Last updated November 10, 2022

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Basic Life Support

Passive Ventilation Techniques

We suggest against the routine use of passive ventilation techniques during conventional CPR. (C, VL)
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Minimizing Pauses in Chest Compressions

We suggest that CPR fraction and perishock pauses in clinical practice be monitored as part of a comprehensive quality improvement program for cardiac arrest designed to ensure high-quality CPR delivery and resuscitation care across resuscitation systems. (C, VL)
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We suggest that preshock and postshock pauses in chest compressions be as short as possible. (C, VL)
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We suggest that the CPR fraction during cardiac arrest (CPR time devoted to compressions) should be as high as possible and be at least 60%. (C, VL)
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CPR During Transport

We suggest that providers deliver resuscitation at the scene rather than undertake ambulance transport with ongoing resuscitation unless there is an appropriate indication to justify transport (eg, extracorporeal mem-brane oxygenation). (C, VL)
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BLS Task Force Interpretation of Available Evidence for CPR Quality Outcomes

Category Interpretation
Correct hand positioning Transport appears to have little impact on cor- rect hand positioning.
Chest compression rate Appropriate chest compression rates can be achieved during transport; however, there is greater variation in chest compression rate dur- ing transport compared with at the scene.
Chest compression depth Appropriate chest compression depth can be achieved during transport; however, there is greater variation in chest compression depth during transport compared with at the scene.
Pauses Transport appears to have little impact on extending pauses.
Leaning on the chest/ incomplete release Transport appears to have little impact on complete release.
CPR fraction There is significant variation in chest compres- sion fraction. Transport appears to have a nega- tive impact on chest compression fraction.
Ventilation Transport appears to have little impact on ventilation rates.
Overall correct CPR There is significant variation in overall correct CPR. Transport appears to have a negative impact on overall correct CPR.
BLS indicates Basic Life Support; and CPR, cardiopulmonary resuscitation

C-A-B or A-B-C in Drowning

We recommend a compression-first strategy (C-A-B) forlaypeople providing resuscitation for adults and chil-dren in cardiac arrest caused by drowning. (U, U)
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We recommend that health care professionals and those with a duty to respond to drowning (eg, lifeguards) consider providing rescue breaths/ventilation first (A-B-C) before chest compressions if they have been trained to do so. (U, U)
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BLS Unchanged Recommendations

Basic Life Support Unchanged Recommendations in 2022

Topic/PICO Existing treatment recommendation
ALS-E-030A Paddle size and placement for defibrillation It is reasonable to place pads on the exposed chest in an anterior-lateral position. An accept- able alternative position is anterior posterior. In large-breasted individuals, it is reasonable to place the left electrode pad lateral to or below the left breast, avoiding breast tissue. Consid- eration should be given to the rapid removal of excessive chest hair before the application of pads, but emphasis must be on minimizing delay in shock delivery.
There is insufficient evidence to recommend a specific electrode size for optimal external
defibrillation in adults. However, it is reasonable to use a pad size >8 cm.
BLS 342 Barrier devices Providers should take appropriate safety pre- cautions when feasible and when resources are available to do so, especially if the subject is known to have a serious infection (for ex- ample, HIV, tuberculosis, HBV, or SARS).
BLS 343 Chest compres- sion rate We recommend a manual chest compression rate of 100–120/min (strong recommendation, very low–certainty evidence).
BLS 345 Rhythm check timing We suggest immediate resumption of chest compressions after shock delivery for adults in cardiac arrest in any setting (weak recommen- dation, very low–certainty evidence).
BLS 346 Timing of CPR cycles (2 min vs other) We suggest pausing chest compressions every 2 min to assess the cardiac rhythm (weak rec- ommendation, low-certainty evidence).
BLS 347 Public-access AED programs We recommend the implementation of PAD programs for patients with OHCA (strong rec- ommendation, low-certainty evidence).
BLS 348 Check for circulation during BLS Outside of the ALS environment, when invasive monitoring is available, there are insufficient data on the value of a pulse check while per- forming CPR. We therefore do not make a treatment recommendation for the value of a pulse check.
BLS 349 Rescuer fatigue in CCO-CPR We recommend no modification to current CCO-CPR guidelines for cardiac arrest to miti- gate rescuer fatigue (strong recommendation, very low–certainty evidence).
BLS 353 Harm from CPR to victims not in arrest We recommend that laypeople initiate CPR for presumed cardiac arrest without concerns of harm to patients not in cardiac arrest (strong recommendation, very low–certainty evidence).
BLS 354 Harm to rescu- ers from CPR Evidence supporting rescuer safety during CPR is limited. The few isolated reports of adverse effects resulting from the widespread and frequent use of CPR suggest that perform- ing CPR is relatively safe. Delivery of a defibril- lator shock with an AED during BLS is also safe. The incidence and morbidity of defibrilla- tor-related injuries in the rescuers are low.
BLS 357 Hand position during compres- sions We suggest performing chest compressions on the lower half of the sternum on adults in cardiac arrest (weak recommendation, very low–certainty evidence).
BLS 359 Dispatch- assisted CCO-CPR vs conventional CPR We recommend that dispatchers provide CCO-CPR instructions to callers for adults with suspected OHCA (strong recommenda- tion, low-certainty evidence).
BLS 360 EMS CCO-CPR vs conven- tional CPR We recommend that EMS providers perform CPR with 30 compressions to 2 breaths (30:2 ratio) or continuous chest compressions with PPV delivered without pausing chest compres- sions until a tracheal tube or supraglottic de- vice has been placed (strong recommendation, high-certainty evidence).
We suggest that when EMS systems have adopted minimally interrupted cardiac resusci- tation, this strategy is a reasonable alternative to conventional CPR for witnessed shockable OHCA (weak recommendation, very low– certainty evidence).
BLS 362 CV ratio We suggest a CV ratio of 30:2 compared with any other CV ratio in patients with cardiac ar- rest (weak recommendation, very low–quality evidence).
BLS 363
CPR before defibrillation
We suggest a short period of CPR until the defibrillator is ready for analysis or defibrillation in unmonitored cardiac arrest (weak recom- mendation, low-certainty evidence).
BLS 366 Chest compres- sion depth We recommend a chest compression depth of »5 cm (2 in; strong recommendation, low- certainty evidence) while avoiding excessive chest compression depths (>6 cm [>2.4 in] in an average adult) during manual CPR (weak recommendation, low-certainty evidence).
BLS 367 Chest wall recoil We suggest that rescuers performing manual CPR avoid leaning on the chest between com- pressions to allow full chest wall recoil (weak recommendation, very low–quality evidence).
BLS 368 Foreign-body airway obstruc- tion We suggest that backslaps be used initially in adults and children with a foreign-body airway obstruction and an ineffective cough (weak recommendation, very low–certainty evidence).
We suggest that abdominal thrusts be used in adults and children (>1 y of age) with a foreign-body airway obstruction and an inef- fective cough when backslaps are ineffective (weak recommendation, very low–certainty evidence).
We suggest that rescuers consider the man- ual extraction of visible items in the mouth (weak recommendation, very low–certainty evidence).
We suggest against the use of blind finger sweeps in patients with a foreign-body airway obstruction (weak recommendation, very low– certainty evidence).
We suggest that appropriately skilled health care providers use Magill forceps to remove a foreign-body airway obstruction in patients
with OHCA resulting from foreign-body airway obstruction (weak recommendation, very low– certainty evidence).
We suggest that chest thrusts be used in unconscious adults and children with a foreign- body airway obstruction (weak recommenda- tion, very low–certainty evidence).
We suggest that bystanders undertake in- terventions to support foreign-body airway obstruction removal as soon as possible after recognition (weak recommendation, very low– certainty evidence).
We suggest against the routine use of suction- based airway clearance devices (weak recom- mendation, very low–certainty evidence).
BLS 370 Firm surface for CPR We suggest performing chest compressions on a firm surface when possible (weak recom- mendation, very low–certainty evidence)
During IHCA, we suggest that when a bed has a CPR mode that increases mattress stiffness, it should be activated (weak recommendation, very low–certainty evidence).
During IHCA, we suggest against moving a pa- tient from the bed to the floor to improve chest compression depth (weak recommendation, very low–certainty evidence).
During IHCA, we suggest in favor of either a backboard or no-backboard strategy to improve chest compression depth (conditional recom- mendation, very low–certainty evidence).
BLS 372 In-hospital CCO-CPR vs conventional CPR Whenever tracheal intubation or an SGA is achieved during in-hospital CPR, we suggest that providers perform continuous compres- sions with PPV delivered without pausing chest compressions (weak recommendation, very low–certainty evidence).
BLS 373 Analysis of rhythm during chest compression We suggest against the routine use of artifact- filtering algorithms for analysis of electrocardio- graphic rhythm during CPR (weak recommen- dation, very low–certainty evidence).
We suggest that the usefulness of artifact- filtering algorithms for analysis of electrocar- diographic rhythm during CPR be assessed in clinical trials or research initiatives (weak recommendation, very low–certainty evi- dence).
BLS 374 Alternative compression techniques (cough, precor- dial thump, fist pacing) We recommend against the routine use of cough CPR for cardiac arrest (strong recom- mendation, very low–certainty evidence).
We suggest that cough CPR may be consid- ered only as a temporizing measure in excep- tional circumstance of a witnessed, monitored IHCA (for example, in a cardiac catheterization laboratory) if a nonperfusing rhythm is recog- nized promptly before loss of consciousness (weak recommendation, very low–certainty evidence).
We recommend against fist pacing for cardiac arrest (strong recommendation, very low– certainty evidence).
We suggest that fist pacing may be consid- ered only as a temporizing measure in the exceptional circumstance of a witnessed, monitored IHCA (for example, in a cardiac catheterization laboratory) attributable to bradyasystole if such a nonperfusing rhythm is recognized promptly before loss of con- sciousness (weak recommendation, very low–certainty evidence).
We recommend against the use of a precordial thump for cardiac arrest (strong recommenda- tion, very low–certainty evidence).
BLS 546 Tidal volumes and ventilation rates For mouth-to-mouth ventilation for adult victims using exhaled air or bag-mask ventilation with room air or oxygen, it is reasonable to give each breath within a 1-s inspiratory time and with a volume of »600 mL to achieve chest rise. It is reasonable to use the same initial tidal volume and rate in patients regardless of the cause of the cardiac arrest.
BLS 547 Lay rescuer CCO-CPR vs conventional CPR We continue to recommend that bystanders perform chest compressions for all patients in cardiac arrest (good practice statement).
We suggest that bystanders who are trained, able, and willing to give rescue breaths and chest compressions do so for all adult patients in cardiac arrest (weak recommendation, very low–certainty evidence).
BLS 661 Starting CPR (C-A-B vs A- B-C) We suggest starting CPR with compressions rather than ventilation in adults with cardiac ar- rest (weak recommendation, very low–certainty evidence).
BLS 740 Dispatcher recognition of cardiac arrest We recommend that dispatch centers imple- ment a standardized algorithm or standardized criteria to immediately determine whether a patient is in cardiac arrest at the time of emer- gency call (strong recommendation, very low– certainty evidence).
We suggest that dispatch centers monitor and track diagnostic capability.
We suggest that dispatch centers look for ways to optimize sensitivity (minimize false- negatives).
We recommend high-quality research that ex- amines gaps in this area.
BLS 811 Resuscitation care for sus- pected opioid- associated emergencies We suggest that CPR be started without delay in any unconscious person not breathing nor- mally and that naloxone be used by lay rescu- ers in suspected opioid-related respiratory or circulatory arrest (weak recommendation based on expert consensus).
BLS 1527 CPR before call for help We recommend that a lone bystander with a mobile phone should dial EMS, activate the speaker or other hands-free option on the mo- bile phone, and immediately begin CPR with dispatcher assistance if required (strong rec- ommendation, very low–certainty evidence).
BLS Video- Based Dispatch Systems We suggest that the usefulness of video-based dispatch systems be assessed in clinical trials or research initiatives (weak recommendation, very low–certainty evidence).
BLS Head-Up CPR We suggest against the routine use of head-up CPR during CPR (weak recommendation, very low–certainty evidence).
We suggest that the usefulness of head-up CPR during CPR be assessed in clinical trials or research initiatives (weak recommendation, very low–certainty evidence).

Advanced Life Support

Temperature Management After Cardiac Arrest

We suggest actively preventing fever by targeting a temperature ≤37.5° C for patients who remain comatose after ROSC from cardiac arrest. (C, L)
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Whether subpopulations of cardiac arrest patients may benefit from targeting hypothermia at 32° C to 34° C remains uncertain. Comatose patients with mild hypothermia after ROSC should not be actively warmed to achieve normothermia. (U, U)
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We recommend against the routine use of prehospital cooling with rapid infusion of large volumes of cold intravenous fluid immediately after ROSC. (S, M)
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We suggest surface or endovascular temperature control techniques when temperature control is used in comatose patients after ROSC. (C, L)
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When a cooling device is used, we suggest using a temperature control device that includes a feedback system based on continuous temperature monitoring to maintain the target temperature. (U, U)
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We suggest active prevention of fever for at least 72 hours in post–cardiac arrest patients who remain comatose. (U, U)
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POCUS as a Diagnostic Tool During Cardiac Arrest

We suggest against routine use of POCUS during CPR to diagnose reversible causes of cardiac arrest. (C, VL)
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We suggest that if POCUS can be performed by experienced personnel without interrupting CPR, it may be considered as an additional diagnostic tool when clinical suspicion for a specific reversible cause is present. (C, VL)
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Any deployment of diagnostic POCUS during CPR should be carefully considered and weighed against the risks of interrupting chest compressions and misinterpreting the sonographic findings. (U, U)
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Use of Vasopressin and Corticosteroids During Cardiac Arrest

We suggest against the use of the combination of vasopressin and corticosteroids in addition to usual care for adult IHCA because of low confidence in effect estimates for critical outcomes. (C, L)
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We suggest against the use of the combination of vasopressin and corticosteroids in addition to usual care for adult OHCA. (C, VL)
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Post–Cardiac Arrest Coronary Angiography

When CAG is considered for comatose postarrest patients without ST-segment elevation, we suggest that either an early or a delayed approach for angiography is reasonable. (C, L)
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We suggest early CAG in comatose post–cardiac arrest patients with ST-segment elevation. (U, U)
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ALS Unchanged Recommendations

Advanced Life Support Unchanged Recommendations in 2022

Topic/PICO Existing treatment recommendation
ALS 659 Vasopressors during cardiac arrest We recommend administration of epinephrine during CPR (strong recommendation, low- to moderate-certainty evidence).
For nonshockable rhythms (PEA/asystole), we recommend administration of epinephrine as soon as feasible during CPR (strong recommendation, very low–certainty evidence).
For shockable rhythms (VF/pVT), we suggest administration of epinephrine after initial defibrillation attempts are unsuccessful during CPR (weak recommendation, very low–certainty evidence).
We suggest against the administration of vasopressin in place of epinephrine during CPR (weak recommendation, very low– certainty evidence).
We suggest against the addition of vasopressin to epinephrine during CPR (weak recommendation, low-certainty evidence).
ALS 581 Cardiac arrest from PE We suggest administering fibrinolytic drugs for cardiac arrest when PE is the suspected cause of cardiac arrest (weak rec- ommendation, very low–certainty evidence).
We suggest the use of fibrinolytic drugs, surgical embolec- tomy, or percutaneous mechanical thrombectomy for cardiac arrest when PE is the known cause of cardiac arrest (weak recommendation, very low–certainty evidence).
The role of extracorporeal life support (ECPR) techniques was addressed in the 2019 ILCOR CoSTR.
We suggest that ECPR may be considered as a rescue therapy for selected patients with cardiac arrest when conven- tional CPR is failing in settings in which it can be implemented (weak recommendation, very low–certainty evidence).

Pediatric Life Support

Public-Access Devices

We suggest the use of an AED by lay rescuers for all children >1 year of age who have nontraumatic OHCA. (C, VL)
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We cannot make a recommendation for or against the use of an AED by lay rescuers for all children <1 year of age with nontraumatic OHCA. (U, U)
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PEWSs With or Without Rapid Response Teams

We suggest using PEWSs to monitor hospitalized children, with the aim of identifying those who may be deteriorating. (C, L)
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PLS Unchanged Recommendations

Pediatric Life Support Unchanged Recommendations in 2022

Topic/PICO Existing treatment recommendation
Peds 709 Sequence of chest compressions and ventilations: C-A-B vs A-B-C The confidence in effect estimates is so low that the panel decided a recommendation was too speculative.
Peds 414 CCO-CPR vs conventional CPR We recommend that rescuers provide rescue breaths and chest compressions for pediatric IHCA and OHCA. If rescuers cannot provide rescue breaths, they should at least perform chest compressions (strong recommendation, low-quality evidence).
PLS new Drugs for the treatment of bradycardia Epinephrine may be administered to infants and children with bradycardia and poor perfu- sion that is unresponsive to ventilation and oxygenation. It is reasonable to administer atropine for bradycardia caused by increased vagal tone or anticholinergic drug toxicity.
There is insufficient evidence to support or refute the routine use of atropine for pediatric cardiac arrest.
PLS new Emergency transcutaneous pacing for bradycardia In selected cases of bradycardia caused by complete heart block or abnormal function of the sinus node, emergency transthoracic
pacing may be lifesaving. Pacing is not helpful in children with bradycardia secondary to a postarrest hypoxic/ischemic myocardial insult or respiratory failure. Pacing was not shown to be effective in the treatment of asystole in children.
Peds 407 ECPR for pediatric cardiac arrest We suggest that ECPR may be considered as an intervention for selected infants and children (for example, cardiac populations) with IHCA refractory to conventional CPR in settings in which resuscitation systems allow ECPR to be well performed and implemented (weak recommendation, very low–certainty evidence).
There is insufficient evidence in pediatric OHCA to formulate a treatment recommenda- tion for the use of ECPR.
PLS, part of nodal ALS 2046 Intraosseous versus intravenous route of drug administration Intraosseous cannulation is an acceptable route of vascular access in infants and children with cardiac arrest. It should be considered early in the care of critically ill children whenever venous access is not read- ily available.
Sodium bicarbon- ate administration for children in cardiac arrest (PLS 388) Routine administration of sodium bicarbonate is not recommended in the management of pediatric cardiac arrest.
TTM* The PLS Task Force recommendations from 2020 for the pediatric population remain unchanged in 2021, with minor wording clari- fication of temperature targets:
We suggest that for infants and children who remain comatose after ROSC from OHCA or IHCA, active control of temperature be used to maintain a central temperature £37.5° C (weak recommendation, moderate-certainty evidence). There is inconclusive evidence
to support or refute the use of induced hypothermia (32° C–34° C) compared with active control of temperature at normothermia (36° C–37.5° C; or an alternative temperature) for children who achieve ROSC but remain comatose after OHCA or IHCA.
*The International Liaison Committee on Resuscitation PLS Task Force issued “Post-Arrest Temperature Management in Children: Statement on Post Cardiac Arrest Temperature Management in Children” in November 2021,139 following the CoSTR “Temperature Management in Adult Cardiac Arrest: Advanced Life Support Systematic Review” by the Advanced Life Support Task Force.

Neonatal Life Support

Maintaining Normal Temperature Immediately After Birth in Late Preterm and Term Infants

In late preterm and term newborn infants (≥34 weeks’ gestation), we suggest the use of room temperatures of 23º C compared with 20º C at birth in order to maintain normal temperature. (C, VL)
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In late preterm and term newborn infants (≥34 weeks’ gestation) at low risk of needing resuscitation, we suggest the use of skin-to-skin care with a parent immediately after birth rather than no skin-to-skin care to maintain normal temperature. (C, VL)
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In some situations in which skin-to-skin care is not possible, it is reasonable to consider the use of a plastic bag or wrap, among other measures, to maintain normal temperature. (C, VL)
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In late preterm and term newborn infants (≥34 weeks’ gestation), for routine use of a plastic bag or wrap in addition to skin-to-skin care immediately after birth compared with skin-to-skin care alone, the balance of desirable and undesirable effects was uncertain. Furthermore, the values, preferences, and cost implications of the routine use of a plastic bag or wrap in addition to skin-to-skin care are not known; therefore, no treatment recommendation can be formulated. (U, U)
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Suctioning Clear Amniotic Fluid at Birth

We suggest that suctioning of clear amniotic fluid from the nose and mouth should not be used as a routine step for newborn infants at birth. (C, VL)
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Airway positioning and suctioning should be considered if airway obstruction is suspected. (U, U)
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Tactile Stimulation for Resuscitation Immediately After Birth

We suggest that it is reasonable to apply tactile stimulation in addition to routine handling with measures to maintain temperature in newborn infants with absent, intermittent, or shallow respirations during resuscitation immediately after birth. (C, VL)
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Tactile stimulation should not delay the initiation of PPV for newborn infants who continue to have absent, intermittent, or shallow respirations after birth. (U, U)
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Delivery Room Heart Rate Monitoring to Improve Outcomes for Newborn Infants

When resources permit, we suggest that the use of ECG for heart rate assessment of a newborn infant requiring resuscitation in the delivery room is reasonable. (C, L)
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When ECG is not available, auscultation with pulse oximetry is a reasonable alternative for heart rate assessment, but the limitations of these modalities should be kept in mind. (C, L)
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There is insufficient evidence to make a treatment recommendation for the use of a digital stethoscope, audible or visible Doppler ultrasound, dry electrode technology, reflectance-mode green light photoplethysmography, or transcutaneous electromyography of the diaphragm for heart rate assessment of a newborn in the delivery room. (U, U)
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Auscultation with or without pulse oximetry should be used to confirm the heart rate when ECG is unavailable or not functioning or when pulseless electric activity is suspected. (U, U)
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CPAP Versus No CPAP for Term Respiratory Distress in the Delivery Room

For spontaneously breathing late preterm and term newborn infants in the delivery room with respiratory distress, there is insufficient evidence to suggest for or against routine use of CPAP compared with no CPAP. (U, U)
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SGAs for Neonatal Resuscitation

Where resources and training permit, we suggest that an SGA may be used in place of a face mask for newborn infants of ≥34 0/7 weeks’ gestation receiving intermittent PPV during resuscitation immediately after birth. (C, L)
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Respiratory Function Monitoring During Neonatal Resuscitation at Birth

There is insufficient evidence to make a recommendation for or against the use of an RFM in newborn infants receiving respiratory support at birth. (C, L)
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Education, Implementation, and Teams

Prearrest Prediction of Survival After IHCA

We recommend against using any currently available prearrest prediction rule as a sole reason not to resuscitate an adult with IHCA. (S, VL)
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We are unable to make a recommendation about using prearrest prediction rules to facilitate do not attempt CPR (DNACPR) discussions with adult patients, pediatric patients, or their substitute decision maker because there are no studies investigating the clinical implementation of such a score for this indication. (U, U)
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We are unable to provide any recommendation for pediatric patients because no studies on children were identified. (U, U)
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BLS Training for Likely Rescuers of High-Risk Populations

We recommend BLS training for likely rescuers of populations at high risk of OHCA. (S, L)
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We recommend that health care professionals encourage and direct likely rescuers of populations at high risk of cardiac arrest to attend BLS training. (U, U)
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Patient Outcome and Resuscitation Team Members Attending ALS Courses

We recommend the provision of accredited ALS training (ACLS, ALS) for health care providers who provide ALS care for adults. (S, VL)
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We recommend the provision of accredited courses in NRT (NRT, NRP) and HBB for health care providers who provide ALS care for newborns and babies. (S, VL)
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We have made a discordant recommendation because we have placed a very high value on an uncertain but potentially life-preserving benefit, and the intervention is not associated with prohibitive adverse effects (S, VL)
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Blended Learning for Life Support Education

We recommend a blended-learning as opposed to nonblended approach for life support training when resources and accessibility permit its implementation. (S, VL)
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Faculty Development Approaches for Life Support Courses

There was no treatment recommendation on faculty development programs for resuscitation course instructors previously. This ScopRev has not identified sufficient evidence to support a new SysRev, and no treatment recommendation was generated.From this ScopRev and expert opinion from the task force members, faculty development for resuscitation course instructors remains an important element contributing to improved teaching and the learners’ outcomes in accredited life support courses. However, no clear picture of the most appropriate and most effective faculty development programs could be identified from the studies reviewed. Different approaches need to consider the local training environment and resource availability, as well as instructors’ needs, to maximize learning outcomes of such programs. The best ways to maintain and assess instructor competency while concurrently maximizing cost-effectiveness need to be established. The task force encourages resuscitation councils to implement faculty development programs for their teaching staff of their accredited resuscitation courses. (U, U)
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Tables

Interventions to Improve Instructional Competence

Category Intervention Results
Instructor qualification/training
Internet-based Comparing internet-based AHA CIC with tradi- tional classroom-based AHA CIC There was no difference in pretest and posttest practical scores. Candidates in the online group had significantly higher adjusted posttest scores.
Train-the-trainer courses Instructor course with train-the-trainer model, sending the “trained trainers” to deliver further resuscitation training Train-the-trainer programs may be effective in improving resuscitation knowledge and skills and are important for developing local expertise.
System-wide instructor training program Retrospective analysis of 24 pediatric and neona- tal CPR instructor courses certified by the Span- ish Paediatric and Neonatal Resuscitation Group, held between 1999 and 2019 A specific pediatric and neonatal CPR instructor course is an adequate method for sustainable training of health pro- fessionals to teach pediatric resuscitation.
Modified instructor course with lectures, instruction practice, and self-developed resuscitation scenarios New instructor course compared with conven- tional training There was improved confidence in teaching neonatal CPR when participating in the new course.
Web-based questionnaire survey for instructors Web-based survey with a 29-item Competence Importance Performance scale Several important factors for the competence of instructors were identified.
Assessment tools
Assessment for chest compression with real-time compression feedback Real-time compression feedback There were improved chest compression performance skills with real-time feedback without comparable improvement in chest compression assessment skills in video review.
Assessment for chest compression with self-learning Recorded chest compressions by motion-capture camera There was improved ability of novice instructors to assess chest compressions after self-training, but it does not equal that of experienced instructors.
Delivery of BLS training using fully-body sensor-equipped manikins Use of sensor-equipped manikins for accredited instructors asked to deliver BLS training Instructors felt that the manikins were useful and felt confi- dent when delivering the course, and that may be beneficial to a trainer’s perception.
Teaching skills enhancement
Different feedback method383 Learning conversation structured methods of feedback delivery in BLS training, compared with the sandwich technique (that is, positive feed- back—negative feedback—positive feedback) Using learning conversation structured methods by instruc- tors was preferred over using the sandwich technique by instructors, and may give instructors more confidence.
Using standardized script by novice instruc- tors to facilitate team debriefing386 Use of scripted debriefing by novice instructors or simulator physical realism affects knowledge and performance in simulated cardiopulmonary arrests. Use of a standardized script to debrief by novice instructors improved students’ knowledge acquisition and team leader behavioral performance during subsequent simulated car- diopulmonary arrests.
Tape recording and a later critical viewing of a lecture390 Record the lecture provided by BLS/AED or ALS instructor candidates with a tape, a later video review, and oral self-assessment. The opinion of all participants was positive when they were asked about comparing their subjective impressions with the objective viewing.
Additional course for instructors
Educational program to teach ACLS instructors to evaluate team leader performance389 Educational program to review commonly ob- served errors and to identify critical errors Trained instructors identified more critical errors and gave more correct grade assignments.
ATP ATP as additional training, focusing on decision making in equivocal situations Trained instructors were less prone to incorrectly giving fail- ing scores to candidates.398 Instructors with additional train- ing were significantly more confident at assessing.397
Neonatal resuscitation workshop 2-d neonatal resuscitation workshop There were significant improvements in participants’ per- ceptions of their teaching ability.
Clinical teacher-training course/workshop (enhance teaching skills and methods) 2-d BLS and emergency medicine teacher- training program Students taught by untrained teachers performed better in some domains. Teaching quality was rated significantly bet- ter by students of untrained teachers.

Education, Implementation, and Teams Topics Reviewed by EvUps

Topic/PICO Existing treatment recommendation
EIT 626 Willingness to provide CPR To increase willingness to perform CPR, laypeople should receive training in CPR. This training should include the recognition of gasping or abnormal breathing as a sign of cardiac arrest when other signs of life are absent. Laypeople should be trained to start resuscitation with chest compres- sions in adult and pediatric victims. If unwilling or unable to perform ventilation, rescuers should be instructed to continue CCO-CPR. EMS dispatch- ers should provide CPR instructions to callers who report cardiac arrest. When providing CPR instruc- tions, EMS dispatchers should include recognition of gasping and abnormal breathing.
EIT 631 Team and leadership training We suggest that specific team and leadership training be included as part of ALS training for health care providers (weak recommendation, very low–certainty evidence).
EIT 638 Rapid response sys- tems in adults We suggest that hospitals consider the introduc- tion of a rapid response system (rapid response team/medical emergency team) to reduce the in- cidence of IHCA and in-hospital mortality (weak recommendation, low-quality evidence).
EIT 641 Community initiatives to promote BLS implementation We recommend implementation of resuscita- tion guidelines within organizations that provide care for patients in cardiac arrest in any setting (strong recommendation, very low–quality evi- dence).
EIT 645 and NLS 1562 Debriefing of resuscitation performance EIT 645:
We suggest data-driven, performance-focused debriefing of rescuers after IHCA for both adults and children (weak recommendation, very low– certainty evidence).
We suggest data-driven, performance-focused debriefing of rescuers after OHCA in both adults and children (weak recommendation, very low– certainty evidence).
NLS 1562:
There was no previous treatment recommenda- tion on the topic. This ScopRev did not identify sufficient evidence to prompt a SysRev.
EIT 1601 Spaced vs massed learning For learners undertaking resuscitation courses, we suggest that spaced learning (training or retraining distributed over time) may be used instead of massed learning (training provided at 1 single time point; weak recommendation, very low–certainty evidence).

First Aid

The Recovery Position for Maintenance of Adequate Ventilation and the Prevention of Cardiac Arrest

When providing first aid to a person with a decreased level of responsiveness of nontraumatic origin who does not require immediate resuscitative interventions, we suggest the use of the recovery position. (C, VL)
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When the recovery position is used, monitoring should continue for signs of airway occlusion, inadequate or agonal breathing, and unresponsiveness. (U, U)
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If body position, including the recovery position, is a factor impairing the first aid provider’s ability to determine the presence or absence of signs of life, the person should be immediately positioned supine and reassessed. (U, U)
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People found in positions associated with aspiration and positional asphyxia such as face down, prone, or in neck and torso flexion positions should be repositioned supine for reassessment. (U, U)
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Topics Reviewed by EvUps

Topic/PICO Existing treatment recommendation
FA 202 Oral dilution for caustic substance ingestion Administration of a diluent in FA may be considered if a caustic substance has been ingested, if advised to do so by a health care provider (weak recommendation, very low– certainty evidence
FA 503 Recognition of anaphylaxis FA providers should not be expected to recognize the signs and symptoms of anaphylaxis without repeated episodes of training and encounters with victims of anaphylaxis.
FA 511 Compression wraps for acute closed ankle joint injury We suggest either application of a compression bandage or no application of a compression bandage for adults with an acute closed ankle joint injury (weak recommendation, very low–certainty evidence).
Because of a lack of identified evidence, we are unable to recommend for or against use of a compression bandage for closed joint injuries besides the ankle.
FA 525 Open chest wound dressings We suggest against the application of an occlusive dressing or device by FA providers to individuals with an open chest wound (weak recommendation, very low–quality evidence).
FA 534 Bronchodilators for acute asthma exacerbation When an individual with asthma is experiencing difficulty breathing, we suggest that trained FA providers assist the individual with administration of a bronchodilator (weak rec- ommendation, very low–quality evidence).
FA 770 Optimal duration of cooling of burns with water We recommend the immediate active cooling of thermal burns using running water as a FA intervention for adults and children (strong recommendation, very low–certainty evidence).
Because no difference in outcomes could be demonstrated with the different cooling durations studied, a specific dura- tion of cooling cannot be recommended.
Young children with thermal burns that are being actively cooled with running water should be monitored for signs and symp- toms of excessive body cooling (good practice statement).
FA 798 Preventive interventions for presyncope We recommend the use of any type of physical counterpressure maneuver by individuals with acute symptoms of presyncope attributable to vasovagal or orthostatic causes in the FA setting (strong recommendation, low- and very low–certainty evidence).
We suggest that lower body physical counterpressure maneuvers are preferable to upper body and abdominal physical counterpressure maneuvers (weak recommendation, very low–certainty evidence).
FA 799 Single-stage scoring systems for concussion No recommendation. We acknowledge the role that a simple, validated, single-stage concussion scoring system could play in the FA provider’s recognition and referral of victims of suspected head injury. However, review of the available literature shows no evidence on the application of such scoring systems by the FA provider. 2022 good practice statement:
It is critically important that concussion is recognized and managed appropriately. In the absence of a validated, simple, single-stage concussion scoring system, the FA assessment for a person with a possible concussion should be based on the typical signs and symptoms of concussion.
FA 1545 Cooling techniques for exertional hyperthermia and heatstroke For adults with exertional hyperthermia or exertional heat- stroke, we recommend immediate active cooling using whole- body (neck down) water immersion techniques (1° C–26° C "[33.8° F–78.8° F]) until a core body temperature of <39° C (102.2° F) is reached (weak recommendation, very low– certainty evidence).
We recommend that when water immersion is not available, any other active cooling technique be initiated (weak recom- mendation, very low–certainty evidence).
We recommend immediate cooling using any active or pas- sive technique available that provides the most rapid rate of cooling (weak recommendation, very low–certainty evidence).
For adults with nonexertional heatstroke, we cannot make a recommendation for or against any specific cooling technique compared with an alternative cooling technique (no recom- mendation, very low–certainty evidence).
For children with exertional or nonexertional heatstroke, we cannot make a recommendation for or against any specific cooling technique compared with an alternative cooling tech- nique (no recommendation, very low–certainty evidence).
FA 1549 FA Use of supplemental oxygen for acute stroke For adults with suspected acute stroke, we suggest against the routine use of supplemental oxygen in the FA setting compared with no use of supplemental oxygen (weak recom- mendation, low- to moderate-certainty evidence).
FA 1585 Methods of glucose administration for hypoglycemia in the FA setting We recommend the use of oral glucose (swallowed) for individu- als with suspected hypoglycemia who are conscious and able to swallow (strong recommendation, very low–certainty evidence).
We suggest against buccal glucose administration compared with oral glucose administration for individuals with sus- pected hypoglycemia who are conscious and able to swallow (weak recommendation, very low–certainty evidence).
If oral glucose (for example, tablet) is not immediately avail- able, we suggest a combined oral+buccal glucose (for exam- ple, glucose gel) administration for individuals with suspected hypoglycemia who are conscious and able to swallow (weak recommendation, very low–certainty evidence).
We suggest the use of sublingual glucose administration for suspected hypoglycemia for children who may be uncoopera- tive with the oral (swallowed) glucose administration route (weak recommendation, very low–certainty evidence).
Pediatric tourniquet types for life-threatening extremity bleeding (new) We suggest the use of a manufactured windlass tourniquet for the management of life-threatening extremity bleeding in children (weak recommendation, very low–certainty evidence).
We are unable to recommend for or against the use of other tourniquet types in children because of a lack of evidence. For infants and children with extremities that are too small to allow the snug application of a tourniquet before activating the circumferential tightening mechanism, we recommend the use of direct manual pressure with or without the application of a hemostatic trauma dressing (good practice statement).

Recommendation Grading

Overview

Title

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science

Authoring Organization

Publication Month/Year

November 3, 2022

Document Type

Guideline

Country of Publication

US

Document Objectives

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Childcare center, Correctional facility, Emergency care, Hospital, Long term care, Medical transportation, School, Operating and recovery room

Intended Users

Athletics coaching, law enforcement, medical assistant, nurse, nurse practitioner, paramedic emt, physician, physician assistant

Scope

Assessment and screening, Treatment, Management

Keywords

sudden cardiac arrest, cardiac arrest, Cardiopulmonary Resuscitation, CPR, cardiopulmonary, Life support, Pediatric life support, Neonatal Life support, Basic life support

Source Citation

Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar RJ, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Ong YG, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2022 Nov 3. doi: 10.1161/CIR.0000000000001095. Epub ahead of print. PMID: 36325905.

Methodology

Number of Source Documents
413
Literature Search Start Date
June 1, 2021
Literature Search End Date
March 1, 2022