American Heart Association (AHA) Recommendations (2025; Part 4: Systems of Care) (Circulation, 2025) [MEDLINE]

Prevention of In-Hospital Cardiac Arrest (IHCA)

• Early Warning Score (EWS) Systems Can Be Beneficial to Detect Clinical Deterioration, Prompt an Assessment, and Facilitate Intervention or Transfer to a Higher Level of Care (Class of Recommendation: 2a; Level of Evidence: B-R)
• Rapid Response Teams (RRTs) or Medical Emergency Teams (METs) Can Be Effective in Decreasing the Incidence of Cardiac Arrest, Particularly in General Care Wards (Class of Recommendation: 2a; Level of Evidence: B-NR)
• Implementation of Safety Huddles to Improve Situational Awareness of High-Risk Hospitalized Patients and Mitigate Deterioration Can Be Effective in Decreasing Cardiac Arrest Rates (Class of Recommendation: 2a; Level of Evidence: B-NR)

Public Access Naloxone (see Naloxone)

• Public Policies Should Allow for Possession, Use, and Immunity from Civil and Criminal Liability for Good Faith Administration of Naloxone by Lay Rescuers (Class of Recommendation: 1; Level of Evidence: B-NR)
• Naloxone Distribution Programs Can Be Beneficial to Increase Naloxone Availability Among Lay Rescuers and Decrease Mortality from Opioid-Related Overdose (Class of Recommendation: 2a; Level of Evidence: B-NR)

Community Initiatives to Improve Lay Rescuer Response to Out-of-Hospital Cardiac Arrest (OHCA)

• Implementing a Bundle of Community Initiatives May Improve Lay Rescuer Response to Out-of-Hospital Cardiac Arrest (OHCA) (Class of Recommendation: 2a; Level of Evidence: B-NR)
• Increasing the Availability of Instructor-Led Training in Communities Can Be Effective to Improve Lay Rescuer Response to Out-of-Hospital Cardiac Arrest (OHCA) (Class of Recommendation: 2a; Level of Evidence: B-NR)
• Mobile Technologies to Summon Responders to Nearby Out-of-Hospital Cardiac Arrest (OHCA) Events May Increase Timely Lay Rescuer Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) Use (Class of Recommendation: 2a; Level of Evidence: B-NR)
• Mass Media Campaigns May Be Considered to Promote Learning of Cardiopulmonary Resuscitation (CPR) Skills in All Populations (Class of Recommendation: 2b; Level of Evidence: C-LD)
• Communities Should Implement Policies Which Require Cardiopulmonary Resuscitation (CPR) Certification in the General Public (Class of Recommendation: 2b; Level of Evidence: C-LD)

Telecommunicator Recognition of Cardiac Arrest

• If the Patient is Unresponsive with Abnormal, Agonal, or Absent Breathing, the Telecommunicator Should Assume that the Patient is in Cardiac Arrest (Class of Recommendation: 1; Level of Evidence: C-LD)
• Telecommunicators Should Determine the Location of the Event Before Questioning to Identify Out-of-Hospital Cardiac Arrest (OHCA), to Allow for Simultaneous Dispatching of Emergency Medical Services (EMS) Response (Class of Recommendation: 1; Level of Evidence: C-LD)

T-CPR Instructions for Persons with Suspected Cardiac Arrest

• T-CPR Instructions for Adult Out-of-Hospital Cardiac Arrest (OHCA) Should Advise Compression-Only Cardiopulmonary Resuscitation (CPR) Consistent with Adult Basic Life Support (BLS) Guideline (Class of Recommendation: 1; Level of Evidence: A)
• Telecommunicators Should Instruct Callers to Initiate Cardiopulmonary Resuscitation (CPR) for Individuals with Suspected Out-of-Hospital Cardiac Arrest (OHCA) (Class of Recommendation: 1; Level of Evidence: C-LD)
• T-CPR Instructions for Infants/Children Experiencing Out-of-Hospital Cardiac Arrest (OHCA) Should Advise Conventional Cardiopulmonary Resuscitation (CPR) with Breaths Consistent with Pediatric Basic Life Support (BLS) Guidelines (Class of Recommendation: 1; Level of Evidence: C-LD)

T-CPR Quality Management

• Telecommunicator Recognition of Cardiac Arrest and T-CPR Instructions Should Be Reviewed and Evaluated as Part of an Emergency Medical Services (EMS) System Quality Management Process (Class of Recommendation: 1; Level of Evidence: B-NR)

Video Dispatch Systems

• Video-Based Dispatch Systems for Out-of-Hospital Cardiac Arrest (OHCA) Response Can Be Used in Systems with Such Capabilities (Class of Recommendation: 2b; Level of Evidence: B-NR)

Clinical Debriefing

• Performance-Focused Debriefing of Rescuers After Cardiac Arrest Can Be Effective for Resuscitation Improvement Programs (Class of Recommendation: 2a; Level of Evidence: B-NR)
• Review of Objective and Quantitative Resuscitation Data Can Be Effective in Improving the Quality of Post-Event Debriefing for Adults and Children (Class of Recommendation: 2a; Level of Evidence: B-NR)
• It is Reasonable for Debriefings to Be Facilitated by Healthcare Professionals Familiar with Established Debriefing Processes (Class of Recommendation: 2a; Level of Evidence: C-LD)
• Incorporating Immediate and Delayed Debriefing is Reasonable and May Identify Different Opportunities for System Improvement (Class of Recommendation: 2a; Level of Evidence: C-LD)

Out-of-Hospital Cardiac Arrest Team Composition

• Advanced Life Support–Level Clinician Should Be Present During the Resuscitation of a Person with Suspected Out-of-Hospital Cardiac Arrest (OHCA) (Class of Recommendation: 2a; Level of Evidence: B-NR)
• Emergency Medical Services (EM) Systems Should Have a Team Size Sufficient to Achieve Discretely Assigned Roles within the Team (Class of Recommendation: 2a; Level of Evidence: B-NR)

In-Hospital Code Team Composition and Training

• In-Hospital Code Teams Should Be Composed of Members with Advanced Life Support (ALS) Training (Class of Recommendation: 1; Level of Evidence: B-NR)
• Designated or Dedicated Code Teams with Clearly Defined Roles, Diverse Expertise, and Adequate Training Incorporating Simulation Can Be Beneficial in Improving Patient Outcomes Following In-Hospital Cardiac Arrest (IHCA) (Class of Recommendation: 2a; Level of Evidence: B-NR)

On-Scene Out-of-Hospital Cardiac Arrest Resuscitation

• Emergency Medical Systems (EMS) Systems Should Be Prepared to Perform Termination of Resuscitation (TOR) on Scene, Including Death Notification Training for Emergency Medical Systems (EMS) Professionals (Class of Recommendation: 1; Level of Evidence: B-NR)
• Prioritizing On-Scene Resuscitation Focused on Achieving Sustained Return of Spontaneous Circulation (ROSC) Prior to Initiation of Transport for Most Adults and Children Experiencing Out-of-Hospital (OHCA) Can Be Beneficial in the Absence of Special Circumstances (Class of Recommendation: 2a; Level of Evidence: B-NR)

Public Access Defibrillation

• Public Access Defibrillation (PAD) Programs Should Be Implemented in Communities at High Risk of Out-of-Hospital Cardiac Arrest (OHCA) (Class of Recommendation: 1; Level of Evidence: B-NR)

Recommendations for Cardiac Arrest Centers

• Transport of Resuscitated Patients to Specialized Cardiac Arrest Centers When Comprehensive Postarrest Care is Not Available at Local Facilities May Be Reasonable (Class of Recommendation: 2b; Level of Evidence: B-R)

Extracorporeal Cardiopulmonary Resuscitation (CPR) Systems of Care

• Centers with Extracorporeal Cardiopulmonary Resuscitation (eCPR) Programs Should Develop and Frequently Reassess Patient Selection Criteria to Maximize Cardiac Arrest Survival, Ensure Equitable Access, and Limit Futility (Class of Recommendation: 2a; Level of Evidence: C-LD)
• Clinicians Performing Adult Peripheral Extracorporeal Cardiopulmonary Resuscitation (eCPR) Cannulation Should Be Experienced in Percutaneous Technique (Class of Recommendation: 2a; Level of Evidence: C-LD)
• A Regionalized Approach to Extracorporeal Cardiopulmonary Resuscitation (eCPR) Should Optimize Outcomes and Resource Utilization (Class of Recommendation: 2a; Level of Evidence: C-LD)
• Rapid Intra-Arrest Transport for the Purposes of Extracorporeal Cardiopulmonary Resuscitation (eCPR) May Be Considered for Limited, Highly Selected Adult Out-of-Hospital Cardiac Arrest (OHCA) Patients (Class of Recommendation: 2b; Level of Evidence: B-R)

Organ Donation After Cardiac Arrest

• All Patients Who are Resuscitated from Cardiac Arrest But Who Subsequently Meet Neurologic Criteria for Death (i.e. Brain Death) or Have Planned Withdrawal of Life-Sustaining Therapies Should Be Evaluated for Organ Donation (Class of Recommendation: 1; Level of Evidence: B-NR)
• Institutions Should Develop Systems of Care Focused on Facilitating and Evaluating Organ Donation After Cardiac Arrest Consistent with Local Legal and Regulatory Requirements (Class of Recommendation: 1; Level of Evidence: C-EO)
• Patients Who DO Not Have Return of Spontaneous Circulation (ROSC) After Resuscitation Efforts and Who Would Otherwise Have Termination of Resuscitation Efforts May Be Considered Candidates for Donation in Settings Where Such Programs Exist (Class of Recommendation: 2b; Level of Evidence: B-NR)

Data Registries to Improve System Performance

• Organizations Which Treat Cardiac Arrest Patients Should Collect Processes-of-Care Data and Outcomes to Guide System Improvement (Class of Recommendation: 1; Level of Evidence: B-NR)

Improving Cardiac Arrest Recovery

• The Recovery and Long-Term Functional Outcomes of Cardiac Arrest Survivors are Likely to Benefit from the Use of Integrated Systems Which Assess Patients Prior to Discharge, Reassess Their Needs After Discharge, and Address These Needs on an Ongoing Basis During Recovery (Class of Recommendation: 2a; Level of Evidence: B-R)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• Untrained/Trained Lay Rescuer
  • If a Victim is Unconscious/Unresponsive, with Absent/Abnormal Breathing (i.e. Only Gasping), the Lay Rescuer Should Assume the Victim is in Cardiac Arrest (Class of Recommendation: 1; Level of Evidence: C-LD)
• Healthcare Professional
  • If a Victim is Unconscious/Unresponsive, with Absent/Abnormal Breathing (i.e. Only Gasping), the Healthcare Professional Should Check for a Pulse for ≤10 sec and, if No Definite Pulse is Felt, Should Assume the Victim is in Cardiac Arrest (Class of Recommendation: 1; Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• Untrained/Trained Lay Rescuer
  • All Lay Rescuers Should Provide Chest Compressions for Presumed Cardiac Arrest (Class of Recommendation: 1, Level of Evidence: B-NR)
  • After Identifying an Adult in Cardiac Arrest, a Lone Responder Should Activate the Emergency Response System First, Then Begin Cardiopulmonary Resuscitation (CPR) (Class of Recommendation: 1, Level of Evidence: B-NR)
  • For Adults in Cardiac Arrest, a Lone Rescuer with a Mobile Phone Should Activate the Emergency Response System and Immediately Begin Cardiopulmonary Resuscitation (CPR), Beginning with Chest Compressions (Class of Recommendation: 1, Level of Evidence: C-LD)
  • In Adult Out-of-Hospital Cardiac Arrest (OHCA), Lay Rescuers Trained in Cardiopulmonary Resuscitation (CPR) Should Provide Ventilation (Breaths) in Addition to Chest Compressions (Class of Recommendation: 2a, Level of Evidence: B-R)
  • In Adult Cardiac Arrest, when Immediately Available, Rescuers Should Use Personal Protective Equipment During Cardiopulmonary Resuscitation (CPR) (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Healthcare Professional
  • During Adult Cardiac Arrest, a Lone Healthcare Professional Should Start Chest Compressions Rather than Start with Ventilation (Class of Recommendation: 1, Level of Evidence: C-LD)
  • It is Reasonable for Healthcare Professionals to Perform Chest Compressions and Ventilation for All Adult Patients in Cardiac Arrest from Either a Cardiac or Non-Cardiac Etiology (Class of Recommendation: 2a, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]\

• Absence of Head/Neck Trauma
  • When No Cervical Spine Injury is Suspected, a Healthcare Professional/Lay Rescuer Should Use the Head Tilt–Chin Lift Maneuver to Open the Airway of a Patient in Cardiac Arrest (Class of Recommendation: 1, Level of Evidence: C-EO)
  • In the Presence of Known/Suspected Basal Skull Fracture or Severe Coagulopathy, an Oropharyngeal Airway is Preferred Over a Nasopharyngeal Airway (Class of Recommendation: 2a, Level of Evidence: C-LD)
  • The Use of an Airway Adjunct (Oropharyngeal/Nasopharyngeal Airway) May Be Used in the Unconscious (Unresponsive) Adult Patient with No Cough/Gag Reflex to Facilitate Delivery of Ventilation with a Bag-Valve-Mask (BVM) Device (Class of Recommendation: 2b, Level of Evidence: C-EO)
  • The Routine Use of Cricoid Pressure in Adult Cardiac Arrest is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)
• Presence of Head/Neck Trauma
  • In Adult with Head/Neck Trauma, Trained Rescuers Should Open the Airway by Using a Jaw Thrust without Head Extension (Class of Recommendation: 1, Level of Evidence: C-EO)
  • In Adult with Head/Neck Trauma, if the Airway Cannot Be Opened with a Jaw Thrust and Airway Adjunct Insertion, Trained Rescuers Should Open the Airway by Using a Head Tilt–Chin Lift Maneuver (Class of Recommendation: 1, Level of Evidence: C-EO)
  • In Adult with Head/Neck Trauma, Lay Rescuers Should Not Use Rigid Cervical Devices for Spinal Motion Restriction Because Their Use by Untrained Rescuers May Be Harmful (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• Positioning of Rescuer and Patient
  • In Adult Cardiac Arrest, Rescuers Should Perform Chest Compressions with the Patient’s Torso at Approximately the Level of the Rescuer’s Knees Whenever Possible (Class of Recommendation: 1, Level of Evidence: B-NR)
  • When Providing Chest Compressions for an Adult, the Rescuer Should Place the Heel of One Hand on the Center (Middle) of the Person’s Chest (the Lower Half to Lower Third of the Sternum) and the Heel of the Other Hand on Top of the First So that the Hands are Overlapped (Class of Recommendation: 1, Level of Evidence: C-LD)
  • In Adult Cardiac Arrest, Rescuers May Consider Placing Their Dominant Hand on the Sternum When Performing Chest Compressions (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • For Adult Cardiac Arrest in the Prone Position, it is Reasonable to Turn the Patient Supine Before Initiating Chest Compressions (Class of Recommendation: 2b, Level of Evidence: C-LD)
    • If the Patient Cannot Be Safely Turned Supine, Rescuers May Consider Performing Cardiopulmonary Resuscitation (CPR) in the Prone Position
• Location of Resuscitation
  • In Adult Cardiac Arrest, Resuscitation Should Be Conducted Where the Person is Found, as Long as High-Quality Cardiopulmonary Resuscitation (CPR) Can Be Administered Safely and Effectively (Class of Recommendation: 1, Level of Evidence: C-EO)
  • In Adult Cardiac Arrest, Cardiopulmonary Resuscitation (CPR) Should Be Performed on a Firm Surface and with the Person in the Supine Position, When Feasible and it Does Not Delay Chest Compressions (Class of Recommendation: 2a, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• Preshock and Postshock Pauses
  • In Adult Cardiac Arrest, Preshock and Postshock Pauses in Chest Compressions Should Be as Short as Possible (Class of Recommendation: 1, Level of Evidence: C-LD)
  • In Adult Cardiac Arrest, it is Reasonable to Immediately Resume Chest Compressions After Shock Administration Rather than Pause Cardiopulmonary Resuscitation (CPR) to Perform a Postshock Rhythm Check (Class of Recommendation: 2a Level of Evidence: B-R)
• Pulse Checks
  • During Rhythm Checks for Adult Cardiac Arrest, the Healthcare Professional Should Minimize the Time Taken to Check for a Pulse (≤ 10 sec), and if the Rescuer Does Not Definitely Feel a Pulse, Chest Compressions Should Be Resumed Immediately (Class of Recommendation: 1, Level of Evidence: C-LD)
  • In Adult Cardiac Arrest Outside of the Advanced Life Support Environment (Where Invasive Monitoring is Available), There are Insufficient Data About the Value of a Pulse Check While Performing Cardiopulmonary Resuscitation (CPR) (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Switching Chest Compressors
  • When ≥2 Rescuers are Available During Adult Cardiac Arrest it is Reasonable to Switch Chest Compressors Approximately q2 min (or After About 5 Cycles of Compressions and Ventilation at a Ratio of 30:2) to Prevent Decreases in the Quality of Chest Compressions (Class of Recommendation: 2a, Level of Evidence: B-R)
• Pauses in Compressions for Breaths
  • In Adults Cardiac Arrest without an Advanced Airway, Pause Chest Compressions to Deliver 2 Breaths, Each Given Over 1 sec (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Chest Compression Fraction
  • In Adult Cardiac Arrest, Perform Cardiopulmonary Resuscitation (CPR) with a Chest Compression Fraction (Portion of Time a Patient is Receiving Chest Compressions During Resuscitation) of ≥60% (Class of Recommendation: 2b, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• Depth of Compressions
  • During Manual Cardiopulmonary Resuscitation (CPR), Rescuers Should Perform Chest Compressions to a Depth of ≥2 inches (≥5 cm), for an Average Adult While Avoiding Excessive Chest Compression Depths (>2.4 inches, >6 cm) (Class of Recommendation: 1, Level of Evidence: B-NR
• Audiovisual Feedback
  • In Adult Cardiac Arrest, it is Reasonable to Use Audiovisual Feedback Devices for Real-Time Optimization of Cardiopulmonary Resuscitation (CPR) Performance (B-R)
• Rate of Compressions
  • In Adult Cardiac Arrest, it is Reasonable for Rescuers to Perform Chest Compressions at a Rate of 100-120/min (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Chest Wall Recoil
  • In Adult Cardiac Arrest, it Can Be Beneficial for Rescuers to Allow Complete Chest Wall Recoil (i.e. Not Leaning on Chest Between Compressions) (Class of Recommendation: 2a, Level of Evidence: C-LD)
  • In Adult Cardiac Arrest, it May Be Reasonable to Perform Chest Compressions So that Chest Compression and Recoil/Relaxation Times are Approximately Equal (Class of Recommendation: 2b, Level of Evidence: C-EO)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• Active Compression-Decompression Cardiopulmonary Resuscitation (CPR) and Impedance Threshold Devices
  • The Effectiveness of Active Compression-Decompression Cardiopulmonary Resuscitation (CPR) is Uncertain (Class of Recommendation: 2b, Level of Evidence: B-NR)
    • Active Compression-Decompression Cardiopulmonary Resuscitation (CPR) Might Be Considered for Use When Providers are Adequately Trained and Monitored (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • The Combination of Active Compression-Decompression Cardiopulmonary Resuscitation (CPR) and Impedance Threshold Device May Be Reasonable in Settings with Available Equipment and Properly Trained Personnel (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • The Routine Use of the Impedance Threshold Device as an Adjunct During Conventional Cardiopulmonary Resuscitation (CPR) is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: A)
• Alternative Cardiopulmonary Resuscitation (CPR) Techniques
  • Interposed Abdominal Compression Cardiopulmonary Resuscitation (CPR) May Be Considered During In-Hospital Resuscitation When Sufficient Personnel Trained in its Use are Available (Class of Recommendation: 2b, Level of Evidence: B-NR)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• Witnessed Shockable Out-of-Hospital Cardiac Arrest
  • It May Be Reasonable to Initially Use Minimally Interrupted Chest Compressions (i.e. Delayed Ventilation) for Witnessed Shockable Out-of-Hospital Cardiac Arrest as Part of a Bundle of Care (Class of Recommendation: 2b, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• Technique of Ventilation in Absence of Advanced Airway
  • In Adult Cardiac Arrest without an Advanced Airway (Supraglottic Airway or Endotracheal Tube), Deliver Breaths Either by Mouth-to-Mouth, Mouth-to-Mask, or Bag-Valve-Mask (BVM) Ventilation (Class of Recommendation: 2a, Level of Evidence: C-LD)
  • In Adult Cardiac Arrest, When Delivering Ventilations by Bag-Valve-Mask (BVM) Device, the First Rescuer Should Use 2 Hands to Open the Airway and Seal the Mask to the Face While a Second Rescuer Squeezes the Bag (Class of Recommendation: 2a, Level of Evidence: C-LD)
  • In Adult Cardiac Arrest without an Advanced Airway (Supraglottic Airway or Endotracheal Tube), Lay Rescuers/Healthcare Professionals Should Perform Cardiopulmonary Resuscitation (CPR) with Cycles of 30 Compressions Followed by 2 Breaths (Class of Recommendation: 2a, Level of Evidence: B-NR)
  • In Adult Cardiac Arrest without an Advanced Airway (Supraglottic Airway or Endotracheal Tube), Healthcare Professionals May Consider the Use of Continuous Chest Compressions with Asynchronous Breaths (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Technique of Ventilation in Presence of an Advanced Airway
  • If an Advanced Airway (Supraglottic Airway or Endotracheal Tube) is Present, Deliver 1 Breath q6 sec (10 breaths/min) While Continuous Chest Compressions are Being Performed (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Tidal Volume
  • When Ventilating an Adult Patient in Cardiac Arrest, Give Enough Tidal Volume to Produce Visible Chest Rise (Around 500-600 mL) (Class of Recommendation: 2a, Level of Evidence: C-LD)
  • In Adult Cardiac Arrest without an Advanced Airway, Give Each Breath Over 1 sec (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Respiratory Rate
  • When Providing Breaths to Adult Patients in Cardiac Arrest, Rescuers Should Avoid Hypoventilation (Too Few Breaths or Too Little Volume) or Hyperventilation (Too Many Breaths or Too Large a Volume) (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)
• Mouth-to-Nose Ventilation
  • In Adult Cardiac Arrest, a Rescuer Can Use Mouth-to-Nose Ventilation if Providing Breaths Through the Mouth is Impossible or Impractical (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Mouth-to-Stoma Ventilation
  • In Adult with a Tracheal Stoma Who Requires Breaths, Either Mouth-to-Stoma or Face Mask–to–Stoma Ventilation Can Be Used (Class of Recommendation: 2b, Level of Evidence: C-EO)
• Ventilation in the Presence of Respiratory Arrest with Spontaneous Circulation
  • For an Adult with Spontaneous Circulation (i.e. Strong and Easily Palpable Pulses) and Respiratory Arrest, the Healthcare Professional Should Provide Ventilations (Class of Recommendation: 1, Level of Evidence: C-LD)
  • When Providing Ventilations for an Adult Patient with Respiratory Arrest, the Healthcare Professional Should Give 1 Ventilation q6 sec (10 Breaths/min), with Each Ventilation Creating Visible Chest Rise (Around 500-600 mL) (Class of Recommendation: 2a, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• Training for Advanced Airways
  • In Adult Cardiac Arrest, Frequent Experience or Frequent Retraining is Recommended for Healthcare Professionals Who Perform Endotracheal Intubation (Class of Recommendation: 1, Level of Evidence: B-NR)
  • Emergency Medical Services (EMS) Systems Which Perform Prehospital Intubation in Adults with Cardiac Arrest Should Provide a Program of Ongoing Quality Improvement to Minimize Complications and Track Overall Supraglottic Airway and Endotracheal Tube Placement Success Rates (Class of Recommendation: 1, Level of Evidence: C-EO)
• Interruption of Chest Compressions to Place Advanced Airway
  • If Advanced Airway Placement Will Interrupt Chest Compressions in an Adult, Airway Insertion Should Be Deferred Until the in Cardiac Arrest Fails to Respond to Initial Cardiopulmonary Resuscitation (CPR) and Defibrillation Attempts or Obtains Return of Spontaneous Circulation (ROSC) (Class of Recommendation: 1, Level of Evidence: C-LD)
• End-Tidal Carbon Dioxide (ETCO2) to Confirm Advanced Airway Placement
  • In Adult Cardiac Arrest, Continuous Waveform Capnography is Recommended in Addition to Clinical Assessment as the Most Reliable Method of Confirming and Monitoring Correct Placement of an Endotracheal Tube (Class of Recommendation: 1, Level of Evidence: C-LD)
• Advanced Airway Placement in the Out-of-Hospital Setting
  • Out-of-Hospital Settings with Low Endotracheal Intubation Success Rates (or Minimal Training Opportunities for Endotracheal Intubation)
    • If an Advanced Airway is Used for Adult with Out-of-Hospital Cardiac Arrest (OHCA), a Supraglottic Airway Can Be Used in Settings with Low Endotracheal Intubation Success Rate or Minimal Training Opportunities (Class of Recommendation: 2a, Level of Evidence: B-R)
  • Out-of-Hospital Settings with High Endotracheal Intubation Success Rates (and/or Optimal Training Opportunities for Endotracheal Intubation)
    • If an Advanced Airway is Used, Either a Supraglottic Airway or Endotracheal Tube Can Be Used for Out-of-Hospital Cardiac Arrest (OHCA) in Settings with High Endotracheal Intubation Success Rates or Optimal Training Opportunities for Endotracheal Tube Placement (Class of Recommendation: 2a, Level of Evidence: B-R)
• Advanced Airway Placement in the In-Hospital Setting
  • If an Advanced Airway is Used for Adults in Cardiac Arrest in the In-Hospital Setting by Expert/Trained Healthcare Professionals, Either a Supraglottic Airway or Endotracheal Tube Can Be Used (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Bag-Valve-Mask (BVM) Ventilation vs Advanced Airway Placement
  • In Adult Cardiac Arrest, Either Bag-Valve-Mask (BVM) Ventilation or an Advanced Airway Strategy May Be Considered During Cardiopulmonary Resuscitation (CPR) in Any Setting Depending on the Situation and Skill Set of the Professional (Class of Recommendation: 2b, Level of Evidence: B-R)
• Ventilation Frequency
  • If an Advanced Airway is in Place, Deliver 1 Breath q6 sec (10 breaths/min) While Continuous Chest Compressions are Being Performed (Class of Recommendation: 2b, Level of Evidence: C-LD)

Anticipatory Defibrillator Charging

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• It May Be Reasonable to Charge a Manual Defibrillator During Chest Compressions Either Before or After a Scheduled Rhythm Analysis (Class of Recommendation: 2b, Level of Evidence: C-LD)

Cardiopulmonary Resuscitation (CPR) Before Defibrillation

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• In Adult Cardiac Arrest, Cardiopulmonary Resuscitation (CPR) is Recommended Until a Defibrillator or Automated External Defibrillator (AED) is Applied (Class of Recommendation: 1, Level of Evidence: C-LD)
• In Unmonitored Adult Cardiac Arrest, it is Reasonable to Provide a Brief period of Cardiopulmonary Resuscitation (CPR) While a Defibrillator is Being Obtained and Readied for Use (Class of Recommendation: 2a, Level of Evidence: B-R)
• In Adult Cardiac Arrest, Immediate Defibrillation is Reasonable for Witnessed or Monitored Ventricular Fibrillation (VF)/Pulseless Ventricular Tachycardia (VT) When a Defibrillator is Already Applied or Immediately Available (Class of Recommendation: 2a, Level of Evidence: C-LD)

Pads

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• In Adult Cardiac Arrest, it is Reasonable to Place Defibrillation Paddles or Pads on the Exposed Chest in an Anterolateral or Anteroposterior Position, and to Use a Paddle or Pad Electrode Diameter >8 cm (Class of Recommendation: 2a, Level of Evidence: C-LD)
• In Adult Cardiac Arrest, When Placing Pads for Defibrillation, it Might Be Reasonable to Adjust the Position of a Bra Instead of Removing it (Class of Recommendation: 2b, Level of Evidence: C-EO)

Post-Shock Rhythm Check

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• In Adult Cardiac Arrest, it is Reasonable to Immediately Resume Chest Compressions After Shock Administration Rather than Pause Cardiopulmonary Resuscitation (CPR) to Perform a Postshock Rhythm Check (Class of Recommendation: 2a Level of Evidence: B-R)

Defibrillator Waveform and Energy

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• In Adult Cardiac Arrest, Defibrillators (Using Biphasic or Monophasic Waveforms) are Recommended to Treat Tachyarrhythmias Requiring a Shock, Such as Ventricular Fibrillation/Pulseless Ventricular Tachycardia (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Adult Cardiac Arrest, Biphasic Waveform Defibrillation is Preferred Over Monophasic Waveform Defibrillation for Treatment of Tachyarrhythmias (Class of Recommendation: 2a, Level of Evidence: B-R)
• In Adult Cardiac Arrest, a Single Shock Strategy is Preferred to Stacked Shocks for Defibrillation (Class of Recommendation: 2a, Level of Evidence: B-NR)
• In Adult Cardiac Arrest, with Presumed Shock-Refractory Arrhythmias, it is Reasonable that Selection of Fixed vs Escalating Energy Levels for Subsequent Shocks Be Based on the Specific Manufacturer’s Instructions for that Waveform (Class of Recommendation: 2a, Level of Evidence: C-LD)
• In Adult Cardiac Arrest, if Using a Defibrillator Capable of Escalating Energies, Higher Energy for Second and Subsequent Shocks May Be Considered if the Initial Shock Fails to Restore a Perfusing Rhythm (Class of Recommendation: 2b, Level of Evidence: B-R)
• In Adult Cardiac Arrest, the Absence of Conclusive Evidence that One Biphasic Waveform is Superior to Another in Termination of Ventricular Fibrillation, it May Be Reasonable to Use the Manufacturer’s Recommended Energy Dose for the First Shock (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • If This is Not Known, Defibrillation at the Maximal Dose May Be Considered

Ancillary Waveform Technology

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• In Adult Cardiac Arrest, the Effectiveness of Artifact-Filtering Algorithms for Analysis of Electrocardiogram Rhythms During Chest Compressions Has Not Been Established (Class of Recommendation: 2b, Level of Evidence: C-LD)
• In Adult Cardiac Arrest, the Effectiveness of Ventricular Fibrillation Waveform Analysis to Guide Acute Management Has Not Been Established (Class of Recommendation: 2b, Level of Evidence: C-LD)

Vector Change and Double Sequential Defibrillation

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• In Adult Cardiac Arrest with with Persisting Ventricular Fibrillation/Pulesless Ventricular Tachycardia After ≥3 Consecutive Shocks, the Usefulness of Vector Change Has Not Been Established (Class of Recommendation: 2b, Level of Evidence: B-R)
• In Adult Cardiac Arrest with with Persisting Ventricular Fibrillation/Pulesless Ventricular Tachycardia After ≥3 Consecutive Shocks, the Usefulness of Double Sequential Defibrillation Has Not Been Established (Class of Recommendation: 2b, Level of Evidence: B-R)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• Conscious Patient
  • In Adults with Severe Foreign Body Airway Obstruction (FBAO), Repeated Cycles of 5 Back Blows (Slaps) Followed by 5 Abdominal Thrusts Should Be Performed Until the Object is Expelled or the Person Becomes Unresponsive (Class of Recommendation: 1, Level of Evidence: B-NR)
  • In Adult with Severe Foreign Body Airway Obstruction (FBAO), Rescuers Should Activate the Emergency Response System for (Class of Recommendation: 1, Level of Evidence: C-EO)
  • For Adults with Mild Foreign Body Airway Obstruction (FBAO), the Person Should Be Allowed to Clear the Airway by Coughing While Being Observed for Signs of Severe Airway Obstruction (Class of Recommendation: 1, Level of Evidence: C-EO)
• Unconscious Patient
  • If Adult with Severe Foreign Body Airway Obstruction (FBAO) Becomes Unresponsive, Rescuers Should Start Cardiopulmonary Resuscitation (CPR), Beginning with Chest Compressions, and Activate the Emergency Response System if No One Has Done So (Class of Recommendation: 1, Level of Evidence: C-LD)
  • For Adults with Foreign Body Airway Obstruction (FBAO) Receiving Cardiopulmonary Resuscitation (CPR), Rescuers Should Remove Any Visible Foreign Body When Opening the Airway to Provide Breaths (Class of Recommendation: 1, Level of Evidence: C-EO)
  • For Adult with Foreign Body Airway Obstruction (FBAO), Blind Finger Sweeps Should Not Be Performed (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)
• Special Circumstances
  • For Adult with Severe for Foreign Body Airway Obstruction (FBAO), if the Rescuer is Unable to Encircle the Patient’s Abdomen, Repeated Cycles of 5 Back Blows (Slaps) Followed by 5 Chest Thrusts Should Be Used Until the Object is Expelled or the Patient Becomes Unresponsive (Class of Recommendation: 1, Level of Evidence: C-EO)
  • For Adults in the Late Stages of Pregnancy with Severe Foreign Body Airway Obstruction (FBAO), Repeated Cycles of 5 Back Blows (Slaps) Followed by 5 Chest Thrusts Should Be Used Until the Object is Expelled or the Patient Becomes Unresponsive (Class of Recommendation: 1, Level of Evidence: C-EO)
  • In Adult with Foreign Body Airway Obstruction (FBAO), Effectiveness and Safety of Suction-Based Airway Clearance Devices Have Not Been Established (Class of Recommendation: 2b, Level of Evidence: C-LD)
    • Insufficient Evidence to Make a Recommendation

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• There is Insufficient Evidence to Recommend the Routine Use of Extracorporeal CPR (ECPR) for Patients with Cardiac Arrest (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • eCPR May Be Considered for Select Cardiac Arrest Patients for Whom the Suspected Etiology of the Cardiac Arrest is Potentially Reversible During a Limited Period of Extracorporeal Cardiopulmonary Resuscitation (eCPR) Mechanical Cardiorespiratory Support (Class of Recommendation: 2b, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• In Adult Cardiac Arrest, the Use of Mechanical Cardiopulmonary Resuscitation (CPR) Devices May Be Considered in Specific Settings Where the Delivery of High-Quality Manual Compressions May Be Challenging or Dangerous for the Healthcare Professional, as Long as Rescuers Strictly Limit Interruptions in Cardiopulmonary Resuscitation (CPR) During Deployment and Removal of the Device (Class of Recommendation: 2b, Level of Evidence: C-LD)
• In Adult Cardiac Arrest, the Routine Use of Mechanical Cardiopulmonary Resuscitation (CPR) Devices is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• In Adult Cardiac Arrest, For Single Rescuers, Performing Compressions from “Over-the-Head” of the Patient May Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD)
• In Adult Cardiac Arrest, the Effectiveness of Heel/Foot Compressions is Not Well Established (Class of Recommendation: 2b, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• Precordial Thump
  • Precordial Thump May Be Considered at the Onset of a Rescuer-Witnessed, Monitored, Unstable Ventricular Tachyarrhythmia When a Defibrillator is Not Immediately Ready for Use and is Performed without Delaying Cardiopulmonary Resuscitation (CPR) or Shock Delivery (Class of Recommendation: 2b, Level of Evidence: B-R)
  • Precordial Thump Should Not Be Used Routinely for Established Cardiac Arrest (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)
• Fist/Percussion Pacing
  • Fist (Percussion) Pacing May Be Considered as a Temporizing Measure in Exceptional Circumstances Such as Witnessed, Monitored in-Hospital Cardiac Arrest (Such as in the Cardiac Catheterization Laboratory) for Bradyasystole Before a Loss of Consciousness and if Performed without Delaying Definitive Therapy (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Cough Cardiopulmonary Resuscitation (CPR)
  • “Cough” Cardiopulmonary Resuscitation (CPR) May Be Considered as a Temporizing Measure for the Witnessed, Monitored Onset of a Hemodynamically Significant Tachyarrhythmia or Bradyarrhythmia Before a Loss of Consciousness without Delaying Definitive Therapy (Class of Recommendation: 2b, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• In Established Adult Cardiac Arrest, the Routine Use of Electrical Pacing is Not Recommended During Resuscitation (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• Endotracheal Drug Administration May Be Considered When Other Access Routes are Not Available (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • Endotracheal Drug Administration is Regarded as the Least-Preferred Route of Drug Administration Because it is Associated with Unpredictable (But Generally Low) Drug Concentrations and Lower Rates of Return of Spontaneous Circulation/ROSC and Survival

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• Intravenous Access
  • In Adult Cardiac Arrest, it is Recommended that Professionals First Attempt Establishing Intravenous Access for Drug Administration (Class of Recommendation: 1, Level of Evidence: A)
• Intraosseous Vascular Access (see Intraosseous Vascular Access)
  • In Adult Cardiac Arrest, Intraosseous Access is Reasonable if Initial Attempts at Intravenous Access are Unsuccessful or Not Feasible (Class of Recommendation: 2a, Level of Evidence: A)
• Central Venous Catheter (CVC) (see Central Venous Catheter)
  • For Adult Cardiac Arrest, for Appropriately Trained Professionals, Central Venous Catheter (CVC) Access May Be Considered if Attempts to Establish Intravenous and Intraosseous Access are Unsuccessful or Not Feasible (Class of Recommendation: 2b, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• Epinephrine (see Epinephrine)
  • In Adult Cardiac Arrest, Epinephrine Administration is Recommended (Class of Recommendation: 1, Level of Evidence: B-R)
  • In Adult Cardiac Arrest, Administer Epinephrine (1 mg) q3-5 min (Class of Recommendation: 2a, Level of Evidence: B-R)
  • In Adult Cardiac Arrest with a Non-Shockable Rhythm, with Respect to Timing, Administer Epinephrine as Soon as Feasible (Class of Recommendation: 2a, Level of Evidence: B-NR)
  • In Adult Cardiac Arrest with a Shockable Rhythm, with Respect to T, Administer Epinephrine After Initial Defibrillation Attempts Have Failed (Class of Recommendation: 2a, Level of Evidence: B-NR)
  • In Adult Cardiac Arrest, High-Dose Epinephrine is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)
• Vasporessin (see Vasporessin)
  • In Adult Cardiac Arrest, Vasopressin Alone or Vasopressin in Combination with Epinephrine Offers No Advantage as a Substitute for Epinephrine (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• Amiodarone (see Amiodarone)
  • In Adult Cardiac Arrest, Amiodarone or Lidocaine May Be Considered for Ventricular Fibrillation/Pulseless Ventricular Tachycardia Which is Unresponsive to Defibrillation (Class of Recommendation: 2b, Level of Evidence: B-R)
• Lidocaine (see Lidocaine)
  • In Adult Cardiac Arrest, Amiodarone or Lidocaine May Be Considered for Ventricular Fibrillation/Pulseless Ventricular Tachycardia Which is Unresponsive to Defibrillation (Class of Recommendation: 2b, Level of Evidence: B-R)
• β-Blockers (see β-Adrenergic Receptor Antagonists)
  • In Adult Cardiac Arrest, the Use of β-Blockers, Bretylium, Procainamide, or Sotalol for Ventricular Fibrillation/Pulseless Ventricular Tachycardia Unresponsive to Defibrillation is of Uncertain Benefit (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Sotalol (see Sotalol)
  • In Adult Cardiac Arrest, the Use of β-Blockers, Bretylium, Procainamide, or Sotalol for Ventricular Fibrillation/Pulseless Ventricular Tachycardia Unresponsive to Defibrillation is of Uncertain Benefit (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Bretylium (see Bretylium)
  • In Adult Cardiac Arrest, the Use of β-Blockers, Bretylium, Procainamide, or Sotalol for Ventricular Fibrillation/Pulseless Ventricular Tachycardia Unresponsive to Defibrillation is of Uncertain Benefit (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Procainamide (see Procainamide)
  • In Adult Cardiac Arrest, the Use of β-Blockers, Bretylium, Procainamide, or Sotalol for Ventricular Fibrillation/Pulseless Ventricular Tachycardia Unresponsive to Defibrillation is of Uncertain Benefit (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Steroids (see Corticosteroids)
  • In Adult Cardiac Arrest, the Use of Steroids is of Uncertain Benefit (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Calcium (see Calcium Chloride)
  • In Adult Cardiac Arrest, Routine Administration of Calcium is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)
• Sodium Bicarbonate (see Sodium Bicarbonate)
  • In Adult Cardiac Arrest, Routine Administration of Sodium Bicarbonate is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)
• Magnesium (see Magnesium Sulfate)
  • In Adult Cardiac Arrest, Routine Administration of Magnesium is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

End-Tidal Carbon Dioxide (ETCO2) Monitoring (see End-Tidal Carbon Dioxide)

• Confirmation of Endotracheal Tube Placement
  • In Adult Cardiac Arrest, Continuous Waveform Capnography is Recommended in Addition to Clinical Assessment as the Most Reliable Method of Confirming and Monitoring Correct Placement of an Endotracheal Tube (Class of Recommendation: 1, Level of Evidence: C-LD)
• Monitoring of Quality of Cardiopulmonary Resuscitation (CPR)
  • In Adult Cardiac Arrest, it May Be Reasonable to Use Physiological Parameters (Such as Arterial Blood Pressure or End-Tidal Carbon Dioxide (ETCO2) when Feasible to Monitor and Optimize Cardiopulmonary Resuscitation (CPR) Quality (Class of Recommendation: 2b, Level of Evidence: C-LD)
    • Targeting Compressions to >10 mm Hg (and Ideally ≥20 mm Hg) is Recommended
    • End-Tidal Carbon Dioxide (ETCO2) Values Reflect Pulmonary Circulation and Cardiac Output and are Positively Correlated with Increased Compression Depth and Release Velocity
      • During Cardiopulmonary Resuscitation (CPR), End-Tidal Carbon Dioxide (ETCO2) Values Serve as a Surrogate for Cardiac Output (Crit Care Med, 1985) [MEDLINE] (Ann Emerg Med, 1990) [MEDLINE]
      • For Every 1 cm Increase in Chest Compression Depth, End-Tidal Carbon Dioxide (ETCO2) Increases 1.4 mm Hg (Resuscitation, 2015) [MEDLINE]
    • However, the Following Factors Also Influence End-Tidal Carbon Dioxide (ETCO2) During Cardiopulmonary Resuscitation (CPR)
      • Airway Management Strategies (see Airway Management)
      • Epinephrine Administration (see Epinephrine)
      • Etiology of Cardiac Arrest
      • Minute Ventilation
      • Quality of Cardiopulmonary Resuscitation (CPR)
      • Sodium Bicarbonate Administration (see Sodium Bicarbonate)
• Detection of Return of Spontaneous Circulation (ROSC)
  
  • In Adult Cardiac Arrest, an Abrupt Increase in End-Tidal Carbon Dioxide (ETCO2) May Be Used to Detect Return of Spontaneous Circulation (ROSC) During Chest Compressions or When a Rhythm Check Reveals an Organized Rhythm (Class of Recommendation: 2b, Level of Evidence: B-NR)
    • Systematic Review of End-Tidal Carbon Dioxide (ETCO2) as a Prognostic Indicator for Return of Spontaneous Circulation (ROSC) (Resuscitation, 2018) [MEDLINE]
      • Study Found Variability in Cutoff Values, But End-Tidal Carbon Dioxide (ETCO2) <10 mm Hg was Generally Associated with Poor Outcome and End-Tidal Carbon Dioxide (ETCO2) >20 mm Hg had a Stronger Association with Return of Spontaneous Circulation (ROSC) than a Value of >10 mm Hg
    • Secondary Analysis of Pragmatic Airway Resuscitation Trial (JAMA Netw Open, 2024) [MEDLINE]
      • Temporal Increases in ETCO2 were Associated with Return of Spontaneous Circulation (ROSC)
• Termination of Resuscitation
  • In Intubated Adult Patients, Failure to Achieve an End-Tidal Carbon Dioxide (ETCO2) >10 mm Hg by Waveform Capnography After 20 min of Advanced Life Support Resuscitation May Be Considered as a Component of a Multimodal Approach to Decide When to End Resuscitative Efforts (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Use of End-Tidal Carbon Dioxide (ETCO2) in Non-Intubated Patients
  • In Non-Intubated Adult Patients, a Specific End-Tidal Carbon Dioxide (ETCO2) Cutoff Value at Any Time During Cardiopulmonary Resuscitation (CPR) Should Not Be Used as an Indication to End Resuscitative Efforts (Class of Recommendation: 3 = Harm, Level of Evidence: C-EO)
  • End-Tidal Carbon Dioxide (ETCO2) is Most Reliable When Measured Through an Endotracheal Tube
  • In Non-Intubated Patients, The Validity and Reliability of End-Tidal Carbon Dioxide (ETCO2) is Not Well Established

Point-of-Care Ultrasound (POCUS) (see xxxx)

• Diagnosis of Reversible Etiologies
  • During Adult Cardiac Arrest Resuscitation, the Use of Point-of-Care Ultrasonography to Diagnose Reversible Etiologies is Not Well Established (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Prognostication
  • During Adult Cardiac Arrest Resuscitation, the Use of Point-of-Care Echocardiography to Assess Cardiac Function for Prognostication is Not Well Established (Class of Recommendation: 2b, Level of Evidence: C-LD)

Supplemental Oxygen (see Oxygen)

• In Adult Cardiac Arrest, When Supplemental Oxygen is Available, Use the Maximal Feasible Inspired Oxygen Concentration During Cardiopulmonary Resuscitation (CPR) (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • Retrospective Studies Have Demonstrated that Higher Intra-Arrest pO2 in the Alveoli is Associated with Survival to Hospital Admission, Survival to Hospital Discharge, and Survival with Favorable Neurological Outcome (Resuscitation, 2013) [MEDLINE] (J Intensive Care Med, 2018) [MEDLINE] (Resuscitation, 2022) [MEDLINE]
    • However, These Findings May Be Influenced by Patient Selection, Airway Management Strategies, Quality of Cardiopulmonary Resuscitation (CPR)

Arterial Blood Gas (ABG) Monitoring (see Arterial Blood Gas)

• The Use of Diastolic blood Pressure Monitoring During Cardiac Arrest is Associated with Higher Probability of Return of Spontaneous Circulation (ROSC), But There are Inadequate Human Data to Suggest Any Specific Diastolic Blood Pressure
  • Small Prospective Studies with Significant Limitations Have Demonstrated that Arterial Blood Gas Parameters (Such as pO2 and pCO2) to Be Predictive of Return of Spontaneous Circulation (ROSC) (Medicine-Baltim, 2016) [MEDLINE] ( Turk J Med Sci, 2019) [MEDLINE]
    • However, Both pO2 and pCO2 are Dependent on Cardiac Output and Can Be Influenced by Patient Factors and the Quality of Cardiopulmonary Resuscitation (CPR)
• In Adult Cardiac Arrest, the Measurement of Arterial Blood Gas (ABG) During Cardiopulmonary Resuscitation (CPR) Has Uncertain Benefit (Class of Recommendation: 2b, Level of Evidence: C-LD)

Arterial Blood Pressure Monitoring

• In Adult Cardiac Arrest, Arterial Blood Pressure Monitoring by Arterial Line May Be Used to Detect Return of Spontaneous Circulation (ROSC) During Chest Compressions or when a Rhythm Check Reveals an Organized Rhythm (Class of Recommendation: 2b, Level of Evidence: C-EO)
  • Retrospective Study from the AHA’s Get With the Guidelines-Resuscitation (Resuscitation, 2016)[MEDLINE]
    • Use of End-Tidal Carbon Dioxide (ETCO2) or Diastolic Bood Pressure Monitoring During Cardiopulmonary Resuscitation (CPR) was Associated with Increased Rate of Return of Spontaneous Circulation (ROSC)
• In Adult Cardiac Arrest, it May Be Reasonable to Use Physiological Parameters (Such as Arterial Blood Pressure or End-Tidal Carbon Dioxide (ETCO2) when Feasible to Monitor and Optimize Cardiopulmonary Resuscitation (CPR) Quality (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • When an Arterial Line is Present, Arterial Diastolic Pressure Can Approximate Coronary Perfusion Pressure and Myocardial Perfusion During Cardiopulmonary Resuscitation (CPR) (Crit Care Med, 1993) [MEDLINE]
  • When a an Arterial Waveform is Present, it is Important to Ensure that it Correlates with a Palpable Pulse to Verify Return of Spontaneous Circulation (ROSC)

Head-Up Cardiopulmonary Resuscitation (CPR)

• In Adult Cardiac Arrest, Head-Up Cardiopulmonary Resuscitation (CPR) is Not Recommended (Except in the Setting of Clinical Trials) (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• Hemodynamically-Stable Wide-Complex Tachycardia
  • In Hemodynamically-Stable Adult Patients with Regular Monomorphic Wide-Complex Tachycardia, Intravenous Adenosine May Be Considered for Treatment or Aiding Rhythm Diagnosis When the Etiology of the Rhythm Cannot Be Determined (Class of Recommendation: 2b, Level of Evidence: B-NR) (see Adenosine)
  • In Adult with Wide-Complex Tachycardia, Any of the Following Treatments Should Be Considered (Class of Recommendation: 2b, Level of Evidence: B-R)
    • Amiodarone (see Amiodarone)
    • Procainamide (see Procainamide)
    • Sotalol (see Sotalol)
  • In Adult Patients with Hemodynamically-Stable Wide-Complex Tachycardia Where Vagal Maneuvers and Pharmacological Therapy is Ineffective or Contraindicated, Synchronized Cardioversion is Recommended for Acute Treatment (Class of Recommendation: 1, Level of Evidence: B-NR)
  • In Adult Patients with Wide-Complex Tachycardia, the Following Atrioventricular Nodal Blocking Agents Should Not Be Administered (Class of Recommendation: 3 = Harm, Level of Evidence: B-NR)
    • Diltiazem (see Diltiazem)
    • Verapamil (see Verapamil)
• Hemodynamically-Unstable Wide-Complex Tachycardia
  • In Adult Patients with Hemodynamically-Unstable Wide-Complex Tachycardia, Synchronized Cardioversion is Recommended for Acute Treatment (Class of Recommendation: 1, Level of Evidence: B-NR)
  • In Adults Patient with Hemodynamically-Unstable, Irregularly Irregular, or Polymorphic Wide-Complex Tachycardia, Adenosine Should Not Be Administered (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD) (see Adenosine)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• Shock
  • Immediate Unsynchronized Shock is Recommended for Adults with Sustained Polymorphic Ventricular Tachycardia (Class of Recommendation: 1, Level of Evidence: B-NR)
• Antiarrhythmics
  • In Adult with Polymorphic Ventricular Tachycardia (in the Absence of a Prolonged QT Interval), Any/All of the Following Should Be Considered to Treat Recurrences of Polymorphic Ventricular Tachycardia (Class of Recommendation: 2b, Level of Evidence: C-LD)
    • Amiodarone (see Amiodarone)
    • Lidocaine (see Lidocaine)
    • Measures to Treat Myocardial Ischemia
• Magnesium (see Magnesium Sulfate)
  • Magnesium May Be Considered for Treatment of Adults with Recurrences of Polymorphic Ventricular Tachycardia Associated with a Long QT Interval (Torsades de Pointes) (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • Routine Use of Magnesium is Not Recommended for the Treatment of Polymorphic Ventricular Tachycardia in Adults with a Normal QT Interval (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• Hemodynamically-Stable Narrow-Complex Tachycardia
  • In Adult with Regular Narrow-Complex Tachycardia, Vagal Maneuvers are Recommended (Class of Recommendation: 1, Level of Evidence: B-R)
  • In Adult with Hemodynamically Stable Narrow-Complex Tachycardias When Vagal Maneuvers and Pharmacological Therapy are Ineffective or Contraindicated, Synchronized Cardioversion is Recommended (Class of Recommendation: 1, Level of Evidence: B-NR)
  • In Adult with Regular Narrow-Complex Tachycardia, Adenosine is Recommended (Class of Recommendation: 1, Level of Evidence: B-R) (see Adenosine)
  • In Adult with Hemodynamically Stable Regular Narrow-Complex Tachycardia, the Following Should Be Considered (Class of Recommendation: 2a, Level of Evidence: B-R)
    • Diltiazem (see Diltiazem)
    • Verapamil (see Verapamil)
  • In Adult Hemodynamically Stable Regular Narrow-Complex Tachycardia, Intravenous β-Blockers are Reasonable for Acute Treatment (Class of Recommendation: 2a, Level of Evidence: C-LD)
    • Metoprolol (see Metoprolol)
• Hemodynamically-Unstable Narrow-Complex Tachycardia
  • In Adult with Hemodynamically Unstable Narrow-Complex Tachycardia, Synchronized Cardioversion is Recommended (Class of Recommendation: 1, Level of Evidence: B-NR)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

Electrical Therapy

• In Adult Patients with Hemodynamic Instability Attributable to Atrial Fibrillation/Atrial Flutter with Rapid Ventricular Response (RVR), Immediate Electrical Cardioversion Should Be Performed to Restore Sinus Rhythm (Class of Recommendation: 1, Level of Evidence: C-LD)
• In for Adult Patients with Hemodynamic Compromise, Ongoing Ischemia, or Inadequate Rate Control, Urgent Direct-Current Cardioversion of New-Onset Atrial Fibrillation/Atrial Flutter with Rapid Ventricular Rates in the Setting of Acute Coronary Syndrome is Recommended (Class of Recommendation: 1, Level of Evidence: C-LD)
• In Adults, for Synchronized Cardioversion of Atrial Fibrillation Using Any Currently US-Approved Biphasic Waveform Defibrillator, an Initial Energy Setting of ≥200 J is Reasonable and Incremented in the Event of Shock Failure, Depending on the Biphasic Defibrillator Used (Class of Recommendation: 2a, Level of Evidence: B-R)
• For Synchronized Cardioversion of Atrial Flutter in Adults, an Initial Energy Setting of 200 J May Be Reasonable and Incremented in the Event of Shock Failure, Depending on the Biphasic Defibrillator Used (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Double Synchronized Cardioversion
  • In Adults, the Usefulness of Double Synchronized Cardioversion of Atrial Fibrillation as an Initial Treatment Strategy is Uncertain (Class of Recommendation: 2b, Level of Evidence: B-R)
  • In Adults, the Usefulness of Double Synchronized cardioversion as a Rescue Treatment for Shock-Refractory Atrial Fibrillation is Uncertain (Class of Recommendation: 2b, Level of Evidence: C-LD)

Medical Therapy

• In Adult Patients with Atrial Fibrillation/Atrial flutter with Rapid Ventricular Response without Preexcitation, Intravenous Administration of a β-Blocker or Non-Dihydropyridine Calcium Channel Blocker (Diltiazem, Verapamil) is Recommended to Acutely Slow the Ventricular Heart Rate (Class of Recommendation: 1, Level of Evidence: B-NR)
  • In Critically Ill Adults with Atrial Fibrillation with Rapid Ventricular Response (RVR) without Preexcitation, Intravenous Amiodarone Can Be Useful for Rate Control (Class of Recommendation: 2a, Level of Evidence: B-NR)
  • In Adult Patients with Preexcitation Atrial Fibrillation/Atrial Flutter, Digoxin, Non-Dihydropyridine Calcium Channel Blockers (Diltiazem, Verapamil), β-Blockers (Metoprolol, etc), and Intravenous Amiodarone Should Not Be Administered Because They May Increase the Ventricular Response and Result in Ventricular Fibrillation (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)
  • Non-Dihydropyridine Calcium Channel Blockers (Diltiazem, Verapamil) and Intravenous β-Blockers (Metoprolol, etc) Should Not Be Used in Adult Patients with Left Ventricular Systolic Dysfunction and Decompensated Heart Failure Because These May Lead to further Hemodynamic Compromise (Class of Recommendation: 3 = Harm, Level of Evidence: C-EO)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• In Adults with Acute Symptomatic Bradycardia, Evaluation and Treatment of Reversible Etiologies are Recommended (Class of Recommendation: 1, Level of Evidence: C-EO)
• In Adults with Acute Bradycardia Associated with Hemodynamic Compromise, Administration of Atropine is Reasonable to Increase the Heart Rate (Class of Recommendation: 2a, Level of Evidence: B-NR)
• In Adults with Persistent Hemodynamically-Unstable Bradycardia Refractory to Medical Therapy, Temporary Transvenous Pacing is Reasonable to Increase Heart Rate and Improve Symptoms (Class of Recommendation: 2a, Level of Evidence: C-LD)
• If Bradycardia is Unresponsive to Atropine, Intravenous Adrenergic Agonists with Rate-Accelerating Effects (Epinephrine, Dopamine) or Transcutaneous Pacing May Be Effective While the Adult Patient is Prepared for Emergent Transvenous Temporary Pacing if Required (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Immediate Pacing Might Be Considered in Unstable Adult Patients with High-Degree Atrioventricular Block When Intravenous/Intraosseus Access is Not Available (Class of Recommendation: 2b, Level of Evidence: C-EO)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• Full Resuscitative Measures (Including Extracorporeal Rewarming When Available) are Recommended for All Victims of Accidental Hypothermia without Characteristics Which Deem Them Unlikely to Survive and without Any Obviously Lethal Traumatic Injury (Class of Recommendation: 1, Level of Evidence: C-LD)
• Victims of Accidental Hypothermia Should Not Be Considered Dead Before Rewarming Has Been Provided Unless There are Signs of Obvious Death (Class of Recommendation: 1, Level of Evidence: C-EO)
• It May Be Reasonable to Perform Defibrillation Attempts According to the Standard Basic Life Support (BLS) Algorithm Concurrent with Rewarming Strategies (Class of Recommendation: 2b, Level of Evidence: C-LD)
• It May Be Reasonable to Consider Administration of Epinephrine During Cardiac Arrest According to the Standard Advanced Cardiac Life Support (ACLS) Algorithm Concurrent with Rewarming Strategies (Class of Recommendation: 2b, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

Anaphylaxis without Cardiac Arrest (see Anaphylaxis)

• Epinephrine Should Be Administered Early by Intramuscular Injection (or Autoinjector) to All Patients with Signs of a Systemic Allergic Reaction (Especially Hypotension, Airway Swelling, or Difficulty Breathing) (Class of Recommendation: 1, Level of Evidence: C-LD)
  • Injection of Epinephrine into the Lateral Aspect of the Thigh Produces Rapid Peak Plasma Epinephrine Concentrations
• The Recommended Epinephrine Dose in Anaphylaxis is 0.2-0.5 mg (1:1,000) Intramuscularly, to Be Repeated q5-15 min as Required (Class of Recommendation: 1, Level of Evidence: C-LD)
• In Patients with Anaphylactic Shock, Close Hemodynamic Monitoring is Recommended (Class of Recommendation: 1, Level of Evidence: C-LD
• Given the Potential for the Rapid Development of Oropharyngeal/Laryngeal Edema, Immediate Referral to a Health Professional with Expertise in Advanced Airway Placement (Including Surgical Airway Management) is Recommended (Class of Recommendation: 1, Level of Evidence: C-LD)
  • When Anaphylaxis Produces Obstructive Airway Edema, Rapid Advanced Airway Management is Critical
    • In Some Cases, Emergency Cricothyrotomy/Tracheostomy May Be Required
• If an Intravenous (IV) Line is in Place, it is Reasonable to Consider the Intravenous (IV) Route for Epinephrine in Anaphylactic Shock, at a Dose of 0.05-0.1 mg (0.1 mg/mL, aka 1:10 000) (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Intravenous (IV) Infusion of Epinephrine is a Reasonable Alternative to Intravenous (IV) Boluses for the Treatment of Anaphylaxis in Patients Not in Cardiac Arrest (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Intravenous (IV) Infusion of Epinephrine May Be Considered for Postarrest Shock in Patients with Anaphylaxis (Class of Recommendation: 2b, Level of Evidence: C-LD)

Anaphylaxis with Cardiac Arrest (see Anaphylaxis)

• General Comments
  • There are No Randomized Controlled Trials (RCT’s) Evaluating Alternative Treatment Algorithms for Cardiac Arrest Due to Anaphylaxis
    • Evidence is Limited to Case Reports and Extrapolations from Non-Fatal Anaphylaxis Cases, Interpretation of Pathophysiology, and Consensus Opinion
  • Because of Limited Evidence, the Cornerstone of Management of Anaphylaxis-Associated Cardiac Arrest is Standard Basic Life Support/Advanced Cardiac Life Support, Including Airway Management and Early Epinephrine
    • There is No Proven Benefit from the Use of Antihistamines, Inhaled β2-Agonists, and Intravenous Corticosteroids During Anaphylaxis-Induced Cardiac Arrest
• In Cardiac Arrest Secondary to Anaphylaxis, Standard Resuscitative Measures and Immediate Administration of Epinephrine Should Take Priority (Class of Recommendation: 1, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• For Asthmatic Patients with Cardiac Arrest, Sudden Increase in Peak Inspiratory Pressures (PIP) or Difficulty ventilating Should Prompt Evaluation for Tension Pneumothorax (Class of Recommendation: 1, Level of Evidence: C-LD)
• Due to the Potential Effects of Intrinsic Positive End-Expiratory Pressure (Auto-PEEP) and Risk of Barotrauma in an Asthmatic Patient with Cardiac Arrest, a Ventilation Strategy of Low Respiratory Rate and Low Tidal Volume is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD)
• If Increased Auto-PEEP or Sudden Decrease in Blood Pressure is Noted in Asthmatics Receiving Bag-Valve-Mask (BVM) Ventilation/Mechanical Ventilation in a Periarrest State, a Brief Disconnection from the Bag-Valve-Mask (BVM) or Ventilator with Compression of the Chest Wall to Relieve Air Trapping Can Be Effective (Class of Recommendation: 2a, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• External Chest Compressions Should Be Performed if Emergency Resternotomy is Not Immediately Available (Class of Recommendation: 1, Level of Evidence: B-NR)
• In a Trained Provider-Witnessed Arrest of a Post–Cardiac Surgery Patient, Immediate Defibrillation for Ventricular Defibrillation (VF)/Ventricular Tachycardia (VT) Should Be Performed (Class of Recommendation: 1, Level of Evidence: C-LD)
  • Cardiopulmonary Resuscitation (CPR) Should Be Initiated if Defibrillation is Not Successful within 1 min
• In a Trained Provider-Witnessed Arrest of a Post–Cardiac Surgery Patient Where Pacer Wires are Already in Place, We Recommend Immediate Pacing in an Asystolic or Bradycardic Arrest (Class of Recommendation: 1, Level of Evidence: C-LD)
  • Cardiopulmonary Resuscitation (CPR) Should Be Initiated if Pacing is Not Successful within 1 min
• For Patients with Cardiac Arrest After Cardiac surgery, it is Reasonable to Perform Resternotomy Early in an Appropriately Staffed and Equipped Intensive Care Unit (ICU) (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Open-Chest Cardiopulmonary Resuscitation (CPR) Can Be Useful if Cardiac Arrest Develops During Surgery When the Chest or Abdomen is Already Open, or in the Early Postoperative Period After Cardiothoracic Surgery (Class of Recommendation: 2a, Level of Evidence: C-LD)
• In Post-Cardiac Surgery Patients Who are Refractory to Standard Resuscitation Procedures, Mechanical Circulatory Support May Be Effective in Improving Outcome (Class of Recommendation: 2b, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• Rescuers Should Provide Cardiopulmonary Resuscitation (CPR), including Rescue Breathing, as Soon as an Unresponsive Submersion Victim is Removed from the Water (Class of Recommendation: 1, Level of Evidence: C-LD)
• All Victims of Drowning Who Require Any Form of Resuscitation (Including Rescue Breathing Alone) Should Be Transported to the Hospital for Evaluation and Monitoring, Even if They Appear to Be Alert and Demonstrate Effective Cardiorespiratory Function at the Scene (Class of Recommendation: 1, Level of Evidence: C-LD)
• Mouth-to-Mouth Ventilation in the Water May Be Helpful when administered by a Trained Rescuer if it Does Mot Compromise Safety (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Routine Stabilization of the Cervical Spine in the Absence of Circumstances Which Might Suggest a Spinal Injury is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-NR)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

Hyperkalemia (see Hyperkalemia)

• For Cardiac Arrest with Known/Suspected Hyperkalemia, in Addition to Standard Advanced Cardiac Life Support (ACLS) Care, Intravenous Calcium Should Be Administered (Class of Recommendation: 1, Level of Evidence: C-LD)

Hypomagnesemia (see Hypomagnesemia)

• For Cardiotoxicity and Cardiac Arrest from Severe Hypomagnesemia, in Addition to Standard Advanced Cardiac Life Support (ACLS) Care, Intravenous Magnesium is Recommended (Class of Recommendation: 1, Level of Evidence: C-LD)

Hypermagnesemia (see Hypermagnesemia)

• For Cardiac Arrest with Known/Suspected hypermagnesemia, in Addition to Standard Advanced Cardiac Life Support (ACLS) Care, it May Be Reasonable to Administer Empirical Intravenous Calcium (Class of Recommendation: 2b, Level of Evidence: C-EO)

Hypokalemia (see Hypokalemia)

• In Suspected Hypokalemia, Intravenous Bolus Administration of Potassium for Cardiac Arrest is Not Recommended (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 7: Adult Basic Life Support) (Circulation, 2025) [MEDLINE]

• Cardiopulmonary Resuscitation (CPR) for Obese Adults in Cardiac Arrest Should Be Provided by Using the Same Techniques as for the Non-Obese Patient (Class of Recommendation: 1, Level of Evidence: C-LD)
• For Obese Adults in Cardiac Arrest, it is Reasonable for Rescuers to Consider the Impact of Moving the Patient to a Firm Surface on Delays in Initiation of Chest Compressions (Class of Recommendation: 2a, Level of Evidence: C-LD)
• For Obese Adults in Cardiac Arrest, it May Be Reasonable for Rescuers to Increase the Force of Compressions to Achieve Adequate Depth (Class of Recommendation: 2b, Level of Evidence: C-EO)
• For Obese Adults in Cardiac Arrest, the Use of a Partial Backboard (or “CPR Board”) Suring In-Hospital Cardia Arrest (IHCA) Does Not Provide Benefit Over Performing Chest Compressions on a Hospital Mattress (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

Planning and Preparation for Cardiac Arrest in Pregnancy (see Pregnancy)

• Team Planning for Cardiac Arrest in Pregnancy Should Be Done in Collaboration with the Obstetric, Neonatal, Emergency, Anesthesiology, Intensive Care, and Cardiac Arrest Services (Class of Recommendation: 1, Level of Evidence: C-LD)
• Because Immediate Return of Spontaneous Circulation (ROSC) Cannot Always Be Achieved, Local Resources for a Perimortem Cesarean Delivery Should Be Summoned as Soon as Cardiac Arrest in a Woman in the Second Half of Pregnancy is Recognized (Class of Recommendation: 1, Level of Evidence: C-LD)
• Protocols for Management of Out-of-Hospital Cardiac Arrest (OHCA) in Pregnancy Should Be Developed to Facilitate Timely transport to a Center with Capacity to Immediately Perform Perimortem Cesarean Delivery while Providing Ongoing Resuscitation (Class of Recommendation: 1, Level of Evidence: C-LD)

Resuscitation of Cardiac Arrest in Pregnancy (see Pregnancy)

• Priorities for the Pregnant Woman in Cardiac Arrest Should Include Provision of High-Quality Cardiopulmonary Resuscitation (CPR) and Relief of Aortocaval Compression Through Left Lateral Uterine Displacement (Class of Recommendation: 1, Level of Evidence: C-LD)
• Because Pregnant Patients are More Prone to Hypoxia, Oxygenation and Airway Management Should Be Prioritized During Resuscitation from Cardiac Arrest in Pregnancy (Class of Recommendation: 1, Level of Evidence: C-LD)
• Because of Potential Interference with Maternal Resuscitation, Fetal Monitoring Should Not Be Undertaken During Cardiac Arrest in Pregnancy (Class of Recommendation: 1, Level of Evidence: C-EO)
• We Recommend Targeted Temperature Management for Pregnant Women Who Remain Comatose After Resuscitation from Cardiac Arrest (Class of Recommendation: 1, Level of Evidence: C-EO)
• During Targeted Temperature 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 (Class of Recommendation: 1, Level of Evidence: C-EO)

Cardiac Arrest and Perimortem Cesarean Delivery (PMCD) (see Pregnancy)

• During Cardiac Arrest, if the Pregnant Woman with a Fundus Height at or Above the Umbilicus Has Not Achieved Return of Spontaneous Circulation (ROSC) with Usual Resuscitation Measures Plus Manual Left Lateral Uterine Displacement, it is Advisable to Prepare to Evacuate the Uterus While Resuscitation Continues (Class of Recommendation: 1, Level of Evidence: C-LD)
• In Situations Such as Nonsurvivable Maternal Trauma or Prolonged Pulselessness, in which Maternal Resuscitative Efforts are Considered Futile, There is No Reason to Delay Performing Perimortem Cesarean Delivery in Appropriate Patients (Class of Recommendation: 1, Level of Evidence: C-LD)
• To Accomplish Delivery Early, Ideally within 5 min after the Time of Arrest, it is reasonable to Immediately Prepare for Perimortem Cesarean Delivery While Initial Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) Interventions are Being Performed (Class of Recommendation: 2a, Level of Evidence: C-EO)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• In Patients with Confirmed Acute Pulmonary Embolism (PE) as the Precipitant of Cardiac Arrest, Thrombolysis, Surgical Embolectomy, and Mechanical Embolectomy are Reasonable Emergency Treatment Options (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Thrombolysis May Be Considered when Cardiac Arrest is Suspected to Be Caused by Acute Pulmonary Embolism (PE) (Class of Recommendation: 2b, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

Opioid Intoxication (Acute Management) (see Opioids)

• For Patients in Respiratory Arrest, Rescue Breathing or Bag-Valve-Mask (BVM) Vnetilation Should Be Maintained Until Spontaneous Breathing Returns, and Standard Basic Life Support (BLS) and/or Advanced Cardiac Life Support (ACLS) Measures Should Continue if Return of Spontaneous Breathing Does Not Occur (Class of Recommendation: 1, Level of Evidence: C-LD)
• 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 Cardiopulmonary Resuscitation (CPR) (i.e. Compressions Plus Ventilation) (Class of Recommendation: 1, Level of Evidence: C-EO)
• Lay/Trained Responders Should Not Delay Activating Emergency Response Systems While Awaiting the Patient’s Response to Naloxone or Other Interventions (Class of Recommendation: 1, Level of Evidence: C-EO)
• For a Patient with Suspected Opioid Overdose Who has a Definite Pulse But No Normal Breathing or Only Gasping (i.e. Respiratory Arrest), in Addition to Providing Standard Basic Life Support (BLS) and/or Advanced Cardiac Life Support (ACLS) Care, it is Reasonable for Responders to Administer Naloxone (Class of Recommendation: 2a, Level of Evidence: B-NR)

Opioid Intoxication (Post-Resuscitation Management) (see Opioids)

• After Return of Spontaneous Breathing, Patients Should Be Observed in a Healthcare Setting Until the Risk of Recurrent Opioid Toxicity is Low and the Patient’s Level of Consciousness and Vital Signs Have Normalized (Class of Recommendation: 1, Level of Evidence: C-LD)
• If Recurrent Opioid Toxicity Develops, Repeated Small Naloxone Doses or a Naloxone Infusion Can Be Beneficial (Class of Recommendation: 2a, Level of Evidence: C-LD)

Benzodiazepine Intoxication (see Benzodiazepines)

• Administration of Flumazenil to Patients with Undifferentiated Coma Confers Risk and is Not Recommended (Class of Recommendation: 3 = Harm, Level of Evidence: B-R) (see Flumazenil)

β-Blocker Intoxication (see β-Adrenergic Receptor Antagonists)

• In Patients with β-Blocker Intoxication Who are in Refractory Shock, Administration of High-Dose Insulin with Glucose is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD) (see Insulin)
• In Patients with β-Blocker Intoxication Who are in Refractory Shock, Administration of Intravenous Glucagon is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD) (see Glucagon)
• In Patients with β-Blocker Intoxication Who are in Refractory Shock, Administration of Calcium May Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD)
• In Patients with β-Blocker Intoxication Who are in Refractory Shock, Extracorporeal Membrane Oxygenation (ECMO) Might Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD) (see Venoarterial Extracorporeal Membrane Oxygenation)

Calcium Channel Blocker Intoxication (see Calcium Channel Blockers)

• In Patients with Calcium Channel Blocker Overdose Who are in Refractory Shock, administration of Calcium is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD)
• In Patients with Calcium Channel Blocker Overdose Who are in Refractory Shock, Administration of High-Dose Insulin with Glucose is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD) (see Insulin)
• In Patients with Calcium Channel Blocker Overdose Who are in Refractory Shock, Administration of Intravenous Glucagon May Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD)
• In Patients with Calcium Channel Blocker Overdose Who are in Shock Refractory to Pharmacological Therapy, Extracorporeal Membrane Oxygenation (ECMO) Might Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD) (see Venoarterial Extracorporeal Membrane Oxygenation)

Cocaine Intoxication (see Cocaine)

• For Patients with Cocaine-Induced Hypertension, Tachycardia, Agitation, or Chest Discomfort, Benzodiazepines, α-Blockers, Calcium Channel Blockers, Nitroglycerin, and/or Morphine Can Be Beneficial (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Although Contradictory Evidence Exists, it May Be Reasonable to Avoid the Use of Pure β-Blocker Medications in the Setting of Cocaine Intoxication (Class of Recommendation: 2b, Level of Evidence: C-LD)

Local Anesthetic Overdose

• It May Be Reasonable to Administer Intravenous Lipid Emulsion, Concomitant with Standard Resuscitative Care, to Patients with Local Anesthetic Systemic Toxicity (LAST) (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • Particularly to Patients who Have Premonitory Neurotoxicity or Cardiac Arrest Due to Bupivacaine Intoxication (Class of Recommendation: 2b, Level of Evidence: C-LD) (see Bupivacaine)

Sodium Channel Blockers (Including Tricyclic Antidepressant) Intoxication (see Tricyclic Antidepressants)

• Administration of Sodium Bicarbonate for Cardiac Arrest or Life-Threatening Cardiac Conduction Delays (i.e. QRS Prolongation >120 msec) Due to Sodium Channel Blocker/Tricyclic Antidepressant (TCA) Overdose Can Be Beneficial (Class of Recommendation: 2a, Level of Evidence: C-LD)
• The Use of Extracorporeal Membrane Oxygenation (ECMO) for Cardiac Arrest or Refractory Shock Due to Sodium Channel Blocker/Tricyclic Antidepressant Toxicity May Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD)

Digoxin Intoxication (see Digoxin)

• Anti-Digoxin Fab Antibodies Should Be Administered to Patients with Severe Cardiac Glycoside Intoxication (Class of Recommendation: 1, Level of Evidence: B-R) (see xxxx)

Carbon Monoxide Intoxication (see Carbon Monoxide)

• Hyperbaric Oxygen Therapy May Be Beneficial in the Treatment of Acute Carbon Monoxide Poisoning in Patients with Severe Toxicity (Class of Recommendation: 2b, Level of Evidence: B-R) (see Hyperbaric Oxygen)

Cyanide Intoxication (see Cyanide)

• Hydroxocobalamin and 100% Oxygen, with/without Sodium Thiosulfate, Can Be Beneficial for Cyanide Toxicity (Class of Recommendation: 2a, Level of Evidence: C-LD) (see xxxx)

American Heart Association (AHA) Recommendations (2020; Part 3: Adult Basic and Advanced Life Support) (Circulation, 2020) [MEDLINE]

• We Suggest Against the Use of Point-of-Care Ultrasound for Prognostication During Cardiopulmonary Resuscitation (CPR) (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)

American Heart Association (AHA) Recommendations (2025; Part 9: Adult Advanced Life Support) (Circulation, 2025) [MEDLINE]

• When Termination of Resuscitation is Being Considered, Basic Life Support (BLS) Prehospital Professionals Should Use the Basic Life Support Termination of Resuscitation Rule for Adult Patients in Out-of-Hospital Cardiac Arrest (OHCA), Where Advanced Life Support is Not Available or May Be Significantly Delayed (Class of Recommendation: 1, Level of Evidence: B-NR)
  • Basic Life Support Termination of Resuscitation Rule (BLS TOR) Criteria
    • Arrest Not Witnessed by Emergency Medical Services (EMS) Personnel
    • No Return of Spontaneous Circulation Before Transport
    • No Automated External Defibrillator (AED) Shock was Delivered Before Transport
  • If All Criteria are Present: Consider Termination of Resuscitation
  • If Any Criteria are Not Present: Continue Resuscitation and Consider Transport
• In Adult Out-of-Hospital Cardiac Arrest (OHCA), it is Reasonable for Advanced Life Support (ALS) Prehospital Professionals to Use the Advanced Life Support Termination of Resuscitation (ALS TOR) Rule to Terminate Resuscitation Efforts in the Field (Class of Recommendation: 2a, Level of Evidence: B-NR)
  • Advanced Life Support Termination of Resuscitation Rule (ALS TOR) Criteria
    • Arrest Not Witnessed
    • No Bystander Cardiopulmonary Resuscitation (CPR)
    • No Return of Spontaneous Circulation Before Transport
    • No Shock was Delivered Before Transport
  • If All Criteria are Present: Consider Termination of Resuscitation
  • If Any Criteria are Not Present: Continue Resuscitation and Consider Transport
• In Adult Out-of-Hospital Cardiac Arrest (OHCA), in a Tiered Emergency Medical Services (EMS) System with Both Advanced Life Support (ALS) and Basic Life Support (BLS) Professionals, it is Reasonable to Use the Universal Termination of Resuscitation (TOR) Rule (Class of Recommendation: 2a, Level of Evidence: B-NR)
• End-Tidal Carbon Dioxide (ETCO2)
  • In Intubated Adult Patients, Failure to Achieve an End-Tidal Carbon Dioxide >10 mm Hg by Waveform Capnography After 20 min of Advanced Life Support Resuscitation May Be Considered as a Component of a Multimodal Approach to Decide When to End Resuscitative Efforts (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • In Non-Intubated Adult Patients, a Specific End-Tidal Carbon Dioxide Cutoff Value at Any Time During Cardiopulmonary Resuscitation (CPR) Should Not Be Used as an Indication to End Resuscitative Efforts (Class of Recommendation: 3 = Harm, Level of Evidence: C-EO)

Oxygenation Targets Post-Cardiac Arrest

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In Adult Patient After Return of Spontaneous Circulation (ROSC), the Use of 100% Inspired Oxygen is Recommended Until the Arterial Oxygen Saturation (SpO2) or the Partial Pressure of Arterial Pxygen (pO2) Can Be Measured (Class of Recommendation: 1, Level of Evidence: B-R)
• In Adult Patient After Return of Spontaneous Circulation (ROSC), Hypoxemia Should Be Avoided (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Adult Patient After Return of Spontaneous Circulation (ROSC), Once Reliable Measurement of Oxygen Saturation (SpO2) is Available, it is Reasonable to Avoid Hyperoxemia and Hypoxemia by Titrating the Fraction of Inspired Oxygen (FiO2) to Target Oxygen Saturation (SpO2) of 90-98% (pO2 60–105 mm Hg) (Class of Recommendation: 2a, Level of Evidence: B-R)
• When Relying on Pulse Oximetry, Healthcare Professionals Should Be Aware of the Increased Risk of Inaccuracy Which May Conceal Hypoxemia in Patients with Darker Skin Pigmentation (Class of Recommendation: 2b, Level of Evidence: C-LD)

Ventilation Target Post-Cardiac Arrest

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In Adult Who Remains Comatose After Return of Spontaneous Circulation (ROSC), Arterial Partial Pressure of Carbon Dioxide (pCO2) Should Be Maintained within a Normal Physiologic Range (Generally 35–45 mm Hg) (Class of Recommendation: 1, Level of Evidence: B-R)
  • In Mechanically Ventilated Adult Patients After Return of Spontaneous Circulation (ROSC), It May Be Reasonable to Obtain a Blood Gas Measurement to Assess pCO2 (Class of Recommendation: 2b, Level of Evidence: B-NR)

Blood Pressure Target Post-Cardiac Arrest

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In Adult After Return of Spontaneous Circulation (ROSC), Hypotension Should Be Avoided by Maintaining a Minimum Mean Arterial Pressure (MAP) ≥65 mm Hg (Class of Recommendation: 1, Level of Evidence: B-R)

Diagnostic Studies Post-Cardiac Arrest

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In All Adults After Return of Spontaneous Circulation (ROSC), a 12-Lead Electrocardiogram (EKG) Should Be Obtained as Soon as Feasible (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Adult After Return of Spontaneous Circulation (ROSC), it May Be Reasonable to Perform Head-to-Pelvis Computed Tomography (CT) to Investigate the Etiology of Cardiac Arrest and Complications from Resuscitation (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult After Return of Spontaneous Circulation (ROSC), it May Be Reasonable to Perform Echocardiography or Point-of-Care Cardiac Ultrasound for to Identify Clinically Significant Diagnoses Requiring Intervention (Class of Recommendation: 2b, Level of Evidence: C-LD)

Temperature Control Post-Cardiac Arrest (i.e. Targeted Temperature Management) (see Therapeutic Hypothermia)

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• Prehospital Cooling
  • The Benefit of Strategies Other than Rapid Infusion of Cold Intravenous Fluids for Prehospital Cooling is Unclear (Class of Recommendation: 2b, Level of Evidence: B-R)
  • In Adult After Return of Spontaneous Circulation (ROSC), Routine Rapid Infusion of Intravenous Fluids for Prehospital Hypothermic Temperature Control is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)
• In All Adults After Return of Spontaneous Circulation (ROSC) with Unresponsiveness to Verbal Commands, a Deliberate, Protocolized Strategy of Temperature Control is Recommended, Irrespective of Arrest Location or Presenting Rhythm (Class of Recommendation: 1, Level of Evidence: B-R)
• In Adult After Return of Spontaneous Circulation (ROSC) with Unresponsiveness to Verbal Commands, Maintaining a Temperature Between 32-37.5°C is Recommended (Class of Recommendation: 1, Level of Evidence: B-R)
• In Adult After Return of Spontaneous Circulation (ROSC) with Unresponsiveness to Verbal Commands, it is Reasonable for Temperature Control to Be Maintained for ≥36 hrs (Class of Recommendation: 2a, Level of Evidence: B-R)
• In Adults Who Have Spontaneous Hypothermia After Return of Spontaneous Circulation (ROSC) or Who are Warming After Hypothermic Temperature Control, it May Be Reasonable to Avoid Rapid (Faster than 0.5°C/hr) Rewarming (Class of Recommendation: 2b, Level of Evidence: B-R)
• It is Unclear if Maintenance of a Specific Temperature (Hypothermia vs Normothermia) Improves Outcomes in Subgroups of Adult Patients with Higher Illness Severity (Class of Recommendation: 2b, Level of Evidence: B-NR)

Steroids (see Corticosteroids)

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In Adult with Shock After Return of Spontaneous Circulation (ROSC), the Routine Use of Steroids is of Uncertain Benefit (Class of Recommendation: 2b, Level of Evidence: B-R)

Glucose Control

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• Adult After Return of Spontaneous Circulation (ROSC), it May Be Reasonable to Avoid Hypoglycemia (Glucose <70 mg/dL) and Hyperglycemia (Glucose >180 mg/dL) (Class of Recommendation: 2b, Level of Evidence: B-NR)

Antibiotics

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In Adult After Return of Spontaneous Circulation (ROSC), the Routine Use of Prophylactic Antibiotics is of Uncertain Clinical Benefit (Class of Recommendation: 2b, Level of Evidence: B-R)

Mitigation of Neurologic Injury

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In Adult After Return of Spontaneous Circulation (ROSC) with Unresponsiveness to Verbal Commands, the Effectiveness of Agents to Mitigate Neurological injury is Uncertain (Class of Recommendation: 2b, Level of Evidence: B-R)

Vasopressors

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In Adult After Return of Spontaneous Circulation (ROSC), There is Insufficient Evidence to Recommend a Specific Vasopressor to Treat Hypotension (Class of Recommendation: 2b, Level of Evidence: B-NR)

Percutaneous Coronary Intervention (PCI) (see Percutaneous Coronary Intervention)

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In All Patients with Suspected Cardiac Etiology of Arrest and Persistent ST-Segment Elevation on EKG, Coronary Angiography Should Be Performed Emergently After Cardiac Arrest, Regardless of the Presence of Coma (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Adult Cardiac Arrest Survivors with Suspected Cardiac Etiology, Coronary Angiography is Recommended Prior to Hospital Discharge, Particularly in the Presence of an Initial Shockable Rhythm, Unexplained Left Ventricular Systolic Dysfunction, or Evidence of Severe Myocardial Ischemia (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Selected Adult Patients After Cardiac Arrest with Suspected Cardiac Etiology without ST-Segment Elevation on EKG in the Presence of Cardiogenic Shock, Recurrent Ventricular Arrhythmias, or Evidence of Significant Ongoing Myocardial Ischemia, Emergency Coronary Angiography is Reasonable, Regardless of the Presence of Coma (Class of Recommendation: 2a, Level of Evidence: B-NR)
• In Adult Comatose Patients with Return of Spontaneous Circulation (ROSC) After Cardiac Arrest in the Absence of ST-Segment Elevation, Shock, Electrical Instability, or Evidence of Significant Ongoing Myocardial Ischemia, Emergency Coronary Angiography is Not Recommended Over a Delayed or Selective Strategy (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)
• In Adult Patient with Shock After Cardiac Arrest in the Setting of Multivessel Coronary Artery Disease (CAD), Immediate Revascularization of Non–Infarct-Related Coronary Lesions is Not Recommended Over Initial Revascularization of Only the Infarct-Related Artery (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

Temporary Mechanical Circulatory Support (MCS) (see xxxx)

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In Adult with Cardiac Arrest Who Has Been Placed on Mechanical Circulatory Support (MCS), Appropriate Monitoring and Management by a Team with Experience Managing the Device(s) and the Potential Associated Complications is Recommended (Class of Recommendation: 1, Level of Evidence: C-EO)
• In Highly Selected Adult Patients with Refractory Cardiogenic Shock After Cardiac Arrest and Return of Spontaneous Circulation (ROSC), Temporary Mechanical Circulatory Support (MCS) May Be Considered (Class of Recommendation: 2b, Level of Evidence: B-NR)
• In Adult Patients with Cardiogenic Shock After Cardiac Arrest and Return of Spontaneous Circulation (ROSC), Temporary Mechanical Circulatory Support (MCS) Should Not Be Routinely Used (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

Advanced Neuromonitoring

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• In Adult After Return of Spontaneous Circulation (ROSC), the Usefulness of Monitoring Intracranial Pressure (ICP), Cerebral Blood Flow, Brain Tissue Oxygenation, or Jugular Venous Oxygen Saturation is Not Well Established (Class of Recommendation: 2b, Level of Evidence: C-LD)

Seizures/Myoclonus (see Seizures and Myoclonus)

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• Diagnostic Electroencephalogram (EEG) (see Electroencephalogram)
  • In Adult After Return of Spontaneous Circulation (ROSC) with Unresponsiveness to Verbal Commands, Prompt Electroencephalogram (EEG) for the Diagnosis of Seizures is Recommended (Class of Recommendation: 1, Level of Evidence: C-LD)
  • In Adult After Return of Spontaneous Circulation (ROSC) with Unresponsiveness to Verbal Commands, Monitoring Electroencephalogram (EEG) Repeatedly or Continuously is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD)
  • In Adult with Myoclonus After Return of Spontaneous Circulation (ROSC), Prompt Electroencephalogram (EEG) is Recommended for the Diagnosis of Seizures (Class of Recommendation: 1, Level of Evidence: C-LD)
• Treatment of Seizures
  • In Adult After Return of Spontaneous Circulation (ROSC) with Clinically-Apparent Seizures, Treatment is Recommended (Class of Recommendation: 1, Level of Evidence: C-LD)
  • In Adult After Return of Spontaneous Circulation (ROSC), Treatment of Nonconvulsive Seizures (i.e. Diagnosed by Electroencephalogram/EEG Only) is Reasonable (Class of Recommendation: 2a, Level of Evidence: B-R)
  • In Adult After Return of Spontaneous Circulation (ROSC) with Seizures, Standard Anti-Seizure Medications Should Be Used (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • In Adult After Return of Spontaneous Circulation (ROSC) with Unresponsiveness to Verbal Commands and Electroencephalogram (EEG) Patterns on the Ictal-Interictal Continuum, a Therapeutic Trial of a Non-Sedating Anti-Seizure Medication May Be Reasonable (Class of Recommendation: 2a, Level of Evidence: C-EO)
  • In Adult After Return of Spontaneous Circulation (ROSC) with Unresponsiveness to Verbal Commands, Routine Seizure Prophylaxis is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)
  • In Adult Survivor of Cardiac Arrest, Treatment to Suppress Myoclonus without an Electroencephalogram (EEG) Correlate is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)

Neuroprognostication

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• General
  • In Adult Who Remains Comatose After Cardiac Arrest, Neuroprognostication Should Involve a Multimodal Approach and Not Be Based on Any Single Clinical Finding (Class of Recommendation: 1, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, Neuroprognostic Impressions Should Be Delayed Until Adequate Time Has Passed to Ensure Avoidance of Confounding by Medication Effect or a Transiently Poor Examination in the Early Postinjury Period (Class of Recommendation: 1, Level of Evidence: B-NR)
  • Teams Caring for Adult Patients Who Remain Comatose After Cardiac Arrest Should Have Early, Regular, and Transparent Multidisciplinary Discussions with Surrogates About the Anticipated Time Course for Uncertainties Around Neuroprognostication (Class of Recommendation: 1, Level of Evidence: C-EO)
  • In Adult Patients Who Remain Comatose Post-Cardiac arrest, it is Reasonable to Consolidate the Interpretation of Multimodal Prognostic Assessments at a Minimum of 72 hrs After Normothermia and Discontinuation of Sedatives (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Clinical Examination for Neuroprognostication of Unfavorable Post-Cardiac Arrest Outcome
  • In Adult Who Remains Comatose After Cardiac Arrest, When Performed with Other Prognostic Tests, it May Be Reasonable to Consider Bilaterally Absent Pupillary light Reflex at ≥72 hrs After Cardiac Arrest to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Performed with Other Prognostic Tests, it May Be Reasonable to Consider Quantitative Pupillometry at ≥72 hrs After Cardiac Arrest to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Performed with Other Prognostic Tests, it May Be Reasonable to Consider Bilaterally Absent Corneal Reflexes at ≥72 hrs After Cardiac Arrest to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, the Usefulness of Undifferentiated Myoclonus as Predictor of Unfavorable Neurological Outcome is Uncertain, Even When Occurring within 72 hrs After Cardiac Arrest (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, the Usefulness of Best Motor Response in the Upper Extremities of Absent or Extensor Response as a Predictor of Unfavorable Neurological Outcome is Uncertain (Class of Recommendation: 2b, Level of Evidence: B-NR)
• Clinical Examination for Neuroprognostication of Favorable Post-Cardiac Arrest Outcome
  • In Adult Who Remains Comatose After Cardiac Arrest, the Usefulness of Quantitative Pupillometry to Support the Prognosis of Favorable Neurological Outcome is Not Well Established (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, It May Be Reasonable to Consider Withdrawal Motor Response or Better to Support the Prognosis of Favorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, the Finding of Preserved Pupillary Light Reflexes is Not Useful to Support the Prognosis of Favorable Neurological Outcome (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, the Finding of Preserved Corneal Reflexes is Not Useful to Support the Prognosis of Favorable Neurological Outcome (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-NR)
• Serum Biomarkers for Neuroprognostication
  • In Adult Who Remains Comatose After Cardiac Arrest, When Performed in Combination with Other Prognostic Tests, it May Be Reasonable to Consider High Serum Values of Neuron-Specific Enolase or Neurofilament Light Chain within 72 hrs After Cardiac Arrest to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Evaluated with Other Prognostic Tests, it May Be Reasonable to Consider Normal Levels of Neuron-Specific Enolase within 72 hrs After Cardiac Arrest to Support the Prognosis of Favorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, the Usefulness of Other Serum Biomarkers for Neuroprognostication is Uncertain (Class of Recommendation: 2b, Level of Evidence: B-NR)
• Electrophysiology for Neuroprognostication of Unfavorable Outcome
  • In Adult Who Remains Comatose After Cardiac Arrest, When Evaluated with Other Prognostic Tests, the Prognostic Value of Seizures is Uncertain (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Evaluated with Other Prognostic Tests, it May Be Reasonable to Consider Status Epilepticus Continuing ≥72 hrs After Cardiac Arrest to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Evaluated with Other Prognostic Tests, it May be Reasonable to Consider Burst Suppression on EEG in the Absence of Sedating Medications at ≥72 hrs After Arrest to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Evaluated with Other Prognostic Tests, the Usefulness of Rhythmic or Periodic Discharges to Support the Prognosis of Unfavorable Neurological Outcome is Uncertain (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Evaluated with Other Prognostic Tests, it May Be Reasonable to Consider Bilaterally Absent Cortical N20 Waves on SSEPs at ≥48 hrs After Cardiac Arrest to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, Absence of EEG Reactivity within 72 hrs After Cardiac Arrest Should Not Be Used to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-NR)
• Electrophysiology for Neuroprognostication of Favorable Outcome
  • In Adult Who Remains Comatose After Cardiac Arrest, When Evaluated with Other Prognostic Tests, it May Be Reasonable to Consider a Continuous EEG Background without Discharges within 72 hrs After Cardiac Arrest to Support the Prognosis of Favorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, the Usefulness of the Amplitude of the N20 Wave on SSEP Following Medium Nerve Stimulation to Support the Prognosis of Favorable neurological Outcome is Not Well Established (Class of Recommendation: 2b, Level of Evidence: B-NR)
• Neuroimaging for Neuroprognostication of Unfavorable Outcome
  • In Adult Who Remains Comatose After Cardiac Arrest, When Performed with Other Prognostic Tests, it May Be Reasonable to Consider Reduced GWR on Brain CT After Cardiac Arrest to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Performed with Other Prognostic Tests, it May Be Reasonable to Consider Extensive Areas of Restricted Diffusion on Brain MRI at 2-7 Days After Cardiac Arrest to Support the prognosis of Unfavorable neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Performed with Other Prognostic Tests, it May Be Reasonable to Consider Extensive Areas of Reduced ADC on Brain MRI at 2-7 Days After Cardiac Arrest to Support the Prognosis of Unfavorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
• Neuroimaging for Neuroprognostication of Favorable Outcome
  • In Adult Who Remains Comatose After Cardiac Arrest, the Usefulness of GWR on Head CT after Cardiac Arrest to Support the Prognosis of Favorable Neurological Outcome is Not Well Established (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • In Adult Who Remains Comatose After Cardiac Arrest, When Performed with Other Prognostic Tests, it May Be Reasonable to Consider the Absence of Restricted Diffusion on Brain MRI at 2-7 Days After Cardiac Arrest to Support the Prognosis of Favorable Neurological Outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)

Recovery and Survivorship After Cardiac Arrest

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• It is Recommended that Cardiac Arrest Survivors and Their Caregivers Have Structured Assessment and Treatment/Referral for Emotional Distress After Medical Stabilization and Before Hospital Discharge (Class of Recommendation: 1, Level of Evidence: B-R)
• It is Recommended that Cardiac Arrest Survivors Have Multimodal Rehabilitation Assessment and Treatment for Cognitive, Physical, Neurological, and Cardiopulmonary Impairments Before Hospital Discharge (Class of Recommendation: 1, Level of Evidence: C-LD)
• It is Recommended that Cardiac Arrest Survivors and Their Caregivers Have Multidisciplinary Discharge Planning, to Include Medical and Rehabilitative Treatment Recommendations and Return to Activity/Work Expectations (Class of Recommendation: 1, Level of Evidence: C-LD)
• Interventions to Address Healthcare Professional Burnout May Be Beneficial (Class of Recommendation: 2b, Level of Evidence: B-R)
• Debriefings and Referral for Follow-Up for Emotional Support for Lay Rescuers, Emergency Medical Services (EMS) Professionals, and Hospital-Based Healthcare Professionals After a Cardiac Arrest Event May Be Beneficial (Class of Recommendation: 2b, Level of Evidence: C-LD)

Organ Donation After Cardiac Arrest

American Heart Association (AHA) Recommendations (2025; Part 11: Post–Cardiac Arrest Care) (Circulation, 2025) [MEDLINE]

• Organ Donation Should Be Considered in All Adult Patients Resuscitated from Cardiac Arrest Who Meet Neurological Criteria for Death (i.e. Brain Death) (Class of Recommendation: 1, Level of Evidence: B-NR)
• Organ Donation Should Be Considered in All Adult Patients Resuscitated from Cardiac Arrest Before Planned Withdrawal of Life-Sustaining Therapies (Class of Recommendation: 1, Level of Evidence: B-NR)
• Decisions About Organ Donation Should Follow Local Legal and Regulatory Requirements (Class of Recommendation: 1, Level of Evidence: C-EO)
• Organ Donation is an Important Outcome that Should Be Considered in the Development and Evaluation of Systems of Care (Class of Recommendation: 1, Level of Evidence: C-EO)
• It May Be Reasonable to Consider Utilization of Organs from Adult Patients Resuscitated with ECPR Who Remain Supported on ECMO and Who Meet Neurological Criteria for Death (i.e. Brain Death) or for Whom Withdrawal of Life-Sustaining Therapies is Planned (Class of Recommendation: 2b, Level of Evidence: C-LD)