Topics

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

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

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

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

2 American Heart Association

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

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

About the Recommendations

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

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Adult Basic and Advanced Life Support
Summary of Key Issues and Major Changes pressure control, evaluation for percutaneous coronary
In 2015, approximately 350 000 adults in the United States intervention, targeted temperature management, and
experienced nontraumatic out-of-hospital cardiac arrest multimodal neuroprognostication.
(OHCA) attended by emergency medical services (EMS) • Because recovery from cardiac arrest continues long
personnel. Despite recent gains, less than 40% of adults after the initial hospitalization, patients should have formal
receive layperson-initiated CPR, and fewer than 12% have assessment and support for their physical, cognitive, and
an automated external defibrillator (AED) applied before EMS psychosocial needs.
arrival. After significant improvements, survival from OHCA
• After a resuscitation, debriefing for lay rescuers, EMS
has plateaued since 2012.
providers, and hospital-based healthcare workers may be
In addition, approximately 1.2% of adults admitted to US beneficial to support their mental health and well-being.
hospitals suffer in-hospital cardiac arrest (IHCA). Outcomes
from IHCA are significantly better than outcomes from OHCA, • Management of cardiac arrest in pregnancy focuses on
and IHCA outcomes continue to improve. maternal resuscitation, with preparation for early perimortem
cesarean delivery if necessary to save the infant and
Recommendations for adult basic life support (BLS) and
improve the chances of successful resuscitation of
advanced cardiovascular life support (ACLS) are combined
the mother.
in the 2020 Guidelines. Major new changes include the
following:
Algorithms and Visual Aids
• Enhanced algorithms and visual aids provide easy-to- The writing group reviewed all algorithms and made focused
remember guidance for BLS and ACLS resuscitation improvements to visual training aids to ensure their utility as
scenarios. point-of-care tools and reflect the latest science. The major
• The importance of early initiation of CPR by lay rescuers changes to algorithms and other performance aids include
has been re-emphasized. the following:

• Previous recommendations about epinephrine • A sixth link, Recovery, was added to the IHCA and OHCA
administration have been reaffirmed, with emphasis on Chains of Survival (Figure 3).
early epinephrine administration. • The universal Adult Cardiac Arrest Algorithm was modified
• Use of real-time audiovisual feedback is suggested as a to emphasize the role of early epinephrine administration for
means to maintain CPR quality. patients with nonshockable rhythms (Figure 4).

• Continuously measuring arterial blood pressure and end- • Two new Opioid-Associated Emergency Algorithms have
tidal carbon dioxide (ETCO2) during ACLS resuscitation been added for lay rescuers and trained rescuers
may be useful to improve CPR quality. (Figures 5 and 6).

• On the basis of the most recent evidence, routine use of • The Post–Cardiac Arrest Care Algorithm was updated to
double sequential defibrillation is not recommended. emphasize the need to prevent hyperoxia, hypoxemia, and
hypotension (Figure 7).
• Intravenous (IV) access is the preferred route of medication
administration during ACLS resuscitation. Intraosseous (IO) • A new diagram has been added to guide and inform
access is acceptable if IV access is not available. neuroprognostication (Figure 8).

• Care of the patient after return of spontaneous circulation • A new Cardiac Arrest in Pregnancy Algorithm has been
(ROSC) requires close attention to oxygenation, blood added to address these special cases (Figure 9).

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 Adult Basic and Advanced Life Support

Despite recent gains, less than 40%

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

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

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Figure 4. Adult Cardiac Arrest Algorithm.

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

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Figure 6. Opioid-Associated Emergency for Healthcare Providers Algorithm.

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 Adult Basic and Advanced Life Support

Figure 7. Adult Post–Cardiac Arrest Care Algorithm.

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Figure 8. Recommended approach to multimodal neuroprognostication in adult patients after cardiac arrest.

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 Adult Basic and Advanced Life Support

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

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Major New and Updated and unfavorable neurologic outcome in when feasible to monitor and optimize
the epinephrine group. CPR quality, guide vasopressor therapy,
Recommendations
Of 16 observational studies on and detect ROSC.
Early Initiation of CPR by Lay Rescuers timing in the recent systematic review, Why: Although the use of physiologic
all found an association between monitoring such as arterial blood
2020 (Updated): We recommend that earlier epinephrine and ROSC for pressure and ETCO2 to monitor CPR
laypersons initiate CPR for presumed patients with nonshockable rhythms, quality is an established concept,
cardiac arrest because the risk of harm although improvements in survival new data support its inclusion in the
to the patient is low if the patient is not were not universally seen. For patients guidelines. Data from the AHA’s Get
in cardiac arrest. with shockable rhythm, the literature With The Guidelines®-Resuscitation
2010 (Old): The lay rescuer should not supports prioritizing defibrillation and registry show higher likelihood of
check for a pulse and should assume CPR initially and giving epinephrine ROSC when CPR quality is monitored
that cardiac arrest is present if an adult if initial attempts with CPR and using either ETCO2 or diastolic blood
suddenly collapses or an unrespon- defibrillation are not successful. pressure.
sive victim is not breathing normally. Any drug that increases the rate This monitoring depends on the
The healthcare provider should take of ROSC and survival but is given presence of an endotracheal tube (ETT)
no more than 10 seconds to check for after several minutes of downtime or arterial line, respectively. Targeting
a pulse and, if the rescuer does not will likely increase both favorable and compressions to an ETCO2 value of at
definitely feel a pulse within that time unfavorable neurologic outcome. least 10 mm Hg, and ideally 20 mm Hg
period, the rescuer should start chest Therefore, the most beneficial or greater, may be useful as a marker
compressions. approach seems to be continuing of CPR quality. An ideal target has not
to use a drug that has been shown been identified.
Why: New evidence shows that the risk
of harm to a victim who receives chest to increase survival while focusing
compressions when not in cardiac broader efforts on shortening time Double Sequential Defibrillation
arrest is low. Lay rescuers are not able to drug for all patients; by doing so, Not Supported
to determine with accuracy whether more survivors will have a favorable
a victim has a pulse, and the risk of neurologic outcome. 2020 (New): The usefulness of double
withholding CPR from a pulseless victim sequential defibrillation for refractory
exceeds the harm from unneeded chest Real-Time Audiovisual Feedback shockable rhythm has not been
compressions. established.
2020 (Unchanged/Reaffirmed): It may be
Why: Double sequential defibrillation
Early Administration of Epinephrine reasonable to use audiovisual feedback
is the practice of applying near-
devices during CPR for real-time
simultaneous shocks using 2
2020 (Unchanged/Reaffirmed): With optimization of CPR performance.
defibrillators. Although some case
respect to timing, for cardiac arrest Why: A recent RCT reported a 25% reports have shown good outcomes,
with a nonshockable rhythm, it is increase in survival to hospital dis- a 2020 ILCOR systematic review found
reasonable to administer epinephrine charge from IHCA with audio feedback no evidence to support double sequen-
as soon as feasible. on compression depth and recoil. tial defibrillation and recommended
2020 (Unchanged/Reaffirmed): With against its routine use. Existing studies
respect to timing, for cardiac arrest with Physiologic Monitoring of CPR Quality are subject to multiple forms of bias,
a shockable rhythm, it may be reason- and observational studies do not show
able to administer epinephrine after 2020 (Updated): It may be reasonable to improvements in outcome.
initial defibrillation attempts have failed. use physiologic parameters such as A recent pilot RCT suggests that
arterial blood pressure or ETCO2 when changing the direction of defibrillation
Why: The suggestion to administer feasible to monitor and optimize
epinephrine early was strengthened current by repositioning the pads may
CPR quality. be as effective as double sequential
to a recommendation on the basis of a
systematic review and meta-analysis, 2015 (Old): Although no clinical study has defibrillation while avoiding the risks
which included results of 2 randomized examined whether titrating resuscita- of harm from increased energy and
trials of epinephrine enrolling more than tive efforts to physiologic parameters damage to defibrillators. On the basis
8500 patients with OHCA, showing during CPR improves outcome, it may of current evidence, it is not known
that epinephrine increased ROSC and be reasonable to use physiologic whether double sequential defibrillation
survival. At 3 months, the time point felt parameters (quantitative waveform cap- is beneficial.
to be most meaningful for neurologic nography, arterial relaxation diastolic
recovery, there was a nonsignificant in- pressure, arterial pressure monitoring,
crease in survivors with both favorable and central venous oxygen saturation)

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 Adult Basic and Advanced Life Support

IV Access Preferred Over IO The 2020 Guidelines evaluate 19 improvement) as well as recognition of
different modalities and specific the natural stressors associated with
2020 (New): It is reasonable for providers findings and present the evidence caring for a patient near death. An AHA
to first attempt establishing IV access for each. A new diagram presents scientific statement devoted to this
for drug administration in cardiac arrest. this multimodal approach to topic is expected in early 2021.
2020 (Updated): IO access may be neuroprognostication.
considered if attempts at IV access are Cardiac Arrest in Pregnancy
unsuccessful or not feasible. Care and Support During Recovery
2020 (New): Because pregnant patients
2010 (Old): It is reasonable for providers 2020 (New): We recommend that cardiac are more prone to hypoxia, oxygenation
to establish intraosseous (IO) access arrest survivors have multimodal reha- and airway management should be
if intravenous (IV) access is not readily bilitation assessment and treatment for prioritized during resuscitation from
available. physical, neurologic, cardiopulmonary, cardiac arrest in pregnancy.
Why: A 2020 ILCOR systematic review and cognitive impairments before 2020 (New): Because of potential
comparing IV versus IO (principally discharge from the hospital. interference with maternal resusci-
pretibial placement) drug administra- 2020 (New): We recommend that cardiac tation, fetal monitoring should not be
tion during cardiac arrest found that arrest survivors and their caregivers undertaken during cardiac arrest in
the IV route was associated with better receive comprehensive, multidisci- pregnancy.
clinical outcomes in 5 retrospective plinary discharge planning, to include 2020 (New): We recommend targeted
studies; subgroup analyses of RCTs medical and rehabilitative treatment temperature management for pregnant
that focused on other clinical questions recommendations and return to women who remain comatose after
found comparable outcomes when IV activity/work expectations. resuscitation from cardiac arrest.
or IO were used for drug administration.
Although IV access is preferred, for 2020 (New): We recommend structured 2020 (New): During targeted tempera-
situations in which IV access is difficult, assessment for anxiety, depression, ture management of the pregnant
IO access is a reasonable option. posttraumatic stress, and fatigue for patient, it is recommended that the
cardiac arrest survivors and their fetus be continuously monitored for
Post–Cardiac Arrest Care and caregivers. bradycardia as a potential complication,
Neuroprognostication Why: The process of recovering from and obstetric and neonatal consultation
cardiac arrest extends long after the should be sought.
The 2020 Guidelines contain signifi- initial hospitalization. Support is needed Why: Recommendations for manag-
cant new clinical data about optimal during recovery to ensure optimal ing cardiac arrest in pregnancy were
care in the days after cardiac arrest. physical, cognitive, and emotional reviewed in the 2015 Guidelines Update
Recommendations from the 2015 well-being and return to social/role and a 2015 AHA scientific statement.7
AHA Guidelines Update for CPR and functioning. This process should be Airway, ventilation, and oxygenation
ECC about treatment of hypotension, initiated during the initial hospitalization are particularly important in the setting
titrating oxygen to avoid both hypoxia and continue as long as needed. These of pregnancy because of an increase
and hyperoxia, detection and treatment themes are explored in greater detail in in maternal metabolism, a decrease in
of seizures, and targeted temperature a 2020 AHA scientific statement.6 functional reserve capacity due to the
management were reaffirmed with new gravid uterus, and the risk of fetal brain
supporting evidence. Debriefings for Rescuers injury from hypoxemia.
In some cases, the LOE was Evaluation of the fetal heart is not
2020 (New): Debriefings and referral for
upgraded to reflect the availability of helpful during maternal cardiac arrest,
follow up for emotional support for
new data from RCTs and high-quality lay rescuers, EMS providers, and and it may distract from necessary
observational studies, and the post– hospital-based healthcare workers resuscitation elements. In the absence
cardiac arrest care algorithm has after a cardiac arrest event may be of data to the contrary, pregnant
been updated to emphasize these beneficial. women who survive cardiac arrest
important components of care. To be should receive targeted temperature
reliable, neuroprognostication should Why: Rescuers may experience anxiety management just as any other survivors
be performed no sooner than 72 or posttraumatic stress about providing would, with consideration for the status
or not providing BLS. Hospital-based of the fetus that may remain in utero.
hours after return to normothermia,
care providers may also experience
and prognostic decisions should be
emotional or psychological effects of
based on multiple modes of patient
caring for a patient with cardiac arrest.
assessment.
Team debriefings may allow a review of
team performance (education, quality

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Pediatric Basic and Advanced Life Support
Summary of Key Issues and Major Changes or norepinephrine infusions if vasopressors are needed,
More than 20 000 infants and children have a cardiac arrest is appropriate in resuscitation from septic shock.
each year in the United States. Despite increases in survival • On the basis largely of extrapolation from adult data,
and comparatively good rates of good neurologic outcome balanced blood component resuscitation is reasonable
after pediatric IHCA, survival rates from pediatric OHCA for infants and children with hemorrhagic shock.
remain poor, particularly in infants. Recommendations
• Opioid overdose management includes CPR and the timely
for pediatric basic life support (PBLS) and CPR in infants,
administration of naloxone by either lay rescuers or trained
children, and adolescents have been combined with rec-
rescuers.
ommendations for pediatric advanced life support (PALS)
in a single document in the 2020 Guidelines. The causes • Children with acute myocarditis who have arrhythmias, heart
of cardiac arrest in infants and children differ from cardiac block, ST-segment changes, or low cardiac output are at
arrest in adults, and a growing body of pediatric-specif- high risk of cardiac arrest. Early transfer to an intensive care
ic evidence supports these recommendations. Key issues, unit is important, and some patients may require mechanical
major changes, and enhancements in the 2020 Guidelines circulatory support or extracorporeal life support (ECLS).
include the following: • Infants and children with congenital heart disease and
• Algorithms and visual aids were revised to incorporate single ventricle physiology who are in the process of staged
the best science and improve clarity for PBLS and PALS reconstruction require special considerations in PALS
resuscitation providers. management.
• Based on newly available data from pediatric resuscitations, • Management of pulmonary hypertension may include the
the recommended assisted ventilation rate has been use of inhaled nitric oxide, prostacyclin, analgesia, sedation,
increased to 1 breath every 2 to 3 seconds (20-30 breaths neuromuscular blockade, the induction of alkalosis, or
per minute) for all pediatric resuscitation scenarios. rescue therapy with ECLS.
• Cuffed ETTs are suggested to reduce air leak and the need Algorithms and Visual Aids
for tube exchanges for patients of any age who require
The writing group updated all algorithms to reflect the latest
intubation.
science and made several major changes to improve the
• The routine use of cricoid pressure during intubation is no visual training and performance aids:
longer recommended.
• A new pediatric Chain of Survival was created for IHCA in
• To maximize the chance of good resuscitation outcomes, infants, children, and adolescents (Figure 10).
epinephrine should be administered as early as possible,
• A sixth link, Recovery, was added to the pediatric OHCA
ideally within 5 minutes of the start of cardiac arrest from
Chain of Survival and is included in the new pediatric IHCA
a nonshockable rhythm (asystole and pulseless
Chain of Survival (Figure 10).
electrical activity).
• The Pediatric Cardiac Arrest Algorithm and the Pediatric
• For patients with arterial lines in place, using feedback from
Bradycardia With a Pulse Algorithm have been updated to
continuous measurement of arterial blood pressure may
reflect the latest science (Figures 11 and 12).
improve CPR quality.
• The single Pediatric Tachycardia With a Pulse Algorithm
• After ROSC, patients should be evaluated for seizures; status
now covers both narrow- and wide-complex tachycardias in
epilepticus and any convulsive seizures should be treated.
pediatric patients (Figure 13).
• Because recovery from cardiac arrest continues long
• Two new Opioid-Associated Emergency Algorithms have
after the initial hospitalization, patients should have formal
been added for lay rescuers and trained rescuers (Figures 5
assessment and support for their physical, cognitive, and
and 6).
psychosocial needs.
• A new checklist is provided for pediatric post–cardiac arrest
• A titrated approach to fluid management, with epinephrine
care (Figure 14).

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The causes of cardiac arrest in infants

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

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

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Figure 11. Pediatric Cardiac Arrest Algorithm.

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Figure 12.  Pediatric Bradycardia With a Pulse Algorithm.

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Figure 13.  Pediatric Tachycardia With a Pulse Algorithm.

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Figure 14. Pediatric Post–Cardiac Arrest Care Checklist.

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Major New and Updated Cuffed ETTs Emphasis on Early
Recommendations Epinephrine Administration
2020 (Updated): It is reasonable to
choose cuffed ETTs over uncuffed 2020 (Updated): For pediatric patients in
Changes to the Assisted Ventilation ETTs for intubating infants and children. any setting, it is reasonable to admin-
Rate: Rescue Breathing When a cuffed ETT is used, attention ister the initial dose of epinephrine
should be paid to ETT size, position, within 5 minutes from the start of chest
2020 (Updated): (PBLS) For infants and and cuff inflation pressure (usually
children with a pulse but absent or compressions.
<20-25 cm H2O).
inadequate respiratory effort, it is rea- 2015 (Old): It is reasonable to administer
sonable to give 1 breath every 2010 (Old): Both cuffed and uncuffed epinephrine in pediatric cardiac arrest.
2 to 3 seconds (20-30 breaths/min). ETTs are acceptable for intubating
infants and children. In certain circum- Why: A study of children with IHCA
2010 (Old): (PBLS) If there is a palpa- stances (eg, poor lung compliance, high who received epinephrine for an initial
ble pulse 60/min or greater but there airway resistance, or a large glottic air nonshockable rhythm (asystole and
is inadequate breathing, give rescue leak) a cuffed ETT may be preferable to pulseless electrical activity) demon-
breaths at a rate of about 12 to 20/min an uncuffed tube, provided that atten- strated that, for every minute of delay
(1 breath every 3-5 seconds) until tion is paid to [ensuring appropriate] in administration of epinephrine, there
spontaneous breathing resumes. ETT size, position, and cuff inflation was a significant decrease in ROSC,
pressure. survival at 24 hours, survival to dis-
Changes to the Assisted Ventilation charge, and survival with favorable
Why: Several studies and systematic neurological outcome.
Rate: Ventilation Rate During CPR reviews support the safety of cuffed
With an Advanced Airway Patients who received epinephrine
ETTs and demonstrate decreased need
within 5 minutes of CPR initiation
for tube changes and reintubation.
2020 (Updated): (PALS) When perform- compared with those who received
Cuffed tubes may decrease the risk of
ing CPR in infants and children with an aspiration. Subglottic stenosis is rare epinephrine more than 5 minutes
advanced airway, it may be reasonable when cuffed ETTs are used in children after CPR initiation were more likely
to target a respiratory rate range of and careful technique is followed. to survive to discharge. Studies of
1 breath every 2 to 3 seconds pediatric OHCA demonstrated that
(20-30/min), accounting for age and Cricoid Pressure During Intubation earlier epinephrine administration
clinical condition. Rates exceeding increases rates of ROSC, survival to
these recommendations may 2020 (Updated): Routine use of cricoid intensive care unit admission, survival
compromise hemodynamics. pressure is not recommended during to discharge, and 30-day survival.
2010 (Old): (PALS) If the infant or child is endotracheal intubation of pediatric In the 2018 version of the Pediatric
intubated, ventilate at a rate of about patients. Cardiac Arrest Algorithm, patients
1 breath every 6 seconds (10/min) 2010 (Old): There is insufficient evidence with nonshockable rhythms received
without interrupting chest to recommend routine application of epinephrine every 3 to 5 minutes, but
compressions. cricoid pressure to prevent aspiration early administration of epinephrine
during endotracheal intubation in was not emphasized. Although
Why: New data show that higher
children. the sequence of resuscitation has
ventilation rates (at least 30/min in
not changed, the algorithm and
infants [younger than 1 year] and at Why: New studies have shown that
least 25/min in children) are associated recommendation language have been
routine use of cricoid pressure reduces updated to emphasize the importance
with improved rates of ROSC and intubation success rates and does not
survival in pediatric IHCA. Although of giving epinephrine as early as
reduce the rate of regurgitation. The
there are no data about the ideal possible, particularly when the rhythm
writing group has reaffirmed previous
ventilation rate during CPR without is nonshockable.
recommendations to discontinue
an advanced airway, or for children in cricoid pressure if it interferes with
respiratory arrest with or without an ad- ventilation or the speed or ease of Invasive Blood Pressure Monitoring to
vanced airway, for simplicity of training, intubation. Assess CPR Quality
the respiratory arrest recommendation
was standardized for both situations. 2020 (Updated): For patients with
continuous invasive arterial blood
pressure monitoring in place at the
time of cardiac arrest, it is reasonable
for providers to use diastolic blood
pressure to assess CPR quality.

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2015 (Old): For patients with invasive treatment of status epilepticus is Corticosteroid Administration
hemodynamic monitoring in place at beneficial in pediatric patients in
the time of cardiac arrest, it may be general. 2020 (New): For infants and children with
reasonable for rescuers to use blood septic shock unresponsive to fluids and
pressure to guide CPR quality. Evaluation and Support for requiring vasoactive support, it may be
Cardiac Arrest Survivors reasonable to consider stress-dose
Why: Providing high-quality chest
corticosteroids.
compressions is critical to successful
resuscitation. A new study shows that, 2020 (New): It is recommended that Why: Although fluids remain the main-
among pediatric patients receiving pediatric cardiac arrest survivors be stay of initial therapy for infants and
CPR with an arterial line in place, evaluated for rehabilitation services. children in shock, especially in hypovo-
rates of survival with favorable neu- 2020 (New): It is reasonable to refer lemic and septic shock, fluid overload
rologic outcome were improved if the pediatric cardiac arrest survivors for can lead to increased morbidity. In
diastolic blood pressure was at least ongoing neurologic evaluation for at recent trials of patients with septic
25 mm Hg in infants and at least least the first year after cardiac arrest. shock, those who received higher fluid
30 mm Hg in children.8 volumes or faster fluid resuscitation
Why: There is growing recognition that were more likely to develop clinically
Detecting and Treating recovery from cardiac arrest continues significant fluid overload and require
long after the initial hospitalization. mechanical ventilation. The writing
Seizures After ROSC Survivors may require ongoing integrat- group reaffirmed previous recommen-
ed medical, rehabilitative, caregiver, and dations to reassess patients after each
2020 (Updated): When resources are
community support in the months to fluid bolus and to use either crystalloid
available, continuous electroencepha-
years after their cardiac arrest. A recent or colloid fluids for septic shock resus-
lography monitoring is recommended
AHA scientific statement highlights the citation.
for the detection of seizures following
importance of supporting patients and
cardiac arrest in patients with Previous versions of the Guidelines
families during this time to achieve the
persistent encephalopathy. did not provide recommendations
best possible long-term outcome.6
about choice of vasopressor or the
2020 (Updated): It is recommended to
Septic Shock use of corticosteroids in septic shock.
treat clinical seizures following
cardiac arrest. Two RCTs suggest that epinephrine
Fluid Boluses is superior to dopamine as the initial
2020 (Updated): It is reasonable to treat vasopressor in pediatric septic shock,
nonconvulsive status epilepticus 2020 (Updated): In patients with septic and norepinephrine is also appropriate.
following cardiac arrest in consultation shock, it is reasonable to administer Recent clinical trials suggest a benefit
with experts. fluid in 10 mL/kg or 20 mL/kg aliquots from corticosteroid administration in
2015 (Old): An electroencephalography with frequent reassessment. some pediatric patients with refractory
for the diagnosis of seizure should be septic shock.
2015 (Old): Administration of an initial
promptly performed and interpreted fluid bolus of 20 mL/kg to infants and
and then should be monitored frequent- children with shock is reasonable,
Hemorrhagic Shock
ly or continuously in comatose patients including those with conditions such
after ROSC. 2020 (New): Among infants and children
as severe sepsis, severe malaria, and with hypotensive hemorrhagic shock
2015 (Old): The same anticonvulsant dengue. following trauma, it is reasonable to
regimens for the treatment of status administer blood products, when avail-
epilepticus caused by other etiologies Choice of Vasopressor able, instead of crystalloid for ongoing
may be considered after cardiac arrest. volume resuscitation.
2020 (New): In infants and children with
Why: For the first time, the Guidelines Why: Previous versions of the
fluid-refractory septic shock, it is rea-
provide pediatric-specific recommen- Guidelines did not differentiate the
sonable to use either epinephrine or
dations for managing seizures after treatment of hemorrhagic shock from
norepinephrine as an initial vasoactive
cardiac arrest. Nonconvulsive sei- other causes of hypovolemic shock. A
infusion.
zures, including nonconvulsive status growing body of evidence (largely from
epilepticus, are common and cannot 2020 (New): In infants and children
adults but with some pediatric data)
be detected without electroenceph- with fluid-refractory septic shock, if
suggests a benefit to early, balanced
alography. Although outcome data epinephrine or norepinephrine are un-
resuscitation using packed red blood
from the post–cardiac arrest popula- available, dopamine may be considered.
cells, fresh frozen plasma, and platelets.
tion are lacking, both convulsive and Balanced resuscitation is supported by
nonconvulsive status epilepticus are recommendations from the several US
associated with poor outcome, and and international trauma societies.

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Opioid Overdose for managing children with respiratory Single Ventricle: Recommendations
arrest or cardiac arrest from opioid for the Treatment of Preoperative
2020 (Updated): For patients in overdose.
respiratory arrest, rescue breathing and Postoperative Stage I Palliation
These recommendations are
or bag-mask ventilation should be identical for adults and children, except (Norwood/Blalock-Tausig Shunt) Patients
maintained until spontaneous breathing that compression-ventilation CPR is
returns, and standard PBLS or PALS 2020 (New): Direct (superior vena cava
recommended for all pediatric victims
measures should continue if return of catheter) and/or indirect (near infrared
of suspected cardiac arrest. Naloxone
spontaneous breathing does not occur. spectroscopy) oxygen saturation
can be administered by trained
monitoring can be beneficial to trend
2020 (Updated): For a patient with providers, laypersons with focused and direct management in the critically
suspected opioid overdose who has a training, and untrained laypersons. ill neonate after stage I Norwood
definite pulse but no normal breathing Separate treatment algorithms palliation or shunt placement.
or only gasping (ie, a respiratory arrest), are provided for managing opioid-
in addition to providing standard PBLS associated resuscitation emergencies 2020 (New): In the patient with an appro-
or PALS, it is reasonable for responders by laypersons, who cannot reliably priately restrictive shunt, manipulation
to administer intramuscular or intrana- check for a pulse (Figure 5), and by of pulmonary vascular resistance
sal naloxone. trained rescuers (Figure 6). Opioid- may have little effect, whereas low-
associated OHCA is the subject of a ering systemic vascular resistance
2020 (Updated): For patients known or with the use of systemic vasodilators
suspected to be in cardiac arrest, in the 2020 AHA scientific statement.10
(alpha-adrenergic antagonists and/or
absence of a proven benefit from the phosphodiesterase type III inhibitors),
use of naloxone, standard resuscitative Myocarditis with or without the use of oxygen, can
measures should take priority over be useful to increase systemic delivery
naloxone administration, with a focus 2020 (New): Given the high risk of cardiac
arrest in children with acute myocarditis of oxygen (DO2.)
on high-quality CPR (compressions plus
ventilation). who demonstrate arrhythmias, heart 2020 (New): ECLS after stage I Norwood
block, ST-segment changes, and/or low palliation can be useful to treat low
2015 (Old): Empiric administration of cardiac output, early consideration of systemic DO2.
intramuscular or intranasal naloxone transfer to ICU monitoring and therapy
to all unresponsive opioid-associated 2020 (New): In the situation of known
is recommended.
life-threatening emergency patients or suspected shunt obstruction, it
may be reasonable as an adjunct to 2020 (New): For children with myocarditis is reasonable to administer oxygen,
standard first aid and non–healthcare or cardiomyopathy and refractory low vasoactive agents to increase shunt
provider BLS protocols. cardiac output, prearrest use of ECLS perfusion pressure, and heparin
or mechanical circulatory support can (50-100 units/kg bolus) while preparing
2015 (Old): ACLS providers should be beneficial to provide end-organ for catheter-based or surgical
support ventilation and administer support and prevent cardiac arrest. intervention.
naloxone to patients with a perfusing
cardiac rhythm and opioid-associated 2020 (New): Given the challenges to 2020 (Updated): For neonates prior to
respiratory arrest or severe respiratory successful resuscitation of children stage I repair with pulmonary over-
depression. Bag-mask ventilation with myocarditis and cardiomyopathy, circulation and symptomatic low
should be maintained until spontaneous once cardiac arrest occurs, early systemic cardiac output and DO2, it is
breathing returns, and standard ACLS consideration of extracorporeal reasonable to target a Paco2 of 50 to
measures should continue if return of CPR may be beneficial. 60 mm Hg. This can be achieved during
spontaneous breathing does not occur. Why: Although myocarditis accounts mechanical ventilation by reducing
for about 2% of sudden cardiovascular minute ventilation or by administering
2015 (Old): We can make no analgesia/sedation with or without neu-
recommendation regarding the deaths in infants,11 5% of sudden car-
diovascular deaths in children,11 and 6% romuscular blockade.
administration of naloxone in confirmed
opioid-associated cardiac arrest. to 20% of sudden cardiac death in ath- 2010 (Old): Neonates in a prearrest
letes, previous12,13 PALS guidelines did state due to elevated pulmonary-
Why: The opioid epidemic has not not contain specific recommendations to-systemic flow ratio prior to Stage I
spared children. In the United States for management. These recommenda- repair might benefit from a Paco2 of
in 2018, opioid overdose caused 65 tions are consistent with the 2018 AHA 50 to 60 mm Hg, which can be achieved
deaths in children younger than 15 scientific statement on CPR in infants during mechanical ventilation by reduc-
years and 3618 deaths in people 15 to and children with cardiac disease.14 ing minute ventilation, increasing the
24 years old,9 and many more children inspired fraction of CO2, or administer-
required resuscitation. The 2020 Guide- ing opioids with or without chemical
lines contain new recommendations paralysis.

22 American Heart Association

 Neonatal Life Support

Single Ventricle: Recommendations for PALS care. Previous PALS guidelines administration can be useful while
the Treatment of Postoperative Stage II did not contain recommendations for pulmonary-specific vasodilators are
this specialized patient population. administered.
(Bidirectional Glenn/Hemi-Fontan) and These recommendations are con-
Stage III (Fontan) Palliation Patients 2020 (New): For children who develop
sistent with the 2018 AHA scientific
refractory pulmonary hypertension,
statement on CPR in infants and
2020 (New): For patients in a prearrest including signs of low cardiac output
children with cardiac disease.14
state with superior cavopulmonary or profound respiratory failure despite
anastomosis physiology and severe optimal medical therapy, ECLS may
Pulmonary Hypertension be considered.
hypoxemia due to inadequate pul-
monary blood flow (Qp), ventilatory 2020 (Updated): Inhaled nitric oxide or 2010 (Old): Consider administering
strategies that target a mild respiratory prostacyclin should be used as the inhaled nitric oxide or aerosolized
acidosis and a minimum mean airway initial therapy to treat pulmonary hyper- prostacyclin or analogue to reduce
pressure without atelectasis can be tensive crises or acute right-sided heart pulmonary vascular resistance.
useful to increase cerebral and system- failure secondary to increased pulmo-
ic arterial oxygenation. Why: Pulmonary hypertension, a rare
nary vascular resistance.
disease in infants and children, is
2020 (New): ECLS in patients with su- 2020 (New): Provide careful respiratory associated with significant morbidity
perior cavopulmonary anastomosis or management and monitoring to avoid and mortality and requires specialized
Fontan circulation may be considered hypoxia and acidosis in the postoper- management. Previous PALS guidelines
to treat low DO2 from reversible causes ative care of the child with pulmonary did not provide recommendations for
or as a bridge to a ventricular assist hypertension. managing pulmonary hypertension in
device or surgical revision. infants and children. These recommen-
2020 (New): For pediatric patients
Why: Approximately 1 in 600 infants and dations are consistent with guidelines
who are at high risk for pulmonary
children are born with critical con- on pediatric pulmonary hypertension
hypertensive crises, provide adequate
genital heart disease. Staged surgery published by the AHA and the
analgesics, sedatives, and neuromus-
for children born with single ventricle American Thoracic Society in 2015,16
cular blocking agents.
physiology, such as hypoplastic left and with recommendations contained
heart syndrome, spans the first several 2020 (New): For the initial treatment of in a 2020 AHA scientific statement on
years of life.15 Resuscitation of these pulmonary hypertensive crises, oxygen CPR in infants and children with
infants and children is complex and administration and induction of alka- cardiac disease.14
differs in important ways from standard losis through hyperventilation or alkali

Neonatal Life Support

There are over 4 million births every The process of facilitating Summary of Key Issues
year in the United States and Canada. transition is described in the Neonatal
and Major Changes
Up to 1 of every 10 of these newborns Resuscitation Algorithm that starts
will need help to transition from the with the needs of every newborn • Newborn resuscitation requires
fluid-filled environment of the womb and proceeds to steps that address anticipation and preparation by
to the air-filled room. It is essential the needs of at-risk newborns. In providers who train individually and
that every newborn have a caregiver the 2020 Guidelines, we provide as teams.
dedicated to facilitating that transition recommendations on how to follow • Most newly born infants do not
and for that caregiver to be trained and the algorithm, including anticipation require immediate cord clamping or
equipped for the role. Also, a signifi- and preparation, umbilical cord resuscitation and can be evaluated
cant proportion of newborns who need management at delivery, initial actions, and monitored during skin-to-skin
facilitated transition are at risk for com- heart rate monitoring, respiratory contact with their mothers after birth.
plications that require additional trained support, chest compressions,
personnel. All perinatal settings should intravascular access and therapies, • Prevention of hypothermia is
be ready for this scenario. withholding and discontinuing an important focus for neonatal
resuscitation, postresuscitation care, resuscitation. The importance of
and human factors and performance. skin-to-skin care in healthy babies is
Here, we highlight new and updated reinforced as a means of promoting
recommendations that we believe will parental bonding, breastfeeding, and
have a significant impact on outcomes normothermia.
from cardiac arrest.

eccguidelines.heart.org 23
• Inflation and ventilation of the lungs Major New and Updated Clearing the Airway When
are the priority in newly born infants Recommendations Meconium Is Present
who need support after birth.
• A rise in heart rate is the most Anticipation of Resuscitation Need 2020 (Updated): For nonvigorous new-
important indicator of effective borns (presenting with apnea or
ventilation and response to 2020 (New): Every birth should be at- ineffective breathing effort) delivered
resuscitative interventions. tended by at least 1 person who can through MSAF, routine laryngoscopy
perform the initial steps of newborn with or without tracheal suctioning is
• Pulse oximetry is used to guide resuscitation and initiate PPV and not recommended.
oxygen therapy and meet oxygen whose only responsibility is the care of
saturation goals. 2020 (Updated): For nonvigorous new-
the newborn. borns delivered through MSAF who
• Routine endotracheal suctioning for Why: To support a smooth and safe have evidence of airway obstruction
both vigorous and nonvigorous infants newborn transition from being in the during PPV, intubation and tracheal
born with meconium-stained amniotic womb to breathing air, every birth suction can be beneficial.
fluid (MSAF) is not recommended. should be attended by at least 1 person 2015 (Old): When meconium is present,
Endotracheal suctioning is indicated whose primary responsibility is to the routine intubation for tracheal suction
only if airway obstruction is suspected newly born and who is trained and in this setting is not suggested because
after providing positive-pressure equipped to begin PPV without delay. there is insufficient evidence to
ventilation (PPV). Observational and quality-improvement continue recommending this practice.
• Chest compressions are provided if studies indicate that this approach
enables identification of at-risk Why: In newly born infants with MSAF
there is a poor heart rate response who are not vigorous at birth, initial
newborns, promotes use of checklists
to ventilation after appropriate steps and PPV may be provided. Endo-
to prepare equipment, and facilitates
ventilation-corrective steps, which tracheal suctioning is indicated only if
team briefing. A systematic review of
preferably include endotracheal airway obstruction is suspected after
neonatal resuscitation training in low-
intubation. providing PPV. Evidence from RCTs
resourced settings showed a reduction
• The heart rate response to in both stillbirth and 7-day mortality. suggests that nonvigorous newborns
chest compressions and delivered through MSAF have the same
medications should be monitored Temperature Management for outcomes (survival, need for respiratory
electrocardiographically. support) whether they are suctioned
Newly Born Infants before or after the initiation of PPV.
• When vascular access is required Direct laryngoscopy and endotracheal
in newly born infants, the umbilical 2020 (New): Placing healthy newborn
suctioning are not routinely required for
venous route is preferred. When IV infants who do not require resuscitation
newborns delivered through MSAF, but
access is not feasible, the IO route skin-to-skin after birth can be effective
they can be beneficial in newborns who
in improving breastfeeding, tempera-
may be considered. have evidence of airway obstruction
ture control, and blood glucose stability.
• If the response to chest while receiving PPV.
compressions is poor, it may be Why: Evidence from a Cochrane
systematic review showed that Vascular Access
reasonable to provide epinephrine,
early skin-to-skin contact promotes
preferably via the intravascular route.
normothermia in healthy newborns. In 2020 (New): For babies requiring vascular
• Newborns who fail to respond to addition, 2 meta-analyses of RCTs and access at the time of delivery, the um-
epinephrine and have a history or an observational studies of extended skin- bilical vein is the recommended route.
exam consistent with blood loss may to-skin care after initial resuscitation If IV access is not feasible, it may be
require volume expansion. and/or stabilization showed reduced reasonable to use the IO route.
mortality, improved breastfeeding,
• If all these steps of resuscitation Why: Newborns who have failed to respond
shortened length of stay, and improved
are effectively completed and there to PPV and chest compressions require
weight gain in preterm and low-birth-
is no heart rate response by 20 vascular access to infuse epinephrine and/
weight babies.
minutes, redirection of care should be or volume expanders. Umbilical venous
discussed with the team and family. catheterization is the preferred technique in
the delivery room. IO access is an alter-
native if umbilical venous access is not
feasible or care is being provided outside
of the delivery room. Several case reports
have described local complications associ-
ated with IO needle placement.

24 American Heart Association

 Resuscitation Education Science

Termination of Resuscitation reason, a time frame for decisions advantages in psychomotor perfor-
about discontinuing resuscitation mance and knowledge and confidence
2020 (Updated): In newly born babies efforts is suggested, emphasizing when focused training occurred every
receiving resuscitation, if there is no engagement of parents and the resus- 6 months or more frequently. It is
heart rate and all the steps of resusci- citation team before redirecting care. therefore suggested that neonatal
tation have been performed, cessation resuscitation task training occur more
of resuscitation efforts should be Human and System Performance frequently than the current 2-year
discussed with the healthcare team and interval.
the family. A reasonable time frame for 2020 (Updated): For participants who
Why: Educational studies suggest that
this change in goals of care is around have been trained in neonatal resus-
cardiopulmonary resuscitation knowl-
20 minutes after birth. citation, individual or team booster
edge and skills decay within 3 to 12
training should occur more frequently
2010 (Old): In a newly born baby with no months after training. Short, frequent
than every 2 years at a frequency that
detectable heart rate, it is appropriate booster training has been shown to
supports retention of knowledge, skills,
to consider stopping resuscitation if the improve performance in simulation
and behaviors.
heart rate remains undetectable for studies and reduce neonatal mortality
10 minutes. 2015 (Old): Studies that explored how in low-resource settings. To anticipate
frequently healthcare providers or and prepare effectively, providers and
Why: Newborns who have failed to
healthcare students should train teams may improve their performance
respond to resuscitative efforts by
showed no differences in patient with frequent practice.
approximately 20 minutes of age have
outcomes but were able to show some
a low likelihood of survival. For this

Resuscitation Education Science

Effective education is a key variable support training, and incorporating • Virtual reality, which is the use of
in improving survival outcomes from repetition with feedback and minimum a computer interface to create
cardiac arrest. Without effective passing standards, can improve skill an immersive environment, and
education, lay rescuers and acquisition. gamified learning, which is play and
healthcare providers would struggle • Booster training (ie, brief retraining competition with other students, can
to consistently apply the science sessions) should be added to massed be incorporated into resuscitation
supporting the evidence-based learning (ie, traditional course based) training for laypersons and healthcare
treatment of cardiac arrest. Evidence- to assist with retention of CPR skills. providers.
based instructional design is critical to Provided that individual students can • Laypersons should receive training in
improving provider performance and attend all sessions, separating training how to respond to victims of opioid
patient-related outcomes from cardiac into multiple sessions (ie, spaced overdose, including the administration
arrest. Instructional design features are learning) is preferable to massed of naloxone.
the active ingredients, the key elements learning.
of resuscitation training programs that • Bystander CPR training should target
determine how and when content is • For laypersons, self-directed training, specific socioeconomic, racial,
delivered to students. either alone or in combination and ethnic populations who have
In the 2020 Guidelines, we provide with instructor-led training, is historically exhibited lower rates of
recommendations about various recommended to improve willingness bystander CPR. CPR training should
instructional design features in and ability to perform CPR. Greater address gender-related barriers to
resuscitation training and describe use of self-directed training may improve rates of bystander CPR
how specific provider considerations remove an obstacle to more performed on women.
influence resuscitation education. widespread training of laypersons in • EMS systems should monitor how
Here, we highlight new and updated CPR. much exposure their providers
recommendations in education that we • Middle school– and high school–age receive in treating cardiac arrest
believe will have a significant impact on children should be trained to provide victims. Variability in exposure among
outcomes from cardiac arrest. high-quality CPR. providers in a given EMS system
• In situ training (ie, resuscitation may be supported by implementing
Summary of Key Issues targeted strategies of supplementary
education in actual clinical spaces)
and Major Changes can be used to enhance learning training and/or staffing adjustments.
• The use of deliberate practice outcomes and improve resuscitation • All healthcare providers should complete
and mastery learning during life performance. an adult ACLS course or its equivalent.

eccguidelines.heart.org 25
• Use of CPR training, mass training, The frequency of booster sessions In Situ Education
CPR awareness campaigns, and should be balanced against student
hands-only CPR promotion should availability and the provision of 2020 (New): It is reasonable to conduct
continue on a widespread basis to resources that support implementation in situ simulation-based resuscitation
improve willingness to provide CPR of booster training. Studies show that training in addition to traditional train-
to cardiac arrest victims, increase the spaced-learning courses, or training ing.
prevalence of bystander CPR, and that is separated into multiple sessions, 2020 (New): It may be reasonable to
improve outcomes from OHCA. are of equal or greater effectiveness conduct in situ simulation-based resus-
when compared with courses delivered citation training in place of traditional
Major New and Updated as a single training event. Student training.
Recommendations attendance across all sessions is
required to ensure course completion Why: In situ simulation refers to train-
ing activities that are conducted in
Deliberate Practice and because new content is presented at
actual patient care areas, which has the
Mastery Learning each session.
advantage of providing a more realistic
training environment. New evidence
2020 (New): Incorporating a deliberate Lay Rescuer Training shows that training in the in situ envi-
practice and mastery learning model ronment, either alone or in combination
into basic or advanced life support 2020 (Updated): A combination of
with traditional training, can have a
courses may be considered for improv- self-instruction and instructor-led
positive impact on learning outcomes
ing skill acquisition and performance. teaching with hands-on training is
(eg, faster time to perform critical tasks
recommended as an alternative to
Why: Deliberate practice is a training and team performance) and patient
instructor-led courses for lay rescuers.
approach where students are given a outcomes (eg, improved survival, neu-
If instructor-led training is not available,
discrete goal to achieve, immediate rological outcomes).
self-directed training is recommended
feedback on their performance, and for lay rescuers. When conducting in situ simulation,
ample time for repetition to improve instructors should be wary of potential
performance. Mastery learning is 2020 (New): It is recommended to train risks, such as mixing training supplies
defined as the use of deliberate middle school– and high school–age with real medical supplies.
practice training and testing that children in how to perform high-quality
includes a set of criteria to define CPR. Gamified Learning and Virtual Reality
a specific passing standard, which 2015 (Old): A combination of self-
implies mastery of the tasks being instruction and instructor-led 2020 (New): The use of gamified learning
learned. teaching with hands-on training can and virtual reality may be considered for
Evidence suggests that incorporating be considered as an alternative to basic or advanced life support train-
a deliberate practice and mastery traditional instructor-led courses for lay ing for lay rescuers and/or healthcare
learning model into basic or advanced providers. If instructor-led training is not providers.
life support courses improves multiple available, self-directed training may be Why: Gamified learning incorporates
learning outcomes. considered for lay providers learning competition or play around the topic of
AED skills. resuscitation, and virtual reality uses a
Booster Training and Why: Studies have found that self- computer interface that allows the user
Spaced Learning instruction or video-based instruction to interact within a virtual environment.
is as effective as instructor-led training Some studies have demonstrated
2020 (New): It is recommended to imple- for lay rescuer CPR training. A shift positive benefits on learning outcomes
ment booster sessions when utilizing a to more self-directed training may (eg, improved knowledge acquisition,
massed-learning approach for resusci- lead to a higher proportion of trained knowledge retention, and CPR skills)
tation training. lay rescuers, thus increasing the with these modalities. Programs
chances that a trained lay rescuer looking to implement gamified learning
2020 (New): It is reasonable to use a
will be available to provide CPR when or virtual reality should consider
spaced-learning approach in place of a
needed. Training school-age children high start-up costs associated with
massed-learning approach for resusci-
to perform CPR instills confidence and purchasing equipment and software.
tation training.
a positive attitude toward providing
Why: The addition of booster training CPR. Targeting this population with CPR
sessions, which are brief, frequent training helps build the future cadre of
sessions focused on repetition of prior community-based, trained lay rescuers.
content, to resuscitation courses im-
proves the retention of CPR skills.

26 American Heart Association

 Resuscitation Education Science

Bystander CPR training should target

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

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

eccguidelines.heart.org 27
Systems of Care
Survival after cardiac arrest requires an • Early warning scoring systems and rescuers via a smartphone app or
integrated system of people, training, rapid response teams can prevent text message alert is associated with
equipment, and organizations. Willing cardiac arrest in both pediatric and shorter bystander response times,
bystanders, property owners who adult hospitals, but the literature higher bystander CPR rates, shorter
maintain AEDs, emergency service is too varied to understand what time to defibrillation, and higher rates of
telecommunicators, and BLS and ALS components of these systems are survival to hospital discharge for people
providers working within EMS systems associated with benefit. who experience OHCA. The differences
all contribute to successful resuscita- in clinical outcomes were seen only
• Cognitive aids may improve in the observational data. The use of
tion from OHCA. Within hospitals, the resuscitation performance by
work of physicians, nurses, respirato- mobile phone technology has yet to be
untrained laypersons, but in simulation studied in a North American setting, but
ry therapists, pharmacists, and other settings, their use delays the start of the suggestion of benefit in other coun-
professionals supports resuscitation CPR. More development and study are tries makes this a high priority for future
outcomes. needed before these systems can be research, including the impact of these
Successful resuscitation also fully endorsed. alerts on cardiac arrest outcomes in
depends on the contributions diverse patient, community, and geo-
of equipment manufacturers, • Surprisingly little is known about
the effect of cognitive aids on the graphic contexts.
pharmaceutical companies,
resuscitation instructors, guidelines performance of EMS or hospital-
based resuscitation teams. Data Registries to Improve
developers, and many others. Long-
System Performance
term survivorship requires support • Although specialized cardiac
from family and professional caregivers, arrest centers offer protocols and New (2020): It is reasonable for organiza-
including experts in cognitive, physical, technology not available at all tions that treat cardiac arrest patients
and psychological rehabilitation and hospitals, the available literature to collect processes-of-care data and
recovery. A systems-wide commitment about their impact on resuscitation outcomes.
to quality improvement at every outcomes is mixed.
level of care is essential to achieving Why: Many industries, including health-
• Team feedback matters. Structured care, collect and assess performance
successful outcomes.
debriefing protocols improve the data to measure quality and identify
performance of resuscitation teams in opportunities for improvement. This
Summary of Key Issues
subsequent resuscitation. can be done at the local, regional, or
and Major Changes national level through participation in
• System-wide feedback matters.
• Recovery continues long after the Implementing structured data data registries that collect informa-
initial hospitalization and is a critical collection and review improves tion on processes of care (eg, CPR
component of the resuscitation performance data, defibrillation times,
resuscitation processes and survival
Chains of Survival. adherence to guidelines) and outcomes
both inside and outside the hospital.
of care (eg, ROSC, survival) associated
• Efforts to support the ability and with cardiac arrest.
willingness of the members of the Major New and Updated
Three such initiatives are the AHA’s
general public to perform CPR and Recommendations Get With The Guidelines-Resuscitation
use an AED improve resuscitation
registry (for IHCA), the AHA Cardiac
outcomes in communities. Using Mobile Devices to
Arrest Registry to Enhance Survival
• Novel methods to use mobile phone Summon Rescuers registry (for OHCA), and the
technology to alert trained lay Resuscitation Outcomes Consortium
rescuers of events that require New (2020): The use of mobile phone
Cardiac Epistry (for OHCA), and many
CPR are promising and deserve technology by emergency dispatch
regional databases exist. A 2020
more study. systems to alert willing bystanders to
ILCOR systematic review found that
nearby events that may require CPR or
• Emergency system telecommunica- AED use is reasonable. most studies assessing the impact of
tors can instruct bystanders to per- data registries, with or without public
form hands-only CPR for adults and Why: Despite the recognized role of lay reporting, demonstrate improvement in
first responders in improving OHCA cardiac arrest survival in organizations
children. The No-No-Go framework is
outcomes, most communities experi- and communities that participated in
effective.
ence low rates of bystander CPR and cardiac arrest registries.
AED use. A recent ILCOR systematic
review found that notification of lay

28 American Heart Association

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