These guidelines introduce relatively few major

changes from the 2015 ERC-ESICM Guidelines on

Post-Resuscitation Care. Key changes comprise
guidance on GENERAL INTENSIVE CARE
MANAGEMENT such as use of neuromuscular
blocking drugs, stress ulcer prophylaxis and
nutrition, greater detail on the treatment of
seizures, modifications to prognostication
algorithm, greater emphasis on functional
assessments of physical and non-physical
impairments before discharge and long-term
follow up and rehabilitation. Recognition of the
importance of survivorship after cardiac arrest.
Systems Saving
Lives
Basic Life Support
BASIC LIFE SUPPORT

Unresponsive with absent

or abnormal breathing

Call emergency services

Give 30 chest compressions

Give 2 rescue breaths

Continue CPR 30:2

As soon as AED arrives –

switch it on and follow
instructions
BASIC LIFE SUPPORT
STEP-BY-STEP
SEQUENCE/ACTION TECHNICAL DESCRIPTION
SAFETY
• Make sure that you, the victim and any bystanders
are safe

RESPONSE
Check for a response Hello! • Shake the victim gently by the shoulders and ask
loudly: “Are you all right?"

AIRWAY
• If there is no response, position the victim on their
Open the airway
back
• With your hand on the forehead and your fingertips
under the point of the chin, gently tilt the victim’s
head backwards, lifting the chin to open the airway

BREATHING • Look, listen and feel for breathing for no more than
Look, listen and feel 10 seconds
for breathing
• A victim who is barely breathing, or taking
infrequent, slow and noisy gasps, is not breathing
normally

ABSENT OR
• If breathing is absent or abnormal, ask a helper to
ABNORMAL BREATHING 112 call the emergency services or call them yourself
Alert emergency services
• Stay with the victim if possible
• Activate the speaker function or hands-free option
on the telephone so that you can start CPR whilst
talking to the dispatcher

SEND FOR AED

• Send someone to find and bring back an AED if
Send someone to get an AED
available
• If you are on your own, DO NOT leave the victim,
but start CPR

CIRCULATION
• Kneel by the side of the victim
Start chest compressions
• Place the heel of one hand in the centre of the
victim’s chest - this is the lower half of the victim’s
breastbone (sternum)
• Place the heel of your other hand on top of the first
hand and interlock your fingers
• Keep your arms straight
• Position yourself vertically above the victim’s chest
and press down on the sternum at least 5 cm (but
not more than 6 cm)
• After each compression, release all the pressure
on the chest without losing contact between your
hands and the sternum
• Repeat at a rate of 100-120 min-1
BASIC LIFE SUPPORT
STEP-BY-STEP
SEQUENCE/ACTION TECHNICAL DESCRIPTION
COMBINE RESCUE BREATHING WITH • If you are trained to do so, after 30 compressions,
CHEST COMPRESSIONS open the airway again, using head tilt and chin lift
• Pinch the soft part of the nose closed, using the
index finger and thumb of your hand on the
forehead
• Allow the victim’s mouth to open, but maintain chin
lift
• Take a normal breath and place your lips around the
victim’s mouth, making sure that you have an airtight
seal
• Blow steadily into the mouth whilst watching for the
chest to rise, taking about 1 second as in normal
breathing. This is an effective rescue breath
• Maintaining head tilt and chin lift, take your mouth
away from the victim and watch for the chest to fall
as air comes out
• Take another normal breath and blow into the
victim’s mouth once more to achieve a total of two
rescue breaths
• Do not interrupt compressions by more than 10
seconds to deliver the two breaths even if one or
both are not effective
• Then return your hands without delay to the correct
position on the sternum and give a further 30 chest
compressions
• Continue with chest compressions and rescue
breaths in a ratio of 30:2

COMPRESSION-ONLY CPR
• If you are untrained, or unable to give rescue
breathes, give chest-compression-only CPR
(continuous compressions at a rate of 100-120 min-1)

WHEN AED ARRIVES

Switch on the AED and • As soon as the AED arrives switch it on and attach
attach the electrode pads the electrode pads to the victim’s bare chest
• If more than one rescuer is present, CPR should
be continued whilst the electrode pads are being
attached to the chest

FOLLOW THE SPOKEN/ • Follow the spoken and visual directions given by the
VISUAL DIRECTIONS AED
• If a shock is advised, ensure that neither you nor
anyone else is touching the victim
• Push the shock button as directed
• Then immediately resume CPR and continue as
directed by the AED
BASIC LIFE SUPPORT
STEP-BY-STEP
SEQUENCE/ACTION TECHNICAL DESCRIPTION
IF NO SHOCK IS ADVISED
Continue CPR
• If no shock is advised, immediately resume CPR
and continue as directed by the AED

IF NO AED IS AVAILABLE
Continue CPR • If no AED is available, OR whilst waiting for one to
arrive, continue CPR
• Do not interrupt resuscitation until:
• A health professional tells you to stop OR
• The victim is definitely waking up, moving,
opening eyes, and breathing normally
• OR
• You become exhausted
• It is rare for CPR alone to restart the heart. Unless
you are certain that the victim has recovered
continue CPR
• Signs that the victim has recovered
• Waking-up
• Moving
• Opening eyes
• Breathing normally

IF UNRESPONSIVE BUT BREATHING

NORMALLY
Place in the Recovery Position
• If you are certain that the victim is breathing
normally but still unresponsive, place them in the
recovery position SEE FIRST AID SECTION
• Be prepared to restart CPR immediately if the victim
becomes unresponsive, with absent or abnormal
breathing
Adult Advanced
Life Support
Summary of key changes
• There are no major changes in the 2020 Adult ALS Guidelines.
• There is a greater recognition that patients with both in and out of hospital cardiac arrest have premonitory signs,
and that many of these arrests may be preventable.
• High quality chest compressions with minimal interruption and early defibrillation remain priorities.
• During CPR, start with basic airway techniques and progress stepwise according to the skills of the rescuer until
effective ventilation is achieved. If an advanced airway is required, rescuers with a high tracheal intubation success
rate should use tracheal intubation. The expert consensus is that a high success rate is over 95% within two
attempts at intubation.
• When adrenaline is used it should be used as soon as possible when the cardiac arrest rhythm is non-shockable
cardiac arrest, and after 3 defibrillation attempts for a shockable cardiac arrest rhythm.
• The guideline recognises the increasing role of point-of-care ultrasound (POCUS) in peri-arrest care for diagnosis,
but emphasise that it requires a skilled operator, and the need to minimise interruptions during chest compression.
• The guideline reflects the increasing evidence for extracorporeal CPR (eCPR) as a rescue therapy for selected
patients with cardiac arrest when conventional ALS measures are failing or to facilitate specific interventions (e.g.
coronary angiography and percutane- ous coronary intervention (PCI), pulmonary thrombectomy for massive
pulmonary embolism, rewarming after hypothermic cardiac arrest) in settings in which it can be implemented.
• These ERC guidelines have followed European and international guidelines for the treatment of peri-arrest
arrhythmias.
 • If a patient has a monitored and witnessed
cardiac arrest (e.g. in the catheter laboratory,
coronary care unit, or other monitored
critical care setting in or out-of-hospital) and
a manual defibrillator is rapidly available:

One shock versus • Confirm cardiac arrest and shout for help.

three stacked shock

• If the initial rhythm is VF/pVT, give up to
three quick successive (stacked) shocks.

sequence • Rapidly check for a rhythm change and, if

appropriate, ROSC after each defibrillation
attempt.

• Start chest compressions and continue CPR

for 2 min if the third shock is unsuccessful.
 In 2020, there remains no evidence to support
Second and either a fixed or escalating energy protocol. Both
strategies are acceptable; however, if the first

subsequent
shock is not successful and the defibrillator is
capable of delivering shocks of higher energy it is
reasonable to increase the energy for
shocks subsequent shocks.
 In view of the larger study suggesting benefit
Recurrent from higher subsequent energy levels for
refibrillation, we recommend that if a shockable
ventricular rhythm recurs after successful defibrillation with
ROSC, and the defibrillator is capable of
fibrillation delivering shocks of higher energy, it is
reasonable to increase the energy for
(refibrillation) subsequent shocks.
ADVANCED LIFE SUPPORT
Unresponsive with absent
or abnormal breathing

Call EMS/Resuscitation team

CPR 30:2
Attach defibrillator/monitor

Assess rhythm

Shockable Non-shockable
(VF/PULSELESS VT) (PEA/ASYSTOLE)

1 shock

Immediately resume chest Return of spontaneous Immediately resume chest

compressions for 2 minutes circulation (ROSC) compressions for 2 minutes

Give high-quality chest compressions and Identify and treat reversible causes Consider
• Hypoxia • Coronary angiography/percutaneous coronary
• Give oxygen
intervention
• Use waveform capnography • Hypovolaemia
• Mechanical chest compressions to facilitate transfer/treatment
• Hypo-/hyperkalemia/metabolic
• Continuous compressions if advanced airway • Extracorporeal CPR
• Hypo-/hyperthermia
• Minimise interruptions to compressions • Thrombosis – coronary or pulmonary
After ROSC
• Intravenous or intraosseous access • Tension pneumothorax • Use an ABCDE approach
• Give adrenaline every 3-5 min • Tamponade- cardiac • Aim for SpO2 of 94-98% and normal PaCO2
• Give amiodarone after 3 shocks • Toxins • 12 Lead ECG
Consider ultrasound imaging to identify • Identify and treat cause
• Identify and treat reversible causes
reversible causes • Targeted temperature management
TACHYCARDIA
Life-threatening features? Synchronised shock up to 3 attempts
ASSESS with ABCDE approach
YES • Sedation OR anaesthesia if conscious
• Give oxygen if SpO2 < 94% and obtain IV access 1. Shock
If unsuccessful:
• Monitor ECG, BP, SpO2. Record 12 lead ECG 2. Syncope
• Amiodarone 300 mg IV over 10-20 min, UNSTABLE
• Identify and treat reversible causes 3. Myocardial ischaemia or procainamide 10-15 mg/kg over 20 min;
(e.g. electrolyte abnormalities, hypovolaemia) 4. Severe heart failure • Repeat synchronised shock

NO
STABLE
Is QRS narrow (<0.12 S) SEEK EXPERT HELP

Broad QRS Narrow QRS

Is rhythm regular?
Regular Is rhythm regular?

Vagal manoeuvres
Irregular Irregular

If ineffective
Probable atrial fibrillation:
• Treat as narrow complex if AF with bundle
branch block • Control rate with beta-blocker or diltiazem
Adenosine (if no pre-excitation)
• Give 2g Magnesium over 10-minutes if • Consider digoxin or amiodarone if evidence of
• 6 mg rapid IV bolus;
torsades de pointes heart failure
• If unsuccessful give 12 mg
• If unsuccessful give IV 18 mg • Anticoagulate if duration > 48h
• Monitor ECG continuously

If ineffective

Broad QRS? Narrow QRS?

Procainamide 10-15 mg/kg IV over 20 min, or Verapamil, diltiazem, or
Amiodarone 300 mg IV over 10-60 min beta-blocker

If ineffective

Synchronised shock up to 3 attempts

 BRADYCARDIA

ASSESS with ABCDE approach

Assess using the ABCDE approach • Give oxygen if SpO2 < 94% and obtain IV access
• Monitor SpO2 and give oxygen if hypoxic
• Monitor ECG, BP, SpO2 Record 12 lead ECG
• Monitor ECG and BP, and record 12-lead ECG
• Identify and treat reversible causes
• Obtain IV access
(e.g. electrolyte abnormalities, hypovolaemia)
• Identify and treat reversible causes
(e.g. electrolyte abnormalities)

Life-threatening features?
1. Shock
2. Syncope
3. Myocardial ischaemia
4. Severe heart failure

YES

NO
Atropine 500 mcg IV

YES
Satisfactory response? Risk of asystole?
• Recent asystole
NO • Mobitz II AV block
• Complete heart block
YES with broad QRS
Consider interim measures: • Ventricular pause > 3 s
• Atropine 500 mcg IV repeat to
maximum of 3 mg
• Isoprenaline 5 mcg min-1 IV
• Adrenaline 2-10 mcg min-1 IV NO
• Alternative drugs*
and / or
• Transcutaneous pacing

Seek expert help

Observe
Arrange transvenous pacing

* Alternatives include:
• Aminophylline
• Dopamine
• Glucagon (if bradycardia is caused by beta-blocker or calcium channel blocker)
• Glycopyrrolate (may be used instead of atropine)
 There is greater emphasis on the priorisation of recognition and
management for reversible causes in cardiac arrest due to special

Cardiac arrest in
circumstances. The guidelines reflect the increasing evidence for
extracorporeal CPR (eCPR) as management strategy for selected patients
with cardiac arrest in settings in which it can be implemented. The trauma
section has been revised with additional measures for haemorrhage

special control, the toxic agents section comes with an extensive supplement,
focusing on management of specific toxic agents. Prognostication of
successful rewarming in hypothermic patients follows more differentiated

circumstances scoring systems (HOPE score; ICE score). In avalanche rescue priority is given
to ventilations as hypoxia is the most likely reason of cardiac arrest. Caused
by the increasing number of patients from that special settings,
recommendations for cardiac arrest in the catheterisation laboratory and
in the dialysis unit have been added.
SPECIAL CIRCUMSTANCES 2021

5 TOP MESSAGES

1. CHECK
• Follow the ABCDE approach
• Take safety measures where needed

2. TREAT
• Follow the ALS algorithm
• Minimise no-flow time
• Optimise oyxgenation
• Use your resources

3. PRIORITISE
• Reversible causes
• 4 Hs
• 4 Ts

4. MODIFY
• Modify ALS algorithm
• Special causes
• Special settings
• Special patient groups

5. CONSIDER
• Transfer
• ECPR
 • Special Causes
• Hipóxia
• Hipovolémia
• PCR traumática
• Anafilaxia
• Sépsis
• Hipo/hipercaliémia
• Special Settings • Hipo/hipertermia
• Estabelecimentos de cuidados de saúde • Trombose
• BO • TEP
• Cirurgia Cardíaca • EAM
• Sala de Hemodinâmica • Tamponamento cardíaco
• Diálise • Pneumotórax hipertensivo
• Dentista • Agentes tóxicos
• Transporte
• Avião
• Helicoptero • Special Patient Groups
• Cruzeiros • Asma e DPOC
• Desporto • Doenças neurológicas
• Afogamento • Obesidade
• Incidentes com múltiplas vítimas • Gravidez
 • Special Causes
• Hipóxia
• Hipovolémia TRAUMATIC CARDIAC ARREST/
• PCR traumática PERI-ARREST ALGORITHM
• Anafilaxia
• Sépsis
• Hipo/hipercaliémia
• Special Settings • Hipo/hipertermia Trauma Patient in Arrest/ Peri-Arrest
• Estabelecimentos de cuidados de saúde • Trombose
• BO • TEP
• Cirurgia Cardíaca • EAM
• Sala de Hemodinâmica • Tamponamento cardíaco Non-traumatic arrest likely ? YES ALS
• Diálise • Pneumotórax hipertensivo
• Dentista • Agentes tóxicos NO
• Transporte
• Avião
• Helicoptero • Special Patient Groups Hypoxaemia Address reversible causes START
Hypovolaemia simultaneously:
• Cruzeiros • Asma e DPOC CPR
Tension pneumothorax
• Desporto • Doenças neurológicas Tamponade
1. Control external catastrophic
haemorrhage
• Afogamento • Obesidade
2. Secure airway and maximise
• Incidentes com múltiplas vítimas • Gravidez oxygenation
3. Bilateral chest decompression
(thoracostomies) Expertise?
4. Relieve tamponade Equipment?
(penetrating chest injury)
Environment ?
5. Proximal vascular control Elapsed time
(REBOA/manual aortic compression)
since loss of vital
6. Pelvic splint signs < 15 min?

7. Blood products / Massive

Haemorrhage Protocol

Resuscitative
ROSC Thoracotomy

YES NO

Pre-hospital: immediate Consider termination

transport to of resuscitation
appropriate hospital
In-hospital: damage control
surgery / resuscitation
 • Special Causes
• Hipóxia
• Hipovolémia
• PCR traumática
• Anafilaxia
• Sépsis
• Hipo/hipercaliémia
• Special Settings • Hipo/hipertermia
• Estabelecimentos de cuidados de saúde • Trombose
• BO • TEP
• Cirurgia Cardíaca • EAM
• Sala de Hemodinâmica • Tamponamento cardíaco
• Diálise • Pneumotórax hipertensivo
• Dentista • Agentes tóxicos
• Transporte
• Avião
• Helicoptero • Special Patient Groups
• Cruzeiros • Asma e DPOC
• Desporto • Doenças neurológicas
• Afogamento • Obesidade
• Incidentes com múltiplas vítimas • Gravidez
 • Special Causes
• Hipóxia EMERGENCY TREATMENT
• Hipovolémia
• PCR traumática
OF HYPERKALAEMIA
• Anafilaxia • Assess using ABCDE approach
• Sépsis • 12-lead ECG and monitor cardiac rhythm if serum potassium (K+) ≥ 6.5 mmol/L
• Hipo/hipercaliémia • Exclude pseudohyperkalaemia
• Special Settings • Hipo/hipertermia • Give empirical treatment for arrhythmia if hyperkalaemia suspected
• Estabelecimentos de cuidados de saúde • Trombose
• BO • TEP Moderate
Mild Severe
• Cirurgia Cardíaca • EAM K+5.5 - 5.9 mmol/L K+ 6.0 - 6.4 mmol/L K+ ≥ 6.5 mmol/L
Consider cause and need Treatment guided by clinical Emergency treatment
• Sala de Hemodinâmica • Tamponamento cardíaco for treatment condition, ECG and rate of rise indicated
• Diálise • Pneumotórax hipertensivo Seek expert help
• Dentista • Agentes tóxicos
• Transporte ECG Changes?
Peaked T waves Broad QRS Bradycardia
• Avião Flat/ absent P waves Sine wave VT
• Helicoptero • Special Patient Groups NO YES
• Cruzeiros • Asma e DPOC
• Desporto • Doenças neurológicas IV Calcium
10ml 10% Calcium Chloride IV OR
• Afogamento • Obesidade Protect the 30ml 10% Calcium Gluconate IV
heart
• Incidentes com múltiplas vítimas • Gravidez • Use large IV access and give over 5 min
• Repeat ECG
• Consider further dose after 5 min if ECG changes persist

Insulin–Glucose IV Infusion
Glucose 25g with 10 units soluble insulin over 15 - 30 min IV
(25g = 50ml 50% glucose; 125ml 20% glucose, 250ml 10% glucose)
If pre-treatment BG < 7.0 mmol/L:
Shift K+ Start 10% glucose infusion at 50ml/ hour for 5 hours (25g)
into cells
Risk of
Consider
hypoglycaemia

Salbutamol 10 – 20 mg nebulised
Consider Life-threatening
hyperkalaemia

*Sodium zirconium cyclosilicate *Sodium zirconium cyclosilicate

10g X3/day oral for 72 HRS OR 10g X3/day oral for 72 HRS OR
Remove K+ *Patiromer *Patiromer
from body 8.4G /day oral OR 8.4G /day oral
*Calcium resonium
15g X3/day oral
Consider Dialysis
*Follow local practice
Seek expert help

Monitor K+
and blood Monitor serum K+ and blood glucose
glucose K+ ≥ 6.5 mmol/L
despite medical
therapy

Prevention Consider cause of hyperkalaemia and prevent recurrence

Emergency treatment of hyperkalaemia. ECG – electrocardiogram; VT ventricular tachycardia. BG Blood Glucose

• Special Causes
• Hipóxia
• Hipovolémia
• PCR traumática ACCIDENTAL HYPOTHERMIA
• Anafilaxia
• Sépsis Core temperature <35°C or cold to touch
• Hipo/hipercaliémia
• Hipo/hipertermia
• Trombose Vital signs present
• TEP YES NO
• EAM
• Tamponamento cardíaco
• Pneumotórax hipertensivo • Obvious signs off irreversible death (1)
Impaired consciousness YES TO ANY Consider
• Valid DNR order
• Agentes tóxicos NO YES
withholding
• Conditions unsafe for rescuer or termination
• Avalanche burial >60 min, airway packed of CPR
with snow and asystole
• Special Patient Groups
Witnessed NO TO ALL
• Asma e DPOC Transport to nearest hospital
Prehospital cardiac instability
hypothermic
• Doenças neurológicas if injured; consider onsite or • SBP <90 mm Hg (2) cardiac arrest - • Start CPR, do not delay transport
hospital treatment if uninjured • Cardiocirculatory instability Start CPR • If continuous CPR is not possible, consider intermittent
• Obesidade
• Core temperature <32°C in old and or delayed CPR in difficult or dangerous rescue
• Gravidez multimorbid or <30°C in young and healthy • Airway management
• Core temperature <30°C max 3 defibrillations,
HT I (3) no epinephrine
NO TO ALL YES TO ANY
• Warm environment and dry clothing • Gather information of mechanism of accident
• Warm sweet drinks
• Active movement
YES
Transport to nearest
Cardiac arrest from alternative appropriate hospital or
cause prior to cooling manage as per
Transport to nearest Transport to hospital
• Avalanche burial <60 min supervising MD
appropriate hospital with ECLS (4)

NO

Transport to hospital with ECLS

HT II or III (3) (4); do NOT terminate CPR
• Minimal and cautious movements to avoid rescue
collapse
• Prevent further heat loss Consider prognostication to NO TO ANY
• Active external and minimally invasive rewarming determine benefit of ECLS (6)
techniques (5) • HOPE survival probability ≥10
• Airway management as required • ICE score <12

YES TO ANY
Cardiac
instability HT IV (3)
• Prepare for multi-organ failure and resolved No ROSC Consider
need for ECLS respiratory support • Rewarm with ECLS termination
• Post-resuscitation care • If ECLS not available within 6 hrs, CPR and of CPR
non-ECLS rewarming in peripheral hospital
• Rewarm to core temperature ≥32°C
12/10/2020
• Special Causes
• Hipóxia
• Hipovolémia
• PCR traumática
• Anafilaxia ICPR DELAYED AND INTERMITTENT CPR IN HYPOTHERMIC PATIENTS WHEN
CONTINUOUS CPR IS NOT POSSIBLE DURING DIFFICULT RESCUE MISSIONS
• Sépsis
• Hipo/hipercaliémia
• Hipo/hipertermia Cardiac arrest confirmed
• Trombose
• TEP
• EAM
• Tamponamento cardíaco Mechanical chest compression device available?
• Pneumotórax hipertensivo
• Agentes tóxicos YES NO

• Special Patient Groups

• Asma e DPOC Mechanical CPR Manual CPR
• Doenças neurológicas
• Obesidade
• Gravidez

Necessity to transport and inability for continuous CPR

Core temp <28°C

Core temp >28°C , Confirmed core
or unknown, unequivocal
patient warm temperature <20°C
hypothermic CA

Strongly consider HEMS or Alternating 5 min CPR and Alternating 5 min CPR and
wait for mechanical CPR ≤5 min without CPR ≤10 min without CPR
 • Special Causes
• Hipóxia
• Hipovolémia AVALANCHE RESCUE
• PCR traumática
• Anafilaxia
• Sépsis
• Hipo/hipercaliémia
• Special Settings • Hipo/hipertermia Assess patient at extrication
• Estabelecimentos de cuidados de saúde • Trombose
• BO • TEP
• Cirurgia Cardíaca • EAM Lethal injuries or Do not
YES
• Sala de Hemodinâmica • Tamponamento cardíaco whole body frozen start CPR
• Diálise • Pneumotórax hipertensivo
• Dentista • Agentes tóxicos NO
• Transporte
Duration of burial Universal ALS
• Avião (core temperature)1
≤60 MIN (≥30°C)
Algorithm2
• Helicoptero • Special Patient Groups
• Cruzeiros • Asma e DPOC >60 MIN (<30°C)
• Desporto • Doenças neurológicas Minimally
• Afogamento • Obesidade Vital signs3 YES invasive
ECG4
• Incidentes com múltiplas vítimas • Gravidez rewarming 5

Witnessed cardiac arrest

NO

VF, pVT, PEA or any vital signs

Universal ALS6

ASYSTOLE

YES or Consider Hospital

Patent airway7 HOPE survival ≥10%
uncertain with ECLS
probability8

NO

<10%
Consider termination
of CPR

1. Core temperature may substitute if duration of burial is unknown.

2. Transport patient with injuries or potential complications (e.g. pulmonary oedema) to the most appropriate hospital.
3. Check for spontaneous breathing, pulse and any other movements for up to 60 seconds.
4. Use additional tools for detection of vital signs (end-tidal CO2, arterial oxygen saturation (SaO2), ultrasound) if available.
5. Transport patients with core temperature <30°C, systolic blood pressure <90mmHg or any other cardiocirculatory
instability to a hospital with ECLS.
6. With deeply hypothermic patient (<28°C) consider delayed CPR if rescue is too dangerous and intermittent CPR with
difficult transport.
7. If airway is patent, the additional presence of an air pocket is a strong predictor for survival.
8. If HOPE is not possible, serum potassium and core temperature (cut-offs 7 mmol/L and 30°C) can be used but may be
less reliable.
Abbreviations: ALS Advanced life support, CPR cardiopulmonary resuscitation, ECLS extracorporeal life support, PEA
pulseless electrical activity, pVT pulseless ventricular tachycardia, SaO2 arterial oxygen saturation, VF ventricular fibrillation
• Special Causes
• Hipóxia

HYPERTHERMIA
• Hipovolémia
• PCR traumática
• Anafilaxia
• Sépsis
• Hipo/hipercaliémia YES
• Hipo/hipertermia Universal ALS
Require CPR?
algorithm TIME IS KEY: COOL AND RUN APPROACH
• Trombose
• TEP NO • Cool first, transfer to hospital after
• EAM • Immediate cooling
Bathtub, ½ to ¾ filled
• Tamponamento cardíaco water & ice, 1-17°C, • Rapidly cool to <39°C until symptoms resolve
• Pneumotórax hipertensivo stirred or circulated
• Agentes tóxicos Use a YES
Core temperature
temperature
>40.5ºC
probe Continue monitoring for at least
• Special Patient Groups 15 min after cooling
NO Rapid cooling (cold Stop cooling at core
• Asma e DPOC water immerssion) temperature <39°C • Rehydrate as required
• Doenças neurológicas • Check for improved mental status
Core temperature
• Obesidade ≤40.5ºC, & confused/ • Avoid accidental hypothermia
• Gravidez desoriented YES (<35°C)

NO

If abnormal mental state initiate IV

YES 100ml bolus of 3% saline at 10 min
Blood sodium Hyponatraemia
intervals, 2nd and 3rd bolus only
<130 mEq/L algorithm
if required. If normal mental state
administer oral sodium
NO

If abnormal mental state administer

YES IV normal saline or Ringer’s lactated.
Severely
dehydrated? If normal mental state provide oral
rehydration and sodium
NO

NO YES
Release with exercise Appropriate algorithm
Other symptoms
restrictions e.g. Hypoglycaemia
 • Special Causes
• Hipóxia
• Hipovolémia CORONARY THROMBOSIS
• PCR traumática
• Anafilaxia
• Sépsis
• Hipo/hipercaliémia 1. Prevent and be prepared
• Special Settings • Hipo/hipertermia • Encourage cardiovascular prevention to reduce the risk of acute events
• Estabelecimentos de cuidados de saúde • Trombose • Promote health education to reduce delay to first medical contact
• BO • TEP • Promote laypeople BLS to increase the chance of bystander CPR
• Cirurgia Cardíaca • EAM • Ensure adequate resources for better management
• Sala de Hemodinâmica • Tamponamento cardíaco • Improve quality management systems & indicators for better quality monitoring
• Diálise • Pneumotórax hipertensivo
• Dentista • Agentes tóxicos
• Transporte
• Avião 2. Detect parameters suggesting coronary thrombosis &
• Helicoptero • Special Patient Groups Activate STEMI network
• Cruzeiros • Asma e DPOC • Chest pain prior to arrest
• Desporto • Doenças neurológicas • Known coronary artery disease
• Afogamento • Obesidade • Initial rhythm VF or pVT
• Incidentes com múltiplas vítimas • Gravidez • Post-resuscitation ECG: ST elevation

3. Resuscitate and treat possible causes

Sustained ROSC No Sustained ROSC

STEMI patients No STEMI patients Assess setting & patient

Time from conditions and available
Individualise decisions
diagnosis to PCI resources
considering patient
< 120 min characteristics, OHCA If futility:
setting, ECG findings
Activate PCI Consider stopping CPR
laboratory Quick diagnostic work up
Discard non-coronary If no futility:
Transfer for
immediate PCI causes Consider transfer to PCI
Chest patient condition centre with on-going CPR
> 120 min
If there is on Consider mechanical
Perform pre-hospital going ischaemia compressions and extra-
fibrinolysis or haemodynamic corporeal CPR
Transfer to PCI compromise?
centre Consider PCI
Yes – immediate PCI
No - consider delayed PCI
TOXIC EXPOSURE

Toxic exposure

NO Risk of contamination? YES PPE1

Cardiac arrest/peri arrest? Universal ALS

YES algorithm
NO

Poison centre

If indicated:
• Avoid mouth-to-mouth breathing
Decontamination
• Continue resuscitation
Enhanced elimination
• Higher dose of medication
Antidote

• Try to identify the poison

• Consider hypo- or hyperthermia
• Exclude all reversible causes
 • Special Causes
• Hipóxia
• Hipovolémia CARDIAC SURGERY
• PCR traumática
• Anafilaxia
• Sépsis
• Hipo/hipercaliémia 1. Prevent and be prepared
• Special Settings • Hipo/hipertermia • Ensure adequate training of the staff in technical skills and ALS
• Estabelecimentos de cuidados de saúde • Trombose
• BO • TEP • Ensure availability and well-functioning of emergency equipment
• Cirurgia Cardíaca • EAM • Use safety checklists
• Sala de Hemodinâmica • Tamponamento cardíaco
• Diálise • Pneumotórax hipertensivo
• Dentista • Agentes tóxicos
• Transporte
• Avião 2. Detect cardiac arrest and activate cardiac arrest protocol
• Helicoptero • Special Patient Groups • Identify and manage deterioration in the post-operative cardiac patient
• Cruzeiros • Asma e DPOC • Consider echocardiography
• Desporto • Doenças neurológicas • Confirm cardiac arrest by clinical signs and pulseless waveforms
• Afogamento • Obesidade • Shout for help and activate cardiac arrest protocol
• Incidentes com múltiplas vítimas • Gravidez

3. Resuscitate and treat possible causes

Asystole / extreme
VF/pVT PEA
bradycardia

Correct potentially
Defibrillate
reversible causes
(apply up to 3 Apply early pacing
consecutive shocks) Turn off pacing to
exclude VF

No ROSC
• Initiate compressions and ventilation
• Perform early resteronotomy (<5 min)
• Consider circulatory support devices and extracorporeal-CPR
 • Special Causes
• Hipóxia
• Hipovolémia CARDIAC CATHETERISATION
• PCR traumática LABORATORY
• Anafilaxia
• Sépsis
• Hipo/hipercaliémia 1. Prevent and be prepared
• Special Settings • Hipo/hipertermia • Ensure adequate training of the staff in technical skills and ALS
• Estabelecimentos de cuidados de saúde • Trombose • Ensure availability and that equipment is functioning
• BO • TEP • Use safety checklists
• Cirurgia Cardíaca • EAM
• Sala de Hemodinâmica • Tamponamento cardíaco
• Diálise • Pneumotórax hipertensivo
• Dentista • Agentes tóxicos 2. Detect cardiac arrest and activate cardiac arrest protocol
• Transporte • Check patient’s status and monitored vital signs regularly
• Avião • Consider cardiac echocardiogram in case of haemodynamic instability or
• Helicoptero • Special Patient Groups suspected complication
• Cruzeiros • Asma e DPOC • Shout for help and activate cardiac arrest protocol
• Desporto • Doenças neurológicas
• Afogamento • Obesidade
• Incidentes com múltiplas vítimas • Gravidez
3. Resuscitate and treat possible causes

VF / pVT cardiac arrest Asystole / PEA

Defibrillate
(apply up to 3
consecutive shocks)

No ROSC

• Resuscitate according to ALS algorithm

• Check and correct potentially reversible causes including echocardiography
and angiography
• Consider mechanical chest compression and circulatory support devices
(including extracorporeal-CPR)
Post-resuscitation
care
Haemodynamic monitoring and management
• All patients should be monitored with an arterial line for continuous blood pressure
measurements, and it is reasonable to monitor cardiac output in haemodynamically
unstable patients.
• Perform early (as soon as possible) echocardiography in all patients to detect any
underlying cardiac pathology and quantify the degree of myocardial dysfunction.
• During targeted temperature management (TTM) at 33ºC, bradycardia may be left
untreated if blood pressure, lactate, ScvO2 or SvO2 is adequate. If not, consider
increasing the target temperature, but to no higher than 36ºC.
• Maintain perfusion with fluids, noradrenaline and/or dobutamine, depending on
individual patient need for intravascular volume, vasoconstriction or inotropy.
• Consider mechanical circulatory support (such as intra-aortic balloon pump, left-
ventricular assist device or arterio-venous extra corporal membrane oxygenation) for
persisting cardiogenic shock from left ventricular failure if treatment with fluid
resuscitation, inotropes, and vasoactive drugs is insufficient.
 Control of seizures
• We recommend using electroencephalography (EEG) to diagnose
electrographic seizures in patients with clinical convulsions and to monitor
treatment effects.
 Prognostication
• In patients who are comatose after resuscitation from cardiac arrest, neurological prognostication should
be performed using clinical examination, electrophysiology, biomarkers, and imaging, to both inform
patient's relatives and to help clinicians to target treatments based on the patient's chances of achieving
a neurologically meaningful recovery (Fig. 4).
• No single predictor is 100% accurate. Therefore, a multimodal neuroprognostication strategy is
recommended.
• When predicting poor neurological outcome, a high specificity and precision are desirable, to avoid falsely
pessimistic predictions.
• The clinical neurological examination is central to prognostication. To avoid falsely pessimistic predictions,
clinicians should avoid potential confounding from sedatives and other drugs that may confound the
results of the tests.
• When patients are treated with TTM, daily clinical examination is advocated but final prognostic
assessment should be undertaken only after rewarming.
 Prognostication
• In patients who remain comatose at 72 h or later after ROSC the following tests may predict a poor
neurological outcome:
• The bilateral absence of the standard pupillary light reflex.
• Quantitative pupillometry
• The bilateral absence of corneal reflex
• The presence of myoclonus within 96 h and, in particular, status myoclonus within 72 h
• We also suggest recording the EEG in the presence of myoclonic jerks to enable detection of any associated
epileptiform activity or EEG signs, such as background reactivity or continuity, suggesting a potential for
neurological recovery.
• Perform an EEG in patients who are unconscious after the arrest. Highly malignant EEG-patterns include
suppressed background with or without periodic discharges and burst-suppression. We suggest using these
EEG-patterns after the end of TTM and after sedation has been cleared as indicators of a poor prognosis.
• Use presence of generalised brain oedema, manifested by a marked reduction of the grey matter/white
matter ratio on brain CT, or extensive diffusion restriction on brain MRI to predict poor neurological
outcome after cardiac arrest.