitor tracheal tube placement, quality
of cardiopulmonary resuscitation (CPR), and to pro-
vide an early indication of return of spontaneous
circulation.
• Recommendations for drug therapy have not chan-
ged but are now considered to be of secondary im-
portance to high-quality CPR.
• Urgent percutaneous coronary intervention should
follow out-of-hospital cardiac arrest with a sus-
pected cardiac cause.
Cardiorespiratory arrest remains the most challenging of medical
emergencies with ∼18% of in-hospital cardiac arrests surviving to
leave hospital in the UK.1 Despite data showing improvement in
survival rates after cardiac arrest internationally, only 7–8% of
out-of-hospital cardiac arrest (OHCA)2 survive to hospital dis-
charge in England compared with higher rates in other developed
countries. In Seattle, North America, survival rates of 62% have
been reported in patients who had witnessed OHCA with an ini-
tial rhythm of ventricular fibrillation (VF). Continual evaluation
and adjustments in resuscitation guidelines aim to improve sur-
vival rates. Adult resuscitation guidelines were last reviewed in
this journal in 2007. There have been two Resuscitation Council
(UK) [RC (UK)] guideline updates since then: in 2010, and most
© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
doi: 10.1093/bjaed/mkw051
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recently October 2015.3 This article will discuss and summarize
the main changes.
History
In 1767, a Society in Amsterdam was established for the
Recovery of Drowned Persons.4 This was the first resuscitation
organization dealing with education, guidelines, and collabor-
ation between physicians and lay people. Despite some rather
unusual techniques, many described are still used in modern-
day resuscitation, that is, warming the victim and artificial
respiration.
The first scientific paper on survival after closed chest com-
pressions was published in 19605 and was followed by a national
cardiopulmonary resuscitation (CPR) educational programme in
the USA complete with video ‘The Pulse of Life’. The CPR commit-
tee of the American Heart Association (AHA) was started in 1963,
the same year that the AHA formally endorsed CPR.
In 1981, a group of medical practitioners from different
specialities established the RC (UK) to promote scientific
guidelines, education, and training to healthcare professional
and laypersons. In 2012, the National Institute for Health and
Care Excellence (NICE) awarded the RC (UK) accreditation for
the 2010 guidelines. Three years on the RC (UK) has received
accreditation for the process used to assemble its guideline
documents.
The RC (UK) is a partner of the European Resuscitation Council
(ERC), which was established in 1990 and had its first major
conference in the UK in 1992 to which American and Australian
colleagues were invited. This led to the formation of the Inter-
national Liaison Committee on Resuscitation (ILCOR) to provide
a worldwide collaboration forum. The RC (UK) guidelines under-
go a major revision every 5 yr (synchronized with the Internation-
al Consensus on Cardiopulmonary Resuscitation Science
Conferences and new ERC Guidelines), the latest published on
15 October 2015.
Page 1 of 6
Current recommendations on adult resuscitation
Chain of survival
The chain of survival outlines four inter-related actions that
optimize survival from cardiac arrest if delivered correctly (Fig. 1).
Early bystander CPR can dramatically improve survival from
OHCA, but despite this, only 40% of victims receive bystander
CPR in the UK.6
The current guidelines emphasize education with recom-
mendations that everyone should learn CPR. Children should
be taught CPR and how to use an automated external defibrillator
(AED).
Defibrillators registered with local ambulance services ought
to be available anywhere there are large numbers of people,
when cardiac arrest is more likely or where access to emergency
services may be delayed.
Basic life support and automated external
defibrillation
Little has changed in the RC (UK) 2010 guidelines. Rescuers begin
CPR if the victim is unresponsive and breathing abnormally with
the emphasis on minimizing delay in resuscitation. Carotid pulse
check is inaccurate and wastes time and is not recommended.
The 2015 guidelines have advised bystanders and medical emer-
gency dispatchers to be suspicious of any patient presenting with
seizures, as after cardiac arrest, blood flow to the brain is marked-
ly reduced which can result in seizure-like activity.
Rescuers should ensure that help has been summoned and
an AED requested, preferably without leaving the victim, before
starting CPR. Chest compressions are commenced over the
centre of the victim’s chest at a depth of 5–6 cm and a rate
of 100–120 min−1, allowing for permissive recoil. Two rescue
breaths, each over 1 s, should be given after 30 compressions
and then the cycle repeated. The 2010 guidelines emphasized
the importance of good quality uninterrupted compressions to
maintain coronary perfusion pressure. CPR continues until
there are signs of consciousness in the presence of normal
breathing.
Compression only CPR remains an option when it is not pos-
sible to provide rescue breaths or when the rescuer is untrained
or unwilling to do so. It has been shown to be as effective as
standard CPR in pre-hospital studies7 and the 2012 hands-only
CPR campaign by the British Heart Foundation has highlighted
this to the general public.
The 2015 guidelines show a change in the Basic Life Support
(BLS) Algorithm with the inclusion of AED utilization as soon
Fig 1 The chain of survival. Reproduced with the kind permission of Laerdal Medical.
Page 2 of 6 BJA Education | 2016
as it becomes available. Without interrupting CPR, the AED is is
switched on, pads applied, and instructions followed.
Advanced life support
The advanced life support (ALS) algorithm should be used by
healthcare professionals trained in ALS techniques (Fig. 2). It is
a continuum of care from ongoing BLS, which will overlap with
ALS interventions. If cardiac arrest is suspected, the adult resus-
citation team should be called, with the exact location made
explicit. Meanwhile, CPR is commenced while self-adhesive
monitoring and defibrillation pads are applied to allow rapid as-
sessment of rhythm. The treatment algorithm has two branches,
the shockable and the non-shockable pathway, depending on
whether defibrillation is indicated. Interventions including high
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quality chest compressions with minimal interruptions, securing
the airway, vascular access, and seeking reversible causes are
common to both groups.
Shockable rhythms
Approximately 20%1 of in-hospital and out-of-hospital cardiac
arrests have VF or pulseless ventricular tachycardia ( pVT) as
the first monitored rhythm. Defibrillating as soon as possible
increases the likelihood of restoring a perfusing rhythm.
Chest compressions are stopped for a maximum of 5 s to
confirm VF/pVT on the ECG. Chest compressions should then
be immediately resumed while the defibrillator operator selects
the appropriate energy and charges the defibrillator. At this
time, the rest of the team (excluding the individual performing
chest compressions) are instructed to stand clear and the oxygen
delivery device removed if not a closed circuit. Only when the
defibrillator is charged should compressions cease, the person
delivering chest compressions warned to stand clear and the
shock delivered. Without reassessing rhythm or feeling for a
pulse, chest compressions should be resumed immediately. If
the patient is not intubated, chest compressions should be
paused once 30 have been delivered for no longer than 5 s to
allow two breaths to be given. Asynchronous compressions
and ventilations can be commenced when an advanced airway
adjunct is secured.
After 2 min, having prepared the team for a pause in CPR, the
team leader should check the rhythm. If the patient remains in
VF/ pVT, then a second shock is indicated and the process re-
peated. After a third shock, epinephrine 1 mg and amiodarone
300 mg i.v./i.o. should be administered. The 2 min sequence
 Current recommendations on adult resuscitation

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Fig 2 ALS algorithm. Reproduced with the kind permission of the Resuscitation Council (UK).

continues as long as a shockable rhythm persists with epineph- If during the rhythm check there is electrical activity compat-
rine given after alternative shocks, every 3–5 min. A further dose ible with a cardiac output then signs of return of spontaneous
of amiodarone 150 mg i.v. may be given after five defibrillation circulation (ROSC) should be sought. These include a central
attempts. pulse check, observing end-tidal CO2, and signs of life. If present,

BJA Education | 2016 Page 3 of 6

Current recommendations on adult resuscitation
post-resuscitation care should be started. If not the patient is in a
non-shockable rhythm and treatment moves to the alternative
limb of the algorithm.
Compressions must never be stopped during a cycle of CPR
unless there are obvious signs of life.
Defibrillation
Defibrillation aims to restore a rhythm compatible with cardiac
output and tissue perfusion with minimal insult to the myocar-
dium while ensuring the safety of patient and staff. Most defibril-
lators are equipped with adhesive pads rather than paddles
as they are effective, safer, and facilitate a more rapid shock deliv-
ery. The pads are positioned below the right clavicle (sternal) and
in the V6 ECG position in the mid-axillary line. Implantable med-
ical devices must be avoided. Oxygen should be delivered via a
closed circuit or the device removed at least 1 m away due to
the risk of sparks causing ignition.
A single-shock strategy and charging the defibrillator while
compressions continue minimizes pauses in compressions.
An exception to this approach is the delivery of three stacked
shocks before compressions in cardiac arrest during coronary
catheterization, or after recent cardiac surgery. This may also
be considered in a witnessed VF/pVT arrest with the patient con-
nected to a manual defibrillator, as it is unlikely that compres-
sions will improve the already high chance of ROSC.
The majority of defibrillators used in hospitals are biphasic.
This type has greater efficacy in terminating VF/pVT than the
monophasic defibrillators and, therefore, lower energy levels
may be used. The first shock delivered using a biphasic defibrilla-
tor should be at least 150 J. Evidence for appropriate energy levels
for subsequent shocks is lacking and local protocols exist in most
Trusts.
A precordial thump is rarely successful and is no longer
routinely recommended. It can be given in the first few seconds
of a witnessed VF/pVT arrest while waiting for a defibrillator
but it must not delay definitive treatment (with defibrillation).
Treatment of PEA and asystole (non-shockable
rhythms)
Asystole or pulseless electrical activity (PEA—absence of a pulse
with organized electrical activity which would be expected to
produce a cardiac output) are rhythms which do not require
defibrillation. CPR should be started and asystole confirmed by
checking the leads are actually attached. Epinephrine 1 mg i.v./
i.o. is recommended as soon as vascular access is secured. After
2 min, there should be a rhythm check. If there is no palpable
pulse, 2 min cycles of CPR should be continued, with epinephrine
given every 3–5 min. If a shockable rhythm develops, treatment
should switch to the alternative limb of the algorithm. If there
are P waves present, cardiac pacing may be attempted. Studies
have shown no benefit in giving atropine, which is no longer
recommended.
Monitoring during CPR
The importance of monitoring to assist with interventions is em-
phasized in the 2015 RC (UK) guidelines. In addition to clinical
signs, the following methods should be used during CPR:
• End-tidal CO2 with waveform capnography.
• CPR feedback or prompt devices.
• Blood sampling and analysis to help identify reversible causes.
Page 4 of 6 BJA Education | 2016
• Central venous blood analysis which may provide better ana-
lysis of tissue pH than blood gas values.
• Invasive cardiovascular monitoring in a critical care setting.
• Ultrasound to identify and treat reversible causes.
Reversible causes
During CPR, reversible causes for which there is specific treat-
ment should be identified and treated. They are divided into
two groups of four and are included in the ALS algorithm repre-
sented by the four H’s and four T’s:
• Hypoxia is minimized by adequate ventilation using maximal
inspired oxygen.
• Hypovolaemia is usually due to severe haemorrhage.
• Hyperkalemia and metabolic disturbances which may be
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suspected from the history or diagnosed by electrolyte or
ECG abnormalities should be aggressively treated.
• Hypothermia may be suggested by the history, for example,
drowning.
• Tension pneumothorax may be the primary cause of PEA and
requires rapid decompression.
• Tamponade (cardiac) should be suspected after penetrating
chest trauma. The use of ultrasound helps with the clinical
diagnosis.
• Toxins or drug ingestion may be apparent from the history or
the clinical picture. The mainstay of treatment is supportive
as few specific antidotes are available.
• Thromboembolic disease includes pulmonary embolus (PE)
and coronary thrombosis. PE may require thrombolysis
necessitating prolonged resuscitation. Coronary thrombosis
associated with acute coronary syndrome (ACS) is usually di-
agnosed after ROSC but if suspected and ROSC has not been
achieved, urgent coronary angiography should be considered.
This may require support from mechanical chest compres-
sion devices and extracorporeal CPR.
The use of focused echocardiography/ultrasound peri-arrest may
be useful.8 Although no trials have shown this imaging modality
has improved outcome, its use during CPR can help to identify
cardiac tamponade, PE, hypovolaemia, and pneumothorax.
Airway management
The majority of cardiac arrests in the adult population are not of
hypoxic origin with adequate arterial PaO2 immediately after the
arrest. The issue is lack of oxygen delivery to the organs, hence
the emphasis on the importance of maintaining coronary and
cerebral circulation.
Basic airway management remains the same: head tilt and
chin lift or jaw thrust with the addition of airway adjuncts as
required.
Tracheal intubation, once the gold standard of advanced air-
way management, is no longer accorded the same importance.
Although it offers superior airway control and protection against
aspiration, attempts may lead to unacceptable pauses in chest
compressions and result in malposition of the endotracheal
tube (ETT). Early studies suggest that the use of video laryngo-
scopes may improve intubation success rates,9 but further data
are required. Current recommendations are that tracheal intub-
ation should only be attempted by trained personnel and chest
compressions should be interrupted for no longer than 5 s. Alter-
natively, intubation can be delayed until ROSC.
Supraglottic airway devices are now preferred as they can be
inserted rapidly without interruption to chest compressions.

Ventilation with a laryngeal mask airway is easier than with a
bag-valve mask and does provide a degree of protection against
aspiration. A randomized controlled trial is underway comparing
the use of i-gel with tracheal intubation for initial airway man-
agement in OHCA. Currently, a stepwise approach to airway
management is proposed based on patient factors and compe-
tencies of the rescuer.
The guidelines emphasize the importance of waveform cap-
nography in resuscitation. Clinical signs alone are a notoriously
unreliable way to confirm tracheal placement. Waveform capno-
graphy allows conformation of correct ETT placement (although
it will not distinguish between bronchial and tracheal place-
ment). It permits monitoring of ventilation rate during resuscita-
tion, provides monitoring of the quality of chest compressions,
provides an early indicator of ROSC, and allows for a certain de-
gree of prognostication during CPR. Modern portable monitoring
equipment includes waveform capnography.
In the event of a failure to establish an airway and ventilate
an apnoeic patient, needle or surgical cricothyroidotomy can
be life-saving techniques. However, the fourth National Audit
Project (NAP4) showed that needle cricothyroidotomy was un-
successful in 60% of cases.
Drugs
ILCOR systemic reviews have not found sufficient evidence to
comment on survival to discharge and neurological outcomes
with any drug during CPR. Drugs are now considered to be of sec-
ondary importance to high-quality chest compression and CPR.
A recent trial of epinephrine administration in OHCA found
no improvement in survival to hospital discharge, but there
was significantly increased likelihood of achieving ROSC.10 The
PARAMEDIC 2 randomized controlled trial is now recruiting and
aims to determine if epinephrine improves long-term survival
in OHCA. The 2015 guidelines do not propose a change to current
practice until there are high-quality data available.
A bolus of amiodarone 300 mg is still recommended after the
third shock in VF/VT. It has been shown to increase the survival
to hospital admission but not to hospital discharge. A rando-
mized controlled trial comparing outcomes with amiodarone,
lidocaine, and placebo is underway.11
Peripheral venous access remains the preferred route for drug
administration followed by the intraosseous route if this is not
achieved.
Post-resuscitation care
Survival to hospital discharge in comatose patients with ROSC is
∼40–50% and the majority have a good neurological outcome
depending on the cause and quality of care. The pathological pro-
cess after ROSC is described as post-cardiac arrest syndrome and
comprises brain injury, myocardial dysfunction, systemic ischae-
mia/reperfusion response, and persistence of the precipitating
pathology. Little is known about the underlying mechanisms
and the best treatment strategies. Despite this, the knowledge
and skills possessed by anaesthetists and intensivists make
them the best-qualified specialists to manage these patients.
This is arguably the time when they can contribute most in the
resuscitation process with treatment involving airway, breath-
ing, circulation, and neurological optimization.
Oxygenation should be titrated to an arterial saturation of
94–98% and hyperoxia avoided as it has been associated with
worse outcomes. If the airway is compromised, tracheal intub-
ation, ventilation, and sedation may be necessary. Normocarbia
Current recommendations on adult resuscitation
should be the aim as both hypocarbia and hypercarbia have dele-
terious effects.
ACS is a major cause of OHCA. More than 80% of patients with
ROSC and ST segment elevation (STE) or left bundle branch block
will have an acute coronary lesion and it has been shown that
early percutaneous coronary intervention is beneficial.12 In
those patients without STE but potential ACS, there are conflict-
ing data and treatment should be individualized in consultation
with cardiology.
Myocardial function may require optimization guided by
basic monitoring, echocardiography, and plasma lactate clear-
ance. Intra-aortic balloon pumps (IABP) have not been shown to
improve 30 day mortality in patients with cardiogenic shock.
Cooling reduces cerebral metabolism and oxygen free radical
production, inhibits excitatory amino acid release, attenuates the
immune response during reperfusion, and inhibits apoptosis.
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Therapeutic hypothermia was recommended in the 2010 guide-
lines for all unconscious patients with ROSC. The original 2002
trials showed improved neurological outcomes with cooling to
32–34°C for 12–24 h after OHCA in VF.13,14 At the time, the RC
(UK) guidelines expanded this to include all comatose patients
on the basis of data from several non-randomized trials. NICE
guidelines published in 2011 concurred. In fact, the evidence of
improved outcome is less conclusive for non-shockable rhythms.
Subsequently, the Targeted temperature management (TTM)
trial has shown no benefit in cooling to 33°C compared with
36°C in patients with OHCA.15 Importantly in the TTM trial, after
the initial cooling period, both groups of patients had their tem-
perature maintained at normothermia (37.5°C) for 3 days after
ROSC. Many units prefer cooling to the higher temperature as it re-
duces the need for vasopressor support, shortens the rewarming
phase, and lessens the risk of rebound hyperthermia. The 2015
guidelines suggest that TTM should be guided by local policy.
Seizures occur in up to 40% of unconscious survivors and
must be controlled to prevent associated increase in cerebral
metabolic demand.
Hyperglycaemia is strongly associated with a poorer outcome.
However, due to the risks of hypoglycaemia, blood glucose should
be maintained at <10 mmol litre−1 rather than 4.5–6 mmol litre−1.
Post-resuscitation care is complicated, time-intensive, and
expensive. Reliable methods of predicting neurological outcome
after cardiac arrest are needed, so that appropriate management,
including limitation or withdrawal of care, can be followed. There
are currently no clinical tests, biochemical markers, or neuro-
physiological or imaging studies that can reliably allow a progno-
sis at <72 h. Prognostication needs to include multiple different
tests of brain function and should be delayed until any neuro-
logical recovery and clearance of sedatives has occurred. The
2015 guidelines include a prognostication strategy algorithm.
In the event of death, the guidelines emphasize that the pos-
sibility of organ donation should not be overlooked. For patients
who survive to hospital discharge, rehabilitation and follow-up
care is essential.
Summary
The new guidelines emphasize the importance of early interven-
tion by the bystander and emergency dispatcher with rapid
deployment of an AED during BLS. Education of the general pub-
lic is paramount for providing early CPR.
Provision of high-quality chest compressions with minimal
interruptions for interventions and a greater degree of monitor-
ing during CPR to help diagnose and treat reversible causes are
highlighted.
BJA Education | 2016 Page 5 of 6
Current recommendations on adult resuscitation
Patients suspected of having a cardiac cause after OHCA need
urgent referral for coronary catheterization.
Although guidelines are under constant review and develop-
ment, recent studies from the American Heart Association pub-
lished in the British Medical Journal in April 2016 show that
adherence to them is not consistent.
The National Cardiac Arrest Audit (NCAA) continues to moni-
tor in-hospital cardiac arrests while the National Out of Hospital
Cardiac Arrest project measures outcome variables from OHCA.
Both foster quality improvement initiatives with the hope of
improving outcomes.
Declaration of interest
None declared.
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