Supplement to Circulation

2025 International Liaison Committee on Resuscitation Consensus on Science With

Treatment Recommendations

Editors
Katherine M. Berg (Sr. Co-Editor)
Jerry P. Nolan (Sr. Co-Editor)

Editorial Board
Katherine M. Berg (Sr. Co-Editor) Helen G. Liley (NLS Chair)
Jerry P. Nolan (Sr. Co-Editor) William H. Montgomery (ILCOR Coordinator)
Jaylen I. Wright (ILCOR, Science and Health Advisor) Peter T. Morley, MBBS (ILCOR Co-Chair)
Jason Acworth (PLS Vice Chair) Vinay M. Nadkarni (ILCOR Past Co-Chair)
Farhan Bhanji (ILCOR Treasurer) Robert W. Neumar (ILCOR Co-Chair)
Janet E. Bray (BLS Chair) Gavin D. Perkins (ILCOR Past Co-Chair)
Jestin Carlson (SAC Vice Chair) Jeanette K. Previdi (Chair, American Heart Association)
Siddha SC Chakra Rao (Chair, Indian Resuscitation Council) Yacov Rabi (SAC Chair)
Adam Cheng (EIT Vice Chair) Barnaby R. Scholefield (PLS Chair)
Sung Phil Chung (Chair, Resuscitation Council of Asia) Tony Scott (Chair, Australian and New Zealand Committee on
Resuscitation)
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Allan de Caen (Chair, Heart and Stroke Foundation of Canada)

Therese Djärv (First Aid Chair) Fredrico Semeraro (Chair, European Resuscitation Council)
Ian R. Drennan (ALS Chair) Markus B. Skrifvars (ALS Vice Chair)
Matthew J. Douma (First Aid Vice Chair) Michael A. Smyth (BLS Vice Chair)
Raffo Escalante-Kanashiro (Chair, InterAmerican Heart Foundation) David Stanton (Chair, Resuscitation Council of Southern Africa)
Robert Greif (EIT Chair) Gary M. Weiner (NLS Vice Chair)
Amber Hoover (Chair, International Federation of Red Cross and Joyce Yeung (ILCOR Secretary)
Red Crescent Societies)

Participating ILCOR Resuscitation Councils

American Heart Association Emergency Cardiovascular Care Committee
Australian and New Zealand Committee on Resuscitation
European Resuscitation Council
Heart and Stroke Foundation of Canada
Indian Resuscitation Council Federation
InterAmerican Heart Foundation
Resuscitation Council of Asia
Resuscitation Council of Southern Africa

Acknowledgments
We acknowledge the considerable contributions made by Melissa Mahgoub, PhD, Amber Rodriguez, PhD, Jaylen Wright, PhD, and
Veronica Zamora, as well as Paula Blackwell, Carla Bonnett, Julie Eisele, Gabrielle Hayes, Sarah Johnson, Joe Loftin, Tory Price,
Michelle Reneau, and Julie Scroggin
 Circulation

Methodology and Conflict of Interest

Management: 2025 International Liaison
Committee on Resuscitation Consensus on
Science With Treatment Recommendations
Peter T. Morley; Katherine M. Berg; John E. Billi; Jerry P. Nolan; William H. Montgomery; Dianne L. Atkins;
Janet E. Bray, BLS Chair; Jestin N. Carlson; Allan R. de Caen; Therese Djärv, FA Chair; Ian R. Drennan, ALS Chair;
Robert Greif, EIT Chair; Eric J. Lavonas; Helen G. Liley, NLS Chair; Andrew S. Lockey; Ian Maconochie; Robert W. Neumar;
Theresa M. Olasveengen; Aaron M. Orkin; Gavin D. Perkins; Yacov Rabi; Claudio Sandroni; Georg M. Schmölzer;
Barnaby R. Scholefield, PLS Chair; Eunice M. Singletary; Michelle Welsford; Joyce Yeung; Laurie J. Morrison

“Quality in a service or product is not what you put contribute to the prioritization of questions, the col-
into it. It is what the client or customer gets out of it.” lection and interpretation of data, and the creation of
guidance.
–Peter Drucker
ILCOR publishes summaries of the evidence evalua-
tion output each year (as it has since 2017).1,2 In 2025,
as was done in 2020, a more comprehensive update
INTRODUCTION
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is provided, including the past year’s work as well as

The International Liaison Committee on Resuscita- key components of all reviews done in the preceding 4
tion (ILCOR) mission is to promote, disseminate, and years.3–10
advocate for international implementation of evidence- ILCOR has continued to use 3 main approaches to
informed resuscitation and first aid by using transpar- support its guidance: the systematic review (SysRev),
ent evaluation and consensus summary of scientific the scoping review (ScopRev), and evidence updates
data. Six ILCOR task forces work to create the con- (EvUps). These are outlined in more detail later in
sensus on science with treatment recommendations this article. The processes undertaken by ILCOR to
(CoSTR): Advanced Life Support; Basic Life Support; evaluate the evidence are based on the evolving rec-
Education, Implementation, and Teams; First Aid; Neo- ommendations of Preferred Reporting Items for Sys-
natal Life Support; and Pediatric Life Support. Each tematic Reviews and Meta-Analyses (PRISMA)11 and
task force has 17 active members, with emeritus mem- of Grading of Recommendations Assessment, Devel-
bers frequently contributing to task force work; ILCOR opment, and Evaluation (GRADE). ILCOR uses the
accepts applications for task force membership yearly, online project management tool ProofHub12 to provide
and resuscitation and first aid experts from around the a framework for a consistent sequence of steps for
world apply. Applications are considered by the ILCOR each type of review and to provide a repository for all
board, the Scientific Advisory Committee, and current documents. Instructional documents and presentations
task force chairs and vice chairs. Terms are generally are provided for guidance, and checklists are created
3 years, with members eligible for a second 2-year to ensure completion of key steps.13
term. Including task force members and external con- The type of guidance given by ILCOR for each topic
tributors, hundreds of volunteers from across the globe is also based on the published material from the GRADE

Key Words: Scientific Statements ◼ cardiopulmonary resuscitation ◼ first aid ◼ heart arrest ◼ ILCOR ◼ methods ◼ resuscitation

© 2025 American Heart Association, Inc., European Resuscitation Council, and International Liaison Committee on Resuscitation.
Circulation is available at [Link]/journal/circ

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 Morley et al Methodology and Conflict of Interest Management: 2025 CoSTR

working group and is in the form of either treatment rec- previously been evaluated. Each task force maintains a
ommendations (with strength of recommendation and master list of questions for which it aims to provide up-
certainty of the supporting evidence) or good practice dated guidance, and ILCOR strives to update all topics at
statements. least once every 5 years.

What Is a PICOST?
THE EVIDENCE EVALUATION PROCESS
The identified topics are translated into a template based
The steps undertaken during the exploration of the sci- on the standard PICO (population, intervention, compara-
entific literature and creation of new treatment recom- tor, outcome) format with 2 additional components (study
mendations are outlined in Table 1. Several of these design and time frame). Most questions, including diag-
steps, discussed in more detail in this section, relate nostic studies, can use this framework, but several other
mainly to performing a SysRev for questions addressing variations have been used. Alternatives used include
the impact of an intervention. Specific variations based population, exposure, comparator, outcome and popula-
on question type or other reviews (eg, ScopRevs) are tion, concept, context.14
also included.

PICOST Template Review by Task Force

Framing a Question The task force reviews the individual components of the
Which Questions? template created to facilitate the next steps in the review.
A vast array of topics could be explored, so ILCOR must This includes deciding what outcomes are prioritized as
prioritize the questions to ask. The ILCOR task forces critical. The outcomes that are deemed critical can im-
seek input from task force members, ILCOR member pact the certainty of evidence assigned to a treatment
organizations (guideline-writing organizations through- recommendation, because the certainty of evidence for
out the world), and independent input (via the internet a recommendation is defined by the certainty of evi-
or social media). Among factors taken into consider- dence for the critical outcomes. For example, if there is
ation when prioritizing questions are the impact on criti- high-certainty evidence for an important outcome but
cal and important outcomes, the extent of controversy low-certainty evidence for the critical outcomes, a treat-
or uncertainty about effectiveness or cost-benefit of an ment recommendation will be described as supported by
low-certainty evidence. Outcomes and their categoriza-
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intervention, and the emergence of science that has not

tion as critical or important are specified a priori, though
occasionally the outcomes (and their allocated priorities)
Table 1. Outline of the ILCOR Systematic Review Process need to be revisited after the literature search has been
Develop PICOST (including inclusion and exclusion criteria)
completed. There is also discussion about whether any
subgroup analyses should be prespecified and whether
Confirm content expert team
there are any key publications to help the development
Allocate level of importance to individual outcomes
of the search strategies. A modified PICOST template
Develop and fine-tune database-specific search strategies is used to assist with other types of questions such as
Register review with PROSPERO those relating to diagnostic test accuracy.
Conduct search in at least 3 databases
Screen articles identified according to inclusion and exclusion criteria
Content Experts
Compile final list of studies to include
A team of content experts is nominated by the task
Assess bias for individual studies
force for each PICOST. This team comprises members
Extract data for creation of tables
of the task force, an ILCOR Scientific Advisory Commit-
Create GRADE evidence profile table tee representative, and other invited individuals sourced
Complete evidence-to-decision framework from international contacts. In some situations, the ques-
Draft CoSTRs tions are within the scope of multiple task forces (eg,
Revise draft of CoSTR
Basic Life Support and Pediatric Life Support; Education,
Implementation, and Teams; and Neonatal Life Support).
Create summary statement
In these nodal reviews, a task force will take the lead,
Invite public to comment on draft CoSTRs
and 1 or 2 content experts from contributing task forces
Create final CoSTR version for posting and publication will be part of the review team. The task force chairs are
CoSTR indicates consensus on science with treatment recommendations; required to check the conflict-of-interest disclosures for
GRADE, Grading of Recommendations Assessment, Development, and Evalu- the content expert team members and resolve any po-
ation; ILCOR, International Liaison Committee on Resuscitation; PICOST, popu-
lation, intervention, comparator, outcome, study design, and time frame; and
tential conflicts according to the ILCOR conflict of inter-
PROSPERO, Prospective Register of Systematic Reviews. est (COI) policy (vide infra).

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 Morley et al Methodology and Conflict of Interest Management: 2025 CoSTR

Searching the Literature criteria for the type of studies to be included: this is usu-
ally comparative studies (whether randomized or not), but
Once the PICOST has been completed and the review
sometimes they are more restrictive (eg, only random-
team assembled, the search strategies for the required
ized controlled trials if there are known to be a number
databases are finalized. In many situations, similar ques-
of these already published).19 Discrepancies in decisions
tions have already been created, so the search strategies
regarding inclusion are usually resolved by engaging an
may only need to be adapted and updated. Otherwise,
additional adjudicating reviewer or reviewers from within
new search strategies are created using the nuances of
the content expert team. The full list of included stud-
the specific PICOST. At a minimum, it is expected that
ies is then reviewed by the task force to ensure critical
Medline, Embase, and Cochrane databases are searched.
omissions have not occurred. While ILCOR has not yet
Searches are also performed for ongoing or unpublished
adopted the use of artificial intelligence for the screen-
clinical trials by searching the International Clinical Tri-
ing and inclusion stage of reviews, this is a topic currently
als Registry Platform15 and US clinical trials registry.16
under discussion.
These may also be identified by the search of the Co-
chrane CENTRAL database.17 Additional databases and
search strategies are added when deemed essential for Bias Assessment
the specific question being asked. The search for some The individual studies are then assessed for risk of bias;
questions will focus on studies involving only human par- ILCOR uses the revised Cochrane Risk of Bias 2 (RoB 2)
ticipants, but for other questions where most available or tool20 for randomized controlled trials and the Risk of Bias
relevant evidence is from animal studies or manikin stud- in Nonrandomized Studies of Interventions (ROBINS-
ies, different iterations of the search may be required to I)21 tool for nonrandomized studies. The RoB 2 tool as-
ensure that relevant studies are identified. sesses individual studies across 5 domains, with the
It is expected that all languages be included in the overall result for each study being either low risk of bias,
search, provided there is an English abstract to enable some concerns, or high risk of bias.20 The ROBINS-I tool
screening. When multilingual authors are engaged in assesses studies across 7 domains, with the overall re-
the content expert teams or are brought in for help with sult for each study being either low risk of bias, moderate
translation, additional non-English abstracts can also be risk of bias, serious risk of bias, critical risk of bias, or
screened. Information specialists work with the content no information.21 The risk of bias may vary for different
expert team to develop and modify these search strate- outcomes within a given study, and the content experts
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gies. The overarching philosophy is to create a sensitive are expected to comment on this. Other risk-of-bias tools
search, so these searches often result in many thou- are used for studies involving assessment of diagnostic
sands of studies to be screened. test accuracy or prognostication (eg, Quality in Prognosis
Studies or Quality Assessment of Diagnostic Accuracy
Register the PICOST With PROSPERO Studies 2 tool).22 The risk of bias for included studies
(both overall and, if there are wide differences, for spe-
All SysRevs performed by ILCOR are expected to be reg- cific outcomes) is then displayed in a table.
istered in an international database of prospectively reg-
istered SysRevs (called PROSPERO).18 This step should
be performed before data extraction and is included for Data Extraction
several reasons, including transparency of the process, Relevant data from individual studies and their outcomes
avoidance of unnecessary duplication, and discouraging are extracted and used to populate summary tables and
reporting bias. GRADE tables (such as evidence profile tables). The
ILCOR content expert teams use GRADEPro23 to input
Screening the Studies their data into relevant tables, which are included in the
The content expert team allocates its members to en- published SysRevs.
sure at least 2 independent authors screen the studies
in alignment with prespecified inclusion and exclusion
criteria. These criteria are based on whether the study Combining Data Into GRADE Tables
addresses the prespecified population, intervention, and The GRADE evidence profile tables enable an assess-
comparator, although for questions where little evidence ment of the totality of data across the identified pub-
is available, indirect evidence (eg, from animal or simula- lished studies for a prioritized outcome (see example in
tion studies) may also be considered. The initial screen Table 2). GRADE tables enable inclusion of key features
is performed by using titles and abstracts (employing of the extracted data from the identified studies that an-
an online program, such as Covidence or Rayyan), fol- swer the question and report the outcome of interest.
lowed by full text review of those papers included after In addition to the importance of the outcome, and the
the initial abstract screen. Many PICOSTs also specify number and type of studies included, the evidence profile

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 Morley et al Methodology and Conflict of Interest Management: 2025 CoSTR

Table 2. GRADE Evidence Profile Table for Intervention: Prehospital Critical Care Compared With Advanced Life Support for
Patients With Out-of-Hospital Cardiac Arrest24
Certainty assessment No. of patients Effect

Prehospital
Studies Study Risk Other critical care, Advanced life Relative Absolute
(subjects), n design of bias Inconsistency Indirectness Imprecision considerations n (%) support, n (%) (95% CI) (95% CI) Certainty Importance

Survival to hospital admission/return of spontaneous circulation: nontrauma

8 Nonran- Serious* Not Not serious Serious† None 6035/31 337 50 789/608 423 OR, 1.95 67 more per 1000 Low Critical
domized serious (19.3) (8.3) (1.35–2.82) (from 26 more to
studies 121 more)

GRADE indicates Grading of Recommendations Assessment, Development, and Evaluation; and OR, odds ratio.
*ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) tool assessment.
†Some studies not reporting number of events or totals. Some studies with imprecise effect estimates with wide confidence intervals.

table displays an overall assessment of risk of bias Meta-Analyses

(across all included studies), inconsistency, indirectness, The ILCOR review team evaluates the extracted data
imprecision, and other potential influencing factors.25,26 from the identified studies in several ways. Data from
These tables also include absolute outcomes (with nu- each study are ideally expressed in both relative and
merator and denominator) and, where data have been absolute terms, with 95% confidence intervals. If it is
combined, a relative and absolute comparison. Similar agreed that the population of interest, the intervention,
GRADE evidence profile tables are created when asking the comparator, and the outcome being assessed do
questions about diagnostic test accuracy (see example not differ in any substantive ways between the identified
in Table 3). studies, a meta-analysis is considered. There are many
The overall certainty of evidence for each specified subtle variations in published definitions (for example,
outcome is quantified as high, moderate, low, or very low survival outcomes at 30 days versus hospital discharge)
(Table 3).28 The strongest supportive evidence for an and year of resuscitation (where cohorts of patients were
interven­tion is a collection of randomized controlled tri- exposed to different cardiopulmonary resuscitation pro-
als; this evidence would start at high certainty but may be tocols, including advanced life support interventions). If
downgraded according to the factors listed above (con- data are included in a meta-analysis, it is expected that
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sidered in the GRADE Evidence Profile tables).28 Some appropriate sensitivity analyses are performed to assess
reviews use the GRADE summary table as an alternative the impact of key variables (including magnitude of study
way of describing the data (Table 4). bias).

Table 3. GRADE Evidence Profile Table for Diagnostic Test Accuracy: The Index Test of Bedside Sonographic Assessment
During CPR in Adults in Cardiac Arrest in Any Setting27
Certainty assessment Subjects, n Effect

Events Sensitivity
/test (+) (95% CI)
Studies Study Risk of Other Events Specificity
Outcome (subjects), n design bias Indirectness Inconsistency Imprecision considerations /test (−) (95% CI) Certainty

Myocardial infarction (index test = reduced contractility in a region of myocardium and reference standard = autopsy or clinical adjudication)

True positive (subjects with 1 (13) Cohort Very Serious§ Serious‖ Serious¶ None 12/13 0.86 Very low
myocardial infarction) study serious*†‡ (0.57–0.98)

False negative (subjects

incorrectly classified as not
having myocardial infarction)

True negative (subjects without 1 (18) Cohort Very Serious§ Serious‖ Serious¶ None 2/16 0.94 Very low
myocardial infarction) study serious*†‡ (0.71–0.99)

False positive (subjects

incorrectly classified as having
myocardial infarction)

CPR indicates cardiopulmonary resuscitation; and GRADE, Grading of Recommendations Assessment, Development, and Evaluation.
*Convenience sample with unknown proportion of eligible cardiac arrest subjects enrolled.
†Blinding to the index test is not specified.
‡Differential verification bias.
§Includes cardiac arrest subjects with spontaneous cardiac contractility with or without effective cardiac output (eg, pulseless electrical activity or “peri–return of
spontaneous circulation” states).
‖Only 1 study available; indicative that the literature is not well established.
¶Wide confidence intervals that render a range of clinical interpretation.

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 Morley et al Methodology and Conflict of Interest Management: 2025 CoSTR

Table 4. GRADE Summary of Findings Table for Diagnostic Test Accuracy: The Index Test of Bedside Sonographic Assessment
During CPR in Adults in Cardiac Arrest in Any Setting27

Posttest Posttest
Pretest probability probability
Studies probability following a following a
(subjects), Sensitivity Specificity of target positive POCUS negative POCUS
Outcome n (95% CI) (95% CI) condition (95% CI) (95% CI)
Myocardial infarction 1 (31) 0.86 0.94 0.25 0.83 (0.40–0.97) 0.05 (0.01–0.17)
Index test: reduced contractility in a region of myocardium (0.57–0.98) (0.71–0.99)
0.50 0.93 (0.66–0.99) 0.13 (0.02–0.38)
Reference standard: autopsy or clinical adjudication
0.75 0.98 (0.86–1.00) 0.31 (0.06–0.64)

CPR indicates cardiopulmonary resuscitation; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; and POCUS, point-of-care ultra-
sound.

GRADE Evidence-to-Decision Framework working group has also proposed variations in wording to
try to simplify the message, and ILCOR is working with
The GRADE working group developed the evidence-
these suggestions to determine their value.31
to-decision framework to help evidence reviewers to
develop clinical recommendations. It explicitly and trans- Treatment Recommendations
parently requests that evidence reviewers consider The goal of ILCOR’s SysRevs, with the collaboration of
specific criteria, including priority of the problem, benefits the international content experts, is to produce treat-
and harms, certainty of the evidence, resource and equity ment recommendations wherever possible. The wording
implications, cost-benefit, acceptability, and feasibility.29 of the recommendation represents the strength of the
All ILCOR SysRevs are expected to have an accompa- recommendation (which can be strong or weak): we rec-
nying evidence-to-decision table.30 These are presented ommend (strong recommendation) or we suggest (weak
and discussed at task force meetings as they finalize recommendation). The certainty of evidence to support the
their CoSTRs. The evidence-to-decision tables for the recommendation is also included (as listed above): high,
SysRevs are provided in Appendix A of each section. moderate, low, or very low.32 In some situations, this may be
easy and obvious, based on the data identified. It is a reality
that for most PICOSTs, there is either low-certainty or very
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Consensus on Science With Treatment low–certainty evidence for most outcomes. The evidence-
Recommendations to-decision framework considerations may also influence
whether a general or universal treatment recommendation
Consensus on Science
can be made (for example, if an intervention involves such
The consensus on science is produced from the evi-
substantial cost or complexity that it is unlikely to be ac-
dence identified by the SysRev and is a written repre-
cessible in all locations, or if benefit is only demonstrated
sentation of the GRADE Evidence Profile table. For each
for a specific subgroup). Therefore, weak recommenda-
outcome of interest, the consensus on science describes
tions can also include specific subtypes, such as condi-
the number and methodological type of studies, the num-
tional (depending on patient values, resources available,
ber of patients involved, the overall certainty of evidence
or setting), discretionary (based on opinion of patient or
(including reasons for adjusting/downgrading), the di-
practitioner), or qualified (by an explanation regarding the
rection of the evidence, and a description of both relative
issues that would lead to different decisions).33
and absolute outcomes (either individually or combined).
For example, the evidence for the effect of the intraosse- Good Practice Statements
ous compared with the intravenous route for medications In the past, if a weak recommendation could not be made,
during cardiac arrest would be worded as follows: For the ILCOR task forces have often opted for a statement
the critical outcome of survival at 30 days, we identified that includes the words there is insufficient evidence to or
moderate-certainty evidence (downgraded for serious the confidence in effect estimates is so low that the task
imprecision) from 3 randomized controlled trials enroll- force considers a recommendation is too speculative. The
ing 9272 adults with out-of-hospital cardiac arrest, which concern has always been that if there is not clear evi-
showed no benefit from the intraosseous route compared dence to point the task force one way or the other, then
with the intravenous route (odds ratio 0.99, 95% confi- the most transparent option is to say nothing at all. How-
dence interval 0.84–1.17; absolute effect 1 fewer per ever, at times it is unhelpful if the collection of interna-
1000, 95% confidence interval 10 fewer to 11 more). tional minds is unable to give some guidance, even in the
These statements are valuable, but the formulaic style absence of a robust signal from the evidence reviewed.
is not ideal for summarizing all types of evidence. The The GRADE working group has given some guid-
annual CoSTR summary generally uses plain English ance around criteria that they believe would support
to convey the key points of each review. The GRADE a statement that is not an evidence-based treatment

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 Morley et al Methodology and Conflict of Interest Management: 2025 CoSTR

recommendation. The ILCOR task forces use good prac- Scoping Reviews
tice statements when they believe the statements have The first ScopRev by ILCOR was published in 2020,39
met the prerequisite criteria, including a message that is and many ScopRevs have been or are currently being un-
necessary, clear, and actionable; rationale that is based dertaken and published by the 6 task forces. A ScopRev
on indirect evidence; and implementation that will result enables the reviewer to explore (scope) the literature to
in a positive benefit.34,35 The GRADE working group also determine what, if any, next steps may be indicated.14 The
recommends that the evidence-to-decision framework priority of a ScopRev is to determine what populations,
be used to guide a good practice statement, and the task interventions, and outcomes have been investigated, and,
forces have begun to implement this guidance.35 therefore, it starts with a broad search. This usually in-
cludes unpublished manuscripts as well as other types of
Public Comment gray literature (protocols, reports, guidelines, etc). The in-
formation identified is then grouped into thematic areas.
The ILCOR website is used for the posting of all draft Data are extracted from the studies to facilitate broad
CoSTRs from SysRevs, as well as draft ScopRevs. These comparisons, but, unlike a SysRev, there is no formal at-
documents are made available on the ILCOR CoSTR tempt to assess methodological quality of included stud-
website,30 and public comment is invited. The comments ies and, therefore, no need for any meta-analyses. The
made are visible to all and are reviewed by members searches may identify many articles, and the workload is
of the ILCOR task forces. The type of response to the often greater than a focused SysRev.
public comments varies for each question and each task The process that a ScopRev follows is otherwise
force, but any substantive scientific insights are consid- similar to a SysRev, including creation of a PICOST and
ered and, where appropriate, adjustments are made to completion of a modified PRISMA template,40 though
the CoSTR. the end-product is typically a narrative description of
findings (including gaps) and a recommendation about
Guideline Development by Writing Groups whether any SysRevs should be completed. Given the
limitations in methodology, there is no possibility of cre-
Resuscitation guideline writing groups around the globe
ating new treatment recommendations from a ScopRev,
are invited to use the published drafts on the ILCOR
but the task force may at times consider a good practice
CoSTR website. These stay in draft form until they are
statement. If that is the case, ILCOR is adopting the rec-
formally published in the yearly summary documents. The
ommended practice of also completing an evidence-to-
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summary CoSTR manuscripts submitted for publication

decision table.35
are also made available as preprints on the ILCOR web-
site several months before the final online publication. Evidence Updates
ILCOR’s EvUps were created to help task forces de-
Other ILCOR Reviews termine if they need to formally revisit ScopRevs or
The ILCOR task forces conduct several other types of SysRevs. Authors follow specific EvUp guidance and a
reviews that are incorporated into the summary CoSTR worksheet template to document their findings. Rerun-
publications. These include adolopment, ScopRevs, and ning the original search in at least one of the original
EvUps. These were all available for use for the 2020 datasets accessed in the existing SysRev enables iden-
CoSTR publication.36,37 tification of studies published since the prior review
and an assessment of whether the GRADE tables, the
Adolopment evidence-to-decision table, and the CoSTR needed to
The GRADE working group introduced the concept of be updated. Ideally, these searches would be run on a
adolopment to facilitate the combination of adoption, continuous basis, but pragmatically, the results of the
adaptation, and de novo development of recommenda- searches are reviewed every 12 to 24 months, or less
tions.38 The ILCOR task forces may identify recently frequently if other methods of literature surveillance sug-
performed SysRevs and meta-analyses. ILCOR has de- gest that a longer interval is reasonable. This process
veloped a process to review the published manuscript enables the task forces to determine when a CoSTR
and consider whether it is methodologically sufficiently needs to be updated, but treatment recommendations
similar (eg, search strategy and databases searched, in- cannot be changed based on an EvUp alone. In some
clusion/exclusion criteria, scientific rigor) to incorporate cases, task forces have conducted EvUps of topics with
its findings. The additional requirements are usually to up- older treatment recommendations that were not based
date the search and to complete an evidence-to-decision on SysRevs, as the ILCOR process has evolved to be-
table. This enables the task force to conclude whether come more rigorous over the past several years. In some
a consensus on science statement and, if appropriate, of these cases, existing treatment recommendations (of-
treatment recommendations can be made based on the ten dating back to 2010 or before) were withdrawn or
evidence identified in the adoloped review. converted to good practice statements if direct evidence

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 Morley et al Methodology and Conflict of Interest Management: 2025 CoSTR

to support them was not identified. The complete EvUp Ongoing Challenges and Opportunities
worksheets are provided in Appendix B of each section.
The world of evidence evaluation continues to evolve.
There are regular updates to guidance and recommen-
Management of Potential Conflicts of Interest dations including for PRISMA and GRADE. Many of the
Throughout the Process future processes may well become streamlined or even
assisted with artificial intelligence software. Some of the
To ensure the integrity of the evidence evaluation and key issues are discussed below.
consensus on science processes, ILCOR follows rigor-
ous COI management policies at all times. A full descrip- Newer Analytic Approaches
tion of these policies and their implementation can be The advances in computing and sophistication in statisti-
found in the ILCOR Internal Rules.41,42 Any person in- cal analyses have enabled several additional approaches
volved in any part of the process discloses all commer- to evaluating the literature. These have strong method-
cial relationships and other potential conflicts by using ological support, but how they are integrated with the
the ILCOR online COI disclosure process. All participants standard interpretation of evidence is still evolving.
always have access to this full list of disclosures through
Network Meta-Analysis
the ILCOR website, including both during and between
Network meta-analysis is a statistical tool that enables
meetings. COI is also included in each ILCOR publication
researchers to compare multiple treatments at once,
so that it can be referenced easily by readers.
even when treatments have not been directly compared
Each year from 2020 to 2024, ILCOR processed
with each other. Like all analyses, there are some specif-
between 100 and 400 COI declarations. In addition
ic assumptions that are made. These include transitivity
to disclosing commercial relationships, volunteers are
(assuming that factors affecting outcomes are similarly
asked to be sensitive to any potential intellectual con-
distributed) and coherence (consistency between direct
flicts, such as having authored key studies related to a
and indirect evidence). The GRADE working group has
topic or involvement in ongoing studies related to a topic.
published some guidance when considering network
All disclosures are considered by the ILCOR Board in
meta-analyses.43 These analyses are increasingly being
the selection of task force chairs, vice chairs, members,
adopted by resuscitation scientists.44
and other leadership roles. Relationships and potential
for COI are reviewed by task force chairs when assign- Bayesian Analysis
Downloaded from [Link] by on October 27, 2025

ing individual PICOST questions to task force members Bayesian analyses enable assessment of the likelihood
or content experts so that COI can be minimized. The of an outcome in the context of existing beliefs about
selection criteria for the lead reviewers on a given topic the effects of interventions. This results in an estimate of
include ensuring that the lead reviewers do not have any probabilities around the size of the effect (described as
commercial relationships that could pose a conflict. a 95% credible interval). Bayesian analyses are also be-
Participants, task force chairs, task force members, coming more common in the resuscitation literature45,46
staff, and the COI chair and vice chair raise COI ques- and can be combined with network meta-analyses.47
tions and issues throughout the process and refer them
to the COI chair or vice chair if they cannot be resolved Artificial Intelligence
within the task force. The COI chair keeps a log of each A detailed review of the science to support resuscitation
COI-related issue and its resolution. None of the COI can be labor intensive. Artificial intelligence in its many
issues for the work in this 2025 CoSTR required serious guises may well be able to assist in components of the
intervention, such as replacement of anyone in a leader- evidence evaluation process. These include developing
ship role. When a commercial relationship or intellectual search strategies, conducting regular searches, screening
conflict was discovered for a specific PICOST question, identified studies, extracting data from included studies,
that conflict was reviewed, roles within the team may summarizing the findings, and assisting in the develop-
have been adjusted, and at times the question was reas- ment of treatment recommendations. Online software for
signed to a content expert without a potential conflict. many of these is already commercially available. While
During conferences, a full list of disclosures is available ILCOR has not yet incorporated the use of artificial intel-
to all participants throughout the meeting. Participants ligence into its processes, how this could enhance the IL-
are asked to state any potential conflict when they par- COR review process is being considered and discussed.
ticipate in discussions, and they abstain from voting on
any issue for which they had a conflict. COI committee
representatives are available during conferences for Summary
anonymous reporting; no such reports were received ILCOR’s evidence evaluation process enables summaries
from 2021 to 2025. In addition, all ILCOR Board and of resuscitation science and facilitates the development
General Assembly meetings begin with a reminder of our of treatment recommendations and good practice state-
COI policies. ments. The rigor of the evidence evaluation process and

Circulation. 2025;152(suppl 1):S23–S33. DOI: 10.1161/CIR.0000000000001366 October 21, 2025 S29

 Morley et al Methodology and Conflict of Interest Management: 2025 CoSTR

its responsiveness to the needs of the international com- Rabi Y, Sandroni C, Schmölzer GM, Scholefield BR, Singletary EM, Welsford M,
Yeung J, Morrison LJ. Methodology and conflict of interest management: 2025
munity are essential if ILCOR is to continue to achieve its International Liaison Committee on Resuscitation Consensus on Science With
vision of saving more lives globally through resuscitation. Treatment Recommendations. Circulation. 2025;152(suppl 1):S23–S33. doi:
10.1161/CIR.0000000000001366
This article has been copublished in Resuscitation. Published by Elsevier Ire-
land Ltd. All rights reserved.
ARTICLE INFORMATION
The American Heart Association requests that this document be cited as follows: Acknowledgment
Morley PT, Berg KM, Billi JE, Nolan JP, Montgomery WH, Atkins DL, Bray JE, The authors wish to thank Jaylen I. Wright for his organizational and administra-
Carlson JN, de Caen AR, Djärv T, Drennan IR, Greif R, Lavonas EJ, Liley HG, tive assistance in the preparation of this paper through the various stages of
Lockey AS, Maconochie I, Neumar RW, Olasveengen TM, Orkin AM, Perkins GD, review and publication.

Disclosures

Writing Group Disclosures

Writing Other Consultant/

group Research research Speakers’ bureau/ Expert Ownership advisory
member Employment grant support honoraria witness interest board Other
Peter T. University of Melbourne None None None None None None None
Morley (Australia)
Jerry P. Warwick Medical None None None None None None None
Nolan School, University of
Warwick Coventry
(United Kingdom)
Katherine M. Beth Israel Deaconess None None None None None AHA/ILCOR† None
Berg Medical Center and Har-
vard Medical School
Dianne L. University of Iowa None None None None None None None
Atkins
John E. Billi The University of Michi- None None None None None None None
gan Medical School
Janet E. Bray Monash University Australian Resuscitation None None None None None Elsevier†;
Downloaded from [Link] by on October 27, 2025

and Curtin University Council†; Laerdal Heart

(Australia) Foundation†; Heart Foundation
Foundation of Australia† of Australia†
Jestin N. Allegheny Health Net- None None None None None None None
Carlson work
Allan R. de Alberta Health Services None None None None None None None
Caen and University of
Alberta (Canada)
Therese Karolinska Institutet and None None None None None None None
Djärv Karolinska University
Hospital (Sweden)
Ian R. Sunnybrook Health Sci- ZOLL Medical† None Speakers’ bureau: None None None None
Drennan ence Centre and Univer- ZOLL Medical†,
sity of Toronto (Canada) Relationship: Myself
Robert Greif University of Bern None None None None None None None
(Switzerland)
Eric J. Denver Health None None None None None AHA/ILCOR† None
Lavonas
Helen G. The University of None None None None None None None
Liley Queensland (Australia)
Andrew S. Calderdale Royal Hos- None None None None None None None
Lockey pital (United Kingdom)
Ian Imperial College NHS None None None None None None None
Maconochie Healthcare Trust and
Centre for Reviews and
Dissemination (United
Kingdom)
William H. Straub Clinic and None None None None None ILCOR† None
Montgomery Hospital

(Continued )

S30 October 21, 2025 Circulation. 2025;152(suppl 1):S23–S33. DOI: 10.1161/CIR.0000000000001366

 Morley et al Methodology and Conflict of Interest Management: 2025 CoSTR

Writing Group Disclosures Continued

Writing Other Consultant/
group Research research Speakers’ bureau/ Expert Ownership advisory
member Employment grant support honoraria witness interest board Other
Laurie J. St. Michael's Hospital None None None None None None None
Morrison and University of
Toronto (Canada)
Robert W. University of Michigan NIH†; Laerdal Founda- None None None None None None
Neumar tion*; BrainCool*; Corpuls*
Theresa M. Oslo University None None None None None Laerdal None
Olasveengen Hospital and University Foundation*
of Oslo (Norway)
Aaron M. University of Toronto None None None None None None None
Orkin (Canada)
Gavin D. Warwick Medical None None None None None None Elsevier†
Perkins School and University
Hospitals NHS
Foundation Trust (Unit-
ed Kingdom)
Yacov Rabi University of Calgary None None None None None None None
(Canada)
Claudio Università Cattolica None None None None None None None
Sandroni del Sacro Cuore -
Fondazione Policlinico
Universitario A. Gemelli
– IRCCS (Italy)
Georg M. University of Alberta None None None None None None None
Schmölzer (Canada)
Barnaby R. Hospital for Sick None None None None None None None
Scholefield Children (Canada)
Eunice M. UVA Health Sciences None None None None None None None
Singletary Center and University
of Virginia
Downloaded from [Link] by on October 27, 2025

Michelle McMaster University, None None None None None None None
Welsford Hamilton Health
Sciences (Canada)
Joyce Yeung University of Warwick, None None None None None None None
Warwick Medical School
(United Kingdom)
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Reviewer Disclosures

Other Speakers’ Consultant/

Research research bureau/ Ownership advisory
Reviewer Employment grant support honoraria Expert witness interest board Other
Fredrik Folke Gentofte University Hospital, None None None None None None None
Hellerup (Denmark)
Joel Lexchin University Health Network None None None None None None None
(Canada)
Robert T. University of North Texas None None None None None None None
Mallet Health Science Center
Taylor Sawyer Seattle Children’s Hospital/ None None None Gideon, Essary, Tardio None Verathon Inc.† None
University of Washington & Carter, PLC*
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-
tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any
12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of
the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Circulation. 2025;152(suppl 1):S23–S33. DOI: 10.1161/CIR.0000000000001366 October 21, 2025 S31

 Morley et al Methodology and Conflict of Interest Management: 2025 CoSTR

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Circulation. 2025;152(suppl 1):S23–S33. DOI: 10.1161/CIR.0000000000001366 October 21, 2025 S33

 Circulation

Executive Summary: 2025 International Liaison

Committee on Resuscitation Consensus on
Science With Treatment Recommendations
Katherine M. Berg, Co-Editor; Janet E. Bray, BLS Chair; Therese Djärv, FA Chair; Ian R. Drennan, ALS Chair;
Robert Greif, EIT Chair; Helen G. Liley, NLS Chair; Barnaby R. Scholefield, PLS Chair; Dianne L. Atkins, SAC;
Jestin N. Carlson, SAC; Allan R. de Caen, SAC; Eric J. Lavonas, SAC; Andrew S. Lockey, SAC; William H. Montgomery, SAC;
Laurie J. Morrison, SAC; Theresa M. Olasveengen, SAC; Yacov Rabi, SAC; Claudio Sandroni, SAC; Georg M. Schmölzer, SAC;
Eunice M. Singletary, SAC; Michelle Welsford, SAC; Joyce Yeung, SAC; John E. Billi, ILCOR Officer; Farhan Bhanji, ILCOR Officer;
Vinay M. Nadkarni, ILCOR Officer; Robert W. Neumar, ILCOR Officer; Gavin D. Perkins, ILCOR Officer; Jeanette K. Previdi, AHA;
Raffo Escalante-Kanashiro, IAHF; Sung Phil Chung, RCA; Tony Scott, ANZCOR; David Stanton, RSCA;
Siddha SC Chakra Rao, IRCF; Federico Semeraro, ERC; Amber V. Hoover, IFRC; Peter T. Morley*,
Jerry P. Nolan*, Co-Editor
Key Words: Scientific Statements ◼ cardiopulmonary resuscitation ◼ first aid ◼ heart arrest ◼ ILCOR ◼ return of spontaneous circulation

INTRODUCTION aeration and other critical adaptations to extrauterine life.

First aid is also included as it encompasses a wide range
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The International Liaison Committee on Resuscitation (IL- of treatment, including potentially lifesaving interventions
COR) was formed in 1992 with the goal of creating global that can be delivered by lay rescuers.
consensus on evidence-based emergency cardiovascular ILCOR work is divided into 6 task forces: Basic Life
care, cardiopulmonary resuscitation (CPR), and first aid, Support (BLS); Advanced Life Support (ALS); Pediatric
providing a resource for regional councils crafting clinical Life Support (PLS); Neonatal Life Support (NLS); Educa-
guidelines. ILCOR currently includes representatives from tion, Implementation, and Teams (EIT); and First Aid. This
the American Heart Association, the European Resuscita- 2025 International Liaison Committee on Resuscitation
tion Council, the Heart and Stroke Foundation of Canada, Consensus on Science With Treatment Recommendations
the Australia and New Zealand Committee on Resusci- (CoSTR) includes separate publications from each of the
tation, the Resuscitation Council of Southern Africa, the 6 task forces, this Executive Summary, and a methodology
InterAmerican Heart Foundation, the Resuscitation Council section detailing the evidence evaluation process and man-
of Asia, and the Indian Resuscitation Council Federation, agement of potential conflicts of interest. The task force
also benefitting from a collaboration with the International papers detail work completed in the past year. They also
Federation of Red Cross and Red Crescent Societies. IL- summarize topics reviewed since 2020 to provide a com-
COR’s vision is to save more lives globally through resusci- prehensive 5-year update. This Executive Summary sum-
tation, and the ILCOR mission is to promote, disseminate, marizes select topics each task force wanted to highlight
and advocate international implementation of evidence-­ as being of particular interest. Not all relevant references
informed resuscitation and first aid, using transparent eval- are cited here, although studies are cited when discussed
uation and consensus summary of scientific data. individually; refer to each task force publication in this
Resuscitation includes all responses necessary to issue for details of the reviews and task force deliberations
treat sudden life-threatening events affecting the cardio- and citations for all studies included in the reviews. The
vascular and respiratory systems, with a focus on sud- task force papers provide additional information on these
den cardiac arrest. For newborns, there is also a focus and many other important topics. Because the task force
on prevention of cardiac arrest by promoting initial lung papers are summaries of a large body of work and must be

*Indicates co-senior authors

© 2025 American Heart Association, Inc., European Resuscitation Council, and International Liaison Committee on Resuscitation.
Circulation is available at [Link]/journal/circ

S2 October 21, 2025 Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361

 Berg et al Executive Summary: 2025 CoSTR

concise, readers are directed to the full online versions and cardiogenic shock after return of spontaneous cir-
to published systematic reviews (SysRevs) when available. culation (ROSC).
• Several recommendations address prognostication
of favorable neurological outcome after cardiac
SELECT RECOMMENDATIONS, NEW OR arrest, adding to existing guidance on the prognos-
UPDATED SINCE 2020 tication of outcome.
• Extracorporeal CPR is not suggested for routine
While many more treatment recommendations than can
use but may be considered in select patients when
be listed here were updated or newly drafted since 2020,
conventional CPR is failing, in settings where this
the list below includes the key points from recommenda-
can be implemented.
tions considered the most impactful over the last 5 years.

PEDIATRIC LIFE SUPPORT

BASIC LIFE SUPPORT
• Several new recommendations for the use of clini-
• Head-up CPR continues to be discouraged except cal exam, biomarkers, imaging, and electroencepha-
in the context of research. lography for prognostication of good neurological
• Dispatcher-assisted automated external defibrillator outcome were created in 2023.
(AED) retrieval and use is supported, while possible • New recommendations for prediction of poor neu-
negative consequences are also discussed. rological outcome were drafted in 2025.
• Storage of public access AEDs without locks is • A new good practice statement suggests that either
encouraged to make them easy to retrieve. a compression-first or ventilation-first approach for
• Use of a firm surface for CPR, when possible, con- starting CPR in children is reasonable
tinues to be supported. • The PLS Task Force has added specific diastolic
• Defibrillator pad placement in the anterolateral posi- blood pressure targets during CPR for infants <1
tion for most adult patients is supported with a good year and for children 1 to 18 years with invasive
practice statement. blood pressure monitoring in place at the time of
• The importance of providing training in defibrillation of cardiac arrest.
women, including pad placement around breast tissue, • A prior recommendation to begin CPR unless a
is emphasized, and the task force states that reposi- pulse is palpated within 10 seconds was replaced
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tioning a bra rather than removing it may be adequate, with a new good practice statement that rescuers
as long as defibrillation pads are placed on bare skin. should start CPR for any unresponsive child who is
• A new recommendation suggests that CPR tech- not breathing and does not have signs of life, with-
niques do not need to be modified in obese people. out relying on palpation of a pulse.

ADVANCED LIFE SUPPORT NEONATAL LIFE SUPPORT

• Recommendations for postcardiac arrest tempera- • Recommendations support deferring umbilical
ture control changed in 2022; a normothermic tar- cord clamping for at least 60 seconds in vigor-
get of ≤37.5 °C is now suggested. ous infants of all gestational ages, and milking of
• The task force continues to suggest against rou- the intact umbilical cord in circumstances where
tinely using mechanical CPR devices while acknowl- deferred cord clamping is precluded for all infants
edging their utility in specific situations. ≥28 weeks. Cord milking is not recommended for
• Double sequential external defibrillation (DSED) infants <28 weeks.
and vector change defibrillation are now suggested • Support for supraglottic airway devices as an alter-
strategies for ventricular fibrillation refractory to 3 native to face mask ventilation or tracheal intubation
consecutive shocks. continues, and they are now also suggested during
• The intravenous route continues to be preferred chest compressions, in a good practice statement.
instead of the intraosseous route as the initial • While the recommendation continues to be that
access attempt for drug administration during CPR. preterm infants have resuscitation initiated with a
• Treatment with insulin and glucose is newly sug- fraction of inspired oxygen (Fio2) of ≥0.3 (30%) and
gested for cardiac arrest caused by hyperkalemia, term infants with 0.21 (room air), the recommenda-
while the evidence for calcium or bicarbonate in tion against starting resuscitation with an Fio2 of 1.0
cardiac arrest caused by hyperkalemia is insuffi- (100%) for term and late preterm infants has been
cient to support a recommendation. withdrawn.
• A new good practice statement suggests against • Video laryngoscopes are suggested for initial intu-
routine use of mechanical circulatory support for bation attempts in infants, where resources allow.

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 Berg et al Executive Summary: 2025 CoSTR

EDUCATION, IMPLEMENTATION, AND a treatment recommendation, but were reviewed due to

awareness of a growing interest in them within the re-
TEAMS suscitation community. These are presented by the task
• Debriefing after clinical resuscitation and CPR force below.
coaches are suggested.
• The EIT Task Force now suggests that prehospital
critical care teams attend out-of-hospital cardiac BASIC LIFE SUPPORT
arrest events where emergency medical services
(EMS) systems have sufficient resources. Head-Up CPR
• The use of feedback devices during training is Although head-up CPR (slight elevation of the head and
strongly recommended. torso of the patient while performing CPR) is not in wide-
• In situ CPR training and gamified learning both spread use, it has garnered significant attention over the
improve learning and are suggested. past several years and is used by some EMS systems
• Resuscitation team members should attend an for out-of-hospital cardiac arrest (OHCA). The BLS Task
accredited CPR course. Force conducted a SysRev of this topic in 2021, at which
• Resuscitation training should be adapted to the point a single pre-post study was identified.1 In that study,
needs of special populations (eg, hearing or visually outcomes when supine CPR with a mechanical CPR de-
impaired). vice was standard practice were compared with outcomes
• Family presence during CPR helps cosurvivors cope after a new bundle was implemented. This bundle in-
with the impact of the situation, but resuscitation cluded (1) applied oxygen but deferred positive-pressure
teams and families need proper support when fami- ventilation for several minutes, (2) a pit crew approach
lies are present at these events. for rapid mechanical CPR device placement, and (3) el-
evation of the patient’s head and torso by approximately
20°. While that study reported increased event survival
FIRST AID with the head-up CPR bundle, there was no improvement
• For people assisting someone who is choking, the in favorable neurological outcome at hospital discharge,
task force recommends an escalating strategy of and the task force concluded that this practice should be
encouraging cough and then using back slaps, and used only in the context of research, including clinical tri-
using abdominal thrusts if back slaps are ineffective. als. In the 2025 SysRev, 2 more studies were identified,
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• Lay rescuers should start CPR in cases of pre- both of which compared patients in a registry of those
sumed cardiac arrest without concerns for causing receiving head-up CPR with patients from past clinical
injury. trials in which supine CPR was used.2,3 One of these tri-
• The First Aid Task Force now suggests manual uter- als found no significant difference in ROSC, survival, or
ine massage immediately after birth in the first aid neurological outcome.2 The other found no improvement
setting to prevent postpartum hemorrhage. in ROSC, but more survival and favorable neurological
• To improve the chances of successful replantation outcome at hospital discharge with the head-up CPR
of an amputated or avulsed body part, the task force bundle.3 The head-up CPR intervention uses an automat-
recommends wrapping the body part in a moist cloth ed device that gradually elevates the patient’s head and
and plastic bag and then cooling it. torso during CPR. Based on the inconsistent findings and
• Attempts should be made to retrieve and preserve the concern about bias in the available studies (pre-post
avulsed or amputated body parts to increase the studies, in some cases with the supine CPR group hav-
possibility of replantation. ing their event several years before), the recommendation
• For first aid providers trained in the use of supple- continues to be that this intervention be used only in the
mental oxygen, titration of oxygen to a peripheral context of research until its effects are clarified.
blood oxygen saturation of 88% to 92% is sug-
gested for patients who report a history of chronic Optimization of Dispatcher-Assisted
obstructive pulmonary disease.
Recognition of Cardiac Arrest, CPR, and
Automated External Defibrillator Retrieval and
HOT TOPICS Use
The ILCOR Task Force chairs were asked to highlight Dispatchers play a vital role in resuscitation for OHCA,
4 to 6 topics most important to highlight from the work both in helping a caller recognize that someone is in
conducted over the last 5 years. While many of the top- cardiac arrest and in coaching them to start CPR. IL-
ics selected were reviews that generated new treatment COR has not previously reviewed how to optimize these
recommendations (some of which are included above), key dispatcher roles, and this prompted the BLS Task
others were new topics with insufficient data to support Force to undertake Scoping reviews (ScopRevs) on the

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 Berg et al Executive Summary: 2025 CoSTR

topics of dispatcher-assisted recognition of cardiac ar- EvUp was done for 2025. Several simulation studies and
rest, dispatcher-assisted CPR, and dispatcher-assisted real-life feasibility studies have compared d­ispatched
AED retrieval and use. The ScopRevs were initially done drones with a traditional EMS response. A prospective
for the 2024 CoSTR summary4,5 and were updated with observational study included in the 2025 EvUp found
evidence updates (EvUps) for 2025. that in the minority of 211 suspected OHCA cases in
which a drone was dispatched at the same time as the
Dispatcher-Assisted Recognition of Cardiac Arrest traditional EMS response, a drone was successfully de-
Evidence consists mostly of observational studies that livered 81% of the time, and the AED arrived earlier than
document the percentage of cardiac arrest cases that EMS (by an average of 3 minutes) 67% of the time.14
are recognized as such by dispatchers, and what factors These findings were similar to a much smaller pilot study
are associated with successful recognition. Determin- identified in the 2023 ScopRev.15 The BLS Task Force
ing whether a patient is breathing normally, with agonal concluded that there continues to be too little data to
breathing being a key indicator of the likely presence of support a SysRev or good practice statement.
cardiac arrest, continues to be a key challenge for dis-
patchers. Various strategies to determine if someone is
breathing normally have been evaluated (although not in AED Accessibility: Locked Cabinets
randomized trials); thus far, none appear more effective The BLS Task Force reviewed the effect of locking cabi-
than the often-used 2-question strategy (ie, “Is the per- nets that hold public access AEDs to ascertain if this
son conscious?” and “Are they breathing normally?”).6 delayed AED use in cases of OHCA, and to evaluate the
Dispatcher-Assisted CPR actual occurrence of AED theft or damage.16 Limited ob-
Dispatcher-assisted CPR instructions are currently rec- servational studies report that theft rates are low (<2%)
ommended, but the most effective way to do this is not and do not differ significantly between locked and un-
known. Multiple strategies have been investigated to op- locked cabinets. Simulation studies suggest that retrieval
timize dispatcher-assisted CPR, but several of these (eg, of an AED takes longer when a cabinet is locked. The
metronome use, use of prerecorded instructions, inclu- BLS Task Force, therefore, made a good practice state-
sion of instructions to undress the patient) have too few ment suggesting these cabinets not be locked. If they are
published studies to support a recommendation. Some locked, then instructions to unlock them must be clearly
studies focusing on simplifying the language used to visible. They also emphasized that EMS should endeavor
to return AEDs to the owner organization after use.17
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coach CPR (eg, “Push as hard as you can”) or using vid-

eo calls to enable direct feedback on CPR performance
found improvement in both hand positioning and com- Removal of Bra Before Defibrillation
pression depth and rate.7,8
The task force conducted a ScopRev on this topic for
Dispatcher-Assisted AED Retrieval and Use 2025 because bra removal for defibrillation has not been
Dispatcher-assisted AED retrieval and use have become reviewed previously and there is a lack of clarity on best
more common, but the evidence consists mostly of ob- practice.18 Some guidelines recommend bra removal for
servational and simulation studies. Findings are some- pad placement and defibrillation,19 but this is not univer-
what inconsistent, with some reporting that rescuers are sal. Studies have also reported that women are less likely
more likely to retrieve and use an AED if dispatchers in- to receive CPR and defibrillation, and there is concern
clude instructions on retrieval or that dispatcher instruc- that reluctance to expose the female chest may be part
tions helped rescuers use AEDs properly, while other of the reason.20,21 The ScopRev identified very limited evi-
studies found that dispatcher instructions on AED use dence from a single animal study and 2 simulation stud-
sometimes confused rescuers and potentially delayed ies. No reports of harm to patient, rescuer, or defibrillator
use. The task force decided to make good practice state- from defibrillation use with a bra in place were found,
ments on this topic in 2024 because of the need for and the animal study using defibrillation with underwire
guidance around this increasingly common practice. The in direct contact did not find any harm (abstract only).22
task force states that dispatchers should ask if an AED is A simulation study found that men were less likely to
present in the immediate vicinity; if not, and there is more remove all clothing from female manikins than women
than 1 rescuer, they should offer instruction on how to were.23 The task force issued good practice statements
find the nearest one. They should also provide instruc- acknowledging that we don’t know if it is better to re-
tions on AED use once it is present.9 move the bra before defibrillation but that pads should
be adhered to bare skin, and this can often be done with
repositioning a bra rather than removing it. They also
Drone AED Delivery emphasized that CPR and defibrillation training should
The use of drones to deliver AEDs was first evaluated in include female manikins and should address the topic of
a ScopRev10,11 for the 2023 CoSTR summary,12,13 and an bra repositioning or removal.

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 Berg et al Executive Summary: 2025 CoSTR

Effectiveness of Ultraportable/Pocket AEDs compromised rescuer safety (eg, in a procedural setting,

prolonged resuscitation, for CPR during transport).30,31
Ultraportable AEDs have become available, but there is
Use of mechanical CPR devices increased during the
a lack of evidence on how they perform in comparison
COVID-19 pandemic and has remained more common
with standard AEDs. A ScopRev of this new topic was
than in prepandemic practice. This updated SysRev fo-
initially included in the 2024 CoSTR summary.4,5 The
cused on randomized controlled trials (RCTs) only and
ScopRev identified no studies evaluating the effective-
identified 5 new trials since the 2015 review.32–36 Un-
ness of these ultraportable devices, and the task force
fortunately, the heterogeneity of available trials (in type
concluded that there is an urgent need for research as-
of device, inclusion criteria, timing of mechanical CPR
sessing their effectiveness because they are already be-
initiation, and variability in co-interventions) made meta-
ing marketed and sold to the public.24,25
analyses inadvisable. However, most studies, including all
large trials, have found no difference in outcomes be-
CPR in Obese People tween mechanical and manual CPR.37 Potential delays
in initial defibrillation with mechanical CPR use can be
Obesity is increasing in prevalence globally, and whether
avoided by delaying setup of the device until after the
the effects of obesity on chest wall compliance and im-
first rhythm assessment and shock, if indicated. While
pedance necessitate alterations in standard CPR proto-
these devices continue to be useful and reasonable al-
cols has not been reviewed. A ScopRev on this topic was,
ternatives for situations in which manual CPR is difficult
therefore, undertaken by the BLS Task Force for 2025, as
or unsafe to continue, the ALS Task Force highlights that
a nodal review with involvement of the ALS, PLS, and EIT
there is no evidence that mechanical CPR is superior to
Task Forces.26 Observational studies in adults were incon-
manual CPR.
sistent in finding any relationship between obesity and car-
diac arrest outcomes. Only 2 pediatric studies were found,
and these both reported worse outcomes in children with Double Sequential External Defibrillation
obesity compared with normal-weight children. There
Double sequential external defibrillation (DSED) was
were no studies investigating variations in CPR protocols
investigated in an RCT38 published in 2022, and an
­
in obese patients or differences in rescuer outcomes such
updated SysRev was completed for the 2023 CoSTR
as injuries related to performance of resuscitation. The
summary.12,13 In the cluster RCT, which included OHCA
limited data, with significant heterogeneity in definitions of
patients who remained in ventricular fibrillation after
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obesity and in results, led the task force to conclude that

3 consecutive shocks, more patients survived to hos-
there is currently no reason to deviate from standard CPR
pital discharge in the DSED group compared with the
protocols when resuscitating obese patients.27
standard defibrillation group (27.4% versus 11.2%; ad-
justed relative risk, 2.21; 95% CI, 1.26, 3.88). Survival
with favorable neurological outcome and ROSC were
ADVANCED LIFE SUPPORT
also higher in the DSED group. A third group of patients
Temperature Control After Cardiac Arrest were randomized to vector change defibrillation, in which
The SysRev and recommendations on postarrest tem- the pads were changed from the anterolateral orienta-
perature control have been updated several times in tion to an anteroposterior orientation after 3 consecutive
recent years, most recently in 2022.28,29 The ALS Task shocks. This group also had better survival to hospital
Force now suggests a normothermic target of ≤ 37.5 °C discharge, but ROSC and survival with favorable neuro-
for most patients based on a systematic review of avail- logical outcome were not significantly better compared
able trials while acknowledging that it remains uncertain with the standard defibrillation group.
whether some patients may benefit from cooler tempera- This topic generated considerable discussion within
tures in the mild hypothermia range. This topic remains the ALS Task Force. The trial had significant limitations
controversial, with some experts firmly advocating for and, because no comparison was done between DSED
normothermia while others continue to believe mild hy- and vector change, no conclusions about one approach
pothermia is beneficial. Strictly controlling temperature being superior to the other could be made. Either a DSED
continues to be advocated, whether in the normothermic or a vector change strategy are suggested as reasonable
or mildly hypothermic range. considerations for ventricular fibrillation refractory to 3
consecutive shocks.39

Mechanical CPR
Intravenous Versus Intraosseous Route for
Mechanical CPR devices have been available for many
years. This topic was last reviewed by ILCOR in 2015, at Initial Access Attempt
which time use of mechanical CPR was suggested only Intraosseous access devices have become popular re-
in situations in which manual CPR was not feasible or cently and are used in both the out-of-hospital and

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 Berg et al Executive Summary: 2025 CoSTR

in-hospital settings. They are promoted for their ability to years, and some randomized trials of MCS have in-
help a rescuer gain vascular access quickly in emergen- cluded large subgroups of patients with post–cardiac
cies such as cardiac arrest. The ALS Task Force updated arrest cardiogenic shock. Fourteen trials reported sur-
the ILCOR SysRev on this topic in response to publi- vival outcomes and found no benefit from MCS for all
cation of 3 RCTs comparing initial intravenous (IV) at- cardiogenic shock patients included.46–59 A subgroup of
tempts with initial intraosseous attempts for OHCA.40–42 post–cardiac arrest patients from 6 of the included tri-
Meta-analysis of the 3 trials demonstrated no difference als48,50,51,54,57,58 similarly found no benefit in 30-day sur-
in survival or survival with favorable neurological outcome vival. One RCT included only patients with cardiogenic
or ROSC at any time. The odds of sustained ROSC, an shock after in-hospital cardiac arrest and, again, found
outcome reported in 2 of the RCTs, were slightly lower no difference in survival with the use of MCS.51 The lack
in the group randomized to initial intraosseous access of benefit led to a treatment recommendation suggest-
(odds ratio, 0.89; 95% CI, 0.80–0.99).43 Treatment rec- ing that MCS not be used routinely for post–cardiac
ommendations continue to support IV as the initial route arrest cardiogenic shock, but the task force acknowl-
for access, with intraosseous as an alternative if IV ac- edged that there may be groups of patients who benefit
cess cannot be obtained quickly. Task force discussions from MCS. Limited subgroup data suggest those with a
included concerns about the widespread use of these Glasgow Coma Scale score >8 at hospital arrival with
devices, with the significantly higher cost compared with infarct-related cardiogenic shock,51 patients with ST-
IVs and no evidence for benefit. segment elevation myocardial infarction without prior
resuscitation before arrival of EMS, and those with a
short duration of cardiac arrest (<10 minutes) could be
Treatment of Hyperkalemia reasonable candidates.60
Standard treatment of life-threatening arrhythmias in
the setting of hyperkalemia often involves administration
of calcium, β-agonists, and high-dose insulin therapy, PEDIATRIC LIFE SUPPORT
but the ALS and PLS Task Forces questioned whether
these treatments were evidence based and completed a Prediction of Survival With Poor Neurological
­SysRev of studies assessing the effect of different treat- Outcome After Return of Circulation Following
ments to lower potassium values acutely.44,45 Interven- Pediatric Cardiac Arrest
tions studied in this nodal review included salbutamol,
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The task force conducted a 2-part SysRev on prognos-

insulin and glucose, insulin plus salbutamol, calcium, and
tication of neurological outcome in children after cardiac
sodium bicarbonate. Evidence identified was limited, all
arrest. Prognostication of good outcome was included in
studies were small, and most were in non–cardiac ar-
the 2023 CoSTR summary,12,13 and prognostication of
rest patients. Salbutamol and insulin plus glucose both
poor outcome was included for 2025. For poor outcome,
appeared to lower potassium values. In a study of non–
the false-positive rate was required to be <1% (corre-
cardiac arrest patients, calcium did not affect electrocar-
sponding to a specificity of 99%) for a test to be con-
diogram changes, and in a retrospective study of patients
sidered precise and reliable enough, prioritizing avoiding
with cardiac arrest and hyperkalemia, absolute mortality
discontinuation of life-sustaining therapy in patients who
was higher in the group receiving calcium. The task force
could have had a good outcome. Tools for prognostication
discussed the important lack of data in the cardiac ar-
were broken down into categories that were reviewed
rest population, and the lack of any evidence to support
separately, including biomarkers, clinical exam, neuroim-
calcium for cardiac arrest in the setting of hyperkalemia,
aging, and electrophysiology testing. In all categories, the
although this is recommended in some guidelines.19 The
importance of using multiple tests in combination when
task force suggests insulin and glucose, salbutamol (in-
prognosticating neurological outcome was emphasized.
haled or IV), or the combination of these therapies for
hyperkalemia without cardiac arrest, and insulin and glu- Biomarkers
cose for hyperkalemia with cardiac arrest. The evidence Limited evidence was found, and most studies included
for calcium was considered insufficient to support a rec- were not primarily designed for testing biomarkers for
ommendation for or against. It is suggested that bicar- prognostication. Lactate was not found to be a reliable
bonate not be given in non–cardiac arrest patients with biomarker for poor outcome, so the task force suggested
hyperkalemia, and there is insufficient evidence to rec- not using it for this purpose, and the evidence for other
ommend for or against in cardiac arrest. biomarkers was insufficient to support a recommendation.

Clinical Exam
Mechanical Circulatory Support After ROSC Absence of the pupillary light reflex before 24 hours was
The use of mechanical circulatory support (MCS) for not a reliable prognostic test. At 48 and 72 hours after
cardiogenic shock has increased considerably in recent return of circulation, the false-positive rate was <1% but

Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361 October 21, 2025 S7

 Berg et al Executive Summary: 2025 CoSTR

95% CIs were wide. Glasgow Coma Scale score, includ- and chest compression fraction was higher. Time
ing the total score and the motor score, was also not a to ventilation was about 6 seconds faster with the
reliable predictor of outcome. The task force suggest- airway-breathing-­compressions approach in one study.
ed not using pupillary light response or Glasgow Coma Indirect evidence from before and after OHCA regis-
Scale score at 24 hours, but that lack of pupillary light try studies in adults suggests that switching from the
response at 48 to 72 hours may be considered as part of airway-breathing-circulation to the circulation-airway-
multimodal prognostication of poor outcome. breathing approach may increase rates of bystander
CPR63 and improved patient outcomes.63–65 Similar data
Electroencephalogram on in-hospital cardiac arrest show conflicting evidence
Evidence for electroencephalogram is limited by the for patient o ­utcomes.66,67 One large registry study
few studies, small sample sizes, and heterogene- from Japan demonstrated increased bystander CPR
ity across studies, including in timing and methods rates in children with bystander-witnessed OHCA af-
of interpretation of electroencephalograms. Blinding ter ­compression-only CPR was introduced.68 The task
was also rarely present. The presence of seizures on force concluded that there is insufficient evidence to
electroencephalogram was not a reliable predictor of make a recommendation about the optimal order of re-
poor outcome. Absence of normal background, sleep suscitation. Both airway-breathing-compressions and
architecture or sleep spindles, and reactivity were compressions-airway-breathing approaches are rea-
also not reliable. Status epilepticus, burst suppression, sonable, and both compressions and ventilations are
burst attenuation, or generalized periodic epileptiform important components of pediatric resuscitation.
discharges between 4 to 72 hours and myoclonic
status had much lower false-positive rates and were
considered moderately reliable tests. Somatosensory Blood Pressure Monitoring and Targets During
evoked potential (bilaterally absent N20 waves) had a Pediatric In-Hospital Cardiac Arrest
false-positive rate of 0% at 24 to 48 hours, but there When children have intra-arterial catheters in place,
was only 1 small study. The task force suggested that invasive hemodynamic data may provide information
status epilepticus or a background pattern of burst about the quality of chest compressions during cardiac
suppression, burst attenuation, or generalized periodic arrest.69 In this updated SysRev, 5 observational cohort
epileptiform discharges could be useful as one part of studies were included.70–74 Three were analyses of the
multimodal prognostication. same cohort (Pediatric Intensive Care Quality of CPR
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study) but examined different subpopulations or different

Imaging
outcomes.71,73,74 Two studies of children with in-hospital
Loss of gray-white matter differentiation on a head com-
cardiac arrest and arterial lines in place70,71 found that
puted tomography scan at 24 hours and magnetic reso-
exposure to a diastolic blood pressure of ≥25 mm Hg for
nance imaging apparent diffusion coefficient threshold
infants <1 year and ≥30 mm Hg for children ≥1 year for
<650 × 10-6 mm2/s in ≥10% of brain volume (indicating
the first 10 minutes of CPR was associated with obtain-
high ischemic burden), at a median of 4 days after re-
ing ROSC, when compared with a lower diastolic blood
turn of circulation, were found to be moderately reliable
pressure. Using the same cutoffs, a single study found
tests. The task force suggested that these findings on a
that the higher diastolic blood pressure was associated
computed tomography scan within 24 hours or magnetic
with hospital survival in children with surgical cardiac dis-
resonance imaging at 72 hours or more after return of
ease (n=88) but not in those with medical cardiac dis-
circulation could be useful as one component of multi-
ease (n=24).74 Systolic blood pressure during CPR was
modal prognostication.
not found to be associated with outcomes.
While evidence is limited and of very low certainty, and
Airway, Breathing, Compressions Versus arterial lines are used only in high-resource settings, the
task force concluded there was sufficient evidence to
Compressions, Airway, Breathing: Order of
issue a weak recommendation suggesting targeting an
Ventilation and Compression intra-arrest diastolic blood pressure of ≥25 mm Hg for
Many adult algorithms now begin resuscitation with infants <1 year and ≥30 mm Hg for children 1 to 18
compression instead of airway and ventilations. The years with invasive blood pressure monitoring in place at
task force undertook this SysRev as a nodal review the time of cardiac arrest.
with the BLS Task Force because the merits of start-
ing with ventilations in children were uncertain. This
Pulse Check Accuracy in Children During
was last reviewed for the 2019 CoSTR summary.61,62
Only 5 manikin studies were identified. Findings sug- Resuscitation
gested that time to chest compressions was shorter Guidelines recommend a manual pulse check dur-
with the compressions-airway-breathing approach, ing rhythm analyses to detect ROSC, with different

S8 October 21, 2025 Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361

 Berg et al Executive Summary: 2025 CoSTR

anatomical sites for different age groups.75 With the in- ischemic encephalopathy in nonvigorous, late preterm
creasing availability of ultrasound and arterial lines, the and term infants.
PLS Task Force prioritized this topic and conducted the Together, these reviews suggest a simplified approach
first SysRev, expanding on a previous EvUp in 2023.13 to clinical practice, where deferred cord clamping ≥60
Three studies were identified, including 39 patients and seconds is the preferred option for all infants who are
376 pulse checks.76–78 Two of these studies assessed cli- vigorous at birth, to prevent mortality in very preterm
nicians’ ability to accurately palpate a pulse for children infants and to improve hematologic outcomes in those
with left ventricular assist devices or on extracorporeal who are more mature. There remain some cases in which
membrane oxygenation but without cardiac arrest. Sen- deferred cord clamping is not feasible, for maternal or
sitivity of pulse checks ranged from 76% to 100% in infant reasons, including circumstances in which the
those studies, and specificity 64% to 79%.76,77 In one of baby remains nonvigorous despite tactile stimulation.
these studies,77 only 39% (60/153) of participants de- For those who are not vigorous but ≥28 weeks, milk-
cided on the presence of a pulse within 10 seconds, and ing the intact umbilical cord is now the suggested option
determining whether a pulse was present took a median to improve hematologic outcomes for all and to reduce
of 18 seconds. The third study was a series of cases hypoxic ischemic encephalopathy in late preterm and
in which an ultrasound was used during pulse checks, term infants.
and duration of pulse checks was not reported.78 The
task force reinforced a prior recommendation stating
that pulse checks are not reliable. Based on the lack of Supraglottic Airway Devices During Neonatal
evidence supporting it, a prior recommendation to begin Resuscitation
CPR unless a pulse is palpated within 10 seconds was For 2025, the NLS Task Force completed a ScopRev on
withdrawn and then replaced with a new good practice the use of supraglottic airways during chest compres-
statement that rescuers should start CPR for any unre- sions. EvUps were done on the topics of supraglottic
sponsive child who is not breathing and does not have airways as an alternative to face-mask ventilation and
signs of life. as an alternative to tracheal intubation. Together, these
reviews support that supraglottic airway devices should
be considered as an alternative to face masks or tra-
NEONATAL LIFE SUPPORT cheal tubes for providing positive-pressure ventilation,
Downloaded from [Link] by on October 27, 2025

Umbilical Cord Management especially when an infant’s condition is not improving

despite face-mask ventilation and where there is no-
Since 2020, the NLS Task Force has reviewed the evi-
body immediately available who can intubate, or where
dence for umbilical cord management for vigorous term
intubation is not successful. The ScopRev supports
and late-preterm infants (SysRev 2021, EvUp 2025),79–
that this should include infants who are receiving chest
81
preterm infants (SysRev 2021 and SysRev Adolop-
compressions. Until recently, the devices available have
ment 2024, EvUp 2025),4,5,79,80,82 and nonvigorous term
only been suitable for infants ≥34 weeks’ gestation and,
and late preterm infants (SysRev 2025). In 2021 and
therefore, they are the only group represented in clini-
2024, SysRevs found that deferred cord clamping (for
cal trials. However, newer devices may be suitable for
at least 60 seconds) reduced mortality and transfusion
smaller infants.
requirements for preterm infants and reduced later iron
deficiency and anemia for late preterm and term infants.
The 2024 SysRev for preterm infants incorporated ado-
Oxygen Concentration for Commencing
lopment to include the results of a large, comprehen-
sive meta-analysis that used individual patient data,83 Resuscitation
enabling greater precision of estimates of outcomes Oxygen concentration to be used when commencing
than a study-level meta-analysis. Members of the task resuscitation was reviewed with a SysRev for preterm
force worked with the individual patient data study team infants for 2025, and an EvUp of studies on term in-
to ensure that the study addressed ILCOR population, fants was completed for 2025. In 2019, when both
intervention, comparator, and outcome questions. This topics were reviewed previously, the task force con-
review also concluded that for infants for whom de- cluded that an Fio2 of 0.21 (room air) was preferrable
ferred cord clamping was not feasible for either infant for commencing resuscitation in term infants, or 0.21
or maternal reasons, umbilical cord milking was a rea- to 0.3 (21%–30%) for preterm infants <35 weeks’
sonable option for improving hematologic outcomes in gestation. An individual patient network meta-analysis
infants ≥28 weeks’ gestation, though for infants <28 for preterm infants <32 weeks’ gestation (NetMotion)
weeks’ gestation, it should not be used because of in- cast doubt on the previous review’s findings, suggest-
creased risk of intraventricular hemorrhage. Umbilical ing that a concentration of 0.9 to 1.0 (90%–100%)
cord milking may reduce the occurrence of hypoxic resulted in the best survival.84 An updated NLS Task

Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361 October 21, 2025 S9

 Berg et al Executive Summary: 2025 CoSTR

Force SysRev, which evaluated all available RCTs in a performance-focused debriefings95; positive-pressure
study-level analysis and considered the results of Net- ventilation refresher and performance debriefing94; and
Motion by adolopment, concluded that benefit or harm postresuscitation interdisciplinary team debriefings.96
could not be excluded for any other critical or important Some studies showed no effect following postresuscita-
outcome, and that current and future large multicenter tion debriefing while others showed an association with
trials were needed to define the optimal oxygen con- improvements in several outcomes, such as favorable
centration for commencing resuscitation. Meanwhile, neurological outcome, survival to discharge, ROSC, chest
the use of an Fio2 ≥0.30 (30%) is suggested for pre- compression depth, chest compression rate, chest com-
term infants, and 0.21 (room air) remains the recom- pression fraction, and adherence to guidelines. Given the
mendation for term infants, although the task force lack of RCTs comparing debriefing with no debriefing
plans to update both reviews as further evidence be- after CPR, the task force noted a serious risk of bias
comes available. The task force has withdrawn the rec- in these studies. There are also no data on the cost-­
ommendation against Fio2 1.0 (100%) for term infants, effectiveness of postevent debriefing or on the effect
after concluding that contemporary Grading of Recom- of postevent debriefings in low-resource settings. De-
mendations Assessment, Development, and Evaluation spite these limitations, the findings underpinned a new
would result in an insufficient certainty of evidence for treatment recommendation that suggests performing
that recommendation. postevent debriefing after adult, pediatric, and neonatal
­cardiac arrest in all settings.
Video Laryngoscopes
A 2025 SysRev found evidence that video laryngo- Prehospital Critical Care for OHCA
scopes improve the intubation success rate for both first In many countries, prehospital critical care teams are be-
attempts and overall, although most studies included ing implemented as part of a tiered EMS response.97–99
mostly inexperienced clinicians, and the benefits may be The teams comprise specialists in the care of critically ill
fewer in those who are already experienced in intubation. patients requiring resuscitation,100 and they have compe-
The NLS Task Force suggested video laryngoscopes be tencies in ALS beyond that of standard EMS teams.101
used for initial intubation attempts where resources al- The EIT Task Force undertook a SysRev to determine the
low, especially where less-experienced clinicians may impact of prehospital critical care teams on clinical out-
be intubating, although traditional laryngoscopes are comes among adults and children after OHCA. Fifteen
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more widely available and must be available as a backup observational studies were identified.97–111 Pooled results
device. from these studies showed an association between pre-
hospital critical care teams and higher rates of ROSC,
survival to discharge, survival to 30 days, and favorable
EDUCATION, IMPLEMENTATION, AND neurological outcome at 30 days. The EIT Task Force
TEAMS recommended that prehospital critical care teams attend
adults with nontraumatic OHCA within EMS systems
Debriefing of Clinical Resuscitation with sufficient resource infrastructure and suggested
Performance that prehospital critical care teams attend children with
Debriefing strategies are used widely to improve CPR OHCA within EMS systems with sufficient resource in-
team performance and optimize delivery of care. How- frastructure. Implementing prehospital critical care ser-
ever, there are few data showing the effect on patient vices will incur additional resources, training, and EMS
outcomes or whether there are negative aspects to de- infrastructure costs, which may not be feasible in some
briefing (eg, cost, emotional impact on professionals). health care systems. The optimal composition of prehos-
The topic was last reviewed in 2020, but this included a pital critical care teams has yet to be determined.
mixture of resuscitation and trauma studies.85,86 The EIT
Task Force undertook a new SysRev on debriefing that
CPR Coaching During Adult and Pediatric
included only resuscitation studies in adults, children,
and neonates and that sought clinical and patient out- Cardiac Arrest
comes. Ten observational studies (6 in adults,87–92 3 in It is well recognized that adherence to guidelines is poor
neonates,93–95 and 1 in children96) were identified, and during CPR. A resuscitation team member whose prima-
these included a wide range of interventions: postresus- ry responsibility is to provide real-time coaching on re-
citation debriefing87; audiovisual feedback plus weekly suscitation quality, known as a CPR Coach, may improve
postevent debriefings88; short individual oral debriefing89; compliance with CPR guidelines. To investigate this, the
hot or cold debriefings90; weekly debriefing sessions EIT Task Force undertook a SysRev focusing on coach-
with audiovisual feedback during cardiac arrests91; an ing in which the coach is an active resuscitation team
after-training workshop with debriefing93; video-assisted, member. Of the 7 studies identified, one investigated use

S10 October 21, 2025 Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361

 Berg et al Executive Summary: 2025 CoSTR

of CPR Coaches in a clinical setting,112 and 6 were simu- studies140,143,144 documented improvements in elements
lation studies—although 5 of these were based on the of clinical resuscitation performance following a period
same RCT.113–118 In general, the use of a CPR Coach was of in situ CPR training, eg, reduced time to starting chest
associated with improved CPR performance, and the EIT compressions and reduced delay to defibrillation. Four
Task Force recommended considering the inclusion of a RCTs141,142,145,146 and 1 observational study139 document-
CPR Coach as a member of the resuscitation team dur- ed improvements in resuscitation performance with in
ing cardiac arrest resuscitation in settings with adequate situ simulation training compared with traditional train-
staffing. The effect of CPR Coaches in the setting of ing. Based on these improvements across several out-
real cardiac arrests and their effect on patient survival comes, the EIT Task Force recommended that in situ
remains unknown. simulation may be considered as an option for CPR
training where resources are readily available. The re-
sources required for implementation of in situ simula-
CPR Feedback Device Use in Resuscitation tion training and its feasibility in low- and middle-income
Training countries are knowledge gaps.
Use of CPR feedback devices during resuscitation skills
training may improve CPR skill acquisition and retention,
but the results of studies are inconsistent. The use of FIRST AID
CPR feedback devices during resuscitation courses is Foreign-Body Airway Obstruction
increasing and, although this topic was reviewed in the
2020 CoSTR,85,86 the EIT Task Force considered it im- Foreign-body airway obstruction continues to be rela-
portant to undertake an updated SysRev and included tively common and can be life-threatening. This topic
only RCTs. Twenty relevant studies were identified, 3 was last reviewed for the 2020 CoSTR by the BLS Task
involving lay providers119–121 and 17 in health care pro- Force and was transitioned to the First Aid Task Force in
fessionals.122–138 Use of CPR feedback devices improved 2023148,149; an EvUp was done for 2025. In a retrospec-
compliance with current guidelines among health care tive study of 709 patients, abdominal thrusts as a first in-
professionals and laypersons with respect to compres- tervention was associated with lower odds of relief of the
sion depth and compression rate. Use of CPR feedback obstruction (odds ratio, 0.57; 95% CI, 0.39–0.62) and
devices also improved chest recoil among health care lower odds of survival to hospital discharge (odds ratio,
professionals but not in laypersons. No undesirable ef- 0.2; 95% CI, 0.07–0.59) compared with back blows as a
Downloaded from [Link] by on October 27, 2025

fects were detected in the review, feedback devices are first intervention.150 Multiple publications reported on the
well accepted, and their cost is relatively low. Based on use of several different airway clearance devices.151–155
these data, the EIT Task Force recommended the use of A registry study of 407 patients reported that bystand-
CPR feedback devices during resuscitation training for ers attempted to clear the airway obstruction in 54% of
health care professionals and lay providers. The impact cases and were successful in 48% of these attempts.
on patient outcomes of improved CPR skills from training Survival was significantly higher in patients for whom a
with feedback devices remains a major knowledge gap. bystander had attempted to clear the obstruction.156 The
task force continues to suggest back slaps as the first
strategy for foreign-body airway obstruction removal with
In Situ (at the Workplace) Simulation-Based an ineffective cough, followed by abdominal thrusts for
CPR Training patients over 1 year of age if back slaps are unsuccess-
Training using simulation is traditionally undertaken in ful. It is common for more than 1 of these approaches
the classroom setting, but moving such training to clini- to be needed to relieve an airway obstruction. Because
cal areas may improve fidelity and provide a better test there is no existing recommendation regarding airway
of organizational processes. The EIT Task Force com- clearance devices and their prevalence is increasing, the
pleted a SysRev comparing in situ simulation CPR train- First Aid Task Force is planning a SysRev addressing this
ing with traditional training. Nine studies were identified: topic.
4 studies in adults,139–142 3 in children,143–145 and 2 in
neonates.146,147 One prospective observational study Unintentional Injury From Laypersons Providing
with historical controls documented an association be-
tween the in situ simulation period and higher odds of
Chest Compressions to Patients Who Are Not in
survival to hospital discharge among children with car- Cardiac Arrest
diac arrest (odds ratio, 2.06; 95% CI, 1.02–4.25).144 Lay rescuers may be hesitant to begin CPR because
One observational study reported a lower incidence of of concern for injuring a person, especially if they are
neonatal asphyxia after a period of in situ simulation uncertain about whether the person is truly in car-
training compared with a preintervention period of tra- diac arrest. This topic was last reviewed for the 2020
ditional training.147 Three before-and-after observational CoSTR.148,149,157 One new study was added to the 4

Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361 October 21, 2025 S11

 Berg et al Executive Summary: 2025 CoSTR

identified previously,158–162 and these 5 studies included Most of the evidence came from case ­reports and case
a total of 1031 patients who received CPR but were not series, with some observational and experimental studies
in cardiac arrest. Of these people, 7 (0.7%) sustained a also identified.173 More distal amputated parts (eg, digits)
physical injury attributed to CPR, and an additional 24 without skeletal muscle tolerate periods of ischemia with-
(2%) had symptoms such as chest pain or discomfort. out cold preservation up to 12 hours; cold preservation
Based on this low injury rate and the lifesaving potential extends the tolerable ischemic time before successful
of CPR, the task force made a strong recommendation replantation to 24 hours or more. Observational ­studies
that lay rescuers start CPR in cases of presumed cardiac of major upper extremity amputations also support cold
arrest without concerns for causing unintentional injury. preservation, which may extend tolerable ischemia time
from approximately 6 to 12 hours. The task force good
practice statements suggest retrieving the body part and
External Uterine Massage for Prevention of transporting it to the hospital as soon as possible and
Postpartum Hemorrhage cooling it if feasible. This can be accomplished by wrap-
ping the part in a moist clean cloth or gauze and sealing it
Postpartum hemorrhage is a major cause of global
in a watertight bag or container before cooling, avoiding
morbidity and mortality, particularly in lower-resource
freezing. A SysRev is planned.
­settings where most birth attendants have limited pro-
fessional health education and may be considered lay
or first aid providers.163 Many international guidelines
and other knowledge syntheses recommend external
FUTURE DIRECTIONS
uterine massage for the prevention and management of ILCOR continues to endeavor to review evidence as it
postpartum hemorrhage.164–171 This simple and safe in- emerges and update CoSTRs whenever this is warranted
tervention may reduce morbidity and mortality, and the by new science. As the volume of research in the fields of
First Aid Task Force reviewed evidence for its provision resuscitation and first aid continues to increase, and as
by lay or first aid providers specifically, without advanced the resources used by clinicians for updating treatment
training. A single RCT172 was identified including 127 recommendations and guidelines evolve (with growing
women who had recently given birth in Kenya and were use of online platforms and artificial intelligence), ILCOR
advised to perform self-massage cued by an alarm ev- will ensure that its evidence evaluation and CoSTR pro-
ery 15 minutes for the first 120 minutes after birth. The duction processes continue to serve the mission of “sav-
Downloaded from [Link] by on October 27, 2025

study reported better compliance with the intervention ing more lives globally through resuscitation.”
but a nonsignificant difference in blood loss and blood
transfusion. Given the safety of this maneuver, the task ARTICLE INFORMATION
force suggests manual uterine massage, including self-
The American Heart Association requests that this document be cited as fol-
massage, to prevent postpartum hemorrhage in the im- lows: Berg KM, Bray JE, Djärv T, Drennan IR, Greif R, Liley HG, Scholefield BR,
mediate postpartum period. Atkins DL, Carlson JN, de Caen AR, Lavonas EJ, Lockey AS, Montgomery WH,
Morrison LJ, Olasveengen TM, Rabi Y, Sandroni C, Schmölzer GM, Singletary
EM, Welsford M, Yeung J, Billi JE, Bhanji F, Nadkarni VM, Neumar RW, Perkins
GD, Previdi JK, Escalante-Kanashiro R, Chung SP, Scott T, Stanton D, Chakra
Preservation of Amputated Body Parts Rao SSC, Semeraro F, Hoover AV, Morley PT, Nolan JP. Executive summary:
2025 International Liaison Committee on Resuscitation Consensus on Science
The First Aid Task Force recognizes that the top priority With Treatment Recommendations. Circulation. 2025;152(suppl 1):S2–S22. doi:
when approaching a patient with an amputated or avulsed 10.1161/CIR.0000000000001361
body part is stopping the bleeding and resuscitating the This article has been copublished in Resuscitation. Published by Elsevier Ire-
land Ltd. All rights reserved.
patient. Retrieval and preservation of the amputated body
part should not be overlooked, however, so that replanta- Acknowledgments
tion can be attempted. This ScopRev identified evidence The writing group would like to thank Jaylen I. Wright for assistance with edit-
ing of text, including supplemental materials, as well as administrative assistance
on methods of preserving avulsed or amputated body throughout the writing process. We would like to thank Veronica Zamora for ad-
parts to maximize the chance of successful replantation. ministrative support.

S12 October 21, 2025 Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361

 Berg et al Executive Summary: 2025 CoSTR

Disclosures
Writing Group Disclosures

Writing Other Consultant/

group Research research Speakers’ bureau/ Expert Ownership advisory
member Employment grant support honoraria witness interest board Other
Katherine M. Beth Israel None None None None None AHA/ILCOR† None
Berg Deaconess
Medical Center
and Harvard
Medical
School
Peter T. University of None None None None None None None
Morley Melbourne
(Australia)
Jerry P. Nolan Warwick None None None None None None None
Medical
School,
University
of Warwick,
Coventry
(United
Kingdom)
Dianne L. University of None None None None None None None
Atkins Iowa
Farhan Bhanji McGill None None None None None None None
University
(Canada)
John E. Billi The University None None None None None None None
of Michigan
Medical
School
Janet E. Bray Monash Australian None None None None Australian Elsevier†;
Downloaded from [Link] by on October 27, 2025

University Resuscitation Resuscitation Heart

(Australia) Council†; Laerdal Council* Foundation
Foundation†; Heart of Australia†
Foundation of
Australia†;
Allan R. de Alberta Health None None None None None None None
Caen Services and
University
of Alberta
(Canada)
Jestin N. Allegheny None None None None None None None
Carlson Health
Network
Siddha SC Chairman of None None None None None None None
Chakra Rao the Indian
Resuscitation
Council
Sung Phil Gangnam None None None None None None None
Chung Severance
Hospital,
Yonsei
University
(Korea)
Therese Djärv Karolinska None None None None None None None
Institutet
(Sweden)

(Continued )

Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361 October 21, 2025 S13

 Berg et al Executive Summary: 2025 CoSTR

Writing Group Disclosures Continued

Writing Other Consultant/

group Research research Speakers’ bureau/ Expert Ownership advisory
member Employment grant support honoraria witness interest board Other
Ian R. Sunnybrook ZOLL Medical† None Speakers’ Bureau:: None None None None
Drennan Health Science ZOLL Medical
Centre and Relationship:: Myself
University Compensation::
of Toronto Compensated Level::
(Canada) Significant (≥$5K or
≥5%)
Raffo Inter-American None None None None None None None
Escalante- Heart
Kanashiro Foundation
and Instituto
Nacional de
Salud del Niño
(Peru)
Robert Greif University of None None None None None None None
Bern
(Switzerland)
Amber V. American Red None None None None None None None
Hoover Cross
Eric J. Denver Health None None None None None AHA/ILCOR† None
Lavonas
Helen G. The University None None None None None None None
Liley of Queensland
(Australia)
Andrew S. Calderdale None None None None None None None
Lockey Royal Hospital
(United
Kingdom)
William H. Straub Clinic None None None None None ILCOR† None
Downloaded from [Link] by on October 27, 2025

Montgomery and Hospital

Laurie J. St. Michael's None None None None None None None
Morrison Hospital and
University
of Toronto
(Canada)
Vinay M. Children’s Zoll Medical*; None None None None None Citizen CPR
Nadkarni Hospital Nihon-Kohden*; Foundation*
Philadelphia, Laerdal Foundation*; Society of
University of American Heart Simulation in
Pennsylvania Association* Healthcare*
Perelman
School of
Medicine
Robert W. University of NIH† Laerdal None None None None None None
Neumar Michigan Foundation*;
BrainCool*; Corpuls*
Theresa M. Oslo University None None None None None None None
Olasveengen Hospital and
University of
Oslo
(Norway)
Gavin D. Warwick NIHR†; BHF†; University None None None None None
Perkins Medical RCUK†; Laerdal Hospitals
School and Foundation† Coventry and
University Warwickshire†;
Hospitals NHS Elsevier†
Foundation
Trust
(United
Kingdom)

(Continued )

S14 October 21, 2025 Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361

 Berg et al Executive Summary: 2025 CoSTR

Writing Group Disclosures Continued

Writing Other Consultant/
group Research research Speakers’ bureau/ Expert Ownership advisory
member Employment grant support honoraria witness interest board Other
Jeanette K. Retired None None None None None American None
Previdi Heart
Association†

Yacov Rabi University None None None None None None None
of Calgary
(Canada)
Claudio Università None None None None None None None
Sandroni Cattolica del
Sacro Cuore
- Fondazione
Policlinico
Universitario
A. Gemelli –
IRCCS (Italy)
Georg M. University None None None None None None None
Schmölzer of Alberta
(Canada)
Barnaby R. Hospital for None None None None None None None
Scholefield Sick Children
(Canada)
Tony Scott North Shore None None None None None None None
Hospital and
Waitemata
District, Te
Whatu Ora/
Health (New
Zealand)
Federico European None None None None None None None
Semeraro Resuscitation
Downloaded from [Link] by on October 27, 2025

Council and
Maggiore
Hospital (Italy)
Eunice M. University of None None None None None None None
Singletary Virginia
David Wellkin None None None None None None None
Stanton Hospital
(Mauritius)
Michelle McMaster None None None None None None None
Welsford University,
Hamilton
Health
Sciences
(Canada)
Joyce Yeung University None None None None None None None
of Warwick,
Warwick
Medical
School (United
Kingdom)

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361 October 21, 2025 S15

 Berg et al Executive Summary: 2025 CoSTR

Reviewer Disclosures

Research Other research Speakers’ Expert Ownership Consultant/

Reviewer Employment grant support bureau/honoraria witness interest advisory board Other
Aarti Bavare Baylor College of None None None None None None None
Medicine
Alexandra Children’s Hospital of None None None None None None None
Marquez Philadelphia
Mary Ann University of None None None None None None None
McNeil Minnesota
Robert Wake Forest University None None None None None None None
Darrell Health Sciences
Nelson
Donald H. Johns Hopkins None None None None None None None
Shaffner Hospital

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-
tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any
12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of
the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

8. Dainty KN DG, Vaillancourt C, Smyth M, Olasveengen T, Bray J on behalf

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Training for Neonatal Resuscitation: An RCT. Pediatrics. 2014;134:e790– quency and consequences of cardiopulmonary resuscitation performed by
e797. doi: 10.1542/peds.2013-3988 bystanders on patients who are not in cardiac arrest. Prehosp Emerg Care.
147. Xu C, Zhang Q, Xue Y, Chow C-B, Dong C, Xie Q, Cheung P-Y. Improved 2011;15:282–287. doi: 10.3109/10903127.2010.541981
neonatal outcomes by multidisciplinary simulation—a contemporary prac- 163. Bazirete O, N M, Uwimana MC, Umubyeyi A, Marilyn E. Factors affect-
tice in the demonstration area of China. Front Pediatr. 2023;11: doi: ing the prevention of postpartum hemorrhage in Low-and Middle-
10.3389/fped.2023.1138633 Income Countries: A scoping review of the literature. J Nurs Educ Pract.
148. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castren M, 2020;11:66. doi: 10.5430/jnep.v11n1p66
Chung SP, Considine J, Couper K, Escalante R, et al; Adult Basic Life Support 164. Saccone G, Caissutti C, Ciardulli A, Abdel-Aleem H, Hofmeyr GJ, Berghella
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on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care labour for preventing postpartum haemorrhage during vaginal deliv-
Science With Treatment Recommendations. Circulation. 2020;142:S41– ery: a systematic review and meta-analysis of randomised trials. BJOG.
S91. doi: 10.1161/CIR.0000000000000892 2018;125:778–781. doi: 10.1111/1471-0528.14923
149. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castren M, 165. Escobar MF, Nassar AH, Theron G, Barnea ER, Nicholson W,
Chung SP, Considine J, Couper K, Escalante R, et al; Adult Basic Life Ramasauskaite D, Lloyd I, Chandraharan E, Miller S, Burke T, et al; FIGO
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on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care tions on the management of postpartum hemorrhage 2022. Int J Gynaecol
Science With Treatment Recommendations. Resuscitation. 2020;156:A35– Obstet. 2022;157:3–50. doi: 10.1002/ijgo.14116
A79. doi: 10.1016/[Link].2020.09.010 166. Giouleka S, Tsakiridis I, Kalogiannidis I, Mamopoulos A, Tentas I,
150. Dunne CL, Cirone J, Blanchard IE, Holroyd-Leduc J, Wilson TA, Sauro Athanasiadis A, Dagklis T. Postpartum Hemorrhage: A Comprehensive
K, McRae AD. Evaluation of basic life support interventions for foreign Review of Guidelines. Obstet Gynecol Surv. 2022;77:665–682. doi:
body airway obstructions: A population-based cohort study. Resuscitation. 10.1097/OGX.0000000000001061
2024;201:110258. doi: 10.1016/[Link].2024.110258 167. Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA. Uterine massage for
151. Bhanderi BG, Palmer Hill S. Evaluation of DeChoker, an Airway Clearance preventing postpartum haemorrhage. Cochrane Database Syst Rev.
Device (ACD) Used in Adult Choking Emergencies Within the Adult 2013;2013:CD006431. doi: 10.1002/14651858.CD006431.pub3
Care Home Sector: A Mixed Methods Case Study. Front Public Health. 168. Likis FE, Sathe NA, Morgans AK, Hartmann KE, Young JL, Carlson-Bremer
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resource settings: current perspectives. Int J Womens Health. 2013;5:737– 173. Singletary EM, L J, Berry D, Cassan P, Pek JH, Thilakasiri K, Djärv T, on
752. doi: 10.2147/IJWH.S51661 behalf of the International Liaison Committee on Resuscitation First Aid
170. Tuncalp O, Souza JP, Gulmezoglu M; World Health Organization. Task Force. Preservation of traumatic complete amputated or avulsed body
New WHO recommendations on prevention and treatment of post- parts in the out-of-hospital setting Task Force Synthesis of a Scoping
partum hemorrhage. Int J Gynaecol Obstet. 2013;123:254–256. doi: Review. [Internet] Brussels, Belgium: International Liaison Committee on
10.1016/[Link].2013.06.024 Resuscitation (ILCOR) First Aid Task Force. 2024. Accessed December
171. Weeks A. The prevention and treatment of postpartum haemorrhage: what 4, 2024. [Link]
do we know, and where do we go to next? BJOG. 2015;122:202–210. doi: complete-amputated-or-avulsed-body-parts-in-the-prehospital-setting-fa-
10.1111/1471-0528.13098 7391-tf-scoping-review.
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S22 October 21, 2025 Circulation. 2025;152(suppl 1):S2–S22. DOI: 10.1161/CIR.0000000000001361

 Circulation

Basic Life Support: 2025 International Liaison

Committee on Resuscitation Consensus on
Science With Treatment Recommendations
Janet E. Bray, Chair; Michael A. Smyth, Vice Chair; Gavin D. Perkins; Rebecca E. Cash; Sung Phil Chung; Julie Considine;
Katie N. Dainty; Vihara Dassanayake; Guillaume Debaty; Maya Dewan; Bridget Dicker; Natasha Dodge; Fredrik Folke;
Takanari Ikeyama; Carolina Malta Hansen; Nicholas J. Johnson; George Lukas; Anthony Lagina; Siobhan Masterson;
Peter T. Morley; Laurie J. Morrison; Ziad Nehme; Tatsuya Norii; Violetta Raffay; Giuseppe Ristagno; Aloka Samantaray;
Federico Semeraro; Baljit Singh; Christopher M. Smith; Christian Vaillancourt; Katherine M. Berg, Senior Editor;
Theresa M. Olasveengen; on behalf of the Basic Life Support Task Force Collaborators

ABSTRACT: The International Liaison Committee on Resuscitation conducts continuous review of new, peer-reviewed
published cardiopulmonary resuscitation science, and publishes more comprehensive reviews every 5 years. The Basic
Life Support Task Force chapter of the 2025 International Liaison Committee on Resuscitation Consensus on Science With
Treatment Recommendations addressed all published resuscitation evidence reviewed by the Basic Life Support Task Force
science experts since 2020. Topics addressed by systematic reviews in the last year include chest compression–only
cardiopulmonary resuscitation, starting cardiopulmonary resuscitation with compressions or airway and breathing, chest
compression and ventilation ratios, durations of cardiopulmonary resuscitation cycles, hand positioning during compressions,
head-up cardiopulmonary resuscitation, ventilation feedback devices, and pad and paddle size and placement. Members from
the Basic Life Support Task Force have assessed, discussed, and debated the quality of the evidence, based on Grading of
Downloaded from [Link] by on October 27, 2025

Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment
recommendations. Insights into the deliberations of the task force are provided in the Justification and Evidence-to-Decision
Framework Highlights sections. In addition, the task force lists priority knowledge gaps for further research.

Key Words: Scientific Statements ◼ cardiopulmonary resuscitation ◼ defibrillators ◼ drowning ◼ heart arrest ◼ ILCOR ◼ obesity

INTRODUCTION CoSTR includes the data reviewed and draft treatment

recommendations, with public comments accepted for
This is the 2025 International Liaison Committee on Re- 2 weeks after posting. The task force considered public
suscitation (ILCOR) Consensus on Science With Treat- feedback and provided responses. All CoSTRs are now
ment Recommendations (CoSTR), from the ILCOR Basic available online, adding to the existing CoSTR statements.
Life Support (BLS) Task Force. All reviews conducted by Although only SysRevs can generate a full CoSTR
the BLS Task Force in the last 12 months are included; and new treatment recommendations, many other topics
reviews conducted and published since the 2020 publi- were evaluated with more streamlined processes, includ-
cation are also summarized to provide a single reference ing scoping reviews (ScopRevs) and evidence updates
document for readers. The BLS Task Force work present- (EvUps). Good practice statements, which represent the
ed here encompasses 33 questions reviewed in some ca- expert opinion of the task force in light of very limited
pacity, including 22 systematic reviews (SysRevs). Draft or no direct evidence, can be generated after ScopRevs
CoSTRs for all topics evaluated with SysRevs were post- and occasionally after EvUps in cases where the task
ed on a rolling basis on the ILCOR website.1 Each draft force thinks providing guidance is especially important.

Supplemental Material is available at [Link]

© 2025 American Heart Association, Inc., European Resuscitation Council, and International Liaison Committee on Resuscitation.
Circulation is available at [Link]/journal/circ

S34 October 21, 2025 Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364

 Bray et al Basic Life Support: CoSTR 2025

A separate article in this issue includes the full details of • Optimization of dispatcher-assisted automated
the evidence evaluation process.2 external defibrillator (AED) retrieval and use (BLS
This summary statement contains the final wording 2120: ScopRev 2024)
of the treatment recommendations and good practice • Drone AED delivery (BLS 2122: ScopRev, 2023
statements as approved by the ILCOR BLS Task Force CoSTR summary; EvUp 2025)
as well as summaries of the key evidence identified. The • AED accessibility: locked cabinets (BLS 2123:
year that treatment recommendations or good practice ScopRev 2025)
statements were generated or last updated by a Sys- • Starting CPR (compressions-airway-breathing
Rev is provided in parentheses. In cases where existing [CAB] versus airway-breathing-compressions
treatment recommendations have changed for 2025, the [ABC]) (BLS 2201: SysRev 2025)
prior recommendations are also presented so the reader • Compression-ventilation ratio (BLS 2202: SysRev
can easily see what has changed. SysRevs include 2025)
evidence-to-decision highlights and knowledge gaps, • Duration of CPR cycles (BLS 2212: SysRev 2025)
and ScopRevs summarize Task Force insights on spe- • Emergency medical services (EMS) continuous–
cific topics and include evidence-to-decision highlights chest compression CPR versus conventional CPR
if good practice statements are generated. Links to the (BLS 2221: SysRev 2025)
published reviews and full online CoSTRs are provided in • In-hospital continuous–chest compression CPR
the corresponding sections. Evidence-to-decision tables versus conventional CPR (BLS 2222: SysRev
for SysRevs are provided in Appendix A, and the com- 2025)
plete EvUp worksheets are provided in Appendix B. A • Hand position during compressions (BLS 2502:
summary of treatment recommendation changes and SysRev 2025)
knowledge gaps is provided in Appendix C. • Head-up CPR (BLS 2503: SysRev 2025)
Most topics are presented using the population, inter- • Minimizing pauses in compressions (BLS 2504:
vention, comparator, outcomes, study design, and time SysRev 2022, EvUp 2025)
frame format. To minimize redundancy, the study designs • Optimal surface for CPR (BLS 2510: SysRev 2024)
have been removed from the text except in cases where • Feedback for CPR quality (BLS 2511: ScopRev
the designs differed from the BLS standard criteria. The 2024)
standard study designs included are randomized clini- • Passive ventilation techniques (BLS 2403: SysRev
cal trials (RCTs) and nonrandomized studies (non-RCTs, 2022, EvUp 2025)
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interrupted time series, controlled before-and-after stud- • Real-time ventilation quality feedback devices (BLS
ies, and cohort studies) were eligible for inclusion. Case 2402: ScopRev 2025)
series, case reports, animal studies, and unpublished • Paddle/pad size and placement in adults (BLS
studies (conference abstracts, trial protocols) were 2601: SysRev 2025)
excluded. All languages were included, provided there • Removal of bra prior to defibrillation (BLS 2604:
was an English abstract. ScopRev 2025)
Two nodal reviews that included the BLS Task Force • Effectiveness of ultraportable/pocket AEDs (BLS
can be found in other CoSTR sections (Family Presence 2603: ScopRev 2024)
During Resuscitation3 in Education, Implementation, and • Immediate resuscitation in water or on boat in
Teams and Resuscitation of Durable Mechanical Circula- drowning (BLS 2702/2703: ScopRev 2021,
tory Supported Patients4 in Advanced Life Support). The SysRev 2023, EvUp 2025)
following topics are addressed in this BLS Task Force • Starting CPR (CAB versus ABC) in drowning (BLS
CoSTR: 2704: ScopRev 2023, SysRev 2024, EvUp 2025)
• Cardiopulmonary resuscitation (CPR) by rescuers • Chest compression–only CPR in drowning (BLS
wearing personal protective equipment (BLS 2003: 2705: ScopRev 2023, SysRev 2023, EvUp 2025)
SysRev 2023, EvUp 2025) • Ventilation equipment in cardiac arrest follow-
• Bystander (without dispatcher-assisted instruc- ing drowning (BLS 2706: ScopRev 2023, SysRev
tions) chest compression–only CPR versus conven- 2023, EvUp 2025)
tional CPR (BLS 2100: SysRev 2025) • Prehospital oxygen administration following drown-
• Optimization of dispatcher-assisted recognition of ing (BLS 2707: SysRev 2023, EvUp 2025)
out-of-hospital cardiac arrest (OHCA) (BLS 2102: • AED use versus CPR first in drowning (BLS 2708:
ScopRev 2024, EvUp 2025) ScopRev 2023, SysRev 2023, EvUp 2025)
• Optimization of dispatcher-assisted CPR (BLS • Public access defibrillation (PAD) programs for
2113: ScopRev 2024, EvUp 2025) drowning (BLS 2709: SysRev 2023, EvUp 2025)
• Dispatcher-assisted chest compression–only CPR • CPR during transport (BLS 2715: SysRev 2022,
versus conventional CPR (BLS 2112: SysRev EvUp 2025)
2025) • CPR in obese patients (BLS 2720: ScopRev 2025)

Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364 October 21, 2025 S35

 Bray et al Basic Life Support: CoSTR 2025

Readers are encouraged to monitor the ILCOR web- topic was prioritized because it had not been reviewed
site1 to provide feedback on planned SysRevs and to pro- since 2017. The SysRev was registered on Prospec-
vide comments when additional draft reviews are posted. tive Register of Systematic Reviews (PROSPERO)
(CRD42024559318), and the full CoSTR for adults can
be found on the ILCOR website.17 To inform the provision
SAFETY AND PREVENTION of immediate bystander CPR, it was decided to examine
this question without cases where dispatcher-assisted
CPR by Rescuers Wearing Personal Protective
CPR (DA-CPR) instructions were provided. Four studies
Equipment (BLS 2003: SysRev 2023, EvUp that included cases with DA-CPR and were previously
2025) included in this CoSTR18–21 have been moved to the DA-
A 2023 SysRev and 2025 EvUp examined the impact of CPR CoSTR.
rescuers wearing personal protective equipment on pa-
tient and CPR outcomes. The details of this review can Population, Intervention, Comparator, Outcome,
be found in the SysRev,5 the 2023 CoSTR summary6,7 Study Design, and Time Frame
and on the ILCOR website.8 The 2025 EvUp is provided • Population: Adults and children in any setting (in-
in Appendix B. hospital or out-of-hospital) with cardiac arrest
• Intervention: Chest compression–only CPR without
Population, Intervention, Comparator, Outcome, and
dispatcher assistance
Time Frame
• Comparator: Conventional CPR with compressions
• Population: Adults and children in any setting (in-
and ventilations without dispatcher assistance
hospital or out-of-hospital) with cardiac arrest
• Outcomes:
(including simulated cardiac arrest)
- Critical: Favorable neurological survival (as mea-
• Intervention: CPR by rescuers wearing personal
sured by Cerebral Performance Category [CPC]
protective equipment
or modified Rankin Scale [mRS]) at discharge or
• Comparator: CPR by rescuers not wearing personal
30 days and at any time interval after 30 days
protective equipment
- Important: Survival to discharge or 30 days, survival
• Outcomes:
to hospital admission, survival to any time interval
- Critical: Survival to discharge, return of spontane-
after discharge or 30 days survival, ROSC, quality
ous circulation (ROSC)
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of life as measured by any indicator or score

- Important: CPR quality, time to the procedure of
• Study design: In addition to standard criteria, obser-
interest, and rescuer’s fatigue and neuropsychiatric
vational studies that reported only unadjusted data
performance such as concentration and dexterity
were excluded.
• Time frame: May 23, 2022, to August 9, 2024
• Time frame: Because the search terms were
Summary of Evidence revised,17 the search was all years to October 21,
The EvUp identified 4 additional studies.9–12 Because the 2024
new evidence does not alter the current treatment rec- Consensus on Science
ommendations, an update to the existing SysRev is not No new studies that directly addressed this topic were
warranted. found. The evidence remains 3 observational studies
that compared bystander chest compression–only CPR
Treatment Recommendations (2023)
with conventional CPR at a ratio of 15:222,23 and 30:224
We recommend monitoring for fatigue in all rescuers
in adults without DA-CPR instructions. Because 15:2
performing CPR (good practice statement).
CPR is no longer recommended, all outcomes with these
We suggest increased vigilance for fatigue in rescu-
studies were downgraded for indirectness. No data was
ers wearing personal protective equipment (weak recom-
available from the included studies for the outcome of
mendation, very low–certainty evidence).
favorable neurological survival. Data for this outcome is
drawn from a study of combined bystander-only CPR
and DA-CPR with a high prevalence of bystander-only
RECOGNITION AND EARLY ACCESS CPR.19 The evidence is summarized in Table 1.
Bystander Chest Compression–Only CPR
Treatment Recommendations (2025, Unchanged
(Without Dispatcher Assistance) (BLS 2100,
From 2017)
SysRev 2025) We recommend that chest compressions be performed
Rationale for Review for all adults in cardiac arrest (good practice statement).
The previous SysRev13 and existing ILCOR treatment We suggest that bystanders who are trained, able,
recommendation were first published in 2017.14,15 This and willing, give chest compressions with rescue breaths

S36 October 21, 2025 Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364

 Bray et al Basic Life Support: CoSTR 2025

Table 1. The Evidence Comparing Chest Compression–Only CPR With Conventional CPR Without Dispatcher Assistance

Outcome (certainty of evidence) Studies (patients) Results

Favorable neurological function No studies without dispatcher assistance CCO-CPR, compared with 15:2 CPR, was associated with
(very low–certainty evidence) favorable neurological function (aOR, 2.22; 95% CI, 1.17–4.21)
1 cohort study of combined bystander (76%
of cases) and DA-CPR (24% of cases)
(4068 adult bystander-witnessed OHCAs)19
Survival to hospital discharge or 3 observational studies: 1 in adults24 and 2 Adult study: higher survival to hospital discharge with CCO-CPR
30 d (very low–certainty evidence) in all ages22,23 compared with 30:2 CPR (aOR, 1.60; 95% CI, 1.08–2.35)24
All-age studies: no difference in survival to 30 d (aOR, 1.18; 95%
CI, 0.89–1.56)23 or hospital discharge (aOR, 1.32; 95% CI, 0.35–
4.94)22 with CCO-CPR compared with 15:2 CPR
Survival to hospital admission 1 observational study in all ages23 No difference with CCO-CPR compared with 15:2 CPR (aOR,
(very low–certainty evidence) 1.03; 95% CI, 0.86–1.23)
ROSC (very low–certainty 1 observational study in all ages22 No difference with CCO-CPR compared with 15:2 CPR (aOR,
evidence) 1.02; 95% CI, 0.60–1.73)

aOR indicates adjusted odds ratio; CCO-CPR, chest compression–only cardiopulmonary resuscitation; CPR, cardiopulmonary resuscitation; DA-CPR, dispatcher-
assisted cardiopulmonary resuscitation; OHCA, out-of-hospital cardiac arrest; and ROSC, return of spontaneous circulation.

for adults in cardiac arrest (weak recommendation, very • A literature review reported that chest compres-
low–certainty evidence). sion–only CPR results in a shorter time to initiate
CPR and a higher total number of chest compres-
Justification and Evidence-to-Decision Framework
sions.34 However, as it continues, rescuers may
Highlights
experience fatigue, which can reduce the depth
The complete evidence-to-decision table is included in
of compressions compared with those delivered in
Appendix A.
conventional CPR with pauses for breaths.34
In making these recommendations, the task force
• Opening the airway and delivering ventilations
acknowledged the very low–certainty evidence in com-
are technical skills, and bystanders, especially if
parison with 15:2 CPR but placed greater emphasis on
untrained or minimally trained, are typically unable to
the need to give chest compressions in adult CPR and the
deliver effective ventilations during simulated CPR.35
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potential to increase rates of bystander CPR with chest

• Both types of CPR are better than no CPR, and
compression–only CPR or compression-focused CPR in
both should be taught in BLS/CPR training.
adults.20,25–27 The task force also considered the following:
• The existing evidence suggests chest compres- Knowledge Gaps
sion–only CPR is comparable to 15:2 CPR in adults. • The effect on outcomes of chest compression–only
Given the included studies were conducted without CPR compared with 30:2 CPR without dispatcher
dispatcher assistance, it could be assumed that the assistance
CPR was performed by CPR-trained individuals or • Data in children are needed.
off-duty health care professionals.
• Three additional studies reported no difference in
unadjusted patient outcomes between chest com- Optimization of Dispatcher-Assisted
pression–only CPR and conventional CPR.28–30 One Recognition of OHCA (BLS 2102: ScopRev
of these studies, conducted in the 1980s, examined 2024, EvUp 2025)
the impact of CPR quality. Using combined objective This topic was first reviewed in an ILCOR nodal Sys-
and subjective measures, this study reported higher Rev in 2020,36 with treatment recommendations for
unadjusted survival when 15:2 was performed cor- ­dispatcher-assisted recognition of OHCA published in
rectly (good technique and effect), compared with the 2020 CoSTR.37,38 In 2024, the BLS Task Force de-
incorrectly (31% versus 8%) or when compared cided to conduct a ScopRev to examine the evidence for
with chest compression–only CPR (31% versus interventions aiming to optimize dispatcher-assisted rec-
20%).30 Rates of correctly applied 15:2 were higher ognition of OHCA, with an EvUp conducted in 2025. The
in bystanders who were health care professionals details of this review can be found in the ScopRev,39 in
than in lay bystanders (58% versus 42%).30 the 2024 CoSTR summary,40,41 and on the ILCOR web-
• A pilot RCT, including high rates of DA-CPR, site.42 The 2025 EvUp is provided in Appendix B.
showed no difference in survival at 1 day between
chest compression–only CPR and conventional Population, Intervention, Comparator, Outcome, and
CPR when delivered by trained laypersons.31 Time Frame
• Chest compression–only CPR is preferred by the • Population: Adults and children who are in cardiac
public32,33 and easier to learn and recall. arrest outside of a hospital

Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364 October 21, 2025 S37

 Bray et al Basic Life Support: CoSTR 2025

• Intervention: Factors and interventions that improve CPR instructions for adult patients in cardiac arrest
dispatcher-assisted recognition of cardiac arrest (strong recommendation, very low–certainty evidence).
• Outcomes: Dispatcher-assisted recognition of car- We recommend that emergency medical dispatchers
diac arrest provide CPR instructions (when deemed necessary) for
• Time frame: June 2, 2023, to November 4, 2024 adult patients in cardiac arrest (strong recommendation,
very low–certainty evidence).
Summary of Evidence The existing evidence did not support a good prac-
The EvUp identified 2 additional studies.43,44 The new evi- tice statement for interventions to improve DA-CPR
dence provided by these studies does not warrant a new instructions.
SysRev.
Treatment Recommendations (2020) Dispatcher-Assisted Chest Compression–Only
We recommend that dispatch centers implement a stan-
dardized algorithm and/or standardized criteria to im- CPR (SysRev 2025)
mediately determine if a patient is in cardiac arrest at Rationale for Review
the time of emergency call (strong recommendation, very The previous SysRev13 and existing ILCOR treatment
low–certainty evidence). recommendation were first published in 2017.14,15 This
We suggest that dispatch centers monitor and track topic was prioritized for a detailed review because it had
diagnostic capability (good practice statement). not been reviewed since 2017. The SysRev was regis-
We suggest that dispatch centers look for ways to tered on PROSPERO (CRD42024559318), and the full
optimize sensitivity (minimize false negatives) (good CoSTR can be found on the ILCOR website.58
practice statement).
Population, Intervention, Comparator, Outcome,
The existing evidence did not support a good prac-
Study Design, and Time Frame
tice statement for interventions to improve dispatcher-
• Population: Adults and children in any setting (in-
assisted recognition.
hospital or out-of-hospital) with cardiac arrest
• Intervention: Dispatcher-assisted chest compres-
Optimization of Dispatcher-Assisted CPR (BLS sion–only CPR
• Comparators: Dispatcher-assisted conventional
2113: ScopRev 2024, EvUp 2025)
CPR with compressions and ventilations
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This topic was last reviewed in an ILCOR nodal Sys- • Study design: In addition to standard criteria, obser-
Rev in 2019, with treatment recommendations for vational studies that reported only unadjusted data
­dispatcher-assisted recognition of OHCA published in were excluded.
the 2019 CoSTR summary.45,46 In 2024, the BLS task • Outcomes:
force decided to conduct a ScopRev to examine the evi- - Critical: Favorable neurological survival (as mea-
dence for interventions to optimize DA-CPR instructions, sured by CPC or mRS) at discharge or 30 days
with an EvUp conducted in 2025. The details of this re- and at any time interval after 30 days
view can be found in the ScopRev,47 the 2024 CoSTR - Important: Survival to discharge or 30 days, sur-
summary,40,41 and on the ILCOR website.48 The 2025 vival to hospital admission, survival to any time
EvUp is provided in Appendix B. interval after discharge or 30-days survival,
ROSC, quality of life as measured by any indica-
Population, Intervention, Comparator, Outcome, and
tor or score
Time Frame
• Time frame: Because the search terms were
• Population: Adults and children with OHCA when
revised,17 search was inception to October 21, 2024
DA-CPR is implemented
• Intervention: Interventions used in addition to Consensus on Science
DA-CPR Four RCTs31,59–61 and 6 observational studies18,19,62–65
• Comparators: Nonmodified DA-CPR were identified that compared dispatcher-assisted chest
• Outcomes: Any outcomes compression–only CPR with conventional CPR at a ra-
• Time frame: May 17, 2023, to November 1, 2024 tio of 15:2 or 30:2 in adults or all ages, with or with-
Summary of Evidence out bystander CPR ongoing at the time of the call. As
The EvUp identified 9 additional studies.49–57 The new 15:2 CPR is no longer recommended, all outcomes were
downgraded for indirectness. The overall certainty of evi-
evidence does not warrant a new SysRev.
dence was rated as low to very low for all outcomes, pri-
Treatment Recommendations (2019 and 2024) marily due to a very serious risk of bias. Because of this
We recommend that emergency medical dispatch centers and a high degree of heterogeneity, meta-analyses were
have systems in place to enable call handlers to provide not performed. The evidence is summarized in Table 2.

S38 October 21, 2025 Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364

 Bray et al Basic Life Support: CoSTR 2025

Table 2. The Evidence Comparing Dispatcher-Assisted Chest Compression–Only CPR With Conventional CPR

Outcome (certainty of evidence) Studies (patients) Results

Favorable neurological function 1 adult RCT59 No difference compared with 15:2
(very low–certainty evidence)
4 observational studies: 1 study included 2 studies of combined bystander and DA-CPR cases, reported higher
adult bystander-witnessed DA-CPR cases62; odds with CCO-CPR compared with 15:2 (aOR, 2.22; 95% CI, 1.17–
3 studies examined combined bystander CPR 4.21)19 or compared with combined 15:2 and 30:2 CPR (aOR, 1.12;
and DA-CPR in adults-witnessed19,63 and all- 95% CI, 1.06–1.19)65
age bystander-witnessed65 cases
2 studies reported no difference compared with 30:262,63
Survival to hospital discharge 3 RCTs: 2 in adults,59,601 in >8 y of age No difference in survival to hospital discharge compared with 30:262,63
or 30 d (very low–certainty bystander-witnessed61
evidence)
5 observational studies: 2 in all ages,64,65 2 in 1 reported higher odds with CCO-CPR compared with C-CPR of either
adults,18,62 and 1 in adult-witnessed63 15:2 or 30:2 (aOR, 1.05; 95% CI, 1.01–1.10)65
2 reported lower odds with CCO-CPR compared with either 15:2 (aOR,
0.69; 95% CI, 0.53–0.90)64 or 30:2 CPR (aOR, 0.72; 95% CI, 0.59,
0.88)62
2 studies reported no difference with DA CCO-CPR compared with
either 15:218 or 30:263
Survival to hospital admission 4 RCTs: 3 in adults31,59,60 1 in >8 y of age No difference with DA CCO-CPR compared with either 15:260,61 or
(low-certainty evidence) bystander-witnessed61 30:231
ROSC (very low–certainty 1 all-age observational study65 No difference compared with either 15:2 or 30:2 CPR
evidence)

aOR indicates adjusted odds ratio; C-CPR, conventional CPR; CCO-CPR, chest compression–only CPR; CPR, cardiopulmonary resuscitation; DA, dispatcher-assisted;
DA-CPR, dispatcher-assisted cardiopulmonary resuscitation; RCT, randomized controlled trial; and ROSC, return of spontaneous circulation.

Treatment Recommendations (2025, Unchanged of evidence, particularly related to implementation

From 2017) of DA-CPR. Despite this, most included studies
We recommend that dispatchers provide chest compres- suggested either a slight improvement in favor of
sion–only CPR instructions to callers for adults with sus- dispatcher-assisted chest compression–only CPR
pected OHCA (strong recommendation, low-certainty or no difference in patient outcomes, regardless of
Downloaded from [Link] by on October 27, 2025

evidence). patient population or comparison ratio.

Justification and Evidence-to-Decision Framework Knowledge Gaps

Highlights • Studies in children
The complete evidence-to-decision table is provided in • The number of chest compressions that should be
Appendix A. given, and for how long before ventilation instruc-
In making these recommendations, the task force tions are introduced
acknowledged the low-certainty evidence but strongly • Whether resuscitation instructions should be modi-
endorsed the 2020 CoSTR that all rescuers should per- fied in the context of different causes of arrest (eg,
form chest compressions for all patients in cardiac arrest. choking, drowning)
The task force also considered the following: • The impact of prior CPR training
• Bystander CPR more than doubles OHCA sur-
vival.66 We placed a higher emphasis on the impor-
tance of providing high-quality chest compressions Optimization of Dispatcher-Assisted AED
and increasing the overall rate of bystander CPR Retrieval and Use (BLS 2120: ScopRev 2024)
over providing rescue breaths. A 2024 ScopRev examined the evidence for a new BLS
• Increases in rates of bystander CPR and patient out- question on interventions to optimize dispatcher-assisted
comes have been reported following the introduc- AED retrieval and use for OHCA. The details of this re-
tion of dispatcher-assisted chest compression–only view can be found in the ScopRev,69 the 2024 CoSTR
CPR or compression-focused CPR in adults.20,25–27 summary,40,41 and on the ILCOR website.70
Using a chest compression–only CPR strategy may
increase the willingness of bystanders to respond Population, Intervention, Comparator, Outcome, and
during a cardiac arrest. Time Frame
• Most bystander CPR for adults is given with • Population: Adults and children with OHCA
DA-CPR instructions, even in the presence of CPR- • Intervention: Dispatcher-assisted AED retrieval and
trained lay bystanders.31 use
• In making these recommendations, the task force • Outcomes: Any outcomes
took into consideration heterogeneity in the body • Time frame: All years to April 13, 2023

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 Bray et al Basic Life Support: CoSTR 2025

Treatment Recommendations (2024) functional outcomes.84–86 Concerns about theft, vandal-

EMS implementing dispatcher-assisted public access ism, and misuse of AEDs have led to the use of security
AED systems should monitor and evaluate the effective- measures, including using locked cabinets, to house these
ness of their system (good practice statement). devices in public areas.87–89 Given the lack of a compre-
Once a cardiac arrest is recognized during the emer- hensive review of this approach, this topic was prioritized
gency call and CPR has been started, dispatchers should for review by the BLS Task Force. The full details of this
ask if there is an AED (or defibrillator) immediately avail- review can be found in the ScopRev90 and on the ILCOR
able at the scene and ask the caller to update them when website.91
one arrives (good practice statement).
If an AED is not immediately available and if there is Population, Intervention, Comparator, Outcome, and
more than 1 rescuer present, dispatchers should offer Time Frame
instructions to locate and retrieve an AED. Retrieval • Population: Adults and children in out-of-hospital
instructions should be supported, where resources allow, settings
by up-to-date registries about public access AED loca- • Concept: The benefits and harms of placing AEDs
tions and accessibility (good practice statement). in locked cabinets versus unlocked cabinets
Once an AED is available, dispatchers should offer • Context: Any locations where an AED is placed with
instructions on its use (good practice statement). the intention of the AED being publicly accessible
for use
• Outcomes: Any outcome, including AED outcomes
Drone Delivery of AEDs (BLS 2122: ScopRev (eg, AED use, time to AED use, AED vandalism or
theft)
2023; EvUp 2025)
• Time frame: All years to June 25, 2024
A ScopRev for 2023 and a 2025 EvUp examined the
evidence on drone delivery of AEDs. The details of this Summary of Evidence
review can be found in the ScopRev,71 the 2023 CoSTR Ten reports were included: 7 observational studies re-
summary,6,7 and on the ILCOR website.72 The 2025 EvUp porting rates of theft and vandalism,92–1001 survey re-
is provided in Appendix B. porting on harm to rescuers,101 and 2 AED retrieval
simulation studies.92,93 Four studies were reported as
Population, Intervention, Comparator, Outcome, and conference abstracts97–100 and 2 were letters to the
Time Frame
Downloaded from [Link] by on October 27, 2025

editor.94,96
• Population: Adults and children in OHCA No study reported on the impact of locked AED cabi-
• Intervention: Drone-delivered AEDs nets on patient outcomes. Most studies reported low
• Comparators: Standard EMS response times (or rates (<2%) of theft, missing AEDs, or vandalism and
time for EMS-delivered AED), AEDs delivered by this occurred in locked and unlocked cabinets.92–100 The
bystanders (or activated volunteer responders) only study comparing unlocked and locked cabinets
• Outcomes: Real-world/estimated feasibility, time showed minimal difference in theft and vandalism rates
gain of drone-delivered AEDs (compared with stan- (0.3% versus 0.1%).99 Two simulation studies showed
dard EMS delivery), predicted survival, predicted significantly slower AED retrieval when additional secu-
quality-adjusted life years gained, cost-­effectiveness, rity measures, including locked cabinets, were used.92,93 A
and calculated proportion of defibrillation and sur- survey of first responders reported half (n=25/50) were
vival compared with cases where AEDs are brought injured while accessing an AED that required breaking
to the OHCA scene by standard means glass to access.101
• Time frame: December 1, 2022, to August 6, 2024
Task Force Insights
Summary of Evidence An evidence-to-decision table is provided in Appendix A.
The EvUp identified 11 additional studies.73–83 The new • While acknowledging that most of the data identi-
evidence does not warrant a new SysRev. There is no fied has not undergone peer review and there may
existing treatment recommendation on this topic, and the be publication bias, reported rates of AED theft and
current evidence does not support a new one. vandalism were low across all studies, and thefts
occurred in both locked and unlocked cabinets.
AEDs reported as stolen may have been used in an
AED Accessibility (Locked Cabinets) (BLS
emergency and not returned.
2123: ScopRev 2025) • To ensure EMS is activated for OHCAs, some sys-
Rationale for Review tems use cabinets locked with a code obtained by
Rapid defibrillation is critical to improving patient out- calling EMS.102 However, this may cause delays,
comes because each minute of delay in attempting particularly if a telephone is not readily available,
defibrillation reduces the chances of survival and good and its impact requires further study.103

S40 October 21, 2025 Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364

 Bray et al Basic Life Support: CoSTR 2025

• The cost to replace stolen or vandalized AEDs may - Important: Time to commencement of rescue
be a challenge in low-resource settings (eg, com- breaths, time to commencement of first compres-
munity groups with limited funding). sion, time to completion of first CPR cycle, venti-
• We agree with the 2022 ILCOR scientific state- lation rate, compression rate, chest compression
ment, which focuses on optimizing PAD and advises fraction, minute ventilation
against using locked cabinets.104,105 If locked cabi- • Time frame: Because the search terms were revised,
nets are used, instructions for unlocking them need the search included all years to June 18, 2024
to be clear and ensure no delays in access.
Consensus on Science
Treatment Recommendations One new pediatric manikin simulation study110 (pub-
We advise against using locked cabinets for public ac- lished with corrections111) in addition to the 4 manikin
cess defibrillator storage (good practice statement). simulation studies112–115 found in the previous ILCOR re-
If locked cabinets are used for public access defibril- views37,38,116,117 were identified. Of the 5 manikin studies,
lator storage, instructions for unlocking them must be 3 were randomized studies (1 in adult114 and 2 in pediat-
clear and ensure minimal delays in access (good practice ric resuscitation110,113), and 2 were observational studies
statement). in adult resuscitation.112,115
EMS should devise strategies to return public access No human studies were identified. Evidence was very
defibrillators when used (good practice statement). low certainty for all outcomes, downgraded for very seri-
ous risk of bias and indirectness. Because of this and a
Knowledge Gaps high degree of heterogeneity, no meta-analyses could be
• Peer-reviewed research and human studies on performed, and individual studies are difficult to interpret.
this topic, particularly studies focusing on real-life This evidence from the manikin studies is summarized in
retrieval and the impact of security strategies on Table 3.
delivery times and patient outcomes
Prior Treatment Recommendations (2020)
We suggest commencing CPR with compressions rather
BLS SEQUENCE than ventilations (weak recommendation, very low–cer-
Starting CPR (CAB Versus ABC) in Adults (BLS tainty evidence).
2201, SysRev 2025) Treatment Recommendations (2025)
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Rationale for Review The 2025 treatment recommendation in adults is un-

This was a nodal review with BLS and the Pediatric Life changed from 2020. The pediatric treatment recommen-
Support (PLS) Task Forces. The existing ILCOR treatment dation is reported in the PLS CoSTR section.107
recommendation was last updated in 2020.37,38 This topic In adults in cardiac arrest, we suggest commencing
was prioritized for a detailed nodal review because only CPR with compressions rather than ventilations (weak
EvUps had been done since 2020. The pediatric CoSTR, recommendation, very low–certainty evidence).
treatment recommendations, and evidence-to-decision
Justification and Evidence-to-Decision Framework
table are reported on the ILCOR website106 and in the
Highlights
PLS CoSTR section.107 The SysRev was registered on
The complete evidence-to-decision table is provided in
PROSPERO (CRD42024583890), and the full CoSTR
Appendix A.
can be found on the ILCOR website.106
Please see the PLS section for evidence-to-­
Population, Intervention, Comparator, Outcome, and decision highlights for children. In making these rec-
Time Frame ommendations for adults, the task forces considered
• Population: Adults and children in any setting (in- the following:
hospital or out-of-hospital) with cardiac arrest Most of the existing evidence, all of very low certainty,
• Intervention: Commencing CPR with compressions suggests the following:
first (30:2) • Starting CPR with compressions first results in
• Comparator: Commencing CPR with ventilations improvements in key elements of resuscitation,
first (2:30) such as commencement of chest compressions,
• Outcomes: completion of the first cycle of compressions, and a
- Critical: Survival with favorable neurological out- higher chest compression fraction.
come at hospital discharge or 30 days, survival at • Indirect evidence from before-and-after OHCA reg-
hospital discharge or 30 days, survival with favor- istry studies in adults suggests that switching from
able neurological outcome to 1 year, survival to 1 the ABC to CAB approach was associated with
year, event survival, any ROSC increased rates of bystander CPR25 and improved

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 Bray et al Basic Life Support: CoSTR 2025

Table 3. Compressions First (CAB) Compared With Ventilations First (ABC): Summary of Findings of Manikin Studies

Outcome (certainty of evidence) Studies (participants) Results for cardiac arrest scenarios
Time to commencement of chest 1 crossover pediatric manikin RCT CAB sequence resulted in faster mean time to chest compressions: 19.3 ± 2.6
compressions (very low) (159 two-person teams)113 versus 43.4 ± 5.0 s (P < 0.05)113; 25 ± 9 versus 43 ± 16 s (P < 0.001)114
1 adult manikin RCT (108 two-
person teams)114
2 adult manikin observational CAB sequence was associated with shorter time to chest compressions:
studies (33 six-person teams112; 40 median = 16.0 (IQR = 14.0–26.0) versus 42.0 (IQR = 41.5–59.0) s (P < 0.001)112;
single rescuers115) and mean = 15.4 ± 3.0 versus 36.0 ± 4.1 s (P < 0.001)115
Time to commencement of rescue 1 crossover pediatric manikin RCT CAB sequence resulted in later mean times to commencement of ventilations: 28.4
breaths/ventilations (very low) (159 two-person teams)113 ± 3.1 versus 22.7 ± 3.1 s (P < 0.05)113; 43 ± 10 versus 37 ± 15 s (P < 0.001)114
1 adult manikin RCT (108 two- In the respiratory arrest scenario, CAB sequence resulted in faster mean time to
person teams)114 commencement of ventilations: 19.1 ± 1.5 versus 22.7 ± 0.1 s (P < 0.05)113
Time to completion of first CPR 1 adult manikin RCT (108 two- CAB sequence resulted in shorter mean times to completion of the first
cycle (30 chest compressions and person teams)114 resuscitation cycle (30:2): 48 ± 10 versus 63 ± 17 s (P < 0.001)
2 rescue breaths) (very low)
Ventilation rate (very low) 1 crossover pediatric manikin In a sequence of delivering 5 rescue breaths before commencing chest
RCT110 (28 two-person teams) compressions, ABC resulted in more ventilations delivered in the first minute of
resuscitation: median 13 (IQR = 12–15) versus 10 (IQR = 8–10; P < 0.05)
Compression rate (very low) 1 crossover pediatric manikin No difference in compression rate
RCT110 (28 two-person teams)
1 adult manikin observational study No difference in compression rate
teams (33 six-person teams)112
Compression depth (very low) 1 crossover pediatric manikin No difference in median compression depth
RCT110 (28 two-person teams)
1 adult manikin observational study No difference in compression depth
teams (33 six-person teams)112
CCF (very low) 1 crossover pediatric manikin In a sequence of delivering 5 rescue breaths before commencing chest
RCT110 (28 two-person teams) compressions, ABC resulted in lower median CCF 57% (IQR = 54–64) versus
66% (IQR = 59–68; P < 0.001)
1 adult manikin observational study No difference in CCF
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team (33 six-person teams)112

Minute alveolar ventilation in the 1 crossover pediatric manikin In a sequence of delivering 5 rescue breaths before commencing chest
first minute of resuscitation (very RCT110 (28 two-person teams) compressions, minute alveolar ventilation in the first min of resuscitation was higher
low) with ABC: median 370 mL (IQR = 203–472) versus 276 mL (IQR = 140–360;
P < 0.001)

ABC indicates airway-breathing-compressions; CAB, compressions-airway-breathing; CCF, chest compression fraction; IQR, interquartile range; and RCT, randomized
controlled trial.

patient outcomes.25,118,119 Similar data on in-hospital - Due to the public’s concerns with mouth-to-
cardiac arrest show conflicting evidence in patient mouth ventilation,32 commencing CPR with air-
outcomes.120,121 way and ventilations may result in no bystander
• While important uncertainties remain, in retaining CPR being provided.
this treatment recommendation in adults, the BLS - Evidence suggests that delivering the ABC
task force also considered the following: approach leads to more errors in CPR,113 that lay-
- The benefits of a single training approach in bystanders prefer CAB, and that CAB is easier to
adults learn and retain.113
- Effective chest compressions generate cumula- - The delivery of non–mouth-to-mouth ventilation
tive coronary perfusion pressure, which falls to requires the retrieval and preparation of equip-
near zero when compressions stop. Therefore, ment (eg, bag-mask device, pocket mask), which,
early effective chest compressions are vital to when multiple rescuers are present, can occur
establishing and maintaining coronary perfusion during chest compressions.
pressure.122
- Time to first compression is associated with bet- Knowledge Gaps
ter patient outcomes.123 No human studies directly evaluate this question in
- Bystanders are typically unable to deliver effec- any setting. Because different councils worldwide
tive ventilations during simulated CPR.35 have adopted CAB versus ABC, comparative studies

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 Bray et al Basic Life Support: CoSTR 2025

of different registries may provide evidence to answer at hospital discharge (CPC score 1–2) compared with
this question. a prior period using a CV ratio of 15:2 (odds ratio [OR],
1.56; 95% CI, 1.11, 2.18). In another cohort study of
522 initially shockable OHCA,131 being treated under the
Chest Compression–to–Ventilation Ratios (BLS 2005 guidelines was associated with no change in neu-
2202: SysRev 2025) rologically favorable survival at 30 days (CPC score 1–2)
Rationale for Review compared with being treated with a CV ratio of 15:2 (OR,
This was a nodal review with BLS and the PLS Task 0.50; 95% CI, 0.20, 1.25).
Forces. The previous SysRev13 and existing ILCOR treat- For the critical outcome of survival to hospital dis-
ment recommendation was first published in 2017.14,15 charge or 30-day survival, we identified 6 cohort
This topic was prioritized for a detailed review because studies.119,125–128,130 Because of heterogeneity, no meta-
it had not been reviewed since 2017. The SysRev was analysis was performed.
registered on PROSPERO (CRD42024559318), and • CV ratio 30:2 versus [Link] In 3 studies of OHCA
the full CoSTR can be found on the ILCOR website.124 with all rhythms, a CV ratio of 30:2 compared with
15:2 was associated with higher odds of survival in 2
Population, Intervention, Comparator, Outcome, studies (adjusted OR [aOR], 1.8; 95% CI, 1.2, 2.7128;
Study Design, and Time Frame aOR, 2.5; 95% CI, 1.4, 4.6)127 but not in the third
• Population: Adults and children in-hospital with car- study (aOR, 1.42; 95% CI, 0.79, 2.57).125 For OHCA
diac arrest with initially shockable rhythm, 1 study reported
• Intervention: Any CPR ratio delivered by EMS higher odds of survival to hospital discharge with
• Comparators: Eligible comparator groups include a CV ratio of 30:2 compared with 15:2 (aOR, 1.62;
a CPR ratio different from the one in the interven- 95% CI, 1.33–1.98), which became nonsignificant
tion arm delivered by EMS. Comparator groups that after adjustment for the temporal trend (aOR, 1.07;
received no CPR or compared manual CPR with 95% CI, 0.71, 1.62).130 In OHCA patients with ini-
mechanical CPR were excluded from the review. tial nonshockable rhythm, a CV ratio of 30:2 com-
Studies including automated CPR or any use of pared with 15:2 was associated with higher odds
mechanical devices will only be included if adminis- of survival in one study (aOR 1.53; 95% CI, 1.14,
tered to all treatment arms. 2.05),126 but not in the other (aOR 1.19; 95% CI,
• Outcomes: 0.82, 1.73).130
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- Critical: Favorable neurological survival (as mea- • CV ratio 50:2 versus [Link] A before-after study of
sured by CPC or mRS) at discharge or 30 days 200 bystander-witnessed OHCA with initial shock-
and at any time interval after 30 days able rhythms reported an improvement in survival to
- Important: Survival to discharge or 30 days, sur- hospital discharge following the implementation of a
vival to hospital admission, survival to any time bundled change in resuscitation practice consisting
interval after discharge or 30-day survival, ROSC, of a CV ratio of 50:2 compared with 5:1 (aOR, 2.17;
quality of life as measured by any indicator or 95% CI, 1.26–3.73).119
score For the critical outcome of ROSC, one cohort study
• Study design: In addition to standard criteria, obser- of 1243 OHCA patients found no change in the risk-
vational studies that reported only unadjusted data adjusted odds of ROSC with a CV ratio of 30:2 com-
were excluded. pared with 15:2 (OR, 1.31; 95% CI, 0.99, 1.73).129
• Time frame: Because the search terms were revised,
the search included all years to October 21, 2024 Treatment Recommendations (2025, Unchanged
From 2017)
Consensus on Science We suggest a compression-ventilation ratio of 30:2
Eight studies examined the impact of the 2005 resus- compared with any other compression-ventilation ratio in
citation guidelines, in which changes to compression- adult patients in cardiac arrest (weak recommendation,
to-­
ventilation (CV) ratios were made in combination very low–certainty evidence).
with other bundled interventions.119,125–131 The studies
consisted of 7 retrospective cohort studies,119,125–130 and Justification and Evidence-to-Decision Framework
one prospective study.131 No study included children. Evi- Highlights
dence was very low–certainty in all cases. The complete evidence-to-decision table is provided in
For the critical outcome of favorable neurological sur- Appendix A.
vival at discharge or 30 days, we identified 2 cohort stud- In making this recommendation, the task force placed
ies.126,131 In 1 cohort study of 3960 initially nonshockable a high priority on consistency with our prior treatment
OHCA,126 implementation of the 2005 resuscitation recommendations and the findings identified in this
guidelines (including a CV ratio of 30:2) was associated review, which suggest that the bundle of care, which
with an improvement in neurologically favorable survival included changing to a CV ratio of 30:2, resulted in more

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 Bray et al Basic Life Support: CoSTR 2025

lives being saved. The task force also considered the Treatment Recommendations (2025, Unchanged
following: From 2015)
• All studies included in this review suffered from We suggest pausing chest compressions every 2 min-
serious indirectness, where a change to CV ratio utes to assess the cardiac rhythm (weak recommenda-
was delivered or introduced as part of a bundle of tion, low-certainty evidence).
care that included other changes, such as increases
in the duration of CPR cycles, removal of stacked Justification and Evidence-to-Decision Framework
shocks, removal of postshock rhythm checks and Highlights
fewer interruptions to chest compressions. It is pos- The complete evidence-to-decision table is included in
sible that the benefits observed in these studies are Appendix A.
not related to a change in CV ratio. These included trials were designed to address the
• Future studies and reviews should focus on the question of CPR or defibrillation first and provide only
benefit of higher CV ratios, compared with the cur- indirect evidence for different CPR cycle durations.
rent recommendation of 30:2. In making the suggestion to pause chest compres-
sions every 2 minutes to assess cardiac rhythm, we
Knowledge Gaps placed a high value on being consistent with previous
• The impact of different ratios without any other con- recommendations in the absence of any convincing
current changes in practice evidence indicating potential benefit from changing to
• The benefit of higher CV ratios compared with 30:2 CPR cycles of a different duration. The BLS Task Force
• The ability of those providing CPR to deliver 2 acknowledges that every guideline change comes with
effective ventilations during the short pause in chest significant risk and costs.
compressions during CPR
Knowledge Gaps
• Examination of the ratio-dependent tidal volume
• Whether the optimal CPR interval between rhythm
required to maintain oxygenation
analyses differs between initial cardiac rhythms
• The impact of no-flow and low-flow time
Duration of CPR Cycles (BLS 2212: SysRev • The impact of stopping CPR on the overriding goal
2025) of minimizing interruptions in chest compressions
• The relationship between rescuer fatigue, chest
Rationale for Review
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compression quality and the optimal interval for

This topic was last reviewed in detail132 for the 2020 chest compression cycles, and whether this relation-
CoSTR,37,38 and was prioritized for a detailed review because ship varies based on the number of rescuers present
only EvUps had been done since 2020. The full CoSTR can
be found on the ILCOR website.133 Because there was no
intent to publish this review outside of the 2025 CoSTR, EMS Continuous–Chest Compression CPR vs
PROSPERO registration was not completed. Conventional CPR (BLS 2221: SysRev 2025)
Population, Intervention, Comparator, Outcome, and Rationale for Review
Time Frame The previous SysRev13 and existing ILCOR treatment
• Population: Adults and children in any setting (in- recommendation were first published in 2017.14,15 This
hospital or out-of-hospital) with cardiac arrest. topic was prioritized for a detailed review because it had
• Intervention: Pausing chest compressions at another not been reviewed since 2017. The SysRev was regis-
interval tered on PROSPERO (CRD42024559318), and the full
• Comparators: Pausing chest compressions every 2 CoSTR can be found on the ILCOR website.136
minutes to assess the cardiac rhythm
• Outcomes: Population, Intervention, Comparator, Outcome,
- Critical: Survival with favorable neurological out- Study Design, and Time Frame
come at hospital discharge or 30 days; survival at • Population: Adults and children with out-of-hospital
hospital discharge or 30 days with cardiac arrest
- Important: ROSC; coronary perfusion pressure, • Intervention: Continuous chest compressions with
cardiac output or without ventilations delivered by EMS
• Time frame: September 1, 2019, to September 22, • Comparators: Standard CPR, defined as any CV ratio
2024 delivered by EMS. Comparator groups that receive
no CPR or compared manual CPR with mechani-
Consensus on Science cal CPR were excluded from the review. Studies
No new clinical studies have been identified since the including automated CPR or any use of mechani-
2020 ILCOR SysRev.37,38 The existing evidence consists cal devices were only included if administered to all
of 2 RCTs (Table 4).134,135 treatment arms.

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 Bray et al Basic Life Support: CoSTR 2025

Table 4. Evidence Comparing Duration of CPR Cycles

Outcomes: Certainty of
Study (design) Participants (intervention) RR (95% CI) evidence
3 min versus 1 min
Wik 2003134 200 adult OHCAs Compared with 1 min, there was no difference for 3-min Very low
(RCT) duration: (downgraded
3 min (intervention): immediate defibrillation (up to 3
for risk of
stacked shocks) for VF/VT followed by 3 min of CPR Survival to hospital discharge with favorable neurological
bias and
regardless of postshock rhythm outcome (absolute RR, 1.68; 95% CI, 0.85–3.32; P = 0.13)
imprecision)
1 min (comparator): immediate defibrillation (up to 3 Survival to hospital discharge (absolute RR, 1.52; 95% CI,
stacked shocks) for VF/VT followed by 1 min of CPR for 0.83–2.77; P = 0.17)
patients in refractory VF/VT, and 3 min of CPR for patients
ROSC (absolute RR, 1.22; 95% CI, 0.92–1.50; P = 0.16)
who were in nonshockable rhythms following initial 1–3
shocks
1 min versus 2 min
Baker 2008135 202 adult OHCAs Compared with 2 min, there was no difference for 1-min Very low
duration: (downgraded
1 min (intervention): stacked shocks (up to 3 in refractory
for risk of
VF/VT), 15:2 CPR and 1-min CPR cycles between Survival to hospital discharge (RR, 0.49; 95% CI, 0.23–
bias and
defibrillation 1.06; P = 0.06)
imprecision)
2 min (comparator): single shock, 30:2 CPR and 2-min ROSC (RR, 0.95; 95% CI, 0.73–1.24; P = 0.71)
CPR cycles between defibrillation

CPR indicates cardiopulmonary resuscitation; OHCA, out-of-hospital cardiac arrest; RCT, randomized controlled trial; ROSC, return of spontaneous circulation; RR,
relative risk; and VF/VT, ventricular fibrillation/ventricular tachycardia.

• Outcomes: Treatment Recommendations (2025)

- Critical: Favorable neurological survival (as mea- During basic life support for adults in cardiac arrest,
sured by CPC or mRS) at discharge or 30 days we recommend that EMS personnel use either a 30:2
and at any time interval after 30 days CV ratio or continuous chest compressions with PPV
- Important: Survival to discharge or 30 days, sur- (10/min) delivered without pausing compressions
vival to hospital admission, survival to any time (strong recommendation, moderate-certainty evidence).
interval after discharge or 30 days survival,
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Justification and Evidence-to-Decision Framework

ROSC, quality of life as measured by any indica-
Highlights
tor or score
The complete evidence-to-decision table is provided in
• Study design: In addition to standard criteria, obser-
Appendix A.
vational studies that reported only unadjusted data
The task force noted no high-certainty evidence to
were excluded.
support the superiority of either continuous chest com-
• Time frame: Because the search terms were revised,
pressions or standard CPR for patient outcomes in
the search included all years to October 2024
OHCA and placed a high value on the importance of pro-
Consensus on Science viding high-quality chest compressions and simplifying
We identified 1 cluster crossover RCT137 and 3 cohort resuscitation logistics for EMS personnel.
studies,138–140 including 2 post hoc analyses of the ear- Changes made to the wording of the treatment rec-
lier cluster RCT, providing low to moderate certainty of ommendation were based on several factors. First, the
evidence (downgraded for indirectness and risk of bias). existing wording was open to misinterpretation. Second,
The evidence is summarized in Table 5. highest-quality evidence is a cluster RCT that compared
a 30:2 ratio to ventilations at a rate of 10/min without
Prior Treatment Recommendations (2019) pausing compressions across the first 3 resuscitation
We recommend that EMS providers perform CPR with cycles (ie, 6 minutes of BLS resuscitation). After this
30 compressions to 2 breaths (30:2 ratio) or con- time point, the study arms both switched to the same
tinuous chest compressions with positive-pressure advanced life support (ALS) protocol, including the
ventilation (PPV) delivered without pausing chest
­ placement of an advanced airway and ventilations at a
compressions until a tracheal tube or supraglottic de- rate of 10/min without pausing compressions. Third, a
vice has been placed (strong recommendation, high-­ growing body of evidence suggests that ventilation rates
certainty evidence). vary widely in both synchronous and asynchronous venti-
We suggest that, when EMS systems have adopted lations.141 Additionally, substudies of the included cluster
minimally interrupted cardiac resuscitation, this strategy crossover RCT137 suggest that a CV ratio of 30:2 may be
is a reasonable alternative to conventional CPR for wit- harder to achieve in practice and could result in a higher
nessed shockable OHCA (weak recommendation, very degree of nonadherence compared with continuous
low–certainty evidence). chest compressions140; but when performed correctly, it

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 Bray et al Basic Life Support: CoSTR 2025

Table 5. The Evidence Comparing EMS Chest Compression–Only CPR With Conventional CPR

Outcome (certainty of
evidence) Studies (patients) Results
Favorable neurological 1 adult cluster RCT randomized to either CCC with
137
No difference compared with 30:2
function (moderate) asynchronous PPV or standard CPR with a CV ratio of 30:2
Survival to hospital 1 adult cluster RCT137 No difference compared with 30:2
discharge or 30 d (low to
3 observational studies: 1 compared minimally interrupted Minimally interrupted cardiac resuscitation was associated with
moderate)
cardiac resuscitation with C-CPR (including a CV ratio of improved survival to hospital discharge (aOR, 3.0; 95% CI,
15:2, stacked shocks, and postshock rhythm checks)138; 1 1.1–8.9).138
post hoc analysis of the Nichol cluster RCT137 was restricted
A post hoc analysis of the Nichol cluster RCT137 reported no
to sites in British Columbia139; 1 secondary analysis of patients
significant difference in survival to hospital discharge.139
enrolled into the ROC registry or either the ROC CCC, ALPS,
or PART clinical trials were classified CCC with asynchronous The secondary analysis showed that CCC was associated
ventilations or C-CPR (30:2)140 with improved survival to hospital discharge when compared
with standard CPR (aOR, 1.20; 95% CI, 1.04, 1.38). Further
analysis showed when there was adherence to the intended
strategy, CCC had significantly lower survival (aOR, 0.72; 95%
CI, 0.64, 0.81), while in patients with the intended strategy,
30:2 had higher survival (aOR, 1.05; 95% CI, 0.90, 1.22).140
ROSC (low to moderate) 1 adult cluster RCT137 No difference compared with 30:2
1 cohort study compared minimally interrupted cardiac No difference compared with 15:2
resuscitation C-CPR (including a CV ratio of 15:2, stacked
shocks, and postshock rhythm checks).138

ALPS indicates Amiodarone, Lidocaine, or Placebo Study; aOR, adjusted odds ratio; CCC, continuous chest compressions; C-CPR, conventional cardiopulmonary
resuscitation; CPR, cardiopulmonary resuscitation; CV ratio, compression-to-ventilation ratio; EMS, emergency medical services; PART, Pragmatic Airway Resuscitation
Trial; PPV, positive-pressure ventilation; RCT, randomized controlled trial; ROC, Resuscitation Outcomes Consortium; and ROSC, return of spontaneous circulation.

may be associated with improved outcomes compared Knowledge Gaps

to compressions with asynchronous ventilations140 and • The effect of delaying PPV during CPR
incorrect performance of 30:2.142 • The impact of different elements of minimally inter-
The task force removed the 2017 recommendation rupted cardiac resuscitation (compressions, ventila-
supporting systems that have implemented minimally tion, delayed defibrillation) on patient outcomes
Downloaded from [Link] by on October 27, 2025

interrupted cardiac resuscitation (ie, 200 compressions • The impact of adherence to continuous chest com-
without ventilations) for witnessed shockable OHCA. This pressions or a CV ratio of 30:2 on patient outcomes
decision was made because the former recommendation
was supported by a single retrospective study reporting
adjusted estimates for the intervention,138 with a serious In-Hospital Continuous–Chest Compression
risk of bias from uncontrolled confounding because the CPR vs Conventional CPR (BLS 2222: SysRev
study implemented a bundle including other resuscitation 2025)
practices. The task force also considered the following:
Rationale for Review
• Interruptions in chest compressions have been
This was a nodal review with BLS and the PLS Task
associated with poorer clinical outcomes in obser-
Forces. The previous SysRev13 and existing ILCOR treat-
vational studies.143 Pauses for ventilations are a
ment recommendation was first published in 2017.14,15
significant source of interruptions in chest compres-
This topic was prioritized for a detailed review as it had
sions and may negatively impact coronary and aortic
not been reviewed since 2017. The SysRev was regis-
blood flow.144 Asynchronous PPV (continuous chest
tered on PROSPERO (CRD42024559318), and the full
compressions with PPV delivered without pausing
CoSTR can be found on the ILCOR website.145
chest compressions) may achieve similar oxygen-
ation without compromising chest compression
quality. Population, Intervention, Comparator, Outcome,
• Although there was relative homogeneity in the con- Study Design, and Time Frame
tinuous chest compressions strategies, there was • Population: Adults and children in-hospital with car-
heterogeneity in the use of ventilation strategies, diac arrest
including both asynchronous PPV and passive oxy- • Intervention: Continuous chest compressions with
genation (delivering oxygen during compressions or without ventilations delivered by in-hospital
without providing ventilation). The adequacy of ven- providers
tilation was not assessed in any studies, although • Comparators: Standard CPR, defined as any CV
measures of chest compression quality (eg, chest ratio delivered by in-hospital providers. Comparator
compression fraction) were reported. groups that received no CPR or compared manual

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 Bray et al Basic Life Support: CoSTR 2025

CPR with mechanical CPR were excluded from the In changing the recommendation to a good practice
review. Studies including automated CPR or any statement, the task force acknowledges the lack of evi-
use of mechanical devices were only included if dence of this topic and no studies in children. The good
administered to all treatment arms. practice statement removed reference to the advanced
• Outcomes: airway to fill the treatment gap and provide guidance
- Critical: Favorable neurological survival (as mea- for immediate CPR. The task force also considered the
sured by CPC or mRS) at discharge or 30 days following:
and at any time interval after 30 days • Interruptions in chest compressions have been
- Important: Survival to discharge or 30 days, sur- associated with worse clinical outcomes in obser-
vival to hospital admission, survival to any time vational studies.143 Pauses for ventilations are a
interval after discharge or 30 days survival, significant source of interruptions in chest compres-
ROSC, quality of life as measured by any indica- sions and may negatively impact coronary and aortic
tor or score blood flow.144 PPV during chest compressions may
• Study design: In addition to standard criteria, obser- achieve similar oxygenation without compromising
vational studies that reported only unadjusted data chest compression quality.
were also excluded. • The only included study was conducted with a
• Time frame: Because the search terms were revised, before-and-after design that, although adjusted for
the search included all years to October 21, 2024 demographic and cardiac arrest characteristics, did
not account for potential temporal differences in
Consensus on Science
resuscitation efficiencies between study periods.
No new studies were identified. One single-center cohort
• Data on the same question in EMS found no high-
study included in the previous review provided very low–
quality evidence to support the superiority of either
certainty evidence (downgraded for risk of bias and very
continuous chest compressions or standard CPR
serious imprecision).146 The study evaluated the effect of
for patient outcomes in OHCA.
continuous mechanical chest compressions in adult pa-
• The task force also placed a relatively high value on
tients admitted to an emergency department following
providing high-quality chest compressions and sim-
OHCA. PPV without interruption of chest compressions
plifying resuscitation logistics for clinicians.
after tracheal intubation was compared with interruption
• Substudies of the included cluster crossover RCT137
of chest compressions for one ventilation after every fifth
suggest that a CV ratio of 30:2 may be harder to
Downloaded from [Link] by on October 27, 2025

chest compression (a CV ratio of 5:1) among patients ad-

achieve in practice and could result in a higher degree
mitted to a hospital emergency department after OHCA.
of nonadherence compared with continuous chest
No adjusted data were reported for favorable neuro-
compressions140; but when performed correctly, 30:2
logical survival at discharge or 30 days. For the critical out-
may be associated with improved outcomes com-
come of survival, patients who received tracheal intubation
pared to compressions with asynchronous ventila-
with PPV during continuous compressions had increased
tions140 and incorrect performance of 30:2.142
adjusted survival to hospital discharge (aOR, 2.43; 95%
CI, 1.15–5.12) and higher odds of ROSC (aOR, 1.62;
95% CI, 1.07–2.43) when compared with those who Knowledge Gaps
received mechanical chest compressions interrupted for • Effectiveness of continuous chest compressions
ventilations at a ratio of 5 compressions to 1 ventilation. with or without ventilations compared with standard
CPR with a CV ratio, when delivered by in-hospital
Prior Treatment Recommendation (2019) personnel
Whenever tracheal intubation or a supraglottic airway • The effect of delaying PPV during CPR
is achieved during in-hospital CPR, we suggest that • The effectiveness of passive oxygenation during
­providers perform continuous compressions with PPV resuscitation
delivered without pausing chest compressions (weak • The impact of adherence to chest compression–
recommendation, very low–quality evidence). only CPR or a CV ratio of 30:2 on patient outcomes
• Evidence in pediatric patients
Treatment Recommendations (2025)
In adults in cardiac arrest, in-hospital personnel should
use either a 30:2 CV ratio or continuous chest compres-
sions with PPV (10/min) delivered without pausing com- BLS COMPONENTS—COMPRESSIONS
pressions (good practice statement). Hand Position During Compressions (BLS
Justification and Evidence-to-Decision Framework 2502: SysRev 2025)
Highlights Rationale for Review
The complete evidence-to-decision table is provided in Hand positioning during compressions was last reviewed
Appendix A. in detail for the 2020 CoSTR.37,38 Since 2020, EvUps

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 Bray et al Basic Life Support: CoSTR 2025

have identified evidence only from imaging studies. Be- arrest, and only physiologic surrogate outcomes were
cause these studies contribute new indirect evidence, evaluated.
this topic was prioritized for review. The full CoSTR can Imaging studies were excluded from the current
be found on the ILCOR website.147 Because there was no SysRev because they do not report clinical outcomes
intent to publish this review outside of the 2025 CoSTR, for cardiac arrest patients. However, they provide valu-
PROSPERO registration was not completed. able indirect information. Recent studies indicate that,
in most adults and children, the maximal ventricular
Population, Intervention, Comparator, Outcome, and cross-sectional area is located beneath the lower third
Time Frame of the sternum or the xiphisternal junction. Additionally,
• Population: Adults and children in any setting (in- the ascending aorta and left ventricular outflow tract are
hospital or out-of-hospital) with cardiac arrest positioned beneath the center of the chest.151–157 The
• Intervention: Any other location for chest studies also highlight significant anatomical differences
compressions between individuals based on factors such as age, body
• Comparators: Delivery of chest compressions on mass index, congenital cardiac disease, and pregnancy.
the lower half of the sternum Consequently, no single hand-placement strategy may
• Outcomes: Any clinical outcome be universally optimal for chest compressions across all
- Critical: Survival to hospital discharge with good populations.154,156,158,159
neurological outcome; survival to hospital discharge In reaffirming the recommendation to perform chest
- Important: ROSC; blood pressure; coronary per- compressions on the lower half of the sternum, we priori-
fusion pressure; end-tidal carbon dioxide tized consistency with previous guidelines given the lack
• Time frame: October 1, 2019, to September 26, of compelling clinical evidence necessitating a change
2024 in approach.
Consensus on Science Knowledge Gaps
No studies reported the critical outcomes of favor- • The effects of different hand positions during CPR
able neurological outcome, survival, or ROSC. No new on patient outcomes
clinical studies have been identified since the 2020 • How to determine the optimal hand placement or
ILCOR SysRev.37,38 The existing evidence consists of compression point for individuals in cardiac arrest,
3 very low–certainty studies reporting on physiologic particularly by leveraging physiologic feedback or
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endpoints.148–150 One crossover study in 17 adults with incorporating insights from prior imaging
prolonged resuscitation from nontraumatic cardiac ar-
rest observed improved peak arterial pressure during
compressions and higher end-tidal carbon dioxide when Head-Up CPR (BLS 2503: SysRev 2025)
compressions were performed on the lower third of the Rationale for Review
sternum compared with the center of the chest, whereas This was a nodal review with BLS and the ALS Task
arterial pressure during compression recoil, peak right Forces. The first SysRev with treatment recommen-
atrial pressure, and coronary perfusion pressure did not dations for head-up CPR was published in the 2021
differ.150 A second crossover study in 30 adults observed CoSTR.160,161 Since 2021, the topic has been reviewed in
no association between end-tidal carbon dioxide values EvUps, which identified new observational studies, and
and hand placement.149 A further crossover study in 10 the SysRev was therefore updated for 2025. The SysRev
children observed higher peak systolic pressure and was registered on PROSPERO (CRD42024541714),
higher mean arterial blood pressure when compressions the full details of this review can be found in the Sys-
were performed over the lower third of the sternum com- Rev,162 and the full CoSTR can be found on the ILCOR
pared with the middle of the sternum.148 website.163

Treatment Recommendations (2025, Unchanged Population, Intervention, Comparator, Outcome, and

From 2015) Time Frame
We suggest performing chest compressions on the lower • Population: Adults and children in any setting (in-
half of the sternum on adults in cardiac arrest (weak rec- hospital or out-of-hospital) with cardiac arrest
ommendation, very low–certainty evidence). • Intervention: Head-up CPR or head-up CPR bundle
(eg, head-up position, active compression/decom-
Justification and Evidence-to-Decision Framework pression, and an impedance threshold device)
Highlights • Comparators: Standard or chest compression–only
The complete evidence-to-decision table is provided in CPR in supine position
Appendix A. • Outcomes:
No studies evaluated the effect of a specific hand - Critical outcomes: Survival to hospital discharge
position on short- or long-term survival after cardiac with good neurological outcome, survival to

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 Bray et al Basic Life Support: CoSTR 2025

hospital discharge, event survival, survival to 30 Treatment Recommendations (2025)

days, survival to 30 days with good neurological We suggest against the use of head-up CPR or head-up
outcome CPR bundle during CPR except in the setting of clinical
- Important outcome: ROSC trials or research initiatives (weak recommendation, very
• Time frame: July 22, 2021, to July 19, 2024 low–certainty evidence).

Consensus on Science Justification and Evidence-to-Decision Framework

Two new observational studies were identified, adding to Highlights
the single study identified in 2021.164–166 All studies were The complete evidence-to-decision table is provided in
from the same research group. Details of study designs Appendix A.
and key findings are presented in Table 6. Evidence was In making this recommendation, the BLS Task
deemed very low–certainty for all outcomes because of Force recognized that the currently available evidence
serious risk of bias, inconsistency, and imprecision. remains limited, highlighted by the absence of RCTs or
observational studies with adequate comparisons. The
Prior Treatment Recommendations (2021) comparator groups used in all 3 available studies are
We suggest against the routine use of head-up CPR problematic (eg, earlier time frame), and some out-
during CPR (weak recommendation, very low–certainty comes are reported without adjustment for known con-
evidence). founders or temporal trends. The implementation of the
We suggest that the usefulness of head-up CPR dur- existing head-up CPR bundles requires the purchase
ing CPR be assessed in clinical trials or research initiatives of expensive equipment, which includes an automated
(weak recommendation, very low–certainty evidence). head/thorax-up positioning device, a mechanical CPR

Table 6. Key Design Elements and Findings of Head-Up CPR Studies

Design (time frame), participants, intervention,

Study comparator Outcomes Certainty of evidence
Pepe Before-after study, 2014–2017: Survival to hospital discharge with favorable neurological All outcomes: very
2019166 outcome: Unadjusted 35% to 40% intact neurological low–certainty evidence
2322 adult OHCAs (1356 intervention)
status in both groups (exact data and loss to follow-up not (downgraded for risk of
Intervention: Head-up CPR bundle that included provided) bias, inconsistency, and
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mechanical CPR and ITD; oxygen but deferred PPV for imprecision)
Event survival: Unadjusted 17.9% (n = 144/806) versus
several minutes; a pit-crew approach for rapid placement of
34.2% (n = 464/1356), P < 0.001
the mechanical CPR device; and subsequent placement of
patient in a reverse Trendelenburg position (≈ 20°)
Comparator: Mechanical CPR and ITD (data from same
EMS)
Moore Prospective observational: Automated Controlled Elevation After propensity matching:
2022165 CPR Registry, 2019–2020:
Survival to hospital discharge with favorable neurological
5423 adult OHCAs (227 intervention) outcome: 5.9% (13/222) versus 4.1% (35/860); OR, 1.47
(95% CI, 0.76–2.82)
Intervention: Automated controlled head and thorax
patient positioning device. Immediate elevation of head Survival to hospital discharge: 9.5% (21/122) versus 6.7%
and midthorax to 12 cm and 8 cm, respectively, with (58/860); OR, 1.44 (95% CI, 0.86–2.44)
conventional CPR for 2 min; followed by a gradual
ROSC: 33% (74/222) versus 33% (282/860); OR, 1.02
elevation of patient’s head and torso during CPR over an
(95% CI, 0.75–1.49)
additional 2-min period to a final head and thorax elevation
of 22 cm and 9 cm, respectively.
Comparator: Conventional CPR with supine position (data
from 3 RCTs conducted between 2006 and 2015167–169)
Bashista Prospective observational: Automated Head/Thorax-UP After propensity matching:
2024164 Positioning Registry (2019–2021):
Survival to hospital discharge with favorable neurological
2232 adult nonshockable OHCAs (380 intervention) outcome: 4.2% (15/353) versus 1.1% (4/353); OR, 3.87
(95% CI, 1.27–11.78)
Intervention: Automated controlled head and thorax
patient positioning device, immediate elevation of head Survival to hospital discharge: 7.6% (27/353) versus 2.8%
and midthorax to 12 cm and 8 cm, respectively, with (10/353); OR, 2.84 (95% CI, 1.35–5.96)
conventional CPR for 2 min; followed by a gradual
ROSC: 33% (118/353) versus 29% (101/353); OR, 1.25
elevation of patient’s head and torso during CPR over an
(95% CI, 0.91–1.72)
additional 2-min period to a final head and thorax elevation
of 22 cm and 9 cm, respectively.
Comparator: Conventional CPR with supine position (data
from 2 RCTs conducted between 2006 and 2009167,169)

CPR indicates cardiopulmonary resuscitation; EMS, emergency medical services; ITD, impedance threshold device; OHCA, out-of-hospital cardiac arrest; OR, odds
ratio; PPV, positive-pressure ventilation; ROSC, return of spontaneous circulation; and RCT, randomized controlled trial.

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 Bray et al Basic Life Support: CoSTR 2025

device, and an impedance threshold device, as well as We suggest that preshock and postshock pauses in
considerable training. chest compressions be as short as possible (weak rec-
Although the intervention may sound simple, the included ommendation, very low–certainty evidence).
studies demonstrate the complexities. We did not find clini- We suggest that the CPR fraction during cardiac
cal evidence supporting a particular bundle approach or arrest (CPR time devoted to compressions) should be
indicating that the sole use of head-up elevation is superior as high as possible and be at least 60% (weak recom-
to other bundles without it. There is an indication that faster mendation, very low–certainty evidence).
deployment of head-up CPR is associated with better neu-
rological outcomes,165 but this requires further study. Optimal Surface for Performing CPR (BLS
Knowledge Gaps 2510: SysRev 2024)
• High-quality evidence of the effect of head-up CPR A 2024 SysRev updated the 2019 review177 on the op-
or head-up CPR bundle is required. timal surface for performing CPR. The full details of this
• The optimal approach (eg, the angle and timing of review can be found in the SysRev,178 the 2024 CoSTR
head elevation) when head-up CPR is used summary,40,41 and on the ILCOR website.179
Population, Intervention, Comparator, Outcome, and
Minimizing Pauses in Compressions (BLS Time Frame
2504: SysRev 2022, EvUp 2025) • Population: Adults or children in cardiac arrest
A 2022 SysRev and 2025 EvUp examined the evidence (OHCA and in-hospital cardiac arrest)
on passive ventilation techniques. The details of the • Intervention: The performance of CPR using a hard
2022 SysRev review can be found in the 2022 CoSTR surface (eg, backboard, floor, or deflatable or spe-
summary170,171 and on the ILCOR website.172 The 2025 cialist mattress)
EvUp is provided in Appendix B. • Comparators: The performance of CPR on a regular
mattress or other soft surface
Population, Intervention, Comparator, Outcome, and • Outcomes:
Time Frame - Critical: Survival with a favorable neurological out-
• Population: Adults in cardiac arrest in any setting come at hospital discharge/30 days; survival at
• Intervention: Minimizing pauses in chest compres- hospital discharge/30 days
sions (higher CPR or chest compression fraction or
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- Important: Event survival; ROSC; CPR quality (eg,

shorter perishock pauses compared with control) compression depth, compression rate, compres-
• Comparator: Standard CPR (lower CPR fraction or sion fraction)
longer perishock pauses compared with intervention) • Time frame: September 17, 2019, to February 5,
• Outcomes: 2024.
- Critical: Survival to hospital discharge with
good neurological outcome; survival to hospital Treatment Recommendations (2024)
discharge We suggest performing chest compressions on a firm
- Important: ROSC surface when possible (weak recommendation, very
• Time frame: June 1, 2021, to April 14, 2024 low–certainty evidence).
During in-hospital cardiac arrest, we suggest, where
Summary of Evidence
a bed has a CPR mode, which increases mattress stiff-
The EvUp found 1 new study173 directly relevant to the
ness, it should be activated (weak recommendation, very
population, intervention, comparator, outcome, study de-
low–certainty evidence).
sign, and time frame and several studies with meaning-
During in-hospital cardiac arrest, we suggest against
ful data on interruptions in cardiac arrest care.140,173–176
moving a patient from a bed to floor to improve chest
However, these later studies were excluded because
compression depth (weak recommendation, very low–
they did not address the prespecified outcomes of inter-
certainty evidence).
est. This suggests a SysRev might be warranted in the
During in-hospital cardiac arrest, we suggest in favor
future after revising the population, intervention, com-
of either a backboard or no-backboard strategy, to
parator, outcome, study design, and time frame question.
improve chest compression depth (conditional recom-
Treatment Recommendations (2022) mendation, very low–certainty evidence).
We suggest that CPR fraction and perishock pauses in
clinical practice be monitored as part of a comprehensive
Feedback for CPR Quality (BLS 2511: ScopRev
quality improvement program for cardiac arrest designed
to ensure high-quality CPR delivery and resuscitation 2024)
care across resuscitation systems (weak recommenda- A 2024 ScopRev examined the wider literature on
tion, very low–certainty evidence). feedback for CPR quality during resuscitation. The

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 Bray et al Basic Life Support: CoSTR 2025

details of this review can be found in the ScopRev,180 • Outcomes:

the 2024 CoSTR summary,40,41 and on the ILCOR - Critical: Survival to hospital discharge with
website.181 good neurological outcome; survival to hospital
discharge
Population, Intervention, Comparator, Outcome, and - Important: ROSC
Time Frame • Time frame: October 16, 2021, to July 5, 2024
• Population: Adults and children (excluding neo-
nates) who are in cardiac arrest in any setting who Summary of Evidence
are resuscitated by health professionals responding No new studies were identified, so a new SysRev is not
in a professional capacity warranted.
• Intervention: Real-time feedback and prompt
devices regarding the mechanics of CPR qual- Treatment Recommendations (2022)
ity (eg, rate and depth of compressions or We suggest against the routine use of passive ventilation
ventilations) techniques during conventional CPR (weak recommen-
• Comparators: No feedback or prompt devices or dation, very low–certainty evidence).
alternative devices
• Outcomes: Any outcomes or measure of CPR Real-Time Ventilation Quality Feedback Devices
quality
(BLS 2402: ScopRev 2025)
• Time frame: All years to July 18, 2023. A gray lit-
erature search was performed in the Google search Rationale for Review
engine in addition to the standard databases. A growing body of evidence suggests ventilation param-
eters during resuscitation often fall outside guideline rec-
Treatment Recommendations (2020) ommendations.183,184 This review was prioritized because
We suggest the use of real-time audiovisual feedback new devices are now available to help BLS personnel
and prompt devices during CPR in clinical practice as monitor and improve ventilation in real time. Ventilation
part of a comprehensive quality improvement program parameters were not addressed in detail in our recent
for cardiac arrest designed to ensure high-quality CPR review of real-time feedback.180 The full details of this
delivery and resuscitation care across resuscitation review can be found in the ScopRev185 and on the ILCOR
systems (weak recommendation, very low–certainty website.186
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evidence).
We suggest against the use of real-time audiovisual Population, Intervention, Comparator, Outcome,
feedback and prompt devices in isolation (ie, not part of Study Design, and Time Frame
a comprehensive quality improvement program) (weak • Population: Adults and children in any setting (out-
recommendation, very low–certainty evidence). of-hospital or in-hospital) in cardiac arrest
• Intervention: Real-time ventilation quality feedback
(eg, tidal volume, adequate ventilation, mask leak,
BLS COMPONENTS—VENTILATION ventilation rate)
• Comparators: No real-time ventilation feedback
Passive Ventilation Techniques (BLS 2403: • Outcomes: Any outcome
SysRev 2022, EvUp 2025) • Study designs: In addition to standard study designs,
A 2022 SysRev and 2025 EvUp examined the evidence gray literature (Google Scholar, first 20 pages), let-
on passive ventilation techniques. The details of this re- ters to the editor, and conference abstracts were
view can be found in the 2022 CoSTR summary170,171 eligible for inclusion.
and on the ILCOR website.182 The 2025 EvUp is pro- • Time frame: Inception to September 11, 2024. The
vided in Appendix B. gray literature was searched on November 4, 2024.

Summary of Evidence
Population, Intervention, Comparator, Outcome, and The ScopRev185 identified 19 relevant studies (1 RCT,187
Time Frame 1 before-after prospective study,188 2 observational
• Population: Adults and children with presumed car- studies,190,191 1 case series,192 and 12 simulation stud-
diac arrest in any setting ies193–200,202–205). Three of the simulation studies assessed
• Intervention: Any passive ventilation technique (eg, pediatric scenarios.197,203,205
positioning the body, opening the airway, passive One RCT187 and 1 prospective observational
oxygen administration, Boussignac tube, constant study188 examined clinical outcomes with and with-
flow insufflation of oxygen) in addition to chest out real-time feedback (Table 7). The RCT reported
compressions improved ­immediate-term patient outcomes with real-
• Comparator: Standard CPR time feedback but no change in short-term outcomes.

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 Bray et al Basic Life Support: CoSTR 2025

Table 7. Clinical Studies Examining Real-Time Ventilation Feedback Devices With Control Groups

Author Study design

(year) (country) Population Participants Intervention (control) Outcomes (device versus no feedback)
Lee (2023) 187
RCT (South OHCA BLS and Real-time visual ventilation Survival with good neurological outcome (11.1% versus
Korea) ALS hospital feedback device using a flow 10.3%; P = 0.77)
personnel sensor (n=63); no feedback
Survival to discharge (4.9% versus 8.6%; P = 0.54)
(n=58)
30-h survival (49.2% versus 46.5%; P = 0.001).
ROSC (55.5% versus 36.2%; P = 0.04)
Drennan Prospective OHCA BLS and Real-time visual ventilation ROSC (27% versus 29%, P = NS)
(2024)188 before-after ALS EMS feedback device using a flow
Ventilation rate (12/min [IQR 10, 17] versus 14/min [IQR 11,
(Canada) personnel sensor (n=221); no feedback
19]; P = 0.04)
(n=191)
Rate in target range (53% ± 38 versus 29% ± 9; P < 0.001)
Insufflation volume (401 mL [IQR 353, 472] versus 374 mL
[IQR 274, 453]; P = 0.06)
Volume in target range (28% ± 17 versus 21% ± 16;
P < 0.001)
Rate and volume in target range (19% ± 17 versus 7% ± 10;
P < 0.001)

ALS indicates advanced life support; BLS, basic life support; EMS, emergency medical services; IQR, interquartile range; OHCA, out-of-hospital cardiac arrest; RCT,
randomized controlled trial; and ROSC, return of spontaneous circulation.

The trial did not adjust for group differences or report Based on this ScopRev, at this time there is insuffi-
ventilation quality.187 The observational study found no cient evidence to pursue a new SysRev on this topic.
change in patient outcomes but noted improved venti-
lation parameters with real-time feedback.188 Most of Knowledge Gaps
the simulation studies showed improvements in venti- • High-quality prospective evidence in humans,
lation quality. including changes to ventilation variables and con-
ducted independent of industry, that assess the clin-
Treatment Recommendations (2025) ical efficacy (ie, whether the devices work in optimal
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There is currently insufficient evidence on real-time ven- settings) or clinical effectiveness (real-world set-
tilation quality feedback devices to make a treatment tings) of these devices
recommendation. • Data in children

Task Force Insights BLS COMPONENTS—DEFIBRILLATION

The task force discussed the review findings and noted
the following: Pad/Paddle Size and Placement in Adults (BLS
• Device registration with regulatory authorities alone 2601: SysRev 2025)
does not provide evidence of device performance Rationale for Review
in real-world settings. As rescuer and patient fac- This was a nodal review with BLS, PLS, and the ALS Task
tors influence high-quality ventilation, the current Forces. The existing ILCOR treatment recommendation was
evidence is insufficient to demonstrate the clinical first published in 2010206,207 and reviewed in a ScopRev for
efficacy or effectiveness of real-time ventilation the 2020 CoSTR.37,38 Publications found in EvUps and the
feedback devices. publication of a cluster RCT208 on pad placement prompted
• The lack of studies in humans, the significant hetero- a nodal SysRev209 with the BLS, PLS, and ALS Task Forces
geneity between studies, and industry involvement (PROSPERO registration CRD42024512443). The pedi-
in 7 included studies are all important limitations of atric CoSTR, treatment recommendations, and evidence-
the evidence. to-decision table are reported on the ILCOR website210
• Many of the included studies inaccurately labeled and in the PLS CoSTR section.107 The CoSTR can be found
inflation volume, the amount of airflow measured on the ILCOR website.211
at the mask, or the advanced airway as tidal vol-
ume. We suggest using inspiratory volume rather Population, Intervention, Comparator, Outcome, and
than tidal volume for this measurement, because Time Frame
tidal volume represents the amount of air that • Population: Adults and children in any setting (in-
moves in or out of the lungs with each respiratory hospital or out-of-hospital) with cardiac arrest and a
cycle. shockable rhythm at any time during CPR

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 Bray et al Basic Life Support: CoSTR 2025

• Intervention: The use of any specific pad size/orien- 67.6%; adjusted risk ratio, 1.18; 95% CI, 1.03–1.36) but
tation and position no difference in ROSC (35.4% versus 26.5%; adjusted
• Comparators: Reference standard pad size/orienta- risk ratio, 1.39; 95% CI, 0.97–1.99).
tion and position No studies were identified in the in-hospital setting.
• Outcomes:
- Critical: Survival with favorable neurological out-
Prior Treatment Recommendations (2010)
come at hospital discharge or 30 days; survival at
It is reasonable to place pads on the exposed chest in an
hospital discharge or 30 days
AL position. An acceptable alternative position is AP. In
- Important: ROSC; termination of ventricular fibril-
large-breasted individuals, it is reasonable to place the
lation (VF); rates of refibrillation
left electrode pad lateral to or underneath the left breast,
• Time frame: All years to September 22, 2024
avoiding breast tissue. Consideration should be given to
the rapid removal of excessive chest hair before the ap-
Consensus on Science plication of pads, but emphasis must be on minimizing
Two observational studies212,213 and 1 RCT208 were iden- delay in shock delivery.
tified. Certainty of evidence was very low in all cases. There is insufficient evidence to recommend a spe-
cific electrode size for optimal external defibrillation in
Pad Size
adults. However, it is reasonable to use a pad size greater
No studies compared the effects of different pad sizes
than 8 cm.
with standard size for any critical outcomes or ROSC.
One before-and-after study in OHCA reported no differ- Treatment Recommendations (2025)
ence in defibrillation success with AEDs with large pad For Defibrillator Manufacturers
size (113 cm2), compared with AEDs with small pad size There is insufficient evidence to recommend a specific
(65 cm2) (86% versus 88.8%; OR, 0.82; 95% CI, 0.42– pad or paddle size for optimal external defibrillation in
1.60).212 No studies were identified in the in-hospital adults (good practice statement).
setting. Manufacturers should standardize adult pad or paddle
placement in the AL position (good practice statement).
Pad Positions
One pad or paddle should be placed below the right clav-
No RCTs were found that compared different pad place-
icle, just to the right of the upper sternal border, and the
ments for the initial defibrillation.
other with its center in the left midaxillary line, below the
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One prospective EMS cohort study213 adjusting for

armpit.
known predictors found no significant difference in favor-
Manufacturers should provide clear instructions to
able neurological outcome at hospital discharge with ini-
ensure proper contact between the pad or paddle and
tial anterior-posterior (AP) pad placement compared with
the skin, along with diagrams that accurately show the
initial anterior-lateral (AL) placement (aOR, 1.86; 95%
ILCOR-recommended pad and paddle positions (good
CI, 0.98–3.51). There was also no difference in survival
practice statement).
to hospital discharge (aOR, 1.55; 95% CI, 0.83–2.90)
or in defibrillation success (VF termination at 5-second For AED Users
postshock: OR, 1.08; 95% CI, 0.61–1.91), although AP Follow the manufacturer’s AED guidance and instruc-
pad position was associated with higher ROSC rates tions for adult pad placement (good practice statement).
after adjusting for known predictors (aOR, 2.64; 95% CI,
For Health Care Professionals Trained in Manual
1.50–4.65).
Defibrillation
Pad Positions for Refractory VF In adults, place defibrillator pads or paddles in the AL
One cluster RCT, which was stopped early because of position to optimize placement speed and minimize in-
the COVID-19 pandemic, compared vector-change defi- terruptions to chest compressions (good practice state-
brillation (a change to the AP position) with continuation ment). One pad/paddle should be positioned below the
of the standard AL position in 280 adult OHCA patients patient’s right clavicle, just to the right of the upper ster-
with refractory VF (ie, persistence of VF or pulseless nal border. The other pad/paddle should be placed on
ventricular tachycardia after 3 consecutive AL defibril- the patient’s left midaxillary line, below the armpit.
lations).208 This RCT reported higher adjusted survival to In adults, if the initial AL position is not feasible, con-
hospital discharge with vector change to AP pad posi- sider using the AP pad position if trained (good practice
tion (21.7% versus 13.3%; adjusted risk ratio, 1.71; 95% statement). Place the anterior pad on the left side of the
CI, 1.01–2.88), but no difference in favorable neurologi- chest, between the midline and the nipple. For female
cal outcome at hospital discharge, (aOR, 1.86; 95% CI, patients, place the anterior pad to the left of the lower
0.98–3.51). sternum, ensuring it avoids breast tissue as much as pos-
The same RCT reported higher rates of termination of sible. The posterior pad should be placed on the left side
VF with vector change to AP pad position (79.9% versus of the patient’s spine, just below the scapula.

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 Bray et al Basic Life Support: CoSTR 2025

Pad or paddle placement should avoid breast tissue paddles and that paddle sizes are standard as
(good practice statement). provided by the manufacturer. The task force
did not foresee future development in the use of
For Health Care Professionals Trained in Vector Change
paddles.
For adults in refractory VF (persistent VF after 3 defibril-
• AEDs have diagrams to guide users in correct
lations), consider changing pads to the AP pad position
pad positioning. However, there is wide variation
(good practice statement). Place the anterior pad on the
in these diagrams, and evidence suggests that
left side of the chest, between the midline of the chest
untrained bystanders fail to achieve accurate pad
and the nipple. For female patients, place the anterior
placement when guided by current defibrillation pad
pad to the left of the lower sternum, ensuring it avoids
diagrams.217
breast tissue as much as possible. The posterior pad
should be placed on the left side of the patient’s spine,
Knowledge Gaps
just below the scapula. This treatment recommendation
• The impact of different pad positions in the first 3
does not replace the existing treatment recommendation
shocks on patient outcomes
on vector change and double sequential defibrillation for
• The effect of different pad sizes on patient outcomes
ALS clinicians.6,7
• Optimal pad sizes and positions in children and in-
Justification and Evidence-to-Decision Framework hospital settings
Highlights • The interaction between pad size and orientation
The complete evidence-to-decision table is provided in
Appendix A.
Removal of Bra for Pad Placement and
The pediatric treatment recommendations are
reported in the PLS CoSTR section.107 In making these Defibrillation (BLS 2604, ScopRev 2025)
recommendations for adults, the task forces considered Rationale for Review
the following: The BLS Task Force prioritized this review because the
• All included studies were at serious risk of bias. topic is controversial and, to date, no comprehensive
No study reported patient outcomes for pad size, review has been undertaken. The full details of this re-
and no study compared the effects of different pad view can be found in the ScopRev218 and on the ILCOR
placements on patient outcomes except when being website.219
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used for refractory shockable rhythms. However,

defibrillator manufacturers may have proprietary Population, Intervention, Comparator, Outcome, and
data, and we encourage manufacturers to make this Time Frame
data public. • Population: Adults and children in cardiac arrest
• In the absence of in-hospital cardiac arrest studies, • Concept: Adverse events and outcomes associated
this evidence could be applied to in-hospital cardiac with pad placement or defibrillation without remov-
arrest, with additional downgrading for indirectness. ing the patient’s bra/brassiere (including those with
• Lower transthoracic impedance results in higher metal components)
current flow, possibly enabling higher defibrillation • Context: In patients wearing a bra/brassiere in any
success. Observational studies in adults showed setting (in-hospital or out-of-hospital)
that transthoracic impedance was significantly • Time frame: All years to September 26, 2024; gray
higher with small-sized pads/paddles compared literature searched (Google Scholar, first 200 refer-
with large-sized pads/paddles.212,214,215 ences) October 1, 2024.
• A secondary analysis of the Double Sequential Summary of Evidence
External Defibrillation for Refractory Ventricular No studies reporting patient outcomes were identified.
Fibrillation trial216 explored the relationship between One animal study220 and 2 simulation manikin stud-
vector change to AP placement and the type of VF ies221,222 were included. The evidence is summarized in
(shock-refractory or recurrent) on patient outcomes. Table 8.
The study reported that vector change to AP place-
ment, compared with continuation of AL position- Task Force Insights
ing, was not superior for VF termination, ROSC, or The evidence-to-decision table is included in Appendix
survival for shock-refractory VF. For recurrent VF, A. The task force discussed the review findings and not-
vector-change defibrillation was superior for VF ter- ed the following:
mination, but not for ROSC or survival. • Two included studies were published as conference
• Paddles may still be in use in some low-resource abstracts by the same group of authors who were
ALS settings. However, the Task Force acknowl- employed by a company that develops and manu-
edges that the AP position is not feasible with factures AEDs.5,6 A growing body of research has

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 Bray et al Basic Life Support: CoSTR 2025

Table 8. Summary of the Evidence on Bra Removal for Defibrillation

Study Study design

details (publication type) Intervention Key findings
Di Maio Porcine model (n = 4) with AED pads in direct contact with No scorching or burning of the bra or skin
2015220 induction of arrhythmia and the metal wires of a bra placed
Poor pad placement did not pose a risk to the operator (risk type not specified)
defibrillation by an AED on the pig
No arcing
Conference abstract Induction of VF and defibrillation
with 200 J shocks No redirection of the current
100% first shock success (no instances of refibrillation)
Kramer 69 randomly assigned Voice prompt AED guidance Female manikins less likely to be completely disrobed than the male manikins
2015221 undergraduate students: on opening the case, activating (42.4% versus 91.7%, P < 0.001)
AED, positioning of pads, shock
Simulation of OHCA Male rescuers less likely to completely disrobe the female manikins than female
delivery, administering CPR
with CPR and AED on rescuers were (13.3% versus 66.7%, P = 0.002)
male or female manikins
Opinions on removal of clothes:
(use of a wig, makeup,
silicone breasts, front- Thought they needed only to remove enough clothing to place the defibrillator pads
opening brassiere, color- according to instructions rather than ensuring the brassiere would not affect CPR
coordinated women’s Social norms
clothing)
Concerned for patient modesty
Peer-reviewed article
Men did not want to remove more clothing than necessary
O’Hare 78 randomly selected Removal of clothes (including bra) No difference in time to place electrodes: 52 versus 49 s for female versus male
2014222 untrained AED users: from the manikin guided by the manikin, respectively
AED voice prompt
Simulation of resuscitation No difference in time to first shock: 79.5 versus 77 s for female versus male
with AED use on manikins manikin, respectively
as either “female” (clothed
88.5% of the participants correctly placed the electrodes and delivered a shock
in a front-opening hooded
(sex of manikin not specified)
sweater with a bra) or
“male” (no bra)
Conference abstract

AED indicates automated external defibrillator; CPR, cardiopulmonary resuscitation; OHCA, out-of-hospital cardiac arrest; and VF, ventricular fibrillation.
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identified that women are less likely to receive CPR • Although insufficient studies were identified to sup-
and defibrillation by the public.223–225 Public opinion port a more specific SysRev of defibrillation while
surveys show that some members of the public do wearing a bra at this time, the task force felt the need
not feel comfortable exposing women’s breasts, and to highlight and address the inequality in AED appli-
fear accusations of inappropriate touching and sex- cation in women by making good practice statements
ual assault.226 These concerns may impact bystand- to highlight this issue to the international community.
ers’ willingness to perform CPR and defibrillation
Treatment Recommendations (2025)
and explain why rates are lower in women. Whether
There is insufficient evidence to guide the routine remov-
it is necessary to remove such undergarments is
al of a bra, but it may not always be necessary to remove
unknown.
a bra for defibrillation. Pads must be placed on bare skin
• This ScopRev demonstrated scant evidence on
in the correct position, which may be possible by adjust-
this topic. Peer review occurred for only 2 of the
ing the bra’s position rather than removing it (good prac-
3 included studies. We found no evidence report-
tice statement).
ing patient outcomes or any case studies reporting
Manufacturers should develop realistic manikins that
adverse events from defibrillation without removing
reflect different body sizes that can impact pad place-
a bra.
ment (good practice statement).
• Leaving the bra on could result in inaccurate pad
Where possible, CPR training should cover defibrilla-
placement, but routine removal could compromise
tion for patients wearing bras, focusing on correct pad
timely defibrillation, particularly in bystander situa-
placement and minimizing pauses in compressions (good
tions. Some AED’s verbal and written instructions
practice statement).
do not describe bra removal, so the public may not
currently remove it to place pads. Knowledge Gaps
• There are likely to be privacy and cultural issues • Whether removing a bra is necessary with modern
associated with fully exposing a woman’s chest. bras, pads, and defibrillators
Some resuscitation groups are already actively • Sex-specific barriers to high-quality CPR and defi-
training to keep the bra on to overcome hesitancy in brillation; listening to emergency calls may provide
bystanders. However, correct and timely pad place- critical insights to address in public messaging and
ment must be a priority. CPR training

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 Bray et al Basic Life Support: CoSTR 2025

• A better understanding of public opinions and socio- Summary of Evidence

cultural sensitivities related to exposing the chest The EvUp identified no new studies. A SysRev is not
warranted.
Effectiveness of Ultraportable AEDs (BLS 2603: Treatment Recommendations (2023)
ScopRev 2024) We suggest in-water resuscitation (ventilations only)
A 2024 ScopRev examined the evidence on the effec- may be delivered if rescuers, trained in this technique,
tiveness of ultraportable AEDs. The details of this review determine that it is feasible and safe with the equipment
can be found in the ScopRev,227 the 2024 CoSTR sum- available and the distance to land warrants its use (weak
mary,40,41 and on the ILCOR website.228 recommendation, very low–certainty evidence).
We suggest on-boat CPR may be delivered if res-
Population, Intervention, Comparator, Outcome, and cuers trained in this technique determine that it is fea-
Time Frame sible and safe to attempt resuscitation (good practice
• Population: Adults and children in OHCA statement).
• Intervention: the use of an ultraportable or pocket If the rescuers feel that the application of immediate
AED CPR is or becomes too difficult or unsafe, then the res-
• Outcomes: all outcomes were accepted cuers may delay resuscitation until on land (good prac-
• Time frame: 2012 to October 31, 2023. We did not tice statement).
search gray literature.
Treatment Recommendations (2024) CAB Versus ABC in Drowning (BLS 2704:
There is currently insufficient evidence on the clinical ef- ScopRev 2023, SysRev 2024, EvUp 2025)
fectiveness of ultraportable or pocket AEDs to make a
treatment recommendation. A slight change to the 2023 treatment recommendation
was made to align with the treatment recommendations
for all cardiac arrest patients.
SPECIAL CIRCUMSTANCES Intervention and Comparator
OHCA Following Drowning • Intervention: Resuscitation that incorporates a
A 2021 ScopRev, 2023 SysRev, and 2025 EvUps ex- ­compression-first strategy (CAB)
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amined the evidence on 7 drowning questions. For these • Comparator: Resuscitation that starts with ventila-
questions the population and outcomes are the same tion (ABC)
across all subtopics, and interventions and comparators
Consensus on Science
are detailed for each subtopic. The details of this review
No studies were identified that addressed the popula-
can be found in the ScopRev,229 SysRev,230 the 2023
tion, intervention, comparator, outcome, study design, and
CoSTR summary,6,7 and on the ILCOR website.231–235 The
time frame question in the SysRev or the EvUp.
2025 EvUps are provided in Appendix B.
Population, Intervention, Comparator, Outcome, and Prior Treatment Recommendations (2023)
Time Frame We recommend a compression-first strategy (CAB) for
• Population: Adults and children in cardiac arrest fol- laypeople providing resuscitation for adults and children
lowing drowning in cardiac arrest caused by drowning (good practice
• Outcomes: statement).
- Critical: Survival to discharge or 30 days with We recommend health care professionals and those
favorable neurological outcome; survival to dis- with a duty to respond to drowning (eg, lifeguards) con-
charge or 30 days sider providing rescue breaths/ventilation first (ABC)
- Important: ROSC before chest compressions if they have been trained to
• Time frame: April 25, 2023, to April 14, 2024 do so (good practice statement).

Treatment Recommendations (2025)

Immediate Resuscitation in Water or on Boat We recommend a compression-first strategy (CAB) for
laypeople providing resuscitation for adults in cardiac ar-
in Drowning (BLS 2702/2703: ScopRev 2021,
rest caused by drowning (good practice statement).
SysRev 2023, EvUp 2025) Health care professionals and those trained and
Intervention and Comparator with a duty to respond to drowning (eg, lifeguards)
• Intervention: Immediate resuscitation in water or on should consider providing rescue breaths/ventilation
boat first (ABC) before chest compressions (good practice
• Comparator: Delaying resuscitation until on land statement).

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 Bray et al Basic Life Support: CoSTR 2025

Justification and Evidence-to-Decision Framework We suggest that bystanders who are trained, able, and
Highlights willing to give rescue breaths and chest compressions do
There is no evidence-to-decision table because no evi- so for adults in cardiac arrest.
dence was identified. In making the good practice state- Children: We suggest that bystanders provide CPR
ments, the task force considered the following: with ventilation for infants and children younger than 18
• The compression-first strategy for adults prioritizes years with OHCA.
simplicity and cohesiveness in training recom- We recommend that if bystanders cannot provide
mendations for laypersons, with the goal of faster rescue breaths as part of CPR for infants and children
initiation of resuscitation. We also considered the younger than 18 years with OHCA, they should at least
indirect manikin studies110,112–115 published in the provide chest compressions.
review of this question for all cardiac arrests (BLS For health care professionals and those with a duty
2202). to respond to drowning (eg, lifeguards), we recommend
• The ventilation-first strategy for health care profes- providing ventilation in addition to chest compressions if
sionals and those with a duty to respond consid- they have been trained and are able and willing to do so
ers that indirect evidence from a study examining (good practice statement).
in-water ventilations may improve outcomes236 and
the specialized training of lifeguards and health
care professionals (including cardiac monitoring Ventilation Equipment in Cardiac Arrest
and ventilation-delivery equipment). It is unclear if Following Drowning (BLS 2706: ScopRev 2023,
earlier ventilations improve outcomes once cardiac
SysRev 2023, EvUp 2025)
arrest has occurred or if the benefit is in preventing
respiratory arrest from deteriorating into cardiac Intervention and Comparator
arrest. • Intervention: Ventilation with equipment before hos-
Of note, no direct or indirect evidence is available to pital arrival
support any certain number of initial ventilations if life- • Comparator: Ventilation without equipment before
guards or health care professionals adopt a ventilation- hospital arrival
first strategy. Most importantly, resuscitation should not
be delayed by either selected strategy. Summary of Evidence
The EvUp identified no new studies. No SysRev is
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Knowledge Gaps warranted.

There were no studies that directly evaluated this ques-
tion. Further research, informed by the Utstein tem- Treatment Recommendations (2023)
plate for drowning, may usefully address this ongoing We recommend using mouth-to-mouth, mouth-to-nose,
uncertainty. or pocket-mask ventilation by BLS providers and laypeo-
ple for adults and children in cardiac arrest caused by
drowning (good practice statement).
Chest Compression–Only CPR in Cardiac Arrest We suggest that bag-mask ventilation can be
in Drowning (BLS 2705: ScopRev 2023, SysRev used by lifeguards or other BLS providers with a
2023, EvUp 2025) duty to respond, on the condition that it is part of a
competency-based training program with regular
­
Intervention and Comparator
retraining and maintenance of equipment (good prac-
• Intervention: Chest compression–only CPR
tice statement).
• Comparator: Conventional CPR (compressions and
We recommend that health care professionals follow
ventilations)
the ALS treatment recommendations for airway manage-
Summary of Evidence ment for adults and children in cardiac arrest caused by
The EvUp identified no new studies. No SysRev is drowning.
warranted.
Treatment Recommendations (2023)
Prehospital Oxygen Administration Following
For lay responders, the treatment recommenda-
tions for CPR in drowned OHCA patients who have Drowning (BLS 2707: SysRev 2023, EvUp 2025)
been removed from the water remain consistent with Intervention and Comparator
CPR for all patients in cardiac arrest (good practice • Intervention: Oxygen administration before hospital
statement). arrival
Adults: We recommend that bystanders perform chest • Comparator: No oxygen administration before hos-
compressions for all patients in cardiac arrest. pital arrival

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 Bray et al Basic Life Support: CoSTR 2025

Summary of Evidence Population, Intervention, Comparator, Outcome, and

The EvUp identified no new studies. No SysRev is Time Frame
warranted. • Population: Adults and children receiving CPR fol-
lowing OHCA
Treatment Recommendations (2023) • Intervention: Transport with ongoing CPR
When available, we recommend trained providers use • Comparator: Completing CPR on scene (until ROSC
the highest possible inspired oxygen concentration dur- or termination of resuscitation)
ing resuscitation for adults and children in cardiac arrest • Outcomes:
following drowning (good practice statement). - Critical: Survival to hospital discharge with
good neurological outcome; survival to hospital
discharge
AED Use First Versus CPR First in Cardiac
- Important: Quality of CPR metrics on scene ver-
Arrest in Drowning (BLS 2708: ScopRev 2023, sus during transport (reported outcomes may
SysRev 2023, EvUp 2025) include rate of chest compressions, depth of
Intervention and Comparator chest compressions, chest compression fraction,
• Intervention: AED administered before CPR interruptions to chest compressions, leaning on
• Comparator: CPR administered before AED chest/incomplete release, rate of ventilation, vol-
ume of ventilation, duration of ventilation, pres-
Summary of Evidence sure of ventilation); ROSC
The EvUp identified no new studies. No SysRev is • Time frame: November 2020 to April 22, 2024
warranted.
Summary of Evidence
Treatment Recommendations (2023) The EvUp identified several studies,238–247 including a pro-
We recommend that CPR should be started first and tocol248 and early results in abstract form249 for a recently
continued until an AED has been obtained and is ready completed but not yet fully published RCT. This SysRev
for use for adults and children in cardiac arrest caused by will be updated following the publication of the RCT.
drowning (good practice statement).
When available, we recommend an AED is used in Treatment Recommendations (2022)
cardiac arrest caused by drowning in adults and children We suggest that providers deliver resuscitation at the
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(good practice statement). scene rather than undertake ambulance transport with
ongoing resuscitation unless there is an appropriate indi-
cation to justify transport (eg, extracorporeal membrane
PAD Programs for Drowning (BLS 2709: SysRev oxygenation) (weak recommendation, very low–certainty
2023, EvUp 2025) evidence).
The quality of manual CPR may be reduced during
Intervention and Comparator
transport. We recommend that whenever transport is
• Intervention: PAD program
indicated, EMS providers should focus on the delivery
• Comparator: Absence of PAD program
of high-quality CPR throughout transport (strong recom-
Summary of Evidence mendation, very low–certainty evidence).
The EvUp identified no new studies. No SysRev is Delivery of manual CPR during transport increases
warranted. the risk of injury to providers. We recommend that EMS
systems have a responsibility to assess this risk and,
Treatment Recommendations (2023) where practicable, to implement measures to mitigate
This treatment recommendation is unchanged from the the risk (good practice statement).
standing recommendation for all OHCAs.
We recommend implementing PAD programs for
all patients with OHCA (strong recommendation, low-­ CPR in Obese Patients (BLS 2720, ScopRev
certainty evidence). 2025)
Rationale for Review
This topic was prioritized for review by the BLS, the ALS,
CPR During Transport (BLS 2715: SysRev 2022, the PLS, and the Education, Implementation, and Teams
EvUp 2025) Task Forces because of the increasing prevalence of obe-
A 2022 SysRev and 2025 EvUp examined the evidence sity worldwide and the specific challenges in providing
on CPR during transport. The details of this SysRev can be CPR to this patient cohort. This topic has not previously
found in the 2022 CoSTR summary170,171 and on the ILCOR been reviewed by ILCOR. The full details of this review can
website.237 The 2025 EvUp is provided in Appendix B. be found in the ScopRev250 and on the ILCOR website.251

S58 October 21, 2025 Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364

 Bray et al Basic Life Support: CoSTR 2025

Population, Intervention, Comparator, Outcome, and • The variability in results does not suggest an urgent
Time Frame need to deviate from standard CPR protocols. Some
• Population: Adults and children in any setting (in- evidence suggests CPR duration may be longer in
hospital or out-of-hospital) with cardiac arrest obese adults, which may have staffing and resource
• Intervention: CPR (including mechanical and implications.
e-CPR) in obese patients (as defined in specific
papers) Treatment Recommendations
• Comparators: May have no comparator, comparator Standard CPR protocols should be used in obese pa-
of nonobese patients, or compare modified CPR for tients (good practice statement).
obese patients with standard CPR
Knowledge Gaps
• Outcomes:
• Few studies of CPR in obese infants, children, and
- Critical: Survival to hospital discharge with
adolescents
good neurological outcome; survival to hospital
• A standardized definition of obese, or population-
discharge
specific definition of obese, for the purpose of
- Important: ROSC; CPR quality measures (chest
resuscitation research
compression rate, chest compression depth,
• The true impact of obesity on CPR outcomes when
ventilation rate, tidal volume, end-tidal carbon
other factors are accounted for
dioxide), CPR timing (time to commencement
• The effect of obesity on CPR techniques (such as
of rescue breaths, first compression, first defi-
chest compressions, airway management and ven-
brillation if shockable rhythm); CPR techniques
tilation, and defibrillation), CPR quality, and time to
(chest compressions, defibrillation, ventila-
and delivery of resuscitation interventions (such as
tion and airway management, vascular access
vascular access and medications, use of mechanical
and medications); health-related quality of life
CPR devices, or extracorporeal membrane oxygen-
and CPR provider outcomes (safety, manual
ation) in both adults and children
handling)
• Whether the degree of obesity influences CPR
• Time frame: All years to October 1, 2024
performance, outcomes following CPR (including
Summary of Evidence health-related quality of life), or inclusion in CPR
Thirty-six studies were included.252–287 Definitions of obe- research
Downloaded from [Link] by on October 27, 2025

sity varied. Full reporting of the results can be found in • The effect of patient obesity on outcomes of those
the ScopRev.250 providing CPR (eg, physical exertion, manual han-
In adults, the association between obesity and dling, fatigue)
neurological outcomes, survival to hospital discharge,
­longer-term survival (months to years), and ROSC was
Topics Not Included in the 2025 Review
variable. In children, worse neurological outcomes, lower
survival, and lower ROSC than normal-weight children • PAD programs (BLS 2121)
were reported in 2 studies. Few studies reported resus- • CPR prior to defibrillation (BLS 2203)
citation quality indicators, and no studies reported on • Check for circulation during BLS (BLS 2210)
adjustments to CPR techniques or outcomes for those • Timing of rhythm check (BLS 2211)
providing CPR. • Chest compression rate, depth, recoil (BLS 2501)

Task Force Insights

The task force discussed the review findings and noted Topics Retired or Reposed
the following: • Rescuer fatigue in chest compression–only CPR
• At the time of this review, there was no universal • CPR before call for help
definition of obesity, so for the purposes of this • Alternative compression techniques (cough, precor-
ScopRev, obese was defined according to each indi- dial thump, fist pacing)
vidual study. There was wide variability in the defini-
tions of obesity across the studies.
• In adults, the evidence of the impact of obesity on Topics Moved to the First Aid Task Force
patient outcomes was conflicting. • Harm from CPR to victims not in arrest
• In children, 2 studies suggested that obese chil- • Foreign-body airway obstruction
dren had worse neurological outcomes, lower • Resuscitation care for suspected opioid-associated
survival, and lower ROSC than normal-weight emergencies
children. • Drowning factors related to survival

Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364 October 21, 2025 S59

 Bray et al Basic Life Support: CoSTR 2025

ARTICLE INFORMATION This article has been copublished in Resuscitation. Published by Elsevier Ire-
land Ltd. All rights reserved.
The American Heart Association requests that this document be cited as follows:
Bray JE, Smyth MA, Perkins GD, Cash RE, Chung SP, Considine J, Dainty KN, Das- Acknowledgment
sanayake V, Debaty G, Dewan M, Dicker B, Dodge N, Folke F, Ikeyama T, Hansen The writing group would like to acknowledge Jaylen I. Wright for his organizational
CM, Johnson NJ, Lukas G, Lagina A, Masterson S, Morley PT, Morrison LJ, Nehme and administrative assistance in preparing the manuscript.
Z, Norii T, Raffay V, Ristagno G, Samantaray A, Semeraro F, Singh B, Smith CM,
Vaillancourt C, Berg KM, Olasveengen TM ; on behalf of the Basic Life Support Task Collaborators
Force Collaborators. Basic life support: 2025 International Liaison Committee on The authors thank the following individuals (the Basic Life Support Collabora-
Resuscitation Consensus on Science With Treatment Recommendations. Circula- tors) for their contributions: Stella Le, Lorena Romero, Ingrid Tjelmeland, Anne S.
tion. 2025;152(suppl 1):S34–S71. doi: 10.1161/CIR.0000000000001364 Noerskov, Anne Juul Grabmayr, Lawrence Oonyu.

Disclosures
Writing Group Disclosures

Other Speakers’
Writing group Research research bureau/ Expert Ownership Consultant/
member Employment grant support honoraria witness interest advisory board Other
Janet E. Bray Monash Australian Resuscitation None None None None Australian Elsevier†;
University and Council†; Laerdal Resuscitation Heart
Curtin University Foundation†; Heart Council* Foundation of
(Australia) Foundation of Australia† Australia†
Michael A. University of None None None None None None None
Smyth Warwick
(United Kingdom)
Katherine M. Beth Israel None None None None None AHA/ILCOR† None
Berg Deaconess
Medical Center
and Harvard
Medical School
Rebecca E. Massachusetts NIH†; Society for None None None None American College Massachusetts
Cash General Hospital Academic Emergency of Emergency General
Medicine Foundation† Physicians†; Hospital†
Prehospital
Guidelines
Consortium*;
Downloaded from [Link] by on October 27, 2025

Air Methods
Corporation†
Sung Phil Gangnam None None None None None None None
Chung Severance
Hospital, Yonsei
University
(South Korea)
Julie Considine Deakin University None None None None None None None
and Eastern
Health (Australia)
Katie N. Dainty North York AMS Healthcare*; None None None None Philips North York
General Hospital Canadian Institutes of Healthcare* General
(Canada) Health Research* Hospital†

Vihara University of None None None None None None None

Dassanayake Colombo (Sri
Lanka)
Guillaume University Hospital DGOS (national research None None None None None None
Debaty of Grenoble grant)*; Advanced CPR
(France) solution*; Stryker*
Maya Dewan Cincinnati None None None None None None None
Children’s
Hospital Medical
Center
Bridget Dicker Hato Hone St Health Research Council None None None None None Auckland
John; Auckland New Zealand† University of
University of Technolgy
Technology (New (AUT)†; Hato
Zealand) Hone St John
New Zealand*

(Continued )

S60 October 21, 2025 Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364

 Bray et al Basic Life Support: CoSTR 2025

Writing Group Disclosures Continued

Other Speakers’
Writing group Research research bureau/ Expert Ownership Consultant/
member Employment grant support honoraria witness interest advisory board Other
Natasha Dodge Monash University None None None None None None None
(Australia)
Fredrik Folke Gentofte None None None None None None None
University
Hospital, Hellerup
(Denmark)
Carolina Malta Copenhagen Laerdal Foundation†; None None None None Duke Clinical ERC 2025
Hansen Emergency Novo Nordisk Research Guidelines
Medical Sevices Foundation†; Independent Institute† writing group*
(Denmark) Research Fund
Denmark†; Helsefonden†;
Capital Region of
Denmark Research
Fund†; TrygFonden† Zoll†
Takanari Aichi Children’s Japan Society for the None None None None None None
Ikeyama Health and Promotion of Science
Medical Center (JSPS)*
(Japan)
Nicholas J. University of NIH†; American Heart None None None None None None
Johnson Washington Association†; Centers
for Disease Control and
Prevention†
Anthony Lagina Wayne State NIH* None None 2025 None None None
University expert
witness for
defense,
Aortic
Dissection
Case*
George Lukas Monash Health None None None None None None None
Downloaded from [Link] by on October 27, 2025

(Australia)
Siobhan HSE National None None None None None None None
Masterson Ambulance
Service (Ireland)
Peter T. Morley University of None None None None None None None
Melbourne and
Royal Melbourne
Hospital
(Australia)
Laurie J. St. Michael's None None None None None None None
Morrison Hospital and
University of
Toronto (Canada)
Ziad Nehme Ambulance National Heart None None None None None Rapid
Victoria and Foundation†; National Response
Monash University Health and Medical Revival†
(Australia) Research Council†
Tatsuya Norii The University of Japanese Association for None None None None None None
New Mexico Acute Medicine*
Theresa M. Oslo University None None None None None Laerdal None
Olasveengen Hospital and Foundation*
University of Oslo
(Norway)
Gavin D. Warwick BHF†; RCUK†; NIHR† None None None None Elsevier† University
Perkins Medical School Hospitals
and University Coventry and
Hospitals NHS Warwickshire†
Foundation Trust
(United Kingdom)

(Continued )

Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364 October 21, 2025 S61

 Bray et al Basic Life Support: CoSTR 2025

Writing Group Disclosures Continued

Other Speakers’
Writing group Research research bureau/ Expert Ownership Consultant/
member Employment grant support honoraria witness interest advisory board Other
Violetta Raffay European None None None None None None None
University Cyprus
(Cyprus)
Giuseppe Fondazione None None None None None Phillips North None
Ristagno IRCCS Ca’ America LLC*
Granda Ospedale
Maggiore
Policlinico (Italy)
Aloka Sri Venkateswara None None None None None None None
Samantaray Institute of
Medical Sciences,
Tirupati, India
(India)
Federico Maggiore Hospital None None None None None None None
Semeraro (Italy)
Baljit Singh SS Tantia None None None None None None None
University, Sri
Ganganagar
(India)
Christopher M. Warwick Medical National Institute for None None None None None Resuscitation
Smith School (United Health Research†; British Council UK*
Kingdom) Heart Foundation†;
Resuscitation Council
UK†
Christian University of None None None None None None None
Vaillancourt Ottawa, Ottawa
Hospital Research
Institute
(Canada)
Downloaded from [Link] by on October 27, 2025

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Reviewer Disclosures

Other Speakers’
Research research bureau/ Expert Ownership
Reviewer Employment grant support honoraria witness interest Consultant/advisory board Other
Adam Resuscitation None None None None None None None
Benson Council
Clarke UK (United
Kingdom)
Michael Resuscitation None None None None None British Heart Foundation, Resuscitation Council UK
Bradfield Council Co-Chair of National (Director of Clinical and
UK (United Advisory Board for The Service Development)†;
Kingdom) Circuit (UK defibrillator Bournemouth University
database)*; Trustee, UK (Visiting Fellow)*; South
Dorset and Somerset Air Western Ambulance Service
Ambulance (UK)*; Trustee, NHS Foundation Trust, UK
MedicAlert UK Foundation* (Paramedic)*
Jonathan City and None None None None None None None
Hulme Sandwell
Hospital (United
Kingdom)
Atul All India Institute None None None None None None None
Jindal of Medical
Sciences (India)

(Continued )

S62 October 21, 2025 Circulation. 2025;152(suppl 1):S34–S71. DOI: 10.1161/CIR.0000000000001364

 Bray et al Basic Life Support: CoSTR 2025

Reviewer Disclosures Continued

Other Speakers’
Research research bureau/ Expert Ownership
Reviewer Employment grant support honoraria witness interest Consultant/advisory board Other
Jhuma All India Institute None None None None None None None
Sankar of Medical
Sciences (India)

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-
tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any
12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of
the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

12. Cheng C-H, Cheng Y-Y, Yuan M-K, Juang Y-J, Zeng X-Y, Chen C-Y, Foo
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 Circulation

Advanced Life Support: 2025 International

Liaison Committee on Resuscitation Consensus
on Science With Treatment Recommendations
Ian R. Drennan, Chair; Katherine M. Berg, Senior Editor; Bernd W. Böttiger; Yew Woon Chia; Keith Couper; Conor Crowley;
Sonia D’Arrigo; Charles D. Deakin; Shannon M. Fernando; Rakesh Garg; Asger Granfeldt; Brian Grunau; Karen G. Hirsch;
Mathias J. Holmberg; Peter J. Kudenchuk; Eric J. Lavonas; Carrie Kah-Lai Leong; Neville Vlok; Peter T. Morley; Ari Moskowitz;
Robert W. Neumar; Tonia C. Nicholson; Nikolaos I. Nikolaou; Jerry P. Nolan; Brian J. O’Neil; Shinichiro Ohshimo; Michael Parr;
Helen Pocock; Claudio Sandroni; Tommaso Scquizzato; Jasmeet Soar; Michelle Welsford; Carolyn M. Zelop;
Markus B. Skrifvars, Vice Chair; on behalf of the Advanced Life Support Task Force Collaborators

ABSTRACT: The International Liaison Committee on Resuscitation conducts continuous reviews of new, peer-reviewed
published cardiopulmonary resuscitation science and publishes more comprehensive reviews every 5 years. The Advanced
Life Support Task Force chapter of the 2025 International Liaison Committee on Resuscitation Consensus on Science With
Treatment Recommendations addresses all resuscitation evidence reviewed by the task force in the past year, as well
as brief summaries of topics reviewed since 2020, to provide a comprehensive update. Newly updated topics this year
include defibrillator pad placement, mechanical cardiopulmonary resuscitation devices, mechanical circulatory support
after return of spontaneous circulation, intravenous versus intraosseous access, vasopressor choice and hemodynamic
targets after return of spontaneous circulation, treatment of cardiac arrest related to hyperkalemia and opioid toxicity, and
neuroprotective drugs, among others. Task Force members have assessed, discussed, and debated the certainty of the
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evidence based on Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements
include consensus treatment recommendations. Insights into the deliberations of the task force are provided in the
Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task force lists priority knowledge
gaps for further research.

Key Words: Scientific Statements ◼ advanced life support ◼ cardiac arrest ◼ cardiopulmonary resuscitation
◼ ILCOR ◼ post–cardiac arrest care ◼ resuscitation

INTRODUCTION Numerous topics reviewed from 2021 to 2024 are also

included. Draft CoSTRs for all topics evaluated with
This is the 2025 International Liaison Committee on SysRevs were posted on a rolling basis on the ILCOR
Resuscitation (ILCOR) Consensus on Science With website. Each draft CoSTR includes the data reviewed
Treat­ment Recommendations (CoSTR), from the ILCOR and draft treatment recommendations, with public com-
Advanced Life Support (ALS) Task Force. All reviews ments accepted for 2 weeks after posting. The task force
conducted by the ALS Task Force in the previous year considered public feedback and provided responses. All
are included; reviews conducted and published since the CoSTRs are now available online, adding to the existing
2020 publication are also briefly summarized to provide CoSTR statements.
a single comprehensive reference document for readers. Although only SysRevs can generate a full CoSTR
The new ALS Task Force work this year encompasses and new treatment recommendations, many other topics
12 systematic reviews (SysRevs), 2 scoping reviews were evaluated with more streamlined processes, includ-
(ScopRevs), and multiple evidence updates (EvUps). ing ScopRevs and EvUps. Good practice statements,

Supplemental material is available at [Link]

© 2025 American Heart Association, Inc., European Resuscitation Council, and International Liaison Committee on Resuscitation
Circulation is available at [Link]/journal/circ

S72 October 21, 2025 Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360

 Drennan et al Advanced Life Support: 2025 CoSTR

which represent the opinion of task force experts in light Defibrillation Strategies
of very limited or no direct evidence, can be generated
• Double sequential defibrillation (ALS 3106, SysRev
after ScopRevs and occasionally after EvUps in cases
2023)
where the task force thinks providing guidance is espe-
cially important. A separate paper in this issue includes
the full details of the evidence evaluation process.1 In Airway, Oxygenation, and Ventilation
some cases, topics are evaluated according to the Grad- • Advanced airway management for cardiac arrest
ing of Recommendations Assessment, Development, (ALS 3300, 3301, 3302, 3303, 3304, EvUp 2025)
and Evaluation adolopment recommendations (adapting • Emergency front of neck airway access during car-
an existing SysRev that meets prespecified criteria for diac arrest (ALS 3606, ScopRev 2024)
quality).2 • Oxygen and carbon dioxide targets in patients with
This summary statement contains the final wording return of spontaneous circulation (ROSC) after car-
of the treatment recommendations and good practice diac arrest (ALS 3516, 3517, SysRev 2025)
statements as approved by the ILCOR ALS Task Force,
as well as summaries of the evidence identified. The
year that treatment recommendations or good prac- Circulatory Support During CPR
tice statements were generated or last updated by • Extracorporeal CPR (ECPR) (ALS 3001, SysRev
a SysRev is provided in parentheses. In cases where 2024)
existing treatment recommendations have changed
for 2025, the prior recommendations are also pre-
sented so the reader can easily see what has changed. Medications During CPR
SysRevs include e ­ vidence-to-decision highlights and • Intravenous (IV) versus intraosseous (IO) for initial
knowledge gaps, and ScopRevs summarize task force access during cardiac arrest (ALS 3200, SysRev
insights on specific topics. References to the pub- 2025)
lished reviews and full online CoSTRs are provided in • Administration of vasopressors during cardiac arrest
the corresponding sections. Complete evidence-to- (ALS 3208, 3209, 3211, SysRev 2025)
decision tables for SysRevs are provided in Appendix • Administration of buffering agents during cardiac
A. EvUp summaries are very concise, and the complete arrest (ALS 3205, SysRev 2025)
EvUp worksheets with more study details are provided • Antiarrhythmic medication during cardiac arrest
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in Appendix B. Topics reviewed and previously pub- (ALS 3201, EvUp 2025)
lished from 2021 through 2024 are summarized much • Steroid administration during cardiac arrest (ALS
more briefly. 3202, EvUp 2025)
Topics are presented using the Grading of Recom- • Medication for the treatment of torsades de pointes
mendations Assessment, Development, and Evaluation (ALS 3404, EvUp 2025)
approach3 in the population, intervention, comparator, • Use of vasopressin and corticosteroids during car-
outcome, study design, and time frame format. To mini- diac arrest (ALS 3202, SysRev 2022)
mize redundancy, the study designs have been removed • Use of calcium during cardiac arrest (ALS 3204,
from the text except in cases where the designs dif- SysRev 2023)
fered from the ALS Task Force standard criteria. The
standard study designs included randomized controlled
trials (RCTs) and nonrandomized studies (non-RCTs,
Prognostication and Diagnostics During CPR
interrupted time series, controlled before-and-after • Use of point-of-care ultrasound for prognostication
studies, cohort studies). All languages were included, during cardiac arrest (ALS 3608, SysRev 2022,
provided there was an English abstract. Unpublished EvUp 2025)
studies (eg, conference abstracts, trial protocols), let- • Use of point-of-care ultrasound to identify cardiac
ters, editorials, comments, and case reports were arrest etiology (ALS 3607, EvUp 2025)
excluded.
The following topics are addressed in this ALS Task
Resuscitation of Cardiac Arrest in Special
Force CoSTR summary:
Circumstances
• Pharmacological treatment of hyperkalemia (ALS
Cardiopulmonary Resuscitation 3403, SysRev 2025)
• Mechanical cardiopulmonary resuscitation (CPR) • ALS therapies for opioid-related cardiac arrest (ALS
devices (ALS 3002, SysRev 2025) 3451, SysRev 2025)
• Consciousness during CPR (ALS 3004, ScopRev • Cardiac arrest in the catheterization laboratory (ALS
2021, EvUp 2024) 3406, ScopRev 2025)

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 Drennan et al Advanced Life Support: 2025 CoSTR

• CPR in patients who are prone (ALS 3003, EvUp Registration CRD42024537440). The full CoSTR can
2025) be found on the ILCOR website.5
• Cardiac arrest during pregnancy (ALS 3401,
ScopRev 2024) Population, Intervention, Comparator, Outcome,
• Resuscitation of patients with durable mechanical Study Design, and Time Frame
circulatory support with acutely altered perfusion or • Population: Adults and children with cardiac arrest in
cardiac arrest (ALS 3005, ScopRev 2025) any setting and resuscitation attempted by trained
• Cardiac arrest due to confirmed or suspected pul- medical personnel
monary embolism (ALS 3400, EvUp 2025) • Intervention: Any type of powered automated
mechanical chest compression
• Comparator: Manual chest compressions
Post–Cardiac Arrest Care • Outcomes:
• Post–cardiac arrest temperature control (ALS 3523, – Critical: survival with favorable neurological out-
3524, 3525, SysRev 2024) come, survival, quality of life at any time points
• Mechanical circulatory support after ROSC (ALS – Important: ROSC, survival to hospital admission,
3505, SysRev 2025) adverse events related to resuscitation
• Post–cardiac arrest hemodynamic targets (ALS • Study designs: Only RCTs were included.
3515, SysRev Adolopment 2024) • Time frame: Because the previous search strategy
• Choice of vasopressor in the post–cardiac arrest was amended, we included all years to May 14,
period (ALS 3528, SysRev 2025) 2024.
• Neuroprotective drugs in patients unresponsive
after cardiac arrest (ALS 3507, SysRev Adolopment Consensus on Science
2025) Fourteen studies from 11 trials were included.6–19 Six of
• Post–cardiac arrest percutaneous coronary inter- the trials were from the previous 2014 SysRev. Because
vention with and without ST-segment myocardial of heterogeneity across studies, a meta-analysis was not
infarction (ALS 3500, 3501, EvUp 2025) performed. Key results are summarized by device type
• Post–cardiac arrest steroids (ALS 3504, EvUp below.
2025) Load-Distributing Band Devices
• Glucose control after resuscitation (ALS 3519,
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Three trials10,11,19 examined the critical outcome of neu-

EvUp 2025) rological outcome at hospital discharge. Two studies10,19
• Post–cardiac arrest prophylactic antibiotics (ALS enrolling 4364 patients found no difference in favorable
3522, EvUp 2025) neurological outcome between mechanical CPR and
manual CPR. One trial of 767 patients found worse neu-
Prognostication rological outcome with mechanical CPR devices.11
Three RCTs reported the critical outcome of survival
• Neuroprognostication for poor neurological out- to hospital discharge.10,11,19 One RCT19 of 4231 patients
come (ALS 3510–3513, EvUp 2025) found no difference in survival to hospital discharge
• Neuroprognostication for good neurological out- between mechanical CPR and manual CPR. One RCT11
come (ALS 3529–3532, SysRev 2023) of 767 patients found lower odds of survival to hospi-
• Organ Donation After Cardiac Arrest (ALS 3600, tal discharge with mechanical CPR devices, and 1 RCT
SysRev 2025) with 133 patients found improved survival to hospital dis-
charge with mechanical CPR devices.10
Two RCTs reported the important outcome of
CARDIOPULMONARY RESUSCITATION ROSC.10,19 One RCT19 found lower rates of ROSC with
Mechanical CPR Devices (ALS 3002, SysRev mechanical CPR, and the second RCT10 found higher
2025) rates of ROSC with mechanical CPR.
Two studies reported rates of postresuscitation injury.
Rationale for Review One study of out-of-hospital cardiac arrest reported no
Mechanical CPR device use was last reviewed for the significant difference between mechanical CPR and
2015 CoSTR and routine use was not suggested.4 Me- manual CPR.19 The second study of in-hospital arrest,
chanical CPR device use increased during the COVID-19 designed as a noninferiority trial, could not rule out an
pandemic because it potentially enabled delivery of high- increase in injury.13
quality CPR while minimizing personnel exposure. This
SysRev was undertaken so that new trials could be in- Piston-Based Devices
cluded. The review was registered before initiation (Pro- Two RCTs16,17 enrolling 4471 and 2549 patients, respec-
spective Register of Systematic Reviews [PROSPERO] tively, found no difference between mechanical CPR and

S74 October 21, 2025 Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360

 Drennan et al Advanced Life Support: 2025 CoSTR

manual CPR for neurological outcome at hospital dis- Justification and Evidence-to-Decision Framework
charge,16,17 3 months,16,17 or 6 months.16,17 Highlights
Four RCTs6,16–18 enrolling 8409 patients examined The complete evidence-to-decision table is provided in
survival at different time points. No difference was found Appendix A.
between mechanical and manual CPR for survival at hos- The task force discussed concerns about the poten-
pital discharge or 30 days,6,16–18 90 days,16 survival at 6 tial for delays to initial defibrillation with mechanical CPR
months,17 or survival at 1 year.16 devices in cardiac arrest with shockable rhythms. This
For the important outcome of ROSC, 4 RCTs were concern could be alleviated by not deploying a mechani-
identified,6,16–18 each showing no difference in rates of cal device until after the first shock has been delivered
ROSC between mechanical and manual CPR. (if indicated).
One RCT reported resuscitation-related injuries and The task force discussed the lack of justification for
found no difference between piston-based mechanical the cost associated with mechanical CPR devices and
CPR devices and manual CPR.13 the training required for their use given that the evidence
For in-hospital cardiac arrest, 1 RCT (127 patients) suggests no benefit. However, there is insufficient evi-
documented no difference in favorable neurologi- dence to suggest that health care systems currently
cal outcome at discharge.8 For survival to hospital using mechanical CPR devices routinely need to change
discharge, 1 trial (127 patients) found no benefit of practice.
mechanical CPR compared with manual CPR.8 A sec- The task force agreed that mechanical CPR is use-
ond trial (150 patients) found increased survival to ful in settings where manual CPR either risks provider
hospital discharge with mechanical CPR compared safety (eg, during transport) or interferes with other
with manual CPR.14 potentially lifesaving procedures (eg, in the cardiac cath-
Three trials in in-hospital cardiac arrest reported eterization lab or during extracorporeal membrane oxy-
ROSC. Two trials (75 and 127 patients) found no dif- genation cannulation).
ference in ROSC,7,8 and 1 trial (150 patients) found There are several mechanical CPR devices available
increased rates of ROSC14 with mechanical CPR com- currently, and there is no evidence to favor one over
pared with manual CPR. another.
A single noninferiority trial concluded piston devices The task force discussed the importance of training
did not cause significantly more resuscitation-related when mechanical CPR devices are used to minimize
injuries.13 pauses in compressions during placement and to ensure
Downloaded from [Link] by on October 27, 2025

proper placement so that visceral injuries are minimized.

Prior Treatment Recommendations (2015) One of the included trials16 reported decreased
We suggest against the routine use of automated me- adjusted odds of survival with favorable neurological
chanical chest compression devices to replace manual outcome at 3 months with mechanical CPR (adjusted
chest compressions (weak recommendation, moderate- odds ratio [OR], 0.72; 0.52–0.99). The task force
quality evidence). decided to report the findings of each study as rela-
We suggest that automated mechanical chest com- tive risk (RR) for consistency across studies. Conver-
pression devices are a reasonable alternative to high- sion from adjusted OR to RR resulted in a similar point
quality manual chest compressions in situations where estimate but a broader CI, making the result nonsig-
sustained high-quality manual chest compressions are nificant. The unadjusted OR reported in the original
impractical or compromise provider safety (weak recom- paper was similarly nonsignificant. The task force dis-
mendation, low-quality evidence). cussed the slight differences in these ways of reporting
the outcomes, but it did not impact the final treatment
Treatment Recommendations (2025) recommendation.
We suggest against the routine use of automated me-
chanical chest compression devices to replace manual Knowledge Gaps
chest compressions for out-of-hospital cardiac arrest • Whether mechanical CPR improves outcome from
(weak recommendation, low-certainty evidence). in-hospital cardiac arrest
We suggest against the routine use of automated • Whether the potential benefit of mechanical CPR
mechanical chest compression devices to replace man- depends on timing of use, cardiac arrest rhythm, or
ual chest compressions for in-hospital cardiac arrest setting
(weak recommendation, very low–certainty evidence). • Whether one mechanical CPR device is superior to
Automated mechanical chest compression devices another
may be a reasonable alternative to manual chest com- • Whether rates of CPR-related injuries from mechan-
pressions in situations where sustained high-quality ical CPR vary by patient size and age
manual chest compressions are impractical or compro- • The optimal approach to defibrillation when
mise provider safety (good practice statement). mechanical CPR devices are used (ie, whether

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 Drennan et al Advanced Life Support: 2025 CoSTR

to pause the device for defibrillation versus other Population, Intervention, Comparator, Outcome, and
approaches such as timing defibrillation with com- Time Frame
pression phase) • Population: Adults in any setting (in-hospital or out-
of-hospital) with cardiac arrest and a shockable
ventricular fibrillation (VF)/pulseless ventricular
Consciousness During CPR (ALS 3004, tachycardia (pVT) cardiac arrest rhythm
ScopRev 2021, EvUp 2024) • Intervention: double sequential external defibrillation
CPR-induced consciousness was addressed by a • Comparator: Standard defibrillation strategy
2021 ScopRev,20 and details can be found in the 2021 • Outcomes:
CoSTR summary.21 An EvUp in 2024 did not identify – Critical: Survival with favorable neurological out-
sufficient new evidence to warrant an updated ScopRev come at discharge, 30 days, 60 days, 90 days,
or SysRev. 180 days, or 1 year; survival at discharge, 30
days, 60 days, 90 days, 180 days, or 1 year
Population, Intervention, Comparator, Outcome, – Important: ROSC or survival to hospital admission
Study Design, and Time Frame – Other: Termination of VF/pVT
• Population: Adults in any setting (in-hospital or out- • Time frame: February 28, 2020, to November 7,
of-hospital) with consciousness during CPR 2022
• Interventions: Sedation, analgesia, or other interven-
tions to prevent consciousness
• Comparator: No specific intervention for Treatment Recommendations (2023)
consciousness We suggest that a double sequential defibrillation strat-
• Outcomes: Any clinical outcome including cardiac egy (weak recommendation, low-certainty evidence) or a
arrest outcomes and psychological well-being after vector change defibrillation strategy (weak recommen-
arrest; rescuer outcomes were also considered dation, very low–certainty evidence) may be considered
• Study designs: In addition to the standard study for adults with cardiac arrest who remain in VF or pVT
designs, we included case reports, case series, gray after 3 or more consecutive shocks.
literature, and unpublished studies (eg, conference If a double sequential defibrillation strategy is used,
abstracts, trial protocols). Articles based on the we suggest an approach similar to that in the available
Lazarus phenomenon and cough CPR and narra- trial, with a single operator activating the defibrillators in
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tive articles referring to near-death experiences and sequence (good practice statement).
consciousness were excluded.
• Time frame: All years to November 24, 2020; EvUp
updated to September 21, 2023 AIRWAY, OXYGENATION, AND
VENTILATION
Treatment Recommendations (2021)
In settings in which it is feasible, rescuers may consider Advanced Airway Management for Cardiac
using sedative or analgesic drugs (or both) in very small Arrest (ALS 3300, 3301, 3302, 3303, 3304, EvUp
doses to prevent pain and distress to patients who are 2025)
conscious during CPR (good practice statement).
Advanced airway management for cardiac arrest was last
Neuromuscular-blocking drugs alone should not be
addressed by a SysRev in 2019.24,25 An EvUp was done
given to conscious patients (good practice statement).
for 2024 and again for 2025.
The optimal drug regimen for sedation and analge-
sia during CPR is uncertain. Regimens can be based on Population, Intervention, Comparator, Outcome, and
those used in critically ill patients and according to local Time Frame
protocols (good practice statement). • Population: Adults with cardiac arrest from any cause
and in any setting (in-hospital or out-of-hospital)
• Intervention: A specific airway management method
DEFIBRILLATION STRATEGIES during cardiac arrest
Double Sequential Defibrillation for Cardiac • Comparators: A different advanced airway manage-
ment method or no advanced airway management
Arrest With Refractory Shockable Rhythm (ALS
during cardiac arrest
3106, SysRev 2023) • Outcomes: Resuscitation process metrics, airway
The use of double sequential external defibrillation for process metrics, ROSC, survival or survival with
cardiac arrest with refractory shockable rhythm was ini- favorable neurological outcome at discharge/30
tially addressed by a 2020 SysRev22 and the SysRev was days or longer
updated for the 2023 CoSTR summary.23 • Time frame: August 17, 2023, to October 12, 2024

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 Drennan et al Advanced Life Support: 2025 CoSTR

Summary of Evidence Oxygen and Carbon Dioxide Targets in Patients

The complete EvUp is provided in Appendix B. With ROSC After Cardiac Arrest (ALS 3516,
Overall, there was insufficient new evidence to war-
rant an updated SysRev. The task force agreed that a
3517, SysRev 2025)
SysRev was indicated for the use of video laryngoscopy Rationale for Review
compared with direct laryngoscopy, as this has not been Oxygen and ventilation (carbon dioxide) targets are im-
reviewed previously. portant components of post–cardiac arrest management.
This topic was previously addressed by a SysRev for the
2024 CoSTR summary and was updated for this year so
Treatment Recommendations (2019) that a new secondary analysis of a previous RCT exam-
We suggest using bag-mask ventilation or an advanced ining long-term patient outcomes could be included.27,28
airway strategy during CPR for adult cardiac arrest in any The SysRev was registered before initiation (PROSPE-
setting (weak recommendation, low to moderate–cer- RO Registration CRD42022371007). The full CoSTR
tainty evidence). can be found on the ILCOR website.29
If an advanced airway is used, we suggest a supra-
glottic airway for adults with out-of-hospital cardiac Population, Intervention, Comparator, Outcome, and
arrest in settings with a low tracheal intubation suc- Time Frame
cess rate (weak recommendation, low-certainty • Population: Unresponsive adults with sustained
evidence). ROSC after cardiac arrest in any setting (in-hospital
If an advanced airway is used, we suggest a supra- or out-of-hospital)
glottic airway or tracheal intubation for adults with out- • Intervention: A ventilation strategy targeting specific
of-hospital cardiac arrest in settings with a high tracheal Spo2, Pao2, or Paco2 targets
intubation success rate (weak recommendation, very • Comparators: Treatment without specific targets or
low–certainty evidence). with an alternate target to the intervention
If an advanced airway is used, we suggest a supra- • Outcomes: Clinical outcomes including survival or
glottic airway or tracheal intubation for adults with in- survival with a favorable neurological outcome after
hospital cardiac arrest (weak recommendation, very hospital discharge, 30 days, 90 days, 180 days, 1
low–certainty evidence). year, or longer
• Time frame: June 1, 2023, to May 14, 2024
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Emergency Front of Neck Airway Access During Consensus on Science

Cardiac Arrest (ALS 3606, ScopRev 2024) Only the updated results are summarized here. All other
results are in the 2024 ILCOR CoSTR document.27 One
Emergency front of neck airway access during cardiac
additional secondary analysis of a previously reported
arrest was addressed by a 2024 ScopRev26 and can be
RCT30 of oxygen strategies in the intensive care unit set-
found in the 2024 CoSTR summary.27
ting was identified in our updated search, adding to evi-
Population, Intervention, Comparator, Outcome, and dence on long-term outcomes included in the prior review.
Time Frame For the critical outcome of favorable neurological out-
• Population: Adult patients in cardiac arrest in any come at 1 year, no difference was found between higher
setting (in-hospital or out-of-hospital) in which and lower oxygen targets from a secondary analysis of 1
adequate ventilation cannot be rapidly achieved RCT including 771 patients, (RR, 1.06; 95% CI, 0.94–1.18).
by using basic or advanced airway management For survival at 1 year, 2 RCTs including 1120 patients also
strategies found no difference (RR, 1.03; 95% CI, 0.93–1.14).30–32
• Intervention: Front-of-neck airway access attempt
Treatment Recommendations (2025, Unchanged
• Comparator: Ongoing attempts at basic or advanced
From 2024)
airway management strategies
We recommend the use of 100% inspired oxygen until
• Outcomes: Any clinical outcomes
the arterial oxygen saturation or the partial pressure of
• Time frame: All years to November 2, 2023
arterial oxygen can be measured reliably in adults with
Treatment Recommendations (2024) ROSC after cardiac arrest in the prehospital setting
In adults in cardiac arrest, when standard airway man- (strong recommendation, moderate-certainty evidence)
agement strategies (eg, oropharyngeal airway and bag- and in-hospital setting (strong recommendation, low-
mask, supraglottic airway, or tracheal tube) have failed, certainty evidence).
it is reasonable for appropriately trained rescuers to at- We recommend avoiding hypoxemia in adults with
tempt front-of-neck airway access using a cricothyroid- ROSC after cardiac arrest in any setting (strong recom-
otomy technique (good practice statement). mendation, very low–certainty evidence).

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 Drennan et al Advanced Life Support: 2025 CoSTR

We suggest avoiding hyperoxemia in adults with arrest when conventional CPR is failing to restore
ROSC after cardiac arrest in any setting (weak recom- spontaneous circulation in settings where this can be
mendation, low-certainty evidence). implemented (weak recommendation, l­ow-­ certainty
Following reliable measurement of arterial oxygen levels, evidence).
we suggest targeting an oxygen saturation of 94% to 98% We suggest ECPR may be considered as a rescue
or a partial pressure of arterial oxygen of 75 to 100 mm therapy for selected adults with in-hospital cardiac
Hg (approximately 10–13 kPa) in adults with ROSC after arrest when conventional CPR is failing to restore
cardiac arrest in any setting (good practice statement). spontaneous circulation in settings where this can be
When relying on pulse oximetry, health care profes- implemented (weak recommendation, very low–cer-
sionals should be aware of the increased risk of inaccu- tainty evidence).
racy that may conceal hypoxemia in patients with darker
skin pigmentation (good practice statement).
We suggest targeting normocapnia (a partial pressure MEDICATIONS DURING CPR
of carbon dioxide of 35–45 mm Hg or approximately
4.7–6.0 kPa) in adults with ROSC after cardiac arrest IV Versus IO Approach for Initial Vascular
(weak recommendation, moderate-certainty evidence). Access During Cardiac Arrest (ALS 3200,
Justification and Evidence-to-Decision Framework SysRev 2025)
Highlights Rationale for Review
The complete evidence-to-decision table is provided in Timely vascular access is essential for medication admin-
Appendix A. istration during cardiac arrest. Previous guidelines rec-
No changes were made to the treatment recommen- ommended an IV approach, moving to IO after failed IV
dations as only a single secondary analysis of a previously attempts. The ALS Task Force last conducted a SysRev
reported RCT was identified from the literature search. of this topic for the 2020 CoSTR,34 and prioritized this up-
The results of this study were consistent with previous dated SysRev based on the recent publication of 3 RCTs
research examining shorter-term outcomes included in comparing initial IV with initial IO strategies. The SysRev
the prior CoSTR. was registered before initiation (PROSPERO Registra-
tion CRD42024577647) and has been published.35 The
Knowledge Gaps full CoSTR can be found on the ILCOR website.36
Downloaded from [Link] by on October 27, 2025

• Whether there is a threshold at which hyperoxemia

becomes harmful Population, Intervention, Comparator, Outcome,
• Optimal duration for specific oxygen strategies Study Design, and Time Frame
• Whether there is a threshold at which hypocap- • Population: Adults (≥18 years) with cardiac arrest in
nia and hypercapnia become harmful and if these any setting with an indication for vascular access
thresholds are patient and condition specific • Interventions: Initial attempt(s) at vascular access in
cardiac arrest made via the IO route
• Comparators: Initial attempts(s) at vascular access
CIRCULATORY SUPPORT DURING CPR in cardiac arrest made via the IV route
Extracorporeal CPR (ALS 3001, SysRev 2024) • Outcomes: ROSC, survival (30 days/discharge, 3
months, 6 months), survival with favorable neuro-
The use of ECPR during cardiac arrest was addressed by
logical outcome (30 days/discharge, 3 months, 6
a 2022 SysRev, which was updated again for the 2024
months), health-related quality of life (3 months, 6
CoSTR summary.27,33
months)
Population, Intervention, Comparator, Outcome, and • Study designs: RCTs only
Time Frame • Time frame: All years to September 4, 2024
• Population: Adults (≥18 years) with cardiac arrest in
any setting (in-hospital or out-of-hospital) Consensus on Science
• Intervention: ECPR, including extracorporeal mem- Three RCTs were identified that included 9272 adult
brane oxygenation or cardiopulmonary bypass dur- patients with out-of-hospital cardiac arrest.37–39 There
ing cardiac arrest was no benefit for the IO route compared with the
• Comparators: Manual or mechanical CPR IV route for survival at 30 days, (OR, 0.99; 95% CI,
• Outcomes: Any clinical outcome 0.84–1.17) or survival with favorable neurological out-
• Time frame: June 21, 2022, to May 10, 2023 come at 30 days/hospital discharge (OR, 1.07; 95%
CI, 0.88–1.30).
Treatment Recommendations (2024) Similarly, there was no difference in the outcomes of
We suggest that ECPR may be considered as a rescue health-related quality of life at 3 months or 6 months,
therapy for selected adults with out-of-hospital cardiac ROSC at any time, survival to hospital discharge, survival

S78 October 21, 2025 Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360

 Drennan et al Advanced Life Support: 2025 CoSTR

at 3 months or 6 months, or favorable neurological out- Administration of Vasopressors During Cardiac

come at 3 months. Arrest (ALS 3208, 3209, 3211, SysRev 2025)
For the outcome of sustained ROSC, evidence
from 2 RCTs (7518 adults with out-of-hospital cardiac Rationale for Review
arrest) showed a lower OR with an initial IO strategy This topic was last reviewed with a SysRev for the 2020
compared with an initial IV strategy (OR, 0.89; 95% CI, CoSTR.34,42 The ALS Task Force was aware of a second-
0.80–0.99).37,39 ary analysis of a previously reported RCT43 that examined
long-term outcomes associated with the use of epineph-
Prior Treatment Recommendations (2020) rine that was the impetus for this update to the SysRev,
We suggest IV access as compared to IO access as the which was registered before initiation (PROSPERO
first attempt for drug administration during adult car- Registration CRD42024534331). The full CoSTR can
diac arrest (weak recommendation, very low–certainty be found on the ILCOR website.44
evidence).
If attempts at IV access are unsuccessful or IV access Population, Intervention, Comparator, Outcome,
is not feasible, we suggest IO access as a route for drug Study Design, and Time Frame
administration during adult cardiac arrest (weak recom- • Population: Adults with cardiac arrest in any setting
mendation, very low–certainty evidence). (in-hospital or out-of-hospital)
• Intervention: The use of vasopressor or a combi-
Treatment Recommendations (2025) nation of vasopressors provided intravenously or
We suggest IV access, as compared to IO access, as the intraosseously during cardiac arrest
first attempt for vascular access during adult cardiac ar- • Comparators: No vasopressor, a different vasopres-
rest (weak recommendation, low-certainty evidence). sor, a different combination of vasopressors, a dif-
If IV access cannot be rapidly achieved within 2 ferent vasopressor dose, or a different timing of
attempts, it is reasonable to consider IO access as an vasopressors provided intravenously or intraosse-
alternative route for vascular access during adult cardiac ously during cardiac arrest
arrest (good practice statement). • Outcomes:
– Critical: Survival at 30 days, hospital discharge,
Justification and Evidence-to-Decision Framework or any subsequent time point; survival with
Highlights favorable neurological outcome at 30 days,
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The complete evidence-to-decision table is provided in hospital discharge, or any subsequent time
Appendix A. point
In considering the importance of this topic, the task – Important: ROSC, survival to hospital admission
force noted that several observational studies have • Study designs: Only RCTs were considered.
reported a marked increase in the use of the IO route • Time frame: November 18, 2018, to May 9, 2024
in adult out-of-hospital cardiac arrest in recent years,40,41
despite council guidelines continuing to recommend Consensus on Science
that peripheral IVs should be the primary route for drug Only RCTs were considered for this SysRev update.
administration for adult cardiac arrest. Four additional studies were identified in adult patients
The expected mechanism by which IO drug adminis- since the last review: 1 RCT comparing epinephrine
tration might improve clinical outcomes is by facilitating plus vasopressin with epinephrine alone,45 2 secondary
faster administration of time-critical cardiac arrest drugs. analyses from a prior RCT of epinephrine and placebo
While this effect was observed in an early RCT, time to reporting long-term outcomes43 and time to epineph-
initial drug administration was similar between IO and IV rine administration,46 and 1 cost-effectiveness study.47
groups in all 3 recent RCTs. Only results of the newly included studies are present-
All 3 trials were superiority trials, and the absence of ed here. For details of studies included in the prior re-
an observed effect cannot be interpreted as indication view, see the online CoSTR,44 published SysRev,48 and
that an IO access strategy is equivalent to an IV access 2020 CoSTR.34
strategy.
There was moderate-certainty evidence that the use Epinephrine
of IO access reduced the odds of achieving sustained In one substudy of a prior RCT43,49 (n=7997 patients),
ROSC. the use of epinephrine was associated with improved
survival at 6 months (RR, 1.37; 95% CI, 1.04–1.81) and
Knowledge Gaps 12 months (RR, 1.33; 95% CI, 1.00–1.77) compared
• The optimum anatomical site for IO insertion with placebo. There was no improvement in favorable
• Few data on patient outcomes beyond hospital dis- neurological outcome at 6 months with epinephrine (RR,
charge/30 days 1.34; 95% CI, 0.96–1.88).

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 Drennan et al Advanced Life Support: 2025 CoSTR

Epinephrine Plus Vasopressin a current guideline recommendation, buffering agents (eg,

After adding the newly identified study45 to those includ- sodium bicarbonate) continue to be administered com-
ed in the prior SysRev, there remained no benefit with monly during resuscitation. A recently published SysRev
the use of epinephrine plus vasopressin compared with examining this topic was felt to be of sufficient quality to be
epinephrine alone for any of the outcomes. ­utilized for adolopment.53 The SysRev was registered before
initiation (PROSPERO Registration CRD42024577647).
Treatment Recommendations (2025, Unchanged The full CoSTR can be found on the ILCOR website.54
From 2020)
We recommend administration of epinephrine during Population, Intervention, Comparator, Outcome, and
CPR (strong recommendation, low-certainty evidence). Time Frame
For patients with nonshockable rhythms (pulseless • Population: Adults with cardiac arrest in any setting
electrical activity/asystole), we recommend adminis- (in-hospital or out-of-hospital)
tration of epinephrine as soon as feasible during CPR • Interventions: The use of buffering agents alone or
(strong recommendation, very low–certainty evidence). in combination with other drugs
For patients with shockable rhythms (VF or pVT), we • Comparator: Standard resuscitation
suggest administration of epinephrine after initial defi- • Outcomes:
brillation attempts are unsuccessful during CPR (weak – Critical: Survival at 30 days, hospital discharge,
recommendation, very low–certainty evidence). or any subsequent time point; survival with favor-
We suggest against the administration of vasopressin able neurological outcome at 30 days, hospital
in place of epinephrine during CPR (weak recommenda- discharge, or any subsequent time point
tion, very low–certainty evidence). – Important: ROSC, survival to hospital admission
We suggest against the addition of vasopressin to epi- • Study designs: Only RCTs and propensity-matched
nephrine during CPR (weak recommendation, very low– cohort studies were considered for inclusion.
certainty evidence). • Time frame: Original search all years to July 15,
2023; updated September 27, 2024
Justification and Evidence-to-Decision Framework
Highlights Consensus on Science
The complete evidence-to-decision table is provided in This was an adolopment of a previously published Sys-
Appendix A. Rev.53 A total of 3 RCTs55–57 and 3 propensity score–
Downloaded from [Link] by on October 27, 2025

The ALS Task Force concluded that the additional matched cohort studies58–60 were included. No additional
evidence identified from the SysRev did not warrant studies were identified in the updated literature search.
changes to the current treatment recommendations. None of the studies identified found any difference
Epinephrine plus vasopressin or vasopressin alone between administration of buffering agents and standard
has shown no statistical advantage over epinephrine. The care for any clinical outcome.
task force continues to recommend epinephrine only,
Prior Treatment Recommendations (2010)
instead of vasopressin only or a combination of these
Routine administration of sodium bicarbonate for treat-
vasopressors, to minimize the complexity of the treatment
ment of in-hospital cardiac arrest and out-of-hospital
algorithms. A recent network meta-analysis conducted
cardiac arrest is not recommended.
on this topic,50 considering both direct comparisons
between interventions within trials and indirect compari- Treatment Recommendations (2025)
sons across trials, supports these recommendations. We suggest against the administration of buffering
Knowledge Gaps agents such as sodium bicarbonate in the treatment of
• The optimal timing of epinephrine administration in out-of-hospital cardiac arrest, unless a special circum-
relation to defibrillations stance for its use is present (weak recommendation,
• The optimal dose of epinephrine low-certainty evidence).
• The optimal dosing interval for epinephrine We suggest against the administration of buffering
• No RCTs evaluating epinephrine for in-hospital car- agents such as sodium bicarbonate in the treatment of
diac arrest in-hospital cardiac arrest, unless a special circumstance
for its use is present (weak recommendation, very low–
certainty of evidence).
Administration of Buffering Agents During
Justification and Evidence-to-Decision Framework
Cardiac Arrest (ALS 3205, SysRev Adolopment
Highlights
2025) The complete evidence-to-decision table is provided in
Rationale for Review Appendix A.
This topic has not been evaluated with a SysRev since These recommendations do not address the use of
2010.51,52 Despite a lack of evidence and the absence of buffering agents in special circumstances, such as for

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 Drennan et al Advanced Life Support: 2025 CoSTR

the treatment of hyperkalemia or sodium channel blocker Treatment Recommendations (2018)

or tricyclic antidepressant poisoning. We suggest the use of amiodarone or lidocaine in adults
The task force placed a high value on not allocating with shock-refractory VF/pVT (weak recommendation,
resources to an unproven intervention, which may divert low-certainty evidence).
rescuer time from more beneficial interventions. We suggest against the routine use of magnesium in
The task force cautions against drawing conclusions adults with shock-refractory VF/pVT (weak recommen-
from observational studies on this topic, even with rig- dation, very low–certainty evidence).
orous propensity-score matching, if the study does not The confidence in effect estimates is currently too low
account for resuscitation time bias given the tendency to support an ALS Task Force recommendation about
for clinicians to give sodium bicarbonate late in resus- the use of beta blockers,* bretylium, nifekalant, or sotalol
citation as a last-resort medication. Any study that does in the treatment of adults in cardiac arrest with shock-
not account for resuscitation time bias should be con- refractory VF/pVT.
sidered to have critical risk of bias. A clinical trial exam- The confidence in effect estimates is currently too
ining buffering agents for in-hospital cardiac arrest low to support an ALS Task Force recommendation
(NCT05564130) is currently enrolling patients.61 about the use of prophylactic antiarrhythmic drugs
immediately after ROSC in adults with VF/pVT cardiac
Knowledge Gaps arrest.
• RCT data do not exist for buffering agents for in- *Beta blockers included for clarification based on
hospital cardiac arrest or for pediatric arrest in any identification of studies during 2023 and 2024 EvUps.
setting.
• Whether subpopulations, such as people with pro-
longed cardiac arrest, might have different out- Medication for the Treatment of Torsades de
comes from buffering agent administration than Pointes (ALS 3404, EvUp 2025)
cardiac arrest patients in general.
Population, Intervention, Comparator, Outcome, and
Time Frame
Antiarrhythmic Medication During or After • Population: Adult (>18 years) patients with tors-
Cardiac Arrest (ALS 3201, 3514, EvUp 2025) ades de pointes
Population, Intervention, Comparator, Outcome, and • Intervention: Any drug or combination of drugs
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Time Frame • Comparator: Not using drugs or alternative drugs

• Population: Adults in any setting with cardiac arrest • Outcomes: Any clinical outcome
and a shockable rhythm at any time during CPR or • Time frame: May 2, 2021, to February 10, 2024
immediately after ROSC Summary of Evidence
• Intervention: Administration of antiarrhythmic drugs This topic was reviewed in 2010,51,52 and an EvUp was
(eg, amiodarone, lidocaine) done in 202042 and again for 2025. The complete EvUp
• Comparator: No administration of antiarrhythmic is provided in Appendix B. No new studies were identi-
drugs or administration of another antiarrhythmic fied, and the task force concluded that a full SysRev was
drug not warranted. The 2010 treatment recommendations
• Outcomes: Recurrence of VF/pVT, ROSC, survival have been downgraded to good practice statements to
to hospital discharge (or later time point), neuro- acknowledge that they have not been reviewed using the
logical outcome at hospital discharge (or later time Grading of Recommendations Assessment, Develop-
point) ment, and Evaluation process.
• Time frame: July 1, 2023, to October 7, 2024
Treatment Recommendations (2010)
Summary of Evidence Polymorphic wide-complex tachycardia associated with
The complete EvUp is provided in Appendix B. This re- familial long QT may be treated with IV magnesium, pac-
view was an update of a previous SysRev,62,63 and an ing, or beta blockers; however, isoprenaline should be
EvUp in the 2024 CoSTR summary.27 Seven studies avoided (good practice statement).
were identified that met inclusion criteria: 6 observational Polymorphic wide-complex tachycardia associated
studies64–69 and 1 RCT.70 Given a new RCT of landiolol, with acquired long QT may be treated with magnesium
the task force decided to include beta blockers along (good practice statement).
with other antiarrhythmics. This clarification of the treat- Addition of pacing or IV isoprenaline may be con-
ment recommendation was based on 2 EvUps (2023 sidered when acquired polymorphic wide-complex
and 2024) that occurred since the original SysRev in tachycardia is accompanied by bradycardia or appears
2018.63,71 There was insufficient evidence to warrant a to be precipitated by pauses in rhythm (good practice
SysRev for any antiarrhythmic. statement).

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 Drennan et al Advanced Life Support: 2025 CoSTR

Use of Steroids During Cardiac Arrest (ALS Population, Intervention, Comparator, Outcome, and
3202, SysRev 2022, EvUp 2025) Time Frame
• Population: Adults with cardiac arrest in any setting
Any use of steroids during cardiac arrest was previously (in-hospital or out-of-hospital)
reviewed with an EvUp in 2020.34,42 The use of vasopres- • Intervention: Administration of calcium during car-
sin and corticosteroids during cardiac arrest, a second- diac arrest
ary question addressed by this population, intervention, • Comparator: No administration of calcium during
comparator, and outcome question, was reviewed with a cardiac arrest
SysRev adolopment72 for the 2022 CoSTR summary.73 • Outcomes:
An EvUp for this secondary question was done for 2025 – Critical: Health-related quality of life; survival with
and is included in Appendix B. favorable functional outcome at discharge, 30
Population, Intervention, Comparator, Outcome, days, 60 days, 90 days, 180 days, or 1 year; sur-
Study Design, and Time Frame vival at discharge, 30 days, 60 days, 90 days, 180
• Population: Adults with cardiac arrest in any setting days, or 1 year
(in-hospital or out-of-hospital) – Important: ROSC or survival to hospital admission
• Intervention: Administration of the combination of • Time frame: All years to September 31, 2022
vasopressin and corticosteroids during CPR Treatment Recommendations (2023)
• Comparator: Not using vasopressin and corticoste- We recommend against routine administration of cal-
roids during CPR cium for the treatment of out-of-hospital cardiac arrest
• Outcomes: in adults (strong recommendation, moderate-certainty
– Critical: Health-related quality of life; survival with evidence).
favorable functional outcome at discharge, 30 We suggest against routine administration of calcium
days, 60 days, 90 days, 180 days, or 1 year; sur- for the treatment of in-hospital cardiac arrest in adults
vival at discharge, 30 days, 60 days, 90 days, 180 (weak recommendation, low-certainty evidence).
days, or 1 year
– Important: ROSC, survival to admission
• Study design: Only RCTs were eligible for inclusion. PROGNOSTICATION AND DIAGNOSTICS
• Time frame: September 1, 2022, to April 30, 2024
DURING CPR
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Summary of Evidence Use of Point-of-Care Ultrasound for

The search identified 2 new studies; 1 post hoc analy-
sis of a previous RCT and 1 long-term outcome study
Prognostication During Cardiac Arrest (ALS
of the same RCT.74,75 The studies found no difference in 3608, EvUp 2025)
hemodynamics or long-term outcomes when vasopres- Population, Intervention, Comparator, Outcome,
sin and methylprednisolone were added to standard care. Study Design, and Time Frame
Two ongoing RCTs were identified. The task force did not • Population: Adults (>18 years) with nontraumatic
consider the identified evidence sufficient to warrant a cardiac arrest in any setting
full SysRev. • Intervention: A particular finding on point-of-care
echocardiography during CPR
Treatment Recommendations (2022) • Comparators: The absence of that finding or a dif-
We suggest against the use of the combination of vaso- ferent finding on point-of-care echocardiography
pressin and corticosteroids in addition to usual care for during CPR
adult in-hospital cardiac arrest, due to low confidence in • Outcomes: ROSC, survival to hospital admission,
effect estimates for critical outcomes (weak recommen- survival/survival with a favorable neurological out-
dation, low- to moderate-certainty evidence). come at hospital discharge, and survival/survival
We suggest against the use of the combination of with a favorable neurological outcome beyond hos-
vasopressin and corticosteroids in addition to usual care pital discharge
for adult out-of-hospital cardiac arrest (weak recommen- • Study designs: In addition to standard criteria, ran-
dation, very low– to low-certainty evidence). domized and nonrandomized clinical trials, cohort
studies (prospective and retrospective) and case-
control studies with data on both point-of-care
Use of Calcium During Cardiac Arrest (ALS
ultrasound findings and an external reference stan-
3204, SysRev 2023) dard to contribute to a 2 × 2 contingency table (ie,
The use of calcium during cardiac arrest management true-positive, false-positive, false-negative, true-
was addressed by a 2023 SysRev76 and can be found in negative) were included.
the 2023 CoSTR summary.23 • Time frame: October 2019 to April 2024

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 Drennan et al Advanced Life Support: 2025 CoSTR

Summary of Evidence cardiac arrest (weak recommendation, very low–­certainty

This topic was previously reviewed with a SysRev for evidence).
the 2020 CoSTR.42 The complete EvUp is provided in We suggest that if point-of-care ultrasound can be
Appendix B. Five observational studies (prospective performed by experienced personnel without interrupt-
and retrospective) were identified.77–80 Studies docu- ing CPR, it may be considered as an additional diagnos-
mented a mixture of neutral and positive findings for tic tool when clinical suspicion for a specific reversible
the use of ultrasound; however, significant bias, het- cause is present (weak recommendation, very low–cer-
erogeneity, and lack of clinician blinding make inter- tainty evidence).
pretation of findings difficult. The task force did not Any deployment of diagnostic point-of-care ultra-
consider the identified evidence sufficient to warrant sound during CPR should be carefully considered and
a full SysRev. weighed against the risk of interrupting chest compres-
sions and misinterpreting the sonographic findings (good
practice statement).
Treatment Recommendations (2020)
We suggest against using point-of-care echocardiogra-
phy for prognostication during CPR (weak recommenda- RESUSCITATION OF CARDIAC ARREST IN
tion, very low–certainty evidence).
SPECIAL CIRCUMSTANCES
Pharmacological Interventions for the
Use of Point-of-Care Ultrasound to Identify
Treatment of Hyperkalemia (ALS 3403, SysRev
Cardiac Arrest Etiology (ALS 3607, SysRev
2025)
2022, EvUp 2025)
Rationale for Review
Population, Intervention, Comparator, Outcome, Hyperkalemia is a potentially life-threatening condition
Study Design, and Time Frame leading to cardiac instability, arrhythmia, and cardiac ar-
The use of point-of-care ultrasound during cardiac ar- rest. Standard treatment of life-threatening arrhythmias
rest resuscitation to diagnose the etiology of cardiac ar- in the setting of hyperkalemia often involves adminis-
rest was addressed by a SysRev81 for 2022, and details tration of calcium, beta-agonists, and high-dose insulin
can be found in the 2022 CoSTR summary.73 An EvUp therapy. However, the utility of these interventions once
was done for 2025. The complete EvUp is provided in
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a person has a cardiac arrest is not known and was the

Appendix B. basis for this SysRev,82 which was registered on PROS-
• Population: Adults with cardiac arrest in any setting PERO (CRD42023440553). The full CoSTR for this
• Intervention: A particular finding on point-of-care nodal (multitask force) topic, including ALS and Pediatric
ultrasound during CPR Life Support, can be found on the ILCOR website.83
• Comparator: An external confirmatory test or pro-
cess including some component other than point- Population, Intervention, Comparator, Outcome,
of-care ultrasound Study Design, and Time Frame
• Outcome: A specific etiology of pathophysiologic • Population: Adults and children with hyperkalemia in
state that led to cardiac arrest any setting (both with and without cardiac arrest)
• Study design: In addition to standard criteria, ran- • Intervention: Any acute pharmacological interven-
domized and nonrandomized clinical trials, cohort tion with the aim of mitigating the harmful effect of
studies (prospective and retrospective) and case- hyperkalemia or with the aim of lowering potassium
control studies with data on both point-of-care levels
ultrasound findings and an external reference stan- • Comparators: No intervention, a different interven-
dard to contribute to a 2 × 2 contingency table tion (including a different dose), or placebo
(ie, true-positive, false-positive, false-negative, • Outcomes: Any clinical outcome, including change
true-negative) in potassium; use of dialysis; electrocardiogram
• Time frame: October 6, 2021, to April 2024 changes/arrhythmias; survival at hospital discharge,
28 days, 30 days, and 1 month; favorable neuro-
logical outcome at hospital discharge, 28 days, 30
Summary of Evidence
days, and 1 month; survival at later time frames
No new studies were identified on this topic; thus, a Sys-
(eg, 90 days, 180 days, 1 year); favorable neuro-
Rev is not indicated.
logical outcome at later time frames (eg, 90 days,
180 days, 1 year); health-related quality of life; and
Treatment Recommendations (2022) cost-effectiveness
We suggest against routine use of point-of-care ultra- • Study designs: In addition to standard criteria,
sound during CPR to diagnose reversible causes of we included original studies and trials without a

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 Drennan et al Advanced Life Support: 2025 CoSTR

control group such as single-arm interventional Patients With Cardiac Arrest

trials, observational studies, and experimental For the treatment of cardiac arrest suspected to be
animal studies. Non-English articles were trans- caused by acute hyperkalemia, we suggest IV insulin in
lated using online translation tools such as Google combination with glucose (weak recommendation, very
Translate. low–certainty evidence).
• Time frame: All years to September 9, 2024 For the treatment of cardiac arrest suspected to be
caused by acute hyperkalemia, there is insufficient evi-
Consensus on Science dence to make a recommendation for or against the use
Few studies reported patient-centered outcomes; of IV sodium bicarbonate (weak recommendation, very
therefore, no formal synthesis of the results for these low–certainty evidence).
­outcomes could be performed. Meta-analyses were per- For the treatment of cardiac arrest suspected to be
formed where possible for the outcome of potassium val- caused by acute hyperkalemia, there is insufficient evi-
ues. Results and certainty of evidence are summarized dence to recommend for or against the use of calcium
in Table 1. Inhaled salbutamol, IV salbutamol, insulin, and (weak recommendation, very low–certainty evidence).
glucose all appeared to reduce serum potassium values
in patients without cardiac arrest, while studies of bicar- Justification and Evidence-to-Decision Framework
bonate and calcium did not find an effect. The single Highlights
small observational study in patients with cardiac arrest The complete evidence-to-decision table is provided in
found higher absolute mortality with administration of Appendix A.
calcium in patients with cardiac arrest.84 Treatment recommendations were divided into
patients with and without cardiac arrest because the
Treatment Recommendations (2025)
pathophysiology of the 2 conditions differs making the
Patients Without Cardiac Arrest
treatment effect likely different in each group. Addition-
For the treatment of acute hyperkalemia, we suggest IV
ally, almost all the evidence identified was in patients
insulin in combination with glucose and/or inhaled or IV
without cardiac arrest.
beta2-agonists (weak recommendation, low-certainty
evidence). Patients Without Cardiac Arrest
For the treatment of acute hyperkalemia, we suggest Despite limited evidence, a treatment strategy aimed at
against the routine use of IV sodium bicarbonate (weak acutely lowering extracellular potassium values, in com-
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recommendation, low-certainty evidence). bination with more permanent potassium-lowering strat-

For the treatment of acute hyperkalemia, there is egies seems logical. The rationale for combining insulin
insufficient evidence to recommend for or against the (and glucose) with inhaled or IV beta2-agonists is based
use of calcium for the treatment of hyperkalemia (weak on a meta-analysis of 50 patients that demonstrated a
recommendation, very low–certainty evidence). greater reduction of potassium values with a combination

Table 1. Evidence Summary for the Pharmacological Treatment of Hyperkalemia in Patients With and Without Cardiac Arrest

Studies Certainty of
Pharmacological treatment (participants), n evidence, GRADE Outcome Absolute effect 95% CI
Non–cardiac arrest
Insulin (8–12 U) + glucose 8 (112)85–92 Low Change in serum potassium –0.7 mmol/L –0.9 to –0.6
Salbutamol 10–20 mg inhaled 7 (87) 85,93–98
Very low Change in serum potassium –0.9 mmol/L –1.2 to –0.7
Salbutamol 0.5 mg intravenous + glucose 6 (100)87,89,96–99 Very low Change in serum potassium –1.0 mmol/L –1.4 to –0.6
Salbutamol (0.5 mg) compared to insulin 3 (64) 87,89,92
Very low Change in serum potassium –0.3 mmol/L –0.5 to 0.0
(10 U)
Salbutamol (0.5 mg) plus insulin (10 U) and 3 (25)87,89,92 Very low Change in serum potassium –1.2 mmol/L –1.5 to –0.8
glucose
Salbutamol (0.5 mg) plus insulin (10 U) 3 (50)87,89,92 Very low Change in serum potassium –0.5 mmol/L –0.7 to –0.2
compared to insulin (10 U) alone
Salbutamol (0.5 mg) plus insulin (10 U) 3 (64)87,89,92 Very low Change in serum potassium –0.22 mmol/L –0.5 to 0.1
compared to salbutamol (0.5 mg) alone
Sodium bicarbonate 50–390 mmol intravenous 5 (44)89,100–102 Very low Change in serum potassium –0.1 mmol/L –0.3 to 0.1
Calcium 1 (111) 103
Very low Change in ECG rhythm No changes
Cardiac arrest
Calcium 1 (109)84 Very low Change in ECG rhythm No changes

ECG indicates electrocardiogram; and GRADE, Grading of Recommendations Assessment, Development and Evaluation.

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 Drennan et al Advanced Life Support: 2025 CoSTR

of therapies compared with insulin alone. Only a few • The optimal treatment of hyperkalemia during car-
studies compared different treatment strategies and diac arrest
doses. Specific recommendations on dosing and a rank- • The optimal ratio between insulin and glucose for
ing of specific interventions are not included. treatment of suspected hyperkalemia during car-
diac arrest
Patients With Cardiac Arrest
The recommendation for insulin in combination with glu-
cose is based on indirect evidence from non–cardiac ar- ALS Therapies for Opioid-Related Cardiac
rest patients.
Beta2-agonists were not recommended based on the
Arrest (ALS 3451, SysRev 2025)
following considerations: Rationale for Review
• That beta-adrenergic activation is already provided Opioid-related emergencies, including cardiac arrest,
by the administration of epinephrine continue to be a major public health crisis in some coun-
• The theoretical potential for harmful effects from tries. Opioid antagonists (eg, naloxone) are effective in
excessive beta stimulation during cardiac arrest reversing respiratory depression from opioid overdose,
• The difficulty of dose titration of IV beta2-agonists potentially preventing cardiac arrest. When a patient
during a cardiac arrest goes into cardiac arrest from opioid overdose, however,
• The general recommendation against tracheal it is not known whether specific treatments such as nal-
administration of drugs during cardiac arrest due to oxone should be administered in addition to standard
unpredictable drug delivery resuscitation. This topic was reviewed in 2015,4,104 and
The recommendation regarding sodium bicarbonate the treatment recommendations remained unchanged
is based on the lack of identified studies addressing this after an EvUp in 2020.42 The ALS Task Force, there-
question and the general lack of effect of bicarbonate in fore, prioritized this for review (PROSPERO Registration
cardiac arrest. The decision not to recommend against CRD42024596637).105 The full CoSTR can be found on
was based on the lack of evidence of harm in the general the ILCOR website.106
cardiac arrest population.
Population, Intervention, Comparator, Outcome,
The recommendation regarding calcium was based
Study Design, and Time Frame
on several considerations:
• Population: Adults and children in any setting (in-
• Only anecdotal evidence of a protective effect of
hospital or out-of-hospital) with cardiac arrest sec-
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calcium during hyperkalemia

ondary to suspected opioid poisoning
• Current guidelines recommend the use of calcium
• Intervention: Any opioid-specific ALS-level therapy
for the treatment of hyperkalemia
(eg, intra-arrest naloxone or other drugs, or other
• One small observational study demonstrating a
intra-arrest ALS-level interventions) for cardiac
higher mortality in patients with cardiac arrest
arrest resuscitation
receiving calcium84; the study was assessed as hav-
• Comparators: Standard basic life support or
ing critical risk of bias
advanced cardiac life support
• The potential harm of routine calcium administration
• Outcomes:
during out-of-hospital cardiac arrest
– Critical: Favorable neurological outcome at hospi-
• The general recommendation against routine use of
tal discharge, 30 days, or longer; survival at hos-
calcium during cardiac arrest
pital discharge, 30 days, or longer
The ALS Task Force acknowledges that not recom-
– Important: ROSC or survival to hospital admission
mending calcium administration in cardiac arrest that
• Study designs: In addition to standard criteria, we
is suspected to be caused by acute hyperkalemia chal-
included experimental animal studies and confer-
lenges current guidelines. The task force recognizes that
ence abstracts.
distinguishing between cardiac arrest and the periarrest
• Time frame: All years to September 14, 2024
state can be challenging. The evidence for harm of cal-
cium is based on out-of-hospital cardiac arrest, whereas Consensus on Science
the recommendation for in-hospital cardiac arrest Five observational studies (including 2 conference ab-
patients is based on indirect evidence. stracts) were identified, providing very low–certainty evi-
dence across all outcomes (downgraded for risk of bias
and indirectness, as well as inconsistency).
Knowledge Gaps
• The effect of treatments for hyperkalemia on Naloxone
patient-centered outcomes such as mortality Three observational studies reported the outcome
• The optimal doses or combinations of drugs (eg, of favorable neurological outcome at hospital dis-
insulin, glucose, salbutamol) used for the treatment charge.107–109 One conference abstract108 including
of hyperkalemia 218 adults with out-of-hospital cardiac arrest caused

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 Drennan et al Advanced Life Support: 2025 CoSTR

by presumed overdose (not specific to opioids) report- additional opioid-specific therapies (eg, naloxone) be-
ed that naloxone administration was not associated yond standard resuscitation care.
with favorable neurological outcome (adjusted OR, If rescuers are uncertain whether a patient with sus-
1.99; 95% CI, 0.34–11.55). A subsequent analysis of pected opioid poisoning is actually in cardiac arrest,
the same overall dataset included 1807 cardiac ar- administration of an opioid antagonist (eg, naloxone) is
rests with initial nonshockable rhythms not witnessed warranted (good practice statement).
by emergency medical services, and reported that
naloxone (given prior to vascular access) was asso- Justification and Evidence-to-Decision Framework
ciated with increased odds of favorable neurological Highlights
outcomes (adjusted OR, 4.61; 95% CI, 1.74–12.19).109 The complete evidence-to-decision table is provided in
A third study, also in abstract form only, including 164 Appendix A.
adults with out-of-hospital cardiac arrests with a his- This recommendation is directed at ALS profession-
tory of substance use (not specific to opioids) reported als (ie, clinicians who are able to distinguish respiratory
no difference in favorable neurological outcomes in depression/apnea from cardiac arrest). It is not intended
patients treated with or without naloxone (26% versus to inform care by individuals without training to ascertain
27%; P=0.915).107 pulselessness.
Four observational studies reported survival to hospital The ALS Task Force acknowledges that cardiac
discharge.107–110 One study of 8195 adults with undiffer- arrest resuscitations are time-sensitive, task-saturated
entiated out-of-hospital cardiac arrests found naloxone endeavors with multiple competing priorities. The task
was associated with increased survival to hospital dis- force felt that the very low–certainty evidence for any
charge (risk difference, 6.2%; 95% CI, 2.3%–10.0%).110 benefit of opioid-specific ALS interventions did not out-
Another study of undifferentiated out-of-hospital car- weigh the risk of interfering with other evidence-based
diac arrest reported that naloxone was not associated interventions. We placed a higher value on not adding
with survival to hospital discharge (adjusted OR, 1.01; yet-unproven therapies. Given the uncertain state of the
95% CI, 0.46–2.21).111 An observational study of 1807 evidence, there is also a possibility of harm.
patients with out-of-hospital cardiac arrest unwitnessed The identified studies were limited by serious risk of
by emergency medical services and with an initial non- bias and indirectness. There were no studies that examined
shockable rhythm found that naloxone was associated patients with opioid-associated cardiac arrest, specifically.
with improved survival (adjusted OR, 4.41; 95% CI, 1.78– Previous studies have shown drug-related cardiac
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10.97),109 whereas a smaller study (conference abstract) arrest is associated with improved outcomes compared
based on the same dataset did not detect an association with undifferentiated cardiac arrest, and opioid-related
(adjusted OR, 1.99; 95% CI, 0.39–10.30) among out- cardiac arrest is associated with improved outcomes
of-hospital cardiac arrests due to presumed overdose.108 compared with other drug-related out-of-hospital car-
Three observational studies109–111 reported ROSC, diac arrest. Drug-related cases are more likely to be
and results were similarly mixed, with 2 studies finding treated with naloxone, and, therefore, the treatment with
higher rates of ROSC109,110 with naloxone and 1 study naloxone may simply be a marker of opioid toxicity and
finding no difference.111 improved prognosis rather than providing any benefit.

Sodium Bicarbonate Knowledge Gaps

One observational study112 of 1545 out-of-hospital car- • There were no RCTs that evaluated standard care
diac arrest with suspected drug overdose found that ad- with and without naloxone or other opioid antago-
ministration of sodium bicarbonate was associated with nists in suspected opioid-associated cardiac arrest.
decreased odds of survival (adjusted OR, 0.16; 95% CI, • There was no evidence available for in-hospital or
0.08–0.31). pediatric cardiac arrest.

Prior Treatment Recommendations (2015) Cardiac Arrest in the Catheterization Laboratory

We recommend the use of naloxone by IV, intramuscular, (ALS 3406, ScopRev 2025)
IO, or intranasal routes in respiratory arrest associated
with opioid toxicity (strong recommendation, very low– Rationale for Review
quality evidence). The dose of naloxone required will de- Cardiac arrest in the catheterization laboratory is unique
pend on the route. from other in-hospital cardiac arrest. Patients undergo-
We can make no recommendation about the modifi- ing invasive procedures are extensively monitored, and
cation of standard ALS in opioid-induced cardiac arrest. the circumstances of cardiac arrest differ. It is not known
if management beyond standard basic life support and
Treatment Recommendations (2025) ALS is warranted. The ALS Task Force, therefore, priori-
During ALS for cardiac arrest due to opioid poison- tized this for review. The full CoSTR can be found on the
ing, there is insufficient evidence to recommend any ILCOR website.113

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 Drennan et al Advanced Life Support: 2025 CoSTR

Population, Intervention, Comparator, Outcome, and Nine observational studies described the use of
Time Frame ECPR to treat patients in the cardiac intervention labora-
• Population: Adults (>18 years) who experience a tory.123,124,126,131,134,135,137,138,140 The heterogeneity of patient
cardiac arrest in the cardiac intervention laboratory samples, settings, and procedures across the studies
• Intervention: Patient management other than makes it very challenging to draw definitive conclusions
national/international resuscitation guidelines from the data.
• Comparator: Patient management using national/ Five retrospective observational studies116,121,129,136,144
international resuscitation guidelines and a case series117 described the use of mechanical cir-
• Outcomes: ROSC; survival to hospital discharge, 30 culatory support (mainly microaxial flow pump, or Impella)
days, and longer-term; functional outcome (modified in the cardiac intervention laboratory. Whether cardiac
Rankin Scale or Cerebral Performance Category) at arrest occurred in the cardiac intervention laboratory or
hospital discharge, 30 days, and longer-term before transfer to the laboratory was not clear in most of
• Time frame: All years; the literature search was con- these studies.
ducted on March 12, 2024. Two prospective cohort studies compared intracoro-
nary epinephrine with either peripheral IV or central
Summary of Evidence venous epinephrine in a total of 320 patients developing
The search identified 35 studies meeting our inclusion cardiac arrest.115,143 ROSC, survival to discharge, and sur-
criteria.114–148 Studies were categorized into 6 domains: vival with favorable functional outcome were all signifi-
1. Incidence and outcome of cardiac arrest in the car- cantly higher in the intracoronary groups compared with
diac intervention laboratory the peripheral IV groups.
2. Incidence and outcome from cardiac arrest during
Task Force Insights
percutaneous coronary intervention in the cardiac
Interpretation of the included studies is difficult because
intervention laboratory among patients with and
it is often unclear whether the cardiac arrest occurred in
without acute ST-elevation myocardial infarction
the cardiac intervention laboratory or beforehand.
3. Mechanical CPR in the cardiac intervention
Many studies included patients in cardiogenic shock
laboratory
as well as cardiac arrest, and in most cases, it was not
4. ECPR in the cardiac intervention laboratory
possible to extract outcome data from the cardiac arrest
5. Mechanical circulatory support in the cardiac inter-
cases alone.
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vention laboratory
The performance and quality of standard resuscita-
6. Intracoronary epinephrine in the cardiac interven-
tive measures (eg, CPR) were not characterized in the
tion laboratory
studies.
A brief narrative summary is provided here. See
Tables 1 through 6 in Appendix C for additional details of Knowledge Gaps
included studies for each category. • There are no RCTs of interventions.
Three observational studies (2 retrospective cohort • The outcomes for patients developing cardiac arrest
studies139,142 and 1 prospective cohort study120) described in the catheterization laboratory and then treated
the incidence and outcome from cardiac arrest in the with mechanical chest compression devices, or
cardiac intervention laboratory among patients under- mechanical circulatory support, or centrally admin-
going a variety of interventions. The incidence rate was istered drugs are unclear.
0.2% and 0.5%, and 77% and 67%, respectively, sur- • Further study of the use of intracoronary epineph-
vived the event.139,142 Two studies120,142 reported survival rine should be considered.
to discharge (56.1% and 38.1%).
Three observational studies (1 prospective127 and
2 retrospective114,148) described the incidence and CPR in Patients Who Are Prone (ALS 3003,
outcome from cardiac arrest in the cardiac interven- SysRev 2021, EvUp 2025)
tion laboratory among patients (elective and nonelec- CPR and defibrillation for patients in the prone position
tive) undergoing percutaneous coronary intervention. was addressed by a 2021 SysRev149 and can be found
The incidence of VF cardiac arrest was 0.84% to 2%, in the 2021 CoSTR summary.21 An EvUp was conducted
and the one study reporting outcomes documented for 2025. The complete EvUp is provided in Appendix B.
successful defibrillation within 1 minute and survival
to hospital discharge in all 164 (100%) VF cardiac Population, Intervention, Comparator, Outcome,
arrest.114 Study Design, and Time Frame
Seven observational studies described outcomes • Population: Adults and children with cardiac arrest
following use of a mechanical chest compression in any setting, occurring while in the prone position
to manage cardiac arrest in the cardiac intervention • Intervention: Performing CPR or defibrillation while
laboratory.118,128,145,146 the patient remains in the prone position

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 Drennan et al Advanced Life Support: 2025 CoSTR

• Comparators: Turning the patient supine prior to ini- • Outcomes:

tiation of CPR or defibrillation – Maternal
• Outcomes: ■ Critical: Survival with favorable functional out-
– Critical: Survival and survival with favorable neu- come at discharge, 30 days, 60 days, 90 days,
rological outcome to discharge, 30 days, or longer 180 days, or 1 year; survival at discharge, 30
– Important: Arterial blood pressure during CPR, days, 60 days, 90 days, 180 days, or 1 year
time to initiation of CPR, time to defibrillation for ■ Important: ROSC or survival to hospital
shockable rhythms during CPR, end-tidal cap- admission
nography during CPR, ROSC – Neonatal
• Study designs: In addition to standard criteria, case ■ Critical: Survival with favorable functional out-
series and reports were included as the writing come at discharge, 30 days, 60 days, 90 days,
group was aware that the human data on prone 180 days, or 1 year; survival at discharge, 30
CPR are extremely limited. days, 60 days, 90 days, 180 days, or 1 year
• Time frame: December 9, 2020, to July 15, 2024 ■ Important: ROSC or survival to hospital
admission
Summary of Evidence • Study designs: In addition to standard criteria, case
One SysRev150 and 1 report of 2 cases in adults were series with ≥20 patients, and descriptive studies with-
identified.151 The task force did not consider the identi- out a comparator group were eligible for inclusion.
fied evidence sufficient to warrant a full SysRev. Gray literature, social media, and non–peer-reviewed
Treatment Recommendations (2021) studies, unpublished studies, conference abstracts,
For patients with cardiac arrest occurring while in the and trial protocols were eligible for inclusion.
prone position with an advanced airway already in place • Time frame: August 2014 to September 2023
and for whom immediate supination is not feasible or
poses significant risk to the patient, initiating CPR while Treatment Recommendations (2015, With Addition
the patient is still prone may be a reasonable approach of Good Practice Statements in 2024)
(good practice statement). We suggest delivery of the fetus by perimortem cesarean
Invasive blood pressure monitoring and continuous delivery for women in cardiac arrest in the second half
ETCO2 monitoring may be useful to ascertain whether of pregnancy (weak recommendation, very low–certainty
evidence).
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prone compressions are generating adequate perfusion,

and this information could inform the optimal time to turn There is insufficient evidence to define a specific time
the patient supine (good practice statement). interval by which delivery should begin.
For patients with cardiac arrest occurring while in High-quality usual resuscitation care and therapeutic
the prone position without an advanced airway already interventions that target the most likely cause(s) of car-
in place, we recommend turning the patient supine as diac arrest remain important in this population.
quickly as possible and beginning CPR (strong recom- There is insufficient evidence to make a recommen-
mendation, very low–certainty evidence). dation about the use of left-lateral tilt or uterine displace-
For patients with cardiac arrest with a shockable rhythm ment during CPR in the pregnant patient.
who are in the prone position and cannot be supinated ECPR may be considered as a rescue therapy for
immediately, attempting defibrillation in the prone position selected cardiac arrest patients during pregnancy or in
is a reasonable approach (good practice statement). the postpartum period when conventional CPR fails and
in settings in which it can be implemented (good practice
statement).
Cardiac Arrest During Pregnancy (ALS 3401, Institution readiness and resuscitation education are
ScopRev 2024) required to accommodate the unique physiologic chal-
Cardiac arrest during pregnancy was most recently ad- lenges of cardiac arrest during pregnancy (good practice
dressed by a ScopRev and can be found in the 2024 statement).
CoSTR summary.27 The ScopRev led to 2 new good prac-
tice statements in 2024, adding to the existing treatment
recommendations. Resuscitation of Patients With Durable
Mechanical Circulatory Support With Acutely
Population, Intervention, Comparator, Outcome,
Study Design, and Time Frame
Altered Perfusion or Cardiac Arrest (ALS 3005,
• Population: Pregnant or up to 1 year postpartum ScopRev 2025)
patients in cardiac arrest in any setting Rationale for Review
• Intervention: Any specific intervention(s) This topic was prioritized by the ALS Task Force for re-
• Comparators: Standard care or usual resuscitation view due to the increasing prevalence of durable me-
practice chanical circulatory support devices, left ventricular

S88 October 21, 2025 Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360

 Drennan et al Advanced Life Support: 2025 CoSTR

assist devices (LVADs) in particular, both in-hospital and chest compressions survived to hospital discharge.162
in the community. The optimal approach to the identifica- The study did not make any direct comparisons between
tion and resuscitation of patients with acutely impaired these groups. The third study of 58 patients with LVAD
perfusion supported by mechanical circulatory support who had a cardiac arrest in a single center found no dif-
devices is controversial. This topic has not been previ- ference between those who received chest compres-
ously reviewed by ILCOR. sions compared to those who did not.177
Of all patients with an LVAD who received
Population, Concept, Context, and Time Frame
chest compressions across 11 studies (n=226),
This ScopRev followed the population, concept, context
71 (31%) were reported as having a favorable
framework and not the traditional population, interven-
outcome.154,157,158,160,162,166,169,174,177,178,182
tion, comparator, outcome, study design, and time frame
No study reported dislodgement or other complica-
that is more suitable for SysRevs.
tions related to device function after chest compressions.
• Population: Patients of any age who were receiving
Additional study details are provided in supplementary
durable mechanical support of any kind
Tables 7 and 8 in Appendix C.
• Concept: Acute impaired perfusion resulting in the
need for acute resuscitation Task Force Insights
• Context: In-hospital and out-of-hospital settings The task force highlighted the overall lack of evidence
• Time frame: All years to September 2024 to support recommendations on the optimal approach to
resuscitation. Most publications identified were case re-
Summary of Evidence
ports or case series. The few observational cohort stud-
Of the 3557 studies identified, 32 (0.9%) met inclusion
ies all had significant limitations, including confounding
criteria.152–183 Of the included studies, 25 were case
by indication, lack of generalizability, and high risk of
reports (2 or fewer patients),152,155–159,161,164–176,179–183
misclassification wherein patients with acutely impaired
4 were case series (3–10 patients),153,160,163,178
perfusion are designated as having a cardiac arrest but
and 3 were retrospective cohort studies (10+
may not have had an acute cardiac arrest.
patients).154,162,177 Eleven studies described a pa-
The task force found the evidence compelling that
tient who had a cardiac arrest and received chest
there is low risk of device dislodgement from chest
compressions.154,157,158,160,162,166,169,174,177,178,182 Durable
compressions.
mechanical circulatory support devices were LVADs or
The task force also reviewed a Scientific Statement
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biventricular assist devices in all studies.

from the American Heart Association185 and guidance
Several studies highlighted challenges of identify-
from the British Societies LVAD Emergency Algorithm
ing patients with acutely altered perfusion and cardiac
Working Group.184 One recommendation from the Brit-
arrest.152,160,169,176,178,184,185 These challenges included
ish Society Working Group was to delay chest com-
complexity resulting from expected pulselessness in
pressions for up to 2 minutes while efforts to restart
­continuous-flow LVAD–supported patients who do not
the device are made. The task force considered that
have native heart rates. Other challenges described
these 2 minutes may be unnecessary, and efforts to
included difficulty of measuring blood pressure and chal-
restart the LVAD device could occur in parallel with
lenges determining adequate perfusion.
chest compressions as long as multiple rescuers are
Delays in chest compressions were documented in
available.
several reports.160,162,166,174 In one study of hospitalized
patients, 4 of 9 (44.4%) patients with LVADs who had Treatment Recommendations (2025)
a cardiac arrest had delays of over 2 minutes before In patients receiving durable mechanical circulatory sup-
starting chest compressions.162 The most common rea- port who develop acutely impaired perfusion because of
son clinicians provided for not performing chest com- cardiac arrest and who are not in the immediate peri–de-
pressions was the belief that chest compressions were vice implantation period, we suggest performing, rather
contraindicated in patients with LVADs. Because of the than withholding, chest compressions (good practice
difficulty in assessments and the uncertainty of health statement).
care professionals, the authors of several studies pro- When caring for patients with durable mechanical cir-
posed algorithms for resuscitation of patients with dura- culatory support who have acutely impaired perfusion as
ble mechanical circulatory support. a result of cardiac arrest, we suggest minimizing delays
Three studies compared chest compressions with no in initiating chest compressions while simultaneously
chest compressions with respect to patient outcomes. assessing for device-related reversible causes of acutely
The largest study (n=578) found higher in-hospital mor- impaired perfusion (good practice statement).
tality (74% versus 55%) in patients who received chest We suggest rescuers follow an algorithmic approach
compressions.154 The second study of 16 patients found to concurrently assess and respond to acutely impaired
22% (2 of 9) of patients with chest compressions sur- perfusion in patients receiving durable mechanical circu-
vived to discharge and 43% (3 of 7) who did not receive latory support (good practice statement).

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 Drennan et al Advanced Life Support: 2025 CoSTR

Cardiac Arrest Due to Confirmed or Suspected The population, outcome, study design, and time frame
Pulmonary Embolism (ALS 3400, EvUp 2025) were the same for all comparisons. Details of the SysRev
and the specific interventions and comparators can be
The treatment of cardiac arrest for confirmed or suspect- found in the 2024 CoSTR summary.27,187
ed pulmonary embolism was addressed by an EvUp for
2022, and details can be found in the 2022 CoSTR sum-
mary.73 An EvUp was completed for 2025. The complete Population, Outcome, Study Design, and Time
EvUp is provided in Appendix B. Frame
• Population: Adults with cardiac arrest in any setting
Population, Intervention, Comparator, Outcome, and • Outcome: Critical—survival and favorable neuro-
Time Frame logical/functional outcome at discharge, 30 days, or
• Population: Among adults who are in cardiac arrest longer
due to pulmonary embolism or suspected pulmo- • Study designs: Only controlled trials in humans,
nary embolism in any setting including RCTs and nonrandomized trials (eg,
• Intervention: Any specific alteration in treatment pseudorandomized trials), were included. Studies
algorithm (eg, fibrinolytics) assessing cost-effectiveness were included for a
• Comparators: Standard basic life support and ALS descriptive summary.
care • Time frame: June 17, 2021, to May 31, 2023
• Outcomes: Survival with favorable neurological/
functional outcome at discharge, 30 days, or longer;
Treatment Recommendations (2024)
survival at discharge, 30 days, or longer
We suggest actively preventing fever by targeting a tem-
• Time frame: November 29, 2021, to December 20,
perature ≤37.5 °C for patients who remain comatose
2023
after ROSC from cardiac arrest (weak recommendation,
Summary of Evidence low-certainty evidence).
One retrospective cohort study of 64 patients was iden- Whether subpopulations of cardiac arrest patients
tified.186 The study found that use of thrombolysis (al- may benefit from targeting hypothermia at 32 °C to
teplase) was associated with improved survival compared 34 °C remains uncertain.
with no thrombolysis. The task force did not consider the Comatose patients with mild hypothermia after ROSC
should not be actively warmed to achieve normothermia
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identified evidence sufficient to warrant a full SysRev.

(good practice statement).
Treatment Recommendations (2020) We recommend against the routine use of prehospital
We suggest administering fibrinolytic drugs for cardiac cooling with rapid infusions of large volumes of cold IV
arrest when pulmonary embolism is the suspected cause fluid immediately after ROSC (strong recommendation,
of cardiac arrest (weak recommendation, very low–cer- moderate-certainty evidence).
tainty of evidence). We suggest surface or endovascular temperature
We suggest the use of fibrinolytic drugs or surgical control techniques when temperature control is used in
embolectomy or percutaneous mechanical thrombec- comatose patients after ROSC (weak recommendation,
tomy for cardiac arrest when pulmonary embolism is the low-certainty evidence).
known cause of cardiac arrest (weak recommendation, When a cooling device is used, we suggest using a
very low–certainty evidence). temperature control device that includes a feedback
system based on continuous temperature monitor-
ing to maintain the target temperature (good practice
POST–CARDIAC ARREST CARE statement).
We suggest active prevention of fever for 36 to 72
Post–Cardiac Arrest Temperature Control (ALS hours in post–cardiac arrest patients who remain coma-
3523, 3524, 3525, SysRev 2024) tose (good practice statement).
The SysRev for post–cardiac arrest temperature man-
agement was last updated for the 2024 CoSTR summary.
Post–Cardiac Arrest Seizure Prophylaxis and
This population, intervention, comparator, outcome, study
design, and time frame includes 6 different comparisons: Treatment (ALS 3502, 3503, SysRev 2024)
1. The use of temperature control Post–cardiac arrest seizure prophylaxis and treatment
2. Timing of temperature control were addressed by an updated SysRev for 2024 and de-
3. Optimal temperature tails can be found in the 2024 CoSTR summary.27 This was
4. Duration of temperature control a nodal review between the ALS and Pediatric Life Support
5. Method of temperature control Task Forces. For pediatric recommendations, see the Pe-
6. Rewarming rates diatric Life Support section of the 2024 CoSTR summary.

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 Drennan et al Advanced Life Support: 2025 CoSTR

Population, Intervention, Comparator, Outcome, and – Important: Length of hospital and intensive care unit
Time Frame stay, adverse events or complications (eg, bleeding,
• Population: Adults or children with ROSC after car- limb ischemia, arrhythmias, recurrent cardiac arrest,
diac arrest in any setting acute kidney injury ± renal replacement therapy,
• Intervention: One strategy for prophylactic antisei- stroke, hemolysis), as defined by study authors
zure medication or seizure treatment • Study designs: We included only RCTs. Studies
• Comparators: Another strategy, or no prophylactic where a mechanical circulatory support device was
antiseizure medication or seizure treatment initiated during ongoing CPR (ie, ECPR) were not
• Outcomes: Critical—survival with favorable func- considered.
tional outcome at discharge, 30 days, 60 days, 90 • Time frame: All years to July 3, 2024
days, 180 days, or 1 year; survival at discharge, 30
days, 60 days, 90 days, 180 days, or 1 year Consensus on Science
• Time frame: September 26, 2019, to September 11, For the critical outcome of survival to hospital discharge
2023 or 30-day survival, there were 13 RCTs189–201 examining
patients in cardiogenic shock that found no difference
Treatment Recommendations (2024) with the use of mechanical circulatory support devices.
We suggest against the use of prophylactic antiseizure A subgroup of post–cardiac arrest patients from 6 of the
medication in post–cardiac arrest adults (weak recom- included trials191,193,194,197,200,201 similarly found no differ-
mendation, very low–certainty evidence). ence with the use of mechanical circulatory support de-
We suggest treatment of clinically apparent and elec- vices compared with standard care. One RCT examining
trographic seizures in post–cardiac arrest adults (good in-hospital cardiac arrest again found no difference in
practice statement). survival with the use of mechanical circulatory support.194
We suggest treatment of rhythmic and periodic elec- For longer-term survival (6 months, 12 months, and
troencephalogram (EEG) patterns that are on the ictal- longest follow-up time), 14 RCTs189–202 of patients with
interictal continuum in comatose post–cardiac arrest cardiogenic shock found no difference with the use of
adults (weak recommendation, low-certainty evidence). mechanical circulatory support, including in the post–car-
diac arrest subgroup. A single RCT comparing the use of
Mechanical Circulatory Support After ROSC a microaxial flow pump with standard care in conscious
Following Cardiac Arrest (ALS 3505, SysRev patients with infarct-related cardiogenic shock (20% of
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whom were post–cardiac arrest patients) found improved

2025) survival at 6 months.194
Rationale for Review Three RCTs196,198,200 found no difference in favorable
Temporary mechanical circulatory support refers to de- neurological outcome with mechanical circulatory sup-
vices (eg, microaxial flow pump, or Impella; intra-aortic port for cardiogenic shock. No specific data on cardiac
balloon pump; venoarterial extracorporeal membrane oxy- arrest patients was identified for this outcome.
genation) that can be used in patients with cardiogenic More detailed numeric results are provided in Table 9
shock to support circulation, improve cardiac output, and in Appendix C.
restore end-organ perfusion. This SysRev was undertaken
to incorporate new data on the use of mechanical circula- Treatment Recommendations (2025)
tory support devices in acute myocardial infarction compli- We suggest against the routine use of mechanical circu-
cated by cardiogenic shock, including a large proportion latory support devices in patients with cardiogenic shock
of post–cardiac arrest patients. It was registered before after cardiac arrest and ROSC (weak recommendation,
initiation (PROSPERO Registration CRD42024566810). low-certainty evidence).
The full CoSTR can be found on the ILCOR website.188 We suggest considering mechanical circulatory sup-
port devices in highly selected patients with cardiogenic
Population, Intervention, Comparator, Outcome, shock after cardiac arrest and ROSC, in settings where
Study Design, and Time Frame this can be implemented (weak recommendation, low-
• Population: Adults with cardiogenic shock after certainty evidence).
ROSC following cardiac arrest in any setting When a mechanical circulatory support device is used,
• Intervention: Management with a mechanical circu- we suggest monitoring for adverse events and compli-
latory support device cations to allow their rapid identification and treatment
• Comparators: Management without a mechanical (good practice statement).
circulatory support device or usual post–cardiac
arrest care Justification and Evidence-to-Decision Framework
• Outcomes: Highlights
– Critical: Favorable neurological outcome; quality of The complete evidence-to-decision table is provided in
life; survival at hospital discharge, 30 days, or longer Appendix A.

Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360 October 21, 2025 S91

 Drennan et al Advanced Life Support: 2025 CoSTR

No benefits were found in any outcome between 2024 CoSTR summary.27,187 It was registered before ini-
treatment with mechanical circulatory support and tiation (PROSPERO Registration CRD42024566810).
standard care in patients with cardiogenic shock, with The full CoSTR can be found online.205
or without prior cardiac arrest. Only a single RCT com-
paring the use of a microaxial flow pump with standard Population, Intervention, Comparator, Outcome,
care found improved survival at 6 months, and only 20% Study Design, and Time Frame
of the patients in that trial were post–cardiac arrest • Population: Adults with sustained ROSC after car-
patients. diac arrest
All evidence was indirect, coming from studies in • Intervention: Targeting a mean arterial pressure of
patients with cardiogenic shock (64% of patients resus- 71 mm Hg or higher
citated from cardiac arrest), except a small (n=60) RCT • Comparator: Targeting a mean arterial pressure of
enrolling patients resuscitated from in-hospital cardiac 70 mm Hg or lower
arrest caused by acute coronary syndrome. • Outcomes:
The task force considered that there may be groups – Critical: Survival or good functional outcome
of patients who benefit from mechanical circulatory defined as a modified Rankin Scale score of 1 to
support. There was a lack of evidence on how to select 3 or a Cerebral Performance Category score of 1
patients with cardiogenic shock after cardiac arrest for or 2 at 90 to 180 days
mechanical circulatory support. The patient subgroups – Important: Intensive care unit mortality, new
who may benefit include those with a Glasgow Coma arrhythmia resulting in hemodynamic compromise
Scale score >8 at hospital arrival with infarct-related or cardiac arrest while in the intensive care unit
cardiogenic shock,194 patients with ST-segment elevation • Study design: Only RCTs were eligible for inclusion.
myocardial infarction without prior resuscitation before • Time frame: Original search all years to October
arrival of emergency medical services, or with a short 2022; updated for adolopment in August 2023
duration of cardiac arrest (<10 minutes).203 Treatment Recommendations (2024)
The task force considered that hypoxic brain injury There is insufficient scientific evidence to recommend a
is the leading cause of death post–cardiac arrest, while specific blood pressure goal after cardiac arrest. There-
persistent cardiac failure is the primary cause in those fore, we suggest a mean arterial blood pressure of at
with cardiogenic shock without preceding cardiac arrest. least 60 to 65 mm Hg in patients after out-of-hospital
Therefore, in patients at high risk of brain injury, the ben-
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(moderate-certainty to low-certainty evidence) and in-

efit of mechanical circulatory support devices may be hospital cardiac arrest (low-certainty to very low–cer-
less apparent. tainty evidence).
The task force also considered that implementation
of mechanical circulatory support may incur significant
costs and require specialized resources and skills, which Choice of Vasopressor in the Post–Cardiac
may not be feasible in all settings. Arrest Period (ALS 3528, SysRev 2025)
Knowledge Gaps Rationale for Review
• The effect of mechanical circulatory support devices There are very few data to guide vasopressor choice
on neurologically intact survival in patients with for post–cardiac arrest shock; therefore, a SysRev
ROSC after cardiac arrest was undertaken. It was registered on PROSPERO
• The value of mechanical circulatory support devices (CRD42024549394) prior to undertaking the search.
following cardiac arrest of noncardiac origin The full CoSTR can be found on the ILCOR website.206
• Whether there are differences between different
Population, Intervention, Comparator, Outcome, and
types of mechanical circulatory support devices or
Time Frame
combinations of devices
• Population: Adults with sustained ROSC after car-
• The optimal timing for initiating mechanical circula-
diac arrest and a need for a vasopressor infusion to
tory support after ROSC
manage low blood pressure
• The ideal settings for implementing mechanical cir-
• Interventions: Vasopressor or a combination of
culatory support in post–cardiac arrest patients
vasopressors provided intravenously as an infusion
after ROSC
• Comparators: No vasopressor, a different vasopres-
Post–Cardiac Arrest Hemodynamics (ALS 3515,
sor, or a different combination of vasopressors pro-
2024 SysRev Adolopment) vided intravenously as an infusion after ROSC
Rationale for Review • Outcomes:
Postarrest hemodynamics was reviewed with adolopment – Critical: Survival or good functional outcome
of a SysRev204 in 2024, and details can be found in the defined as a modified Rankin Scale score of 1

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 Drennan et al Advanced Life Support: 2025 CoSTR

to 3 or Cerebral Performance Category scale cardiac arrest. One retrospective cohort study found that
score of 1 or 2 at the longest time point (author norepinephrine and dopamine compared with dopamine
defined) alone was not associated with any difference in survival
– Important: Intensive care unit or emergency to 30 days (adjusted OR, 0.6; 95% CI, 0.3–1.1) but was
department mortality, new arrhythmia resulting in associated with lower odds of favorable neurological
hemodynamic compromise or cardiac arrest while outcome at 30 days (adjusted OR, 0.20; 95% CI, 0.04–
in the emergency department or intensive care 0.78).208 A second retrospective study including 310 pa-
unit tients found that dopamine together with norepinephrine
• Time frame: All years to August 2024 or epinephrine was associated with higher 30-day mor-
tality compared with dopamine alone (adjusted OR, 2.0;
95% CI, 1.3–3.0).214
Consensus on Science
Of 7048 screened, 8 studies were included.207–214 Treatment Recommendation (2025)
The evidence across all outcomes was of very low There is insufficient evidence to recommend a specific
certainty. Three comparisons were performed within vasopressor to treat low blood pressure in patients after
the included studies: norepinephrine compared with cardiac arrest.
­epinephrine,207,209–213 norepinephrine compared with do-
pamine,208 and dopamine compared with dopamine com- Justification and Evidence-to-Decision Framework
bined with a different vasopressor (norepinephrine or Highlights
epinephrine).208,214 The full evidence-to-decision table is provided in
Appendix A.
Norepinephrine Compared With Epinephrine
The evidence for the choice of different vasopressors
For the critical outcome of survival at 30 days, 1 RCT210
is of very low certainty. There is only 1 small feasibility
of 40 out-of-hospital cardiac arrest patients with ROSC
RCT, and all observational studies are prone to con-
in the emergency department showed no difference with
founding by indication (ie, epinephrine is often used in
norepinephrine compared with epinephrine (10% versus
the most critical and unstable patients).
10%; P=1.0). Two retrospective studies207,209 including
There was a lack of consensus about the treatment
766 and 221 patients with ROSC in-hospital after out-
recommendation, with some members suggesting a rec-
of-hospital cardiac arrest showed that epinephrine was
ommendation for norepinephrine as the first-line vaso-
associated with higher in-hospital mortality (adjusted
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pressor (7 members) and some suggesting that there

OR, 2.6; 95% CI, 1.4–4.7 and adjusted OR, 6.2; 95%
is insufficient evidence to make any recommendation (9
CI, 2.4–16.3), and 1 study207 reported higher likelihood
members).
of unfavorable neurological outcome (adjusted OR, 3.4;
The feasibility of giving different vasopressors likely
95% CI, 2.4–5.0) at discharge. Two studies,211,213 includ-
varies between settings. The task force discussed the
ing 451 patients and 1893 patients, respectively, found
possibility that vasopressor choice would vary based
no difference in survival to hospital discharge in those
on clinical situation and timing. Periarrest stabilization
who received epinephrine compared with norepinephrine
and more longitudinal postarrest intensive care unit
(adjusted OR, 1.08; 95% CI, 0.60–1.93 and adjusted
care may require different approaches to vasopres-
OR, 1.0; 95% CI, 0.6–1.7, respectively). One of these
sor choice, but there is little evidence to guide these
studies also found no difference in good neurological
choices.
function at hospital discharge (adjusted OR, 0.89; 95%
Vasopressors are commonly used to manage blood
CI, 0.45–1.77).213
pressure in other critically ill patients. The latest Surviving
Five studies reported the important outcome of rear-
Sepsis Campaign Guidelines recommend norepineph-
rest, with 4 of the 5 favoring norepinephrine207,209,212,213
rine as the first-line vasopressor.215
and 1 finding no difference.211
Vasopressors are commonly used for the manage-
Norepinephrine Compared With Dopamine ment of low blood pressure and low cardiac output in
One retrospective study208 including 1011 patients found patients with cardiogenic shock. The recommendations
no difference in 30-day survival (adjusted OR, 1.0; 95% for the first-line vasopressor for the management of low
CI, 0.48–2.06) or favorable functional outcome (adjusted blood pressure is norepinephrine in some international
OR, 0.80; 95% CI, 0.28–2.53) in patients treated with guidelines.216,217
norepinephrine compared with dopamine.
Knowledge Gaps
Norepinephrine Combined With Dopamine Compared • The effects of norepinephrine and epinephrine on
With Dopamine Alone brain circulation and cerebral blood flow
Two studies examined the use of norepinephrine togeth- • Studies enrolling patients with in-hospital cardiac
er with dopamine compared with dopamine alone for pa- arrest (all studies were conducted in patients with
tients with hypotension in hospital after out-of-hospital out-of-hospital cardiac arrest)

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 Drennan et al Advanced Life Support: 2025 CoSTR

• The effect of intermittent bolus administration of Supportive Drug Therapies

vasopressors to treat low blood pressure after In 5 RCTs223,239,240,247,255 investigating antiplatelet agents,
ROSC sedation, and neuromuscular blockade, there was no dif-
• Whether specific vasopressors are better or worse in ference in the critical outcome of mortality at 30 days
specific clinical scenarios (eg, during patient trans- or hospital discharge. One study found no difference in
port, or when central access is or is not available) 12-month survival in out-of-hospital cardiac arrest pa-
• Whether the use of inotropes such as dobutamine, tients treated with neuromuscular blockade administered
levosimendan, or milrinone together with vasopres- as a continuous infusion or placebo.256 There was no
sors is more effective than vasopressors alone for difference in serious adverse events between interven-
postarrest shock when a cardiogenic component of tion and control arms in the supportive drug therapies
shock is suspected category.
Neuroprotective Agents
Administration of Neuroprotective Drugs in Fourteen studies investigated 13 therapies, includ-
ing thiopental,225 the dopamine agonist amantadine,227
Patients with ROSC after Cardiac Arrest (ALS
calcium channel blockers nimodipine235,253 and lidofla-
3507, SysRev Adolopment 2025) zine,224 inhaled xenon,238 nitric oxide,263 hydrogen,­257 the
Rationale for Review glucagon-like peptide-1 agonist exenatide,260 epoetin
­
A recent ILCOR scientific statement on why therapeutic alfa,226 sodium nitrite,229 magnesium,258 MLC901 (a com-
interventions have failed to translate to improved neuro- bination of 9 herbal components),250 and the anticho-
logical outcomes in clinical trials identified the effect of linergic penehyclidine hydrochloride.259 Thirteen studies
any specific drug therapies for neuroprotection in coma- reported no effect on mortality at 30 days or hospital
tose survivors of cardiac arrest as a significant knowl- discharge. One small single-center study of 80 patients
edge gap.218 The ALS Task Force was aware of a SysRev reported reduced 30-day or hospital mortality with pene-
addressing this question, which was deemed suitable for hyclidine hydrochloride compared with hyoscine hydro-
adolopment.219 The SysRev was registered on PROSPE- bromide (RR, 0.17; 95% CI, 0.04–0.70) (high risk of bias
RO (CRD42023488043). The full CoSTR can be found in 2 domains).259 One multicenter study from Japan com-
on the ILCOR website.220 paring inhaled hydrogen with nitrogen placebo reported
reduced mortality between 30 days of hospital discharge
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Population, Intervention, Comparator, Outcome, and 180 days (RR, 0.39; 95% CI, 0.17–0.91), but this
Study Design, and Time Frame study was terminated early (less than 20% included).257
• Population: Adults aged ≥16 years who are coma- For the critical outcome of good functional outcome, no
tose after cardiac arrest significant effects were seen in any study. Significantly
• Intervention: Neuroprotective drug administration increased rates of serious adverse events were seen in
irrespective of route of administration; the interven- the studies of thiopental (hypotension), lidoflazine (hypo-
tion may have commenced during the cardiac arrest tension), and epoetin alfa (thrombosis) within the inter-
but must have continued after ROSC vention arms.224–226
• Comparators: Placebo or usual care
• Outcomes: Anti-Inflammatory and Antioxidant Agents
– Critical: Mortality and functional outcome at 30 In the anti-inflammatory and antioxidant category, 16
days or hospital discharge, health-related quality studies of 9 therapies were included. Therapies inves-
of life tigated included steroids,230,243,249 vasopressin in con-
– Important: Serious adverse events junction with steroids,242 thiamine,222,231,251 coenzyme
• Study designs: Only RCTs were eligible for inclusion. Q10,228,236,262 vitamin C,252 the interleukin-6 inhibitor to-
Studies with results published on trial registries (but cilizumab,246 the prostacyclin analogue iloprost,245 the
were not published in peer-reviewed journals) were neutrophil elastase inhibitor urinastatin,234 and the tradi-
included. tional Chinese medicine Shenfu.261 Individual study re-
• Time frame: All years to April 12, 2024 sults were variable and are included in the online CoSTR.
Meta-analysis results for mortality at 30 days are pre-
Consensus on Science sented in Table 2.
Forty-two studies221–263 (5502 patients) were included
in the adoloped SysRev.219 Studies are grouped the- Treatment Recommendation (2025)
matically as supportive drug therapy (7 studies), neu- There is insufficient evidence to recommend the use of
roprotective agent (19 studies), and anti-inflammatory/ any specific drug therapy for comatose survivors of car-
antioxidant (16 studies) to facilitate narrative reporting diac arrest (weak recommendation, low- to very low–cer-
of results. tainty evidence).

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 Drennan et al Advanced Life Support: 2025 CoSTR

Table 2. Meta-Analysis Results for the Effect of Anti-Inflammatory and Antioxidant Agents on Mortality at 30 Days or Hospital
Discharge

Studies RR (95% CI) Certainty of

(participants), n Intervention Comparator ARD (95% CI) evidence
5 (739)230,242–244,249 Steroids Placebo RR, 0.93 (0.83–1.04) Low
ARD, 56 fewer deaths/1000 (136 fewer to 32 more deaths/1000)
3 (107)228,236,262 Coenzyme Q10/ubiquinol Placebo RR, 0.91 (0.61–1.37) Low
ARD 40 fewer deaths/1000 (173 fewer to 248 more deaths/1000)
3222,231,251 Thiamine Placebo RR, 1.11 (0.88–1.40) Low
ARD, 67 more deaths/1000 (73 fewer to 242 more deaths/1000)

ARD indicates absolute risk difference; RR, relative risk.

Justification and Evidence-to-Decision Framework • Comparators: Delayed coronary angiography or no

Highlights coronary angiography
The complete evidence-to-decision table is provided in • Outcome: Any clinical outcome
Appendix A. • Time frame: January 8, 2022, to April 5, 2024
The task force recognized that most of the evidence
Summary of Evidence
was derived from single-center trials with few partici-
The complete EvUp is provided in Appendix B. Three addi-
pants in each trial.
tional relevant studies were identified in the updated search.
Trials of the anticholinergic penehyclidine,259 the tra-
All studies investigated early versus delayed coronary an-
ditional Chinese medicine Shenfu,261 and inhaled hydro-
giography in patients without ST-segment elevation myo-
gen257 reported reduced mortality. However, a high risk of
cardial infarction. Two RCTs, both stopped early, found no
bias, small sample size, and lack of supporting evidence
evidence of a difference in outcomes. A secondary analysis
does not support a recommendation of these agents
of a previous RCT examining 1-year mortality found higher
without further studies.
mortality in the immediate angiography group (hazard ratio,
Two trials of intra-arrest vasopressin and methylpred-
1.25; 95% CI, 0.99–1.57). The task force did not consider
nisolone plus hydrocortisone for postresuscitation shock
the identified evidence sufficient to warrant a full SysRev.
reported a reduction in mortality,242 but it was impossible
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to separate the treatment effect of postarrest steroids Treatment Recommendations (2020)

from co-interventions commenced during cardiac arrest, When coronary angiography is considered for comatose
which included vasopressin. A CoSTR review that spe- postarrest patients without ST elevation, we suggest
cifically examined the effect of vasopressin and cortico- that either an early or delayed approach for angiogra-
steroids during cardiac arrest does not recommend the phy is reasonable (weak recommendation, low-certainty
use of intra-arrest vasopressin and corticosteroids.73,264 evidence).
The task force recognized the very low certainty of We suggest performing early coronary angiography in
evidence for thiamine. The task force also noted that 2 comatose post–cardiac arrest patients with ST-segment
studies were stopped early because of concerns about elevation (good practice statement).
harm in a subgroup of patients with lactate >5 mmol/L
at study inclusion.222,231
Post–Cardiac Arrest Steroid Administration
(ALS 3504, EvUp 2025)
Post–Cardiac Arrest Percutaneous Coronary
Intervention With and Without ST-Segment Population, Intervention, Comparator, Outcome,
Study Design, and Time Frame
Myocardial Infarction (ALS 3500, 3501, SysRev • Population: Adult patients with ROSC after cardiac
2022, EvUp 2025) arrest in any setting
The use of coronary angiography for patients with ROSC • Intervention: Treatment with corticosteroids
after cardiac arrest was addressed by a SysRev for 2022, • Comparator: Standard care without use of
and details can be found in the 2022 CoSTR summary.73 corticosteroids
An EvUp was completed for 2025. • Outcome: Any clinical outcome
• Time frame: September 1, 2022, to May 7, 2024
Population, Intervention, Comparator, Outcome, and
Time Frame Summary of Evidence
• Population: Unresponsive adults (>18 years of age) One new RCT and 1 substudy of an RCT were identified.
with ROSC after cardiac arrest The RCT (n=137) found reduced interleukin-6 values
• Intervention: Emergent or early coronary angiography but no differences in clinical outcomes.249 The second-
with percutaneous coronary intervention if indicated ary analysis found reduced need for vasopressors with

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 Drennan et al Advanced Life Support: 2025 CoSTR

glucocorticoid administration.265 No survival outcomes study supported previous findings of reduced rates of
were analyzed. The task force did not consider the iden- ventilator-associated pneumonia and undifferentiated
tified evidence sufficient to warrant a full SysRev. pneumonia but no differences in survival outcomes with
prophylactic antibiotics. The task force did not con-
Treatment Recommendation (2010)
sider the identified evidence sufficient to warrant a full
There is insufficient evidence to support or refute the
SysRev.
use of corticosteroids alone or in combination with other
drugs after cardiac arrest. Treatment Recommendations (2020)
We suggest against the use of prophylactic antibiotics in
Glucose Control After Resuscitation (ALS 3519, patients following ROSC. (weak recommendation, low-
EvUp 2025) certainty evidence).

Population, Intervention, Comparator, Outcome, and

Time Frame POST–CARDIAC ARREST
• Population: Adults (≥18 years) with ROSC after car-
diac arrest in any setting PROGNOSTICATION
• Intervention: Specific target range for blood glu- Neuroprognostication of Poor Neurological
cose management (eg, strict 4–6 mmol/L, 72–108 Outcome (ALS 3510–3513, EvUp 2025)
mg/dL)
• Comparator: Any other target glucose range For prognostication of poor neurological outcome, the
• Outcomes: Critical—survival with favorable neuro- population, comparator, outcomes, study designs, and
logical/functional outcome at discharge, 30 days, time frames were as listed below. The evidence identified
60 days, 180 days, or 1 year; survival to hospital is presented by intervention, and treatment recommen-
discharge, 30 days, 60 days, 90 days, 180 days, or dations are all listed together at the end of this section.
1 year • Population: Adult (≥16 years) who are comatose
• Time frame: April 6, 2014, to March 4, 2024 after ROSC from cardiac arrest in any setting
• Comparator: Accuracy of the index test was
Summary of Evidence assessed by comparing the predicted outcome with
The complete EvUp is provided in Appendix B. No new the final outcome.
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studies were identified that examined active glucose • Outcomes: Poor neurological outcome (defined as
management during post–cardiac arrest care, so a Sys- Cerebral Performance Category score of 3 to 5,
Rev is not warranted. Glasgow Outcome Scale score 1 to 3, or modified
Rankin Scale score of 4 to 6, at hospital discharge,
Treatment Recommendations (2014)
1 month, or later
We suggest no modification of standard glucose man-
• Study designs: Any study design where the sensi-
agement protocols for adults with ROSC after cardiac ar-
tivity and false-positive rate could be calculated (ie,
rest (weak recommendation, moderate-quality evidence).
where the 2 × 2 contingency table of true/false
negatives and positives for prediction of poor neu-
Post–Cardiac Arrest Prophylactic Antibiotic rological outcome was reported or could be calcu-
Administration (ALS 3522, EvUp 2025) lated); all studies were eligible for inclusion provided
there was an English abstract.
Population, Intervention, Comparator, Outcome, and • Time frame: This was an updated search from a pre-
Time Frame vious review. The search included studies from April
• Population: Adult patients with ROSC after cardiac 2020 to June 30, 2024.
arrest in any setting
• Intervention: Early/prophylactic antibiotic adminis-
tration Imaging for Post–Cardiac Arrest
• Comparator: Delayed/clinically driven antibiotic Neuroprognostication (ALS 3510)
administration
• Intervention: Index test based on any imaging
• Outcome: Any clinical outcomes
modality (eg, computed tomography [CT], magnetic
• Time frame: June 1, 2016, to January 27, 2024
resonance imaging [MRI])
Summary of Evidence Summary of Evidence
The complete EvUp is provided in Appendix B. The up- Nine new studies were identified examining CT imag-
dated literature search identified 1 previously included ing268–276 and 10 studies for MRI.270,276–284 All studies of CT
RCT233 (n=194) and 1 new post hoc analysis266 of pa- were observational ranging from 78 to 354 patients and
tients enrolled in a previous RCT (n=696).267 The new measured different aspects of gray-white ratio on brain

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 Drennan et al Advanced Life Support: 2025 CoSTR

CT. Studies of MRI included 1 secondary analysis of a pre- Neuron-Specific Enolase

vious RCT and 9 observational cohort studies (prospective One secondary analysis of a previous RCT,290 2 post hoc
and retrospective) ranging from 50 to 428 patients and analyses of prospective studies,303,306 and 12 observa-
reporting a variety of different findings on MRI imaging tional cohort studies270,285,286,307–315 (retrospective and
within 7 days of ROSC. The task force did not consider prospective) were included ranging from 66 to 623 pa-
the identified evidence sufficient to warrant a full SysRev. tients. Neuron-specific enolase values were measured
between admission and 96 hours after ROSC using a
variety of biomarker thresholds for prognostication.
Neurophysiological Tests for Post–Cardiac The task force did not consider the identified evidence
Arrest Neuroprognostication (ALS 3511) sufficient to warrant a full SysRev.
• Intervention: Index test based on electrophysiol-
ogy: EEG and short-latency somatosensory evoked Clinical Examination for Post–Cardiac Arrest
potentials Neuroprognostication (ALS 3513)
Summary of Evidence • Intervention: Index test based on clinical examination
Nine studies evaluated the presence of highly m ­ alignant • Comparator: The accuracy of the index test was
patterns on EEG (suppression or burst suppression assessed by comparing the predicted outcome with
defined according to the American Clinical Neuro- the final patient outcome.
physiology Society terminology) in a total of 1794 pa- Summary of Evidence
tients278,281,285–291 between 12 hours and 7 days after One substudy of a previous RCT316 and 7 observational
ROSC. In all but one study, the presence of these pat- cohort studies281,286,287,293,296,317,318 (prospective and ret-
terns at ≥24 hours from arrest predicted poor outcome rospective) were identified in the search. Four studies
with 100% specificity. One study291 in 801 patients eval- examined pupillary light reflexes,281,287,293,296 3 studies
uated the additional value of the absence of reactivity on examined automated pupillometry,316–318 3 studies ex-
EEG at 24 hours to 14 days after ROSC, showing that amined corneal reflexes,281,287,293 and 2 studies examined
it predicted poor neurological outcome at 6 months with the presence of myoclonus or status myoclonus.286,293
60% (57%–64%) specificity and 79% (76%–82%) sen- The task force did not consider the identified evidence
sitivity. The false-positive rate was about 40%. sufficient to warrant a full SysRev.
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A total of 6 observational studies281,286,292–297 were

identified ranging from 29 to 260 patients and measured Treatment Recommendations (2020)
different aspects of short-latency somatosensory evoked General
potentials. The task force did not consider the identified We recommend that neuroprognostication always be
evidence sufficient to warrant a full SysRev. undertaken by using a multimodal approach because
no single test has sufficient specificity to eliminate false
positives (strong recommendation, very low–certainty
Biomarkers for Post–Cardiac Arrest evidence).
Neuroprognostication (ALS 3512) Imaging
• Intervention: Index test based on biomarkers (glial We suggest using gray-white matter ratio on brain CT
fibrillary acidic protein, tau protein, neurofilament for predicting neurological outcome of adults who are
light chain, and neuron-specific enolase) comatose after cardiac arrest (weak recommendation,
very low–certainty evidence). However, no gray-white
Summary of Evidence matter ratio threshold for 100% specificity can be
Glial Fibrillary Acidic Protein and Tau Protein recommended.
Five observational studies285,298–301 were identified in the We suggest using diffusion-weighted brain MRI for
search examining glial fibrillary acidic protein. Studies predicting neurological outcome of adults who are coma-
ranged from 77 to 717 patients measuring glial fibril- tose after cardiac arrest (weak recommendation, very
lary acidic protein at a variety of time points after ROSC. low–certainty evidence).
Three observational studies285,299,301 measured tau pro- We suggest using apparent diffusion coefficient on
tein at different time points after ROSC. brain MRI for predicting neurological outcome of adults
who are comatose after cardiac arrest (weak recommen-
Neurofilament Light Chain
dation, very low–certainty evidence).
Four secondary analyses of previous RCTs290,300,302,303 and
3 observational studies301,304,305 (retrospective and pro- Neurophysiological Tests
spective) were included as relevant ranging from 48 to We suggest using a bilaterally absent N20 wave of short-
428 patients. Studies measured neurofilament light chain latency somatosensory evoked potential in combina-
at different time points from 12 to 72 hours after ROSC. tion with other indices to predict poor outcome in adult

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 Drennan et al Advanced Life Support: 2025 CoSTR

patients who are comatose after cardiac arrest (weak Prognostication of Favorable Neurological
recommendation, very low–certainty evidence). Outcome in Patients With ROSC After Cardiac
We suggest against using the absence of EEG back-
ground reactivity alone to predict poor outcome in adult
Arrest (ALS 3529–3532, SysRev Adolopment
patients who are comatose after cardiac arrest (weak 2023)
recommendation, very low–certainty evidence). Prognostication of favorable neurological outcome in pa-
We suggest using the presence of seizure activity on tients with ROSC after cardiac arrest was addressed by
EEG in combination with other indices to predict poor a 2021 SysRev and can be found in the 2023 CoSTR
outcome in adult patients who are comatose after car- summary.23,319 This review was based on adolopment of a
diac arrest (weak recommendation, very low–certainty previously published SysRev.320
evidence).
We suggest using burst suppression on EEG in com- Population, Intervention, Comparator, Outcome,
bination with other indices to predict poor outcome in Study Design, and Time Frame
adult patients who are comatose and effects of sedation • Population: Adults (≥16 years) who are comatose
after cardiac arrest have cleared (weak recommendation, after resuscitation from cardiac arrest in any setting
very low–certainty evidence). (in-hospital or out-of-hospital) regardless of target
temperature
Biomarkers • Intervention: Any prognostication marker such as
We suggest using neuron-specific enolase within 72 Glasgow Coma Scale motor score, imaging studies,
hours after ROSC, in combination with other tests, for biomarkers, EEG, somatosensory evoked potentials
predicting neurological outcome of adults who are co- • Comparator: None
matose after cardiac arrest (weak recommendation, very • Outcome: Critical—Good neurological outcome
low–certainty evidence). There is no consensus on a defined as Cerebral Performance Category score of
threshold value. 1 or 2 or modified Rankin Scale score of 1 to 3 at
We suggest against using S-100B protein for predict- hospital discharge, 1 month, or later
ing neurological outcome of adults who are comatose • Study designs: Prognostic accuracy studies for
after cardiac arrest (weak recommendation, low-certainty which the 2 × 2 contingency table (ie, number of
evidence). true/false negatives and true/false positives for pre-
We suggest against using serum values of glial fibril- diction of poor outcome) was reported or for which
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lary acidic protein, serum tau protein, or neurofilament those variables could be calculated from reported
light chain for predicting poor neurological outcome of data were eligible for inclusion; unpublished studies,
adults who are comatose after cardiac arrest (weak rec- reviews, case reports, case series, studies includ-
ommendation, very low–certainty evidence). ing <10 patients, letters, editorials, and conference
Clinical Examination abstracts and studies published in abstract form
We suggest using pupillary light reflex at 72 hours or were excluded.
more after ROSC for predicting neurological outcome of • Time frame: The original SysRev was conducted on
adults who are comatose after cardiac arrest (weak rec- October 31, 2021, and the search was updated on
ommendation, very low–certainty evidence). May 20, 2022.
We suggest using quantitative pupillometry at 72
Treatment Recommendations (2023)
hours or more after ROSC for predicting neurological
Glasgow Coma Scale Motor Score
outcome of adults who are comatose after cardiac arrest
We suggest assessing the Glasgow Coma Scale motor
(weak recommendation, low-certainty evidence).
score in the first 4 days after cardiac arrest to identify pa-
We suggest using bilateral absence of corneal reflex
tients with a score >3, which may indicate an increased
at 72 hours or more after ROSC for predicting poor neu-
likelihood of favorable outcome (weak recommendation,
rological outcome in adults who are comatose after car-
very low–certainty evidence).
diac arrest (weak recommendation, very low–certainty
evidence). Imaging Studies
We suggest using presence of myoclonus or status We suggest using the absence of diffusion restriction on
myoclonus within 7 days after ROSC, in combination MRI between 72 hours and 7 days after ROSC, in com-
with other tests, for predicting poor neurological out- bination with other tests, for predicting good neurological
come in adults who are comatose after cardiac arrest outcome of adults who are comatose after cardiac arrest
(weak recommendation, very low–certainty evidence). (weak recommendation, very low–certainty evidence).
We also suggest recording EEG in the presence of We suggest against using gray-white matter ratio,
myoclonic jerks to detect any associated epileptiform quantitative regional abnormality, and Alberta Stroke Pro-
activity (weak recommendation, very low–certainty gram Early CT Score on brain CT to predict good neu-
evidence). rological outcome in patients who are comatose after

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 Drennan et al Advanced Life Support: 2025 CoSTR

cardiac arrest (weak recommendation, very low–cer- Organ Donation After Cardiac Arrest (ALS 3600,
tainty evidence). SysRev 2025)
We suggest against using apparent diffusion coeffi-
cient on brain MRI to predict good neurological outcome Rationale for Review
in patients who are comatose after cardiac arrest (weak The effect of preceding cardiac arrest and CPR in the
recommendation, very low–certainty evidence). donor on graft function of the donated organs is not
We suggest against using gradient-recalled echo well understood. This topic was previously reviewed
on brain MRI to predict good neurological outcome in for the 2015 CoSTR, and an ILCOR scientific state-
patients who are comatose after cardiac arrest (weak ment was made in 2023.4,34,321–323 A SysRev was under-
recommendation, very low–certainty evidence). taken for 2025, and it was registered at PROSPERO
(CRD42024599459) prior to undertaking the search.
Brain Biomarkers The full CoSTR can be found on the ILCOR website.324
We suggest using normal neuron-specific enolase (<17
μg/L) within 72 hours after ROSC, in combination with Population, Intervention, Comparator, Outcome, and
other tests, for predicting favorable neurological out- Time Frame
come in adults who are comatose after cardiac arrest • Population: Adults and children receiving solid organ
(weak recommendation, very low–certainty evidence). transplantation in any setting
We suggest against using serum levels of glial fibril- • Intervention: Transplantation of an organ retrieved
lary acidic protein, serum tau protein, or neurofilament from a donor who, following cardiac arrest, received
light chain in clinical practice for predicting favorable CPR (eg, donation after initial successful CPR or
neurological outcome in adults who are comatose after after unsuccessful CPR)
cardiac arrest (weak recommendation, very low–cer- • Comparator: Transplantation of an organ retrieved
tainty evidence). from a donor who did not receive CPR
• Outcome: Graft function or recipient survival at 30
Electroencephalogram
days, 1 year, or the longest available follow-up
We suggest using a continuous or nearly continuous
• Time frame: All years to November 1, 2024
normal-voltage EEG background without periodic dis-
charges or seizures within 72 hours from ROSC in com-
Consensus on Science
bination with other indices to predict good outcome in
Thirty-three observational studies were identified,
patients who are comatose after cardiac arrest (weak
Downloaded from [Link] by on October 27, 2025

grouped by the donated organ (Table 3). Twenty-six

recommendation, very low–certainty evidence).
studies included adults only, 3 included children only, and
There is insufficient evidence to recommend for or
4 included adults and children. The outcomes among re-
against using a low-voltage or a discontinuous EEG
cipients receiving organs from brain-dead donors with
background on days 0 to 5 from ROSC to predict good
prior CPR were compared with those receiving organs
neurological outcome after cardiac arrest (weak recom-
from brain-dead donors who had not had prior CPR in
mendation, very low–certainty evidence).
22 studies. Recipient outcomes following uncontrolled
We suggest using American Clinical Neurophysiol-
donation after circulatory death were compared with do-
ogy Society definitions for favorable EEG patterns when
nation from brain-dead donors without prior CPR in 8
using these to predict good neurological outcome after
studies. Two studies compared outcomes among recipi-
cardiac arrest (weak recommendation, very low–cer-
ents receiving organs from uncontrolled donation after
tainty evidence).
circulatory death with those receiving organs from con-
We suggest against the use of other EEG metrics,
trolled donation after circulatory death without prior CPR.
including reduced montage or amplitude-integrated
Finally, 1 study compared outcomes among recipients
EEG, bispectral index, or EEG-derived indices, to predict
receiving kidneys from controlled donation after circu-
good outcome in patients who are comatose after car-
latory death with prior CPR versus controlled donation
diac arrest (weak recommendation, very low–certainty
after circulatory death with no prior CPR. One study had
evidence).
2 comparison groups (donations after brain death and
We suggest that the American Clinical Neuro-
controlled donations after circulatory death).
physiology Society terminology be used to classify the
Complete results are included in the online CoSTR.
EEG patterns used for prognostication (good practice
Overall, for all organ grafts studied there was no sig-
statement).
nificant difference in graft function or recipient survival
Somatosensory Evoked Potentials with organs from donors who had received CPR before
We suggest against using the amplitude of the N20 donation, compared with donors who had not received
short-latency somatosensory evoked potential wave to CPR. Evidence for the critical outcome of graft function
predict good neurological outcome of adults who are co- or recipient survival at the longest available follow-up
matose after cardiac arrest (weak recommendation, very is presented in Table 3. The longest available follow-up
low–certainty evidence). varied considerably across studies, from days to years.

Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360 October 21, 2025 S99

 Drennan et al Advanced Life Support: 2025 CoSTR

Table 3. Effect of Receiving a Donated Organ From a Donor Who Received CPR Compared With a Donor Who Did Not Receive
CPR on Graft Function or Recipient Survival at the Longest Available Follow-Up*

Donated organ Studies (participants), n Odds ratio (95% CI) Certainty of evidence
Heart 7325–331 (47 842) 1.27 (0.99–1.63) Very low
Lung 1332 (236) 1.50 (0.77–2.90) Very low
Kidney 14 333–346
(17 839) 0.96 (0.69–1.33) Very low
Pancreas 3338,347,348 (14 043) 1.01 (0.83–1.23) Very low
Liver 9333,349–356 (3739) 0.88 (0.68–1.15) Very low
Intestine 1357 (67) 1.11 (0.21–5.88) Very low

*Longest available follow-up ranged from 7 days to 15 years. In most cases, some studies included adults and some included children, while others included both. The
sum of studies exceeds 33 because 2 studies investigated the outcome of more than 1 organ.
CPR indicates cardiopulmonary resuscitation.

Results for other outcomes, including subgroup analyses, Consequently, there was a chance that some donors were
can be found in the online CoSTR. unrecoverable at the arrival of the treating team (found
dead) and that resuscitation was started only with the aim
of potential donation (Maastricht category I). Because of
Treatment Recommendation (2025, Unchanged
this inconsistency, the task force decided not to make any
From 2015)
recommendation regarding uncontrolled organ donors.
We recommend that all patients who have restoration of
circulation after CPR and who subsequently progress to Knowledge Gaps
death be evaluated for organ donation (strong recom- • Future controlled studies that more clearly distin-
mendation, low-certainty evidence). guish between donors who received CPR and then
progressed to brain death after ROSC and those
Justification and Evidence-to-Decision Framework
who were brain dead and then received CPR before
Highlights
organ retrieval
The complete evidence-to-decision table is provided in
• Reliable data on donation from controlled dona-
Appendix A.
tion after circulatory death because this is probably
The suitability of organs for donation is based on cri-
Downloaded from [Link] by on October 27, 2025

underreported
teria established by the transplantation team. This review
• Data on rate of donation after cardiac arrest
suggests that, once these criteria are met, transplant
• There are no established criteria to identify the
organ outcomes are similar regardless of whether the
potential for donation in patients who die after CPR.
donors have had CPR or not before donation.
Despite the low-certainty evidence, the task force
has made a strong recommendation, valuing ensuring Topics Updated by EvUp Only From 2021 to
that those waiting for a donated organ can benefit from 2025
organs donated by those who die after CPR, given that • Administration of fibrinolytics post–cardiac arrest
many studies show organ function and recipient out- (ALS 3520)
comes are similar when comparing donors who received • Administration of fibrinolytics during cardiac arrest
CPR and donors who did not. (ALS 3203)
Nine of the 33 studies in this review compared • Administration of atropine during cardiac arrest
the outcomes of kidneys and livers transplanted from (ALS 3206)
patients who died after unsuccessful resuscitation • Cardiac arrest associated with asthma (ALS 3408,
(uncontrolled donors after cardiac death; Maastricht EvUp 2024)
category II) with those of organs transplanted from
donors after death by neurological criteria (donors
after brain death; 8 studies)335,339,340,343–345,350,356 or from Topics Not Updated in 2021 to 2025
donors who die by cardiac criteria after life-sustaining • Administration of IV fluids post–cardiac arrest (ALS
treatment is suspended because of futility (controlled 3518)
donors after cardiac death: Maastricht category III; 1 • Use of standardized treatment protocols post–car-
study).341 In these studies, the outcomes of organs diac arrest (ALS 3521)
transplanted from uncontrolled donors after cardiac • Administration of IV fluids during cardiac arrest
deaths at 1 month and 1 year were significantly worse (ALS 3207)
than in the comparator group. • Oxygen concentration during CPR (ALS 3305)
In uncontrolled donors after cardiac death studies, the • Use of automatic ventilators during cardiac arrest
donors’ witnessed status was not always explicitly reported. (ALS 3306)

S100 October 21, 2025 Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360

 Drennan et al Advanced Life Support: 2025 CoSTR

• Ventilation rate during continuous chest compres- • Monitoring physiologic parameters during CPR
sions (ALS 3307) (ALS 3602)
• Defibrillation strategies for VF/pVT (ALS 3100) • Prediction rule for in-hospital cardiac arrest out-
• Cardioversion strategies with an implantable cardio- comes (ALS 3605)
verter defibrillator or pacemaker (ALS 3101) • Use of steroids during cardiac arrest (ALS 3202,
• Automated external defibrillator versus manual defi- steroid and vasopressin component only updated)
brillation (ALS 3102)
• Use of adhesive pads versus paddles for defibrilla-
ARTICLE INFORMATION
tion (ALS 3103)
The American Heart Association requests that this document be cited as follows:
• Waveform analysis for predicting successful defi- Drennan IR, Berg KM, Böttiger BW, Chia YW, Couper K, Crowley C, D’Arrigo S,
brillation (ALS 3104) Deakin CD, Fernando SM, Garg R, Granfeldt A, Grunau B, Hirsch KG, Holmberg
• Use of anticipatory charging during defibrillation MJ, Kudenchuk PJ, Lavonas EJ, Leong CK-L, Vlok N, Morley PT, Moskowitz A,
Neumar RW, Nicholson TC, Nikolaou NI, Nolan JP, O’Neil BJ, Ohshimo S, Parr M,
(ALS 3105) Pocock H, Sandroni C, Scquizzato T, Soar J, Welsford M, Zelop CM, Skrifvars MB;
• Use of impedance threshold device during CPR on behalf of the Advanced Life Support Task Force Collaborators. Advanced life
(ALS 3000) support: 2025 International Liaison Committee on Resuscitation Consensus on
Science With Treatment Recommendations. Circulation. 2025;152(suppl 1):S72–
• Cardiac arrest associated with electrolyte distur- S115. doi: 10.1161/CIR.0000000000001360
bances (except for hyperkalemia) (ALS 3402) This article has been copublished in Resuscitation. Published by Elsevier Ire-
• Cardiac arrest associated with cardiac tamponade land Ltd. All rights reserved.
(ALS 3405)
Acknowledgment
• Cardiac arrest in avalanche victims (ALS 3407) The writing group would like to acknowledge the assistance of Jaylen I. Wright in
• Cardiac arrest associated with anaphylaxis (ALS editing supplemental materials and providing overall administrative support.
3409)
• Toxicological causes of cardiac arrest (ALS 3450, Collaborators
The authors thank the following individuals (the Advanced Life Support Task
3452–3459)
Force Collaborators) for their contributions: Lars W. Andersen, Luke Andrea, So-
• Use of end-tidal carbon dioxide to predict outcome fia Cacciola, Ahmed Elshaer, Dean Giustini, Marie K. Jessen, Ranjit Lall, Gavin D.
of cardiac arrest (ALS 3601) Perkins, Mikael Fink Vallentin

Disclosures
Downloaded from [Link] by on October 27, 2025

Writing Group Disclosures

Writing Other Speakers’ Consultant/

group research bureau/ Expert Ownership advisory
member Employment Research grant support honoraria witness interest board Other
Ian R. Sunnybrook Health ZOLL Medical† None Speakers’ None None None None
Drennan Sciences Centre and Bureau:
University of Toronto ZOLL
(Canada) Medical†
Markus B. Helsinki University None None None None None None None
Skrifvars Hospital and University of
Helsinki (Finland)
Katherine Beth Israel Deaconess None None None None None AHA/ILCOR† None
M. Berg Medical Center and
Harvard Medical School
Bernd W. University Hospital of None None Speakers’ None None Doccla None
Böttiger Cologne (Germany) Bureau: Germany†;
Boehringer Forum für
Ingelheim*; Medizinische
Speakers’ Fortbildung†
Bureau:
BD*
Yew Woon Tan Tock Seng Hospital None None None None None None None
Chia (Malaysia)
Keith University of Warwick National Institute None None None None Elsevier- University of
Couper (United Kingdom) for Health and Associate Warwick†;
Care Research†; Editor, University
Resuscitation Council Resuscitation Hospitals
UK* Plus* Birmingham NHS
Foundation Trust†
Conor Lahey Hospital and None None None None None None None
Crowley Medical Center

(Continued )

Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360 October 21, 2025 S101

 Drennan et al Advanced Life Support: 2025 CoSTR

Writing Group Disclosures Continued

Writing Other Speakers’ Consultant/
group research bureau/ Expert Ownership advisory
member Employment Research grant support honoraria witness interest board Other
Sonia Catholic University None None None None None None None
D’Arrigo School of Medicine
Charles D. University Hospital None None None None None None None
Deakin Southampton NHS
Foundation Trust (United
Kingdom)
Shannon M. Lakeridge Health and None None None None None None None
Fernando Queen’s University
(Canada)
Rakesh All India Institute of None None None None None None None
Garg Medical Sciences (India)
Asger Aarhus University None None None None None None None
Granfeldt Hospital (Denmark)
Brian The University of British None None None None None None None
Grunau Columbia and St. Paul’s
Hospital (Canada)
Karen G. Stanford University National Institutes of None None None None None None
Hirsch Health (NIH)*
Mathias J. Aarhus University None None None None None None None
Holmberg Hospital (Denmark)
Peter J. University of Washington NIH/NINDS† None None None None None None
Kudenchuk
Eric J. Denver Health None None None None None American None
Lavonas Heart
Association†;
AHA/ILCOR†
Carrie Kah- Singapore General None None None None None None None
Downloaded from [Link] by on October 27, 2025

Lai Leong Hospital (Malaysia)

Peter T. University of Melbourne None None None None None None None
Morley (Australia)
Ari Montefiore Medical NIH* None None None None None None
Moskowitz Center
Robert W. University of Michigan NIH†; Laerdal None None None None None None
Neumar Foundation*; BrainCool*;
Corpuls*
Tonia C. Waikato Hospital (New None None None None None None None
Nicholson Zealand)
Nikolaos I. Konstantopoulio General Investigator* None None None None None None
Nikolaou Hospital (Greece)
Jerry P. Warwick Medical School, None None None None None None None
Nolan University of Warwick,
Coventry (United
Kingdom)
Brian J. Wayne State University None None None None None None None
O’Neil
Shinichiro Hiroshima University None None None None None None None
Ohshimo (Japan)
Michael Liverpool Hospital, None None None None None None None
Parr University of New South
Wales and Macquarie
University Hospital,
Macquarie University
(Australia)
Helen South Central Ambulance None None None None None None None
Pocock NHS Foundation Trust
(United Kingdom)

(Continued )

S102 October 21, 2025 Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360

 Drennan et al Advanced Life Support: 2025 CoSTR

Writing Group Disclosures Continued

Writing Other Speakers’ Consultant/

group research bureau/ Expert Ownership advisory
member Employment Research grant support honoraria witness interest board Other
Claudio Università Cattolica None None None None None None None
Sandroni del Sacro Cuore -
Fondazione Policlinico
Universitario A. Gemelli
– IRCCS (Italy)
Tommaso IRCCS San Raffaele None None None None None None None
Scquizzato Scientific Institute (Italy)
Jasmeet Southmead Hospital UK NIHR research grant None None None None None North Bristol NHS
Soar (United Kingdom) to my institution* Trust†; Elsevier†
Neville Vlok University of Cape Town None None None None None None None
(South Africa)
Michelle McMaster University, None None None None None None None
Welsford Hamilton Health
Sciences (Canada)
Carolyn M. The Valley Hospital and None None None None None None None
Zelop NYU

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Reviewer Disclosures

Other Speakers’ Consultant/

research bureau/ Expert Ownership advisory
Reviewer Employment Research grant support honoraria witness interest board Other
Downloaded from [Link] by on October 27, 2025

Christian Rigshospitalet Novo Nordisk Foundation (I have received a research None BD* None None None None
Hassager Cardiology grant for a trial that evaluates the effect of steroid
(Denmark) treatment immediately after resuscitation of out-of-
hospital cardiac arrest administered by my hospital.
This grant is used for the expenses in the trial.
This has no impact on my own salary)†; Lundbeck
Foundation (A research grant administered by my
hospital. This has no impact on my own salary)†;
The Danish Heart Foundation (A research grant
administered by my hospital. This has no impact on
my own salary)†
Rudolph Amsterdam None None None None None Stryker None
W. Koster University Emergency
Medical Care*
Center
(Netherlands)
Caroline University None None None None None None None
Leech Hospitals
Coventry and
Warwickshire
(United
Kingdom)
Martin Alberta Health None None None None None None None
Perlsteyn Services
(Canada)

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-
tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any
12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of
the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360 October 21, 2025 S103

 Drennan et al Advanced Life Support: 2025 CoSTR

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M, Kaiser GM, Canbay A, Molmenti E, et al. Safely expanding the donor 2020;24:e13701. doi: 10.1111/petr.13701
pool: brain dead donors with history of temporary cardiac arrest. Liver Int. 354. Totsuka E, Fung JJ, Urakami A, Moras N, Ishii T, Takahashi K, Narumi S,
2015;35:1756–1763. doi: 10.1111/liv.12766 Hakamada K, Sasaki M. Influence of donor cardiopulmonary arrest in
350. Justo I, Marcacuzco A, Garcia-Conde M, Caso O, Cobo C, Nutu A, Manrique human liver transplantation: possible role of ischemic preconditioning.
A, Calvo J, Garcia-Sesma A, Rivas C, et al. Liver transplantation in sexa- Hepatology. 2000;31:577–580. doi: 10.1002/hep.510310305
genarian patients using grafts from uncontrolled circulatory death versus 355. Wilson DJ, Fisher A, Das K, Goerlitz F, Holland BK, De La Torre AN, Merchant
grafts from brain death donation. Transplant Proc. 2022;54:1839–1846. A, Seguel J, Samanta AK, Koneru B. Donors with cardiac arrest: improved or-
doi: 10.1016/[Link].2022.05.037 gan recovery but no preconditioning benefit in liver allografts. Transplantation.
351. Levesque E, Hoti E, Khalfallah M, Salloum C, Ricca L, Vibert E, Azoulay D. 2003;75:1683–1687. doi: 10.1097/[Link].0000064542.63798.6B
Impact of reversible cardiac arrest in the brain-dead organ donor on the 356. De Carlis R, Di Sandro S, Lauterio A, Botta F, Ferla F, Andorno E, Bagnardi
outcome of adult liver transplantation. Liver Transpl. 2011;17:1159–1166. V, De Carlis L. Liver grafts from donors after circulatory death on regional
doi: 10.1002/lt.22372 perfusion with extended warm ischemia compared with donors after brain
352. Mangus RS, Schroering JR, Fridell JA, Kubal CA. Impact of do- death. Liver Transpl. 2018;24:1523–1535. doi: 10.1002/lt.25312
nor pre-procurement cardiac arrest (PPCA) on clinical outcomes 357. Matsumoto CS, Kaufman SS, Girlanda R, Little CM, Rekhtman Y, Raofi
in liver transplantation. Ann Transplant. 2018;23:808–814. doi: V, Laurin JM, Shetty K, Fennelly EM, Johnson LB, et al. Utilization of
10.12659/AOT.910387 donors who have suffered cardiopulmonary arrest and resuscitation
353. Schroering JR, Hathaway TJ, Kubal CA, Ekser B, Mihaylov P, Mangus in intestinal transplantation. Transplantation. 2008;86:941–946. doi:
RS. Impact of donor preprocurement cardiac arrest on clinical outcomes 10.1097/TP.0b013e3181852f9a
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Circulation. 2025;152(suppl 1):S72–S115. DOI: 10.1161/CIR.0000000000001360 October 21, 2025 S115

 Circulation

Pediatric Life Support: 2025 International Liaison

Committee on Resuscitation Consensus on
Science With Treatment Recommendations
Barnaby R. Scholefield, Chair; Jason Acworth, Vice Chair; Kee-Chong Ng; Lokesh Kumar Tiwari; Tia T. Raymond; Andrea Christoff;
Stephan Katzenschlager; Raffo Escalante-Kanashiro; Arun Bansal; Alexis Topjian; Monica Kleinman; Hiroshi Kurosawa;
Michelle C. Myburgh; Jimena del Castillo; Joseph Rossano; Jana Djakow; Anne-Marie Guerguerian; Vinay M. Nadkarni;
Thomaz Bittencourt Couto; Stephen M. Schexnayder; Gabrielle Nuthall; Janice A. Tijssen; Gene Yong-Kwang Ong;
James M. Gray; Jesus Lopez-Herce; Ester Shambekela Ambunda; Jerry P. Nolan, Senior Editor;
Katherine M. Berg, Senior Editor; Laurie J. Morrison, Senior Author; Dianne L. Atkins, Senior Author;
Allan R. de Caen, Senior Author; on behalf of the Pediatric Life Support Task Force Collaborators

ABSTRACT: The International Liaison Committee on Resuscitation conducts continuous review of new peer-reviewed
published cardiopulmonary resuscitation science and publishes annual summaries. More comprehensive reviews are
published every 5 years. The Pediatric Life Support Task Force chapter of the 2025 International Liaison Committee on
Resuscitation Consensus on Science With Treatment Recommendations addresses all published resuscitation evidence
reviewed by International Liaison Committee on Resuscitation Pediatric Life Support Task Force members in the past year,
as well as brief summaries of topics reviewed since 2020, to provide a more comprehensive update. In total, 39 questions
related to pre-arrest, intra-arrest, and postarrest resuscitation phases of pediatric cardiac arrest are included, including
systematic reviews, scoping reviews, and evidence updates. Members of the task force assessed, discussed, and debated
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the quality of evidence, based on Grading of Recommendations, Assessment, Development, and Evaluation criteria, and
their statements include consensus treatment recommendations. Insights into deliberations of the task force are provided in
the Justification and Evidence-to-Decision Framework Highlights sections. The task force has also listed priority knowledge
gaps for further research.

Key Words: Scientific Statements ◼ cardiac arrest ◼ cardiopulmonary arrest ◼ cardiopulmonary resuscitation ◼ children ◼ ILCOR
◼ pediatrics ◼ resuscitation

T
he International Liaison Committee on Resus- and time frame) reports, including 22 systematic reviews
citation (ILCOR) Pediatric Life Support (PLS) (SysRev). Draft CoSTRs for all topics evaluated with a
Task Force section of the 2025 International Liai- SysRev in the past year were posted on a rolling basis on
son Committee on Resuscitation Consensus on Science the ILCOR website.1 Each draft CoSTR included the data
With Treatment Recommendations (CoSTR) includes all reviewed and draft treatment recommendations, with
reviews conducted by the PLS Task Force in the past public comments accepted for 2 weeks after posting.
year. Reviews conducted and published since the 2020 The task force considered public feedback and provided
CoSTR are also summarized to provide a single compre- responses. All CoSTRs are available online.1
hensive reference document for readers. The PLS Task Although only SysRevs can generate a full CoSTR
Force work encompasses 39 reviewed PICOST (popu- and new treatment recommendations, many other top-
lation, intervention, comparator, outcome, study design, ics were evaluated with scoping reviews (ScopRevs) or

Supplemental Materials is available at [Link]

© 2025 American Heart Association, Inc., European Resuscitation Council, International Liaison Committee on Resuscitation, and American Academy of Pediatrics, Inc.
Circulation is available at [Link]/journal/circ

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

evidence updates (EvUps). Good practice statements, • Management of pulmonary hypertension (PLS
which represent the opinion of task force experts in 4160.11, ScopRev 2024, EvUp 2025)
light of very limited or no direct evidence, can be gen-
erated after ScopRevs and occasionally after EvUps in
cases where the task force thinks providing guidance Intra-arrest: Airway, Breathing, Circulation
is especially important. A separate publication in this • Airway, breathing, and circulation (ABC) versus
issue includes the full details of the evidence evaluation compressions, airway, breathing (CAB): order of
process.2 ventilation and compression (PLS 4070.02, SysRev
This statement contains the final wording of the 2025)
treatment recommendations and good practice state- • Advanced airway interventions in cardiac arrest
ments as approved by the ILCOR PLS Task Force, as (PLS 4060.01, SysRev 2024, EvUp 2025)
well as summaries of the key evidence identified, key • Ventilation rate with advanced airway during car-
discussion points, and knowledge gaps. The year that diac arrest (PLS 4120.02, SysRev 2024, EvUp
treatment recommendations or good practice state- 2025)
ments were generated or last updated by a SysRev
is provided in parentheses. In cases where existing
treatment recommendations have changed for 2025, Intra-arrest: Defibrillation
the prior recommendations are also presented so • Energy doses for pediatric defibrillation during
the reader can easily see what has changed. Links resuscitation (PLS 4080.12, SysRev 2025)
to the published reviews and full online CoSTRs are • Paddle/pad size and placement in infants and chil-
provided in the corresponding sections. Evidence-to- dren (PLS 4080.17, SysRev 2025)
decision tables for SysRevs are provided in Appendix • Single or stacked shocks for pediatric defibrillation
A, and the complete EvUp worksheets are provided in (PLS 4080.19, SysRev 2025)
Appendix B. • Lay rescuer use of automated external defibrillators
Topics are presented using the PICOST format. (AEDs) (PLS 4080.01, SysRev 2022, EvUp 2025)
Where appropriate, the population, context, and con-
cept framework was used.3 Search strategies were
kept deliberately broad to capture all clinical outcomes. Intra-arrest: Monitoring
The task force then graded available outcomes into • Pulse check accuracy in pediatrics during resuscita-
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critical or important with a preference for outcomes tion (PLS 4080.18, SysRev 2025)
defined in the Pediatric Core Outcome Set for Cardiac • Blood pressure monitoring and targets during
Arrest (P-COSCA).4 To minimize redundancy, the study pediatric in-hospital cardiac arrest (PLS 4160.08,
designs have been removed from the text except in SysRev 2025)
cases where designs included differed from the PLS • Intra-arrest echocardiography (point-of-care car-
standard criteria. These standard criteria include ran- diac ultrasound) (PLS 4160.05, ScopRev 2020,
domized controlled trials (RCTs) and nonrandomized EvUp 2025)
studies (nonrandomized controlled trials, interrupted • Intra-arrest end-tidal CO2 (PLS 4160.07, ScopRev
time series, controlled before-and-after studies, cohort 2020, EvUp 2025)
studies) were eligible for inclusion. Case series were • Intra-arrest near-infrared spectroscopy (PLS
included if they contained ≥5 cases. Unpublished stud- 4160.09, ScopRev 2020, EvUp 2025)
ies (eg, conference abstracts, trial protocols), animal
studies, mathematical models, simulation and manikin
studies, and algorithm studies with no outcome data Intra-arrest: Drugs and Drug Administration
were excluded. All languages were included, provided • Vasopressor use during cardiac arrest in children
there was an English abstract. The following topics are (PLS 4080.21, SysRev 2025)
addressed in this 2025 PLS Task Force CoSTR: • Epinephrine administration timing in cardiac arrest
(PLS 4090.02, SysRev 2020, EvUp 2025)
• Calcium use during cardiac arrest (PLS 4090.01,
Periarrest SysRev 2023, EvUp 2025)
• Bradycardia with hemodynamic compromise in chil- • Sodium bicarbonate administration in cardiac arrest
dren (PLS 4030.30, ScopRev 2025) (PLS 4090.04, EvUp 2020, EvUp 2025)
• Resuscitation of durable mechanical circulatory • Anti-arrhythmic drugs in cardiac arrest with shock-
supported patients with acutely altered perfusion or able rhythms (PLS 4080.04, SysRev 2018, EvUp
cardiac arrest (PLS 4190.03, ScopRev 2025) 2025)
• Pediatric early warning systems (PLS 4050.02, • Intraosseous (IO) versus intravenous (IV) in cardiac
SysRev 2022) arrest (PLS 4080.15, EvUp 2022, EvUp 2025)

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Intra-arrest: Special Circumstances PERIARREST

• Cardiopulmonary resuscitation in obese patients Bradycardia With Hemodynamic Compromise in
(PLS 4080.22, ScopRev 2025) Children (PLS 4030.30, ScopRev 2025)
• In-hospital cardiac arrest (IHCA) due to suspected
cardiac shunt/stent obstruction (PLS 4030.25, Rationale for Review
SysRev 2025) Bradycardia (heart rate <60 beats per minute) may re-
• Cardiac arrest due to pulmonary embolism (PLS sult from intrinsic heart issues or external factors such
4160.10, SysRev 2025) as hypoxemia and metabolic disorders. Bradycardia can
• Pharmacological interventions for the treatment of lead to hemodynamic compromise, cardiopulmonary
hyperkalemia in children with cardiac arrest (PLS failure, and potentially pulseless cardiac arrest. Current
4160.17, SysRev 2025) resuscitation guidelines recommend epinephrine for
persistent bradycardia with poor perfusion during CPR6;
however, there are few data on the natural progression of
Intra-arrest: Extracorporeal Cardiopulmonary bradycardia during CPR and the efficacy of epinephrine
Resuscitation or other drugs.7 The ILCOR PLS Task Force prioritized a
ScopRev of this topic because of the high prevalence of
• Extracorporeal cardiopulmonary resuscitation this presentation in children. The full ScopRev report can
(ECPR) in pediatric cardiac patients with single ven- be found on the ILCOR website.8
tricle physiology (PLS 4030.09, 4030.10, SysRev
2025)
• ECPR for cardiac arrest (PLS 4160.02, SysRev Population, Intervention, Comparator, Outcome, and
2023, EvUp 2025) Time Frame
• Population: Children (<18 years of age) with brady-
cardia (defined as heart rate of <60 beats per min-
Postresuscitation ute or low for age) with hemodynamic compromise
(defined as age-based hypotension, altered mental
• Post–return of spontaneous circulation (ROSC)
status [Glasgow Coma Scale <15, nonresponsive-
blood pressure targets (PLS 4190.01, SysRev
ness, or comatose], or other signs of shock [low
2025)
urine output or elevated lactate], including cardiac
• Prediction of survival with poor neurological outcome
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arrest) in any setting (in-hospital or out-of-hospital)

after return of circulation (ROC) following pediatric
• Intervention: Any specific management strategies
cardiac arrest, combined prognostic SysRev:
including but not limited to oxygenation or ventila-
– Blood biomarkers (PLS 4220.01, SysRev 2025)
tion, anticholinergic drugs (eg, atropine), inotropes
– Clinical examination (PLS 4220.02, SysRev
or chronotropes (eg, epinephrine, isoproterenol),
2025)
electrophysiologic pacing (eg, transcutaneous pac-
– Electrophysiology testing (PLS 4220.03, SysRev
ing, temporary cardiac pacing) or CPR
2025)
• Comparators: Another specific management strat-
– Brain imaging (PLS 4220.04, SysRev 2025)
egy including another drug, therapy, placebo, or no
• Prediction of survival with good neurological out-
drug
come after ROC following pediatric cardiac arrest—
• Outcomes: Any clinical outcome
combined prognostic SysRev:
• Time frame: All years to October 6, 2024.
– Blood biomarkers (PLS 4220.05, SysRev 2023)
– Clinical examination (PLS 4220.06, SysRev Summary of Evidence
2023) Of the initial 4851 studies identified, 23 were includ-
– Electrophysiology testing (PLS 4220.07, SysRev ed,7,9–30 of which 19 described the prevalence and out-
2023) comes in children who had cardiac arrest with an initial
– Brain imaging (PLS 4220.08, SysRev 2023) documented rhythm of bradycardia with poor perfusion
• Effect of prophylactic antiseizure medication or and thus did not directly address this PICO question.10–28
treatment of seizures on outcome of pediatric Two papers commented on the impact of atropine for
patients following cardiac arrest (PLS 4210.02, bradycardia with hemodynamic compromise, 1 in pa-
SysRev 2024) tients receiving CPR and 1 in patients who never re-
• Post-ROSC oxygenation and ventilation (PLS ceived CPR.9,29 Three papers studied the administration
4180.01, 4180.02, SysRev 2019, EvUp 2025) of epinephrine during CPR for first documented rhythm
Readers are encouraged to monitor the ILCOR website5 of bradycardia with poor perfusion.7,9,30 Studies on at-
to provide feedback on planned systematic reviews and ropine and epinephrine are summarized in Table 1. No
to provide comments when additional draft reviews are studies were identified that assessed administration of
posted. oxygen, ventilation, or transcutaneous pacing.

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Table 1. Studies Reporting Treatment and Outcomes for Bradycardia With Hemodynamic Compromise

Patients Total patients with

Author, Country, analyzed, (N bradycardia and
year design, age Population Treatment/exposure events) poor perfusion Outcomes (%)
Atabek, Turkey, Case Amitraz Atropine (given 6–10 14 8 Survival to hospital discharge: 100% with
200229 series, 2–5 poisoning doses) resolution of bradycardia in all patients
years
Khera, United States, CA CPR 2799 bradycardia 1930 (69%) Survival to hospital discharge
20199 multicenter initial rhythm with maintained pulse (unadjusted) 70% in those who
retrospective poor perfusion 869 (31%) with maintained a pulse versus 30.2% in those
cohort, >30 receiving CPR subsequent with subsequent pulselessness (P <0.01)
days and <18 pulselessness
(50% of 5592 Survival to hospital discharge (adjusted)
years
total CA cohort) 57% lower risk of survival with
subsequent pulselessness compared with
maintained pulse (P <0.01)
RR, 0.43; 95% CI, 0.38–0.50; P <0.00
CPR and atropine 854/2799 519/1930 (26.9%) No outcomes reported for survival to
(30.5%) maintained pulse hospital discharge with CPR and atropine
335/869 (38.6%)
subsequent
pulselessness
CPR and epinephrine 1967/2799 1153/1930 No outcomes reported for survival
(70.3%) (65.5%) maintained to hospital discharge with CPR and
pulse epinephrine
814/869 (95.2%)
subsequent
pulselessness
Holmberg, United States, CA- CPR and epinephrine 7056 7056 Survival to hospital discharge with
20207 multicenter bradycardia (given within 10 min of CPR and epinephrine 38% versus no
retrospective with poor CPR) versus CPR and epinephrine 48% (RR, 0.79; 95% CI,
cohort perfusion no epinephrine 0.74–0.85; P <0.001)
propensity
Survival to 24 hours: lower for CPR and
matched,
epinephrine 0.85 (0.81, 0.90)
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≤18 years
ROSC lower with CPR and epinephrine
0.94 (0.91–0.96)
Favorable neurological outcome
at discharge lower with CPR and
epinephrine
0.76 (0.68–0.84)
O’Halloran, United States, CA- Early “bolus” 452 452 Favorable neurologic outcome at
202430 multicenter bradycardia (epinephrine within hospital discharge with early epinephrine
Subanalysis: Classified as 68
retrospective first 2 min of CPR) administration 51% versus 58% (adjusted
never pulseless,
cohort, <19 versus no early bolus 186 with invasive RR, 0.99; 95% CI, 0.82–1.18; P =0.89)
53 pulseless
years (no bolus epinephrine ABP assessed
and returned to ROSC: 57/68 (84%) never became
or epinephrine >2 min during first 10 min
pulse, 65 became pulseless
after CPR) 322/452 CPR
pulseless and
(71%) CPR and early 33/53 (62%) became pulseless and then
179 received remained pulseless*
epinephrine CPR developed bradycardia with a pulse again
epinephrine and
CPR 28/65 (43%) developed pulselessness
and stayed pulseless (P =0.001)
ROSC (85%) among those patients
who never developed pulselessness and
received early epinephrine (P <0.001)

*On arterial line wave form was described as no pulse or SBP <40 mm Hg for infants (<1 year of age) and <50 mm Hg for children ≥1 year of age.
ABP indicates arterial blood pressure; CA, cardiac arrest; CI, confidence interval; CPR, cardiopulmonary resuscitation; ROSC, return of spontaneous circulation; and
RR, risk ratio.

Task Force Insights CPR versus no CPR) for bradycardia with hemodynamic
The task force identified numerous gaps in the literature, compromise.
including absence of studies evaluating bradycardia with All studies evaluating CPR for bradycardia with hemo-
hemodynamic compromise in patients not receiving CPR dynamic compromise were in patients who were already
and lack of comparison groups for interventions (eg, receiving CPR for presumed cardiac arrest. The task

Circulation. 2025;152(suppl 1):S116–S164. DOI: 10.1161/CIR.0000000000001362 October 21, 2025 S119

 Scholefield et al Pediatric Life Support: 2025 CoSTR

force discussed timing of initiation of CPR for bradycar- devices, particularly left ventricular assist devices (LVADs).
dia for hemodynamic compromise, specifically as most The optimal approach to identification and resuscitation
studies were retrospective, and thus the true reason for of patients with acutely impaired perfusion supported by
CPR initiation is unknown. durable mechanical circulatory supported is controversial.
The task force considered indirect evidence supporting The ScopRev was initiated as a nodal review with the Ad-
CPR for bradycardia with hemodynamic compromise, spe- vanced Life Support (ALS) and PLS Task Forces.31 The
cifically studies that show (1) patients receiving CPR for full ScopRev report can be found on the ILCOR website.32
bradycardia with hemodynamic compromise have better sur-
vival rates than those receiving CPR for asystole or pulseless Population, Concept, Context, Study Design, and
electrical activity, and (2) patients receiving CPR for brady- Time Frame
cardia with hemodynamic compromise who maintained that • Population: Patients of any age receiving durable
rhythm had higher survival rates than those who progressed mechanical circulatory supported of any kind
to pulselessness. There was concern about potential harm • Concept: Acute impaired perfusion resulting in need
associated with delaying initiation of CPR for patients with for acute resuscitation
bradycardia and hemodynamic compromise who are not • Context: In- and out-of-hospital settings
responsive to oxygenation and ventilation as progression to • Study designs: In addition to standard criteria, all
pulselessness is associated with worse outcomes. case series and reports were included.
There was insufficient data to support a good practice • Time frame: Literature search included all years up
statement for atropine, epinephrine, or transcutaneous to May 2024.
pacing. The scoping review did not identify a sufficient Summary of Evidence
evidence base to support a SysRev. Of the 32 studies included,33–66 24 were case reports
including 2 or fewer patients,33,36–40,42,45–53,55–58,62–66 4
Treatment Recommendations (2025)
were case series including 3 to 10 patients,34,41,44,60
For patients with bradycardia and hemodynamic compro-
and 3 were retrospective cohort studies including
mise not responsive to oxygenation and ventilation, con-
more than 10 patients.35,43,59 Thirteen studies described
sider initiating CPR (good practice statement).
patients who had cardiac arrest and received chest
Withdrawn Treatment Recommendations compressions.34,38,39,41,47,50,51,55,56,58–60,65 In all studies, the
Based on the lack of any available direct or indirect evi- durable mechanical circulatory support was a left ven-
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dence considered appropriate by the task force for infer- tricular or biventricular assist device.
ence, these previous treatment recommendations are all Task Force Insights
withdrawn. The task force identified few data to support recommenda-
Epinephrine may be administered to infants and tions on the optimal approach to resuscitation of mechani-
children with bradycardia and poor perfusion that is cal circulatory supported patients who experience acutely
unresponsive to ventilation and oxygenation (2010, with- impaired perfusion. Most publications identified were case
drawn 2025). reports or case series. The few observational cohort stud-
It is reasonable to administer atropine for bradycardia ies had limitations including confounding by indication,
caused by increased vagal tone or anti-cholinergic drug lack of generalizability, and a high risk of misclassification
toxicity. There is insufficient evidence to support or refute whereby patients with acutely impaired perfusion are des-
the routine use of atropine for pediatric cardiac arrest ignated as having a cardiac arrest but may not have had
(2010, withdrawn 2025). a cardiac arrest. No high-quality observational studies or
In selected cases of bradycardia caused by complete randomized controlled trials were identified.
heart block or abnormal function of the sinus node, emer- The task force noted the low risk of device dislodge-
gency transthoracic pacing may be lifesaving. Pacing is ment from chest compressions identified in the ScopRev.
not helpful in children with bradycardia secondary to a While several observational studies did find a higher risk
postarrest hypoxic/ischemic myocardial insult or respira- of poor outcome when chest compressions were admin-
tory failure. Pacing was not shown to be effective in the istered to patients with acutely impaired perfusion as a
treatment of asystole in children (2000, withdrawn 2025). result of cardiac arrest compared with no chest compres-
sions, these observational studies were judged to be at
Resuscitation of Patients Living With Durable high risk for confounding.
Mechanical Circulatory Support With Acutely The task force also reviewed a scientific statement
from the American Heart Association and guidance from
Altered Perfusion or Cardiac Arrest (PLS the British Societies LVAD Emergency Algorithm Working
4190.03, ScopRev 2025) Group.67,68 One area of discussion was around the British
Rationale for Review Societies’ recommendation to delay chest compressions
This topic was chosen for review because of the increasing in LVAD supported patients for up to 2 minutes while
prevalence of durable mechanical circulatory supported efforts to restart the device are made. The task force felt

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

that these 2 minutes may be unnecessary, and efforts to Management of Pulmonary Hypertension (PLS
restart the LVAD device could occur in parallel with chest 4160.11, ScopRev 2024, EvUp 2025)
compressions if multiple rescuers are available.
The ScopRev did not identify sufficient evidence to Population, Intervention, Comparator, Outcome, and
support a systematic review. The good practice state- Time Frame
ments generated are the same as those generated by • Population: Infants and children with pulmonary
the ALS Task Force. hypertension at high risk of pulmonary hypertensive
crises with a cardiac arrest in the in-hospital setting
Treatment Recommendations (2025) including post-operatively.
In patients receiving durable mechanical circulatory sup- • Intervention: Specific management strategies,
port who develop acutely impaired perfusion because of including respiratory management and monitoring
cardiac arrest and who are not in the immediate peri-device to avoid hypoxia and acidosis; use of opioids, seda-
implantation period, we suggest performing rather than tives and neuromuscular blocking agents; or pulmo-
withholding chest compressions (good practice statement). nary arterial hypertension-specific targeted therapy
When caring for patients with durable mechanical • Comparators: Standard care without specific strate-
circulatory support who suffer acutely impaired perfu- gies for pulmonary hypertensive crisis
sion as a result of cardiac arrest, we suggest minimizing • Outcomes: Any clinical outcome
delays in initiating chest compressions while simultane- • Time frame: December 1, 2023, to October 17,
ously assessing for device-related reversible causes of 2024
acutely impaired perfusion (good practice statement).
We suggest rescuers follow an algorithmic approach Summary of Evidence
to concurrently assess and respond to acutely impaired The complete EvUp is provided in Appendix B. There
perfusion in patients receiving durable mechanical circu- is no new published evidence since the ILCOR 2024
latory support (good practice statement). ScopRev on this topic, so a SysRev is not warranted.73,74

Good Practice Statements (2024)

Pediatric Early Warning Systems (PLS 4050.02, In children, including neonates, with pulmonary hyper-
SysRev 2022) tension hospitalized for a clinical worsening event, we
The utility of pediatric early warning systems was ad- propose avoiding factors that may increase pulmonary
Downloaded from [Link] by on October 27, 2025

dressed in a SysRev in 202269 and details can be found vascular resistance while treating the aggravating condi-
in the 2022 CoSTR summary.70–72 tion to decrease the risk of cardiac arrest. Management
strategies include avoiding hypoxia; hypercapnia; aci-
Population, Intervention, Comparator, Outcome, and dosis; stressors, such as pain, agitation, dehydration, or
Time Frame fluid overload; anemia; infection; or arrhythmias. Pulmo-
• Population: Infants, children, and adolescents in any nary hypertension-specific treatments (eg, inhaled nitric
inpatient setting oxide, L-arginine, phosphodiesterase inhibitors [eg, mil-
• Intervention: Pediatric early warning system with rinone, sildenafil], or endothelin-1 inhibitors [eg, bosen-
or without rapid response teams or medical emer- tan]) may be considered (good practice statement).73,74
gency teams In children who develop signs of pulmonary hyperten-
• Comparators: No pediatric early warning system or sive crisis, low cardiac output, or right ventricular failure
standard care (without a scoring system) despite optimal medical therapy, extracorporeal mem-
• Outcomes: brane oxygenation (ECMO) may be considered before
– Critical: significant clinical deterioration event, cardiac arrest or for refractory cardiac arrest (ie, ECPR)
including but not limited to unplanned/crash tra- as a bridge to recovery or as a bridge to the evaluation
cheal intubation; unanticipated fluid resuscitation for organ replacement and transplantation in very select
and inotropic/vasopressor use; CPR or extracor- cases (good practice statement).73,74
poreal membrane oxygenation; death in patients
without a do-not-attempt resuscitation order
– Important: unplanned code events with favorable INTRA-ARREST: AIRWAY, BREATHING,
neurological outcome.
• Time frame: All years to June 26, 2021 AND CIRCULATION
ABC Versus CAB: Order of Ventilation and
Treatment Recommendations (2022)
We suggest using pediatric early warning systems to Compression (PLS 4070.02, SysRev 2025)
monitor hospitalized children, with the aim of identifying Rationale for Review
those who may be deteriorating (weak recommendation, Because the merits of commencing chest compres-
low-certainty evidence). sions before ventilations are uncertain, we updated

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

the previous SysRev, which was included in the 2019 Treatment Recommendation (2025)
CoSTR summary.75,76 Previous SysRevs by ILCOR have There is insufficient evidence to support a treatment rec-
found that in simulation studies starting CPR with com- ommendation regarding the optimal order of commenc-
pressions resulted in faster times to key elements of ing CPR in children (ie, ventilation or compressions first).
resuscitation (rescue breaths, chest compressions, The task force considers that both an ABC (ventila-
completion of first CPR cycle).77,78 A change from ABC tion followed by compression) and a CAB (compression
to compression-first and compression-focused CPR followed by ventilation) approach are acceptable and that
has also been associated with a significant increase both ventilation and chest compressions are important
in rates of bystander CPR and patient survival.79 Most components of CPR in children (good practice statement).
international adult basic life support (BLS) guidelines
now commence CPR with chest compressions be- Justification and Evidence-to-Decision Framework
fore ventilations. Pediatric guidelines vary, with differ- Highlights
ent approaches in various jurisdictions.80 The SysRev The complete evidence-to-decision table is provided in
was registered before initiation (Prospective Register Appendix A.
of Systematic Reviews [PROSPERO] Registration The majority of the existing evidence (5 manikin stud-
CRD42024583890) and conducted as a nodal review ies)82,84–87 suggests that starting CPR with compressions
with the BLS Task Force. The full CoSTR can be found results in faster times to key elements of resuscitation.
on the ILCOR website.81 One simulated study in pediatric resuscitation found
that starting with compressions delayed the commence-
Population, Intervention, Comparator, Outcome, ment of rescue breaths in cardiac arrest by 6 seconds.87
Study Design, and Time Frame This delay may be clinically acceptable. However, alveolar
• Population: Adults and children in any setting (in- minute ventilation and the number of ventilations deliv-
hospital or out-of-hospital) with cardiac arrest ered in the first minute of resuscitation were higher with
• Intervention: Commencing CPR with compressions the ABC (delivering 5 rescue breaths before commenc-
first (30:2) ing chest compressions) sequence.
• Comparators: Commencing CPR with ventilations Indirect evidence from before-and-after out-of-­
first (2:30) hospital cardiac arrest (OHCA) registry studies in adults,
• Outcomes: examining changes in dispatcher telephone CPR instruc-
– Critical: Survival with favorable neurological out- tions79 and implementation of guideline changes,90,91
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come at hospital discharge or 30-days; survival at suggests that switching from the ABC to CAB approach
hospital discharge or 30 days; survival with favor- was associated with increased rates of bystander CPR79
able neurological outcome to 1 year; survival to 1 and improved patient outcomes.79,90,91 Similar data on
year; event survival; any ROSC in-­hospital cardiac arrest show conflicting evidence in
– Important: Time to commencement of rescue patient outcomes.92,93 One large registry study from Japan
breaths; time to commencement of first compres- demonstrated increased bystander CPR rates in children
sion; time to completion of first CPR cycle; venti- with bystander-witnessed OHCA after compression-only
lation rate; compression rate; chest compression CPR was introduced.94 Whether the change in sequence
fraction; minute ventilation to CAB by some ILCOR member councils has resulted
• Study designs: In addition to standard criteria, simu- in more infants and children receiving compression-only
lation studies were included if there were insuffi- CPR overall is unknown, although available data con-
cient human studies. tinues to support the combination of compressions and
• Time frame: September 2019 to June 18, 2024. breaths is needed for optimal pediatric CPR.95,96
The BLS and PLS Task Forces also considered
Consensus on Science • The benefits of a single training approach versus
This updated systematic review identified 1 new pedi- separate approaches for adults and children, recog-
atric manikin study82 (published with corrections83), in nizing regions currently using an ABC approach in
addition to 4 manikin studies84–87 found in the previous children may incur additional short-term costs and
ILCOR reviews.77,78,88,89 Of the 5 manikin studies, 3 were resources to implement a CAB approach
randomized studies, 1 in adult85 and 2 in pediatric resus- • Effective chest compressions generate cumulative
citation,82,87 and 2 were observational studies in adult coronary perfusion pressure, which falls to near zero
resuscitation.84,86 No human studies were identified. when compressions stop,97 emphasizing the value
The overall certainty of evidence was rated as very low of approaches where effective chest compressions
for all outcomes, downgraded for very serious risk of bias are commenced promptly and interrupted sparingly.
and indirectness. • Time to first compression is associated with better
A summary of the outcomes of the included studies is patient outcomes, including good neurological out-
shown in Table 2. comes in adults.98

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Table 2. Summative Results of Studies for CAB Versus ABC Systematic Review

Certainty of evidence
Outcomes (importance) Participants (studies), n (GRADE) CAB versus ABC P value
Time to commencement of chest 159 2-person teams Very low Mean: 19.3 s ± 2.6 s versus P <0.05
compressions 43.4 s ± 5.0 s
(1 crossover pediatric manikin
(important)
randomized study)87
108 2-person teams (1 adult manikin Very low Mean: 25 s ± 9 s versus 43 s P <0.001
randomized study)85 ± 16 s
33 6-person teams and 40 single Very low Median: 16.0 s (IQR: 14.0–26.0) P <0.001
rescuers (2 adult manikin observational versus 42.0 s (IQR: 41.5–59.0)84
P <0.001
studies)84,86
Mean: 15.4 s ± 3.0 s versus
36.0 s ± 4.1 s86
Time to commencement of ventilations 267 2-person teams (2 randomized Very low Mean: 28.4 s ± 3.1 s versus P <0.05
(important) manikin studies)85,87 22.7 s ± 3.1 s87
P <0.001
43 s ± 10 s versus 37 s ± 15 s85
Time to completion of first CPR cycle 108 2-person teams (1 randomized Very low Mean: 48 s ± 10 s versus 63 s P <0.001
(30 chest compressions + 2 breaths) manikin study)85 ± 17 s
(important)
Ventilation rate 28 2-person teams (1 crossover Very low Median ventilations in first P <0.05
(important) pediatric randomized manikin study)82 minute:
10 (IQR: 8–10) versus 13 (IQR:
12–15)
Compression rate 28 2-person teams (1 crossover Very low No difference
(important) pediatric randomized manikin study)82
33 6-person teams (1 adult Very low No difference
observational study)84
Chest compression fraction (important) 28 2-person teams (1 crossover Very low 66% (IQR: 59–680 versus 57% P <0.001
pediatric randomized manikin study)82 (IQR: 54–64)
33 6-person teams (1 adult Very low No difference
observational study)84
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Minute alveolar ventilation in first minute 28 2-person teams (1 crossover Very low Median: 276 mL (IQR: 140–360) P <0.001
(important) pediatric randomized manikin study)82 versus 370 mL (IQR: 203–472)

ABC indicates airway, breathing, circulation; CAB, compressions, airway, breathing; and GRADE, Grading of Recommendations, Assessment, Development, and Evaluation.

• Bystanders are typically unable to deliver effective • Further investigation is needed in children. The task
ventilations during simulated CPR.99 forces noted that Utstein-based registry data may be
• Due to the public’s concerns with mouth-to-mouth the only source of information to answer this question.
ventilations,100 commencing CPR with airway and Because different councils worldwide have adopted
ventilations may result in no bystander CPR being CAB versus ABC, comparative studies of different reg-
provided. istries may provide evidence to answer this question.
• Delivering the ABC approach leads to more errors
in CPR87; lay bystanders prefer CAB, and it is easier Knowledge Gaps
to learn and retain.87 No human studies directly evaluating this question in any
• The delivery of non–mouth-to-mouth ventilation setting were identified.
requires the retrieval and preparation of equipment
(eg, bag-valve-mask, pocket mask), which, when
Advanced Airway Interventions in Cardiac
multiple rescuers are present, can occur during
chest compressions. Arrest (PLS 4060.01, SysRev 2024, EvUp 2025)
• The new treatment recommendation in children is Population, Intervention, Comparator, Outcome, and
about starting CPR and does not mean ventilation Time Frame
should not be provided in resuscitation. • Population: Infants and children (excluding newborn
• While the PLS Task Force appreciates that many infants) who had received CPR after out-of-hospital
cardiac arrests in infants and children have a respi- or in-hospital cardiac arrest
ratory etiology, the short delay in starting ventilation • Intervention: Placement of an advanced airway device
is unlikely to make a clinically significant difference • Comparators: Bag-mask ventilation alone or with
to outcome, and hypovolemia and shock are com- non–advanced airway interventions (primary); or
mon causes as well. another advanced airway device (secondary)

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

• Outcomes: Any clinical outcome per minute may be reasonable. The PLS Task Force sug-
• Time frame: August 15, 2023, to May 22, 2024 gests using ventilatory rates close to age-appropriate
respiratory rates with avoidance of hypoventilation and
Summary of Evidence
hyperventilation (good practice statement).73,74
A SysRev was last done on this topic for 2024.73,74 The
complete EvUp is provided in Appendix B. No new pe-
diatric studies were identified. There is insufficient evi- INTRA-ARREST: DEFIBRILLATION
dence to support the conduct of a SysRev.
Energy Doses for Pediatric Defibrillation During
Treatment Recommendations (2024)
We suggest the use of bag-mask ventilation rather
Resuscitation (PLS 4080.12, SysRev 2025)
than tracheal intubation or supraglottic airway in the Rationale for Review
­management of children during cardiac arrest in the out- Shockable ventricular arrhythmias—ventricular fibrillation
of-­
hospital setting (weak recommendation, very low–­ (VF) and pulseless ventricular tachycardia (pVT)—are
certainty evidence).73,74 less frequently recorded in children than in adults but are
There is insufficient quality evidence to support any associated with a higher survival rate than nonshockable
recommendation for or against the use of the bag-mask rhythms. Early defibrillation is the foundation of treat-
ventilation compared with tracheal intubation or supra- ment, but optimal energy doses for initial and subsequent
glottic airway for in-hospital cardiac arrest. shocks remain controversial, with notable differences in
The main goal of CPR is effective ventilation and oxy- first shock dose recommendations by ILCOR member
genation, by whatever means, without compromising the councils.80,101 This SysRev was registered before ini-
quality of chest compressions. We suggest that clinicians tiation (PROSPERO Registration CRD42024548898).
consider transitioning to an advanced airway interven- The full CoSTR is available on the ILCOR website.102
tion (supraglottic airway or tracheal intubation) when the
Population, Intervention, Comparator, Outcome,
team has sufficient expertise, resources, and equipment
Study Design, and Time Frame
to enable placement to occur with minimal interruptions
• Population: Infants and children (excluding newborn
to chest compressions or when bag-mask ventilation
infants) in ventricular fibrillation or pulseless ventric-
is not providing adequate oxygenation and ventilation
ular tachycardia during out-of-hospital or in-hospital
(good practice statement).73,74
cardiac arrest
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• Intervention: Initial defibrillation dose approximating

Ventilation Rate With Advanced Airway During 2 J/kg (1.5 J/kg–2.5 J/kg)
Cardiac Arrest (PLS 4120.02, SysRev 2024, • Comparators: Initial defibrillation dose of >2.5 J/kg,
EvUp 2025) <1.5 J/kg, or any other specified dose
Population, Intervention, Comparator, Outcome, and • Outcomes:
Time Frame – Critical: Survival to hospital discharge, ROSC
• Population: Infants and children (excluding new- – Important: Termination of VF/pVT.
born infants) with out-of-hospital or in-hospital car- • Study designs: In addition to standard criteria, case
diac arrest (asphyxial or arrhythmic origin) and an series with a minimum of 5 cases were eligible for
advanced airway inclusion.
• Intervention: Use of any specific respiratory rate • Time frame: All years to September 1, 2024
• Comparators: Compared with ventilation rate of 8 to Consensus on Science
10 per minute Seven studies were included,103–109 all of which were
• Outcomes: Any clinical outcome observational studies and provided very low–certainty
• Time frame: July 18, 2023, to September 30, 2024 evidence (downgraded for imprecision and risk of bias)
Summary of Evidence for the important and critical outcomes described. Key
The complete EvUp is provided in Appendix B. No new outcomes are summarized in Table 3.
pediatric studies were identified. An updated SysRev is Acknowledging the very low level of certainty, the cur-
not warranted. rent available data suggest that outcomes are not sig-
nificantly better or worse when initial defibrillation doses
Treatment Recommendations (2024) of <2 J/kg or >2 J/kg are used for children in cardiac
There is currently no supporting evidence to make a arrest with a shockable rhythm, compared with initial
treatment recommendation on a specific ventilatory rate doses of approximately 2 J/kg.
in pediatric cardiopulmonary resuscitation with an ad-
vanced airway.73,74 Prior Treatment Recommendations (2020)
For cardiac arrest that occurs with an advanced air- We suggest the routine use of an initial dose of 2 J/kg to
way in place, the use of ventilatory rates >10 breaths 4 J/kg of monophasic or biphasic defibrillation waveforms

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Table 3. Summative Results of Studies: Pediatric Defibrillation Dose Systematic Review

Certainty of
Outcomes (importance) Participants (studies), n evidence (GRADE) RR (95% CI) ARD with intervention
Defibrillation dose <2 J/kg (I) compared with defibrillation dose approximating 2 J/kg (C) for defibrillation in children in cardiac arrest
Termination of VF/pVT 265 Very low RR, 0.63 179 fewer per 1000
(important) (2 nonrandomized studies)103,105 (0.14–2.84) (from 415 fewer to 888 more)
ROSC 266 Very low RR, 1.06 51 more per 1000
(critical) (4 nonrandomized studies)104,106,108,109 (0.95–1.18) (from 42 fewer to 152 more)
Survival to hospital discharge (critical) 225 Very low RR, 1.06 29 more per 1000
(2 nonrandomized studies)104,106 (0.80–1.40) (from 96 fewer to 192 more)
Defibrillation dose >2 J/kg (I) compared with defibrillation dose approximating 2 J/kg (C) for defibrillation in children in cardiac arrest
Termination of VF/pVT 265 Very low RR, 0.96 22 fewer per 1000
(important) (2 nonrandomized studies)103,105 (0.82–1.13) (from 99 fewer to 77 more)
ROSC 596 Very low RR, 0.95 29 fewer per 1000
(critical) (6 nonrandomized studies) 104–109
(0.77–1.17) (from 133 fewer to 98 more)
Survival to hospital discharge (critical) 225 Very low RR, 1.20 82 more per 1000
(2 nonrandomized studies)104,106 (0.38–3.77) (from 253 fewer to 1000 more)

ARD indicates absolute risk difference; C, comparator; CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development, and Evaluation; I,
intervention; pVT, pulseless ventricular tachycardia; RR, risk ratio; ROSC, return of spontaneous circulation; and VF, ventricular fibrillation.

for infants or children in VF or pVT cardiac arrest (weak settings on defibrillators. So, although no specific energy
recommendation, very low–quality evidence). There is in- dose was found superior, energy selections would gener-
sufficient evidence on which to base a recommendation ally have been approximating either 2 J/kg or 4 J/kg.
for second and subsequent defibrillation doses.110–112
Knowledge Gaps
Treatment Recommendations (2025) • Whether there are any specific undesirable effects
In the absence of evidence to demonstrate a clear pref- (eg, myocardial damage) of defibrillation with the
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erence for any particular energy dose, we suggest the different doses studied
use of an initial defibrillation dose of 2 J/kg to 4 J/kg • Prehospital and in-hospital studies, ideally compar-
for infants or children in VF or pVT cardiac arrest (weak ing existing different dosing strategies with planned
recommendation, very low–certainty evidence). subgroup analyses based on patient age and type
This review did not investigate the evidence for sec- of shockable rhythm (primary versus secondary) are
ond and subsequent defibrillation dosages. ethical, necessary, and critically important to help
guide clinicians in making these complex decisions.
Justification and Evidence-to-Decision Framework As different resuscitation councils recommend
Highlights either 2 J/kg or 4 J/kg as an initial defibrillation
The complete evidence-to-decision table is provided in dose, this may provide an opportunity for an interna-
Appendix A. tional comparative study.
Differences remain in the first shock dose recommended • Potential adverse effects of higher defibrillation
by ILCOR member councils, with the European Resuscita- doses when fixed energy doses are provided (eg,
tion Council and Australian and New Zealand Committee through use of AEDs)
on Resuscitation recommending 4 J/kg for first and all • Effect of different defibrillation energy doses on
subsequent shocks and the American Heart Association other clinically important outcomes as defined in the
recommending an initial dose of 2 J/kg to 4 J/kg (for ease P-COSCA set4
of teaching, a dose of 2 J/kg is used in algorithms and
training materials).6,113,114 For refractory VF, American Heart
Paddle/Pad Size and Placement in Infants and
Association guidelines recommend increasing defibrillation
dose to 4 J/kg, suggesting that subsequent energy doses Children (PLS 4080.17, SysRev 2025)
should be at least 4 J/kg and noting that higher levels may Rationale for Review
be considered, not to exceed 10 J/kg. Definition of proper pad positioning and size to ana-
The task force recognized that most studies were tomically encompass the heart and ensure good contact
conducted in sites where either 2 J/kg or 4 J/kg doses is vital in pediatric defibrillation. The PLS Task Force’s
were recommended for initial defibrillation. The variability previous review of defibrillation strategies115 showed no
of dosing was largely attributable to the few energy dose clear superiority for vector change or double-sequential

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

strategies but reinforced the critical importance of proper For AED Users
pad placement. Since this review, a randomized trial116 Follow the AED specific guidance and instructions for
and retrospective observational study117 have been pads placement in infants and children (good practice
published, prompting this SysRev118 The SysRev was statement).
registered before initiation (PROSPERO Registration
For Health Care Professionals Trained in Manual
CRD42024512443) and conducted in partnership with
Defibrillation
the BLS and ALS Task Forces. The full CoSTR can be
In infants and children, place pads in an anterior-­posterior
found on the ILCOR website and in the BLS section.119
position (good practice statement).
Population, Intervention, Comparator, Outcome, and
Vector Change Strategy
Time Frame
We cannot make a recommendation for or against the
• Population: Adults and children in any setting (in-
use of vector change strategy for the treatment of refrac-
hospital or out-of-hospital) with cardiac arrest and
tory VF or pulseless VT in infants and children.
a shockable rhythm at any time during cardiopulmo-
nary resuscitation (CPR) Justification and Evidence-to-Decision Framework
• Intervention: The use of any specific pad size, orien- Highlights
tation, and position The complete evidence-to-decision table is provided in
• Comparators: Reference standard pad size, orienta- Appendix A.
tion, and position Due to the lack of direct evidence in infants and chil-
• Outcomes: dren, and the very low certainty of the indirect evidence
– Critical: Survival with favorable neurological out- from adults, the task force was unable to make treat-
come at hospital discharge or 30-days; survival at ment recommendations for those using AEDs or manual
hospital discharge or 30 days defibrillators. The task force decision to provide a good
– Important: ROSC; termination of VF; rates of practice statement suggesting positioning pads in the
defibrillation AP position was based on the indirect evidence in adults
• Time frame: All years to September 22, 2024 that it improves ROSC. However, the task force did rec-
ognize the very low certainty of the evidence from this
Consensus on Science
observational study.122
No pediatric studies were identified that addressed the
In making these recommendations, the PLS Task
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questions of defibrillator pad or paddle size, orientation,

Force recognized that AP positioning of pads is easier
or placement.
in infants and children than in adults. Pads may also be
Due to the lack of direct evidence in infants and chil-
used as real-time feedback devices for quality assess-
dren, the PLS Task Force used the very low–certainty evi-
ment of chest compressions. In these circumstances,
dence from adult studies, downgraded for indirectness, to
pads generally need to be in the AP position. The AP
inform the treatment recommendations. Details of the adult
position is not feasible with paddles, which are still used
evidence are available in the BLS CoSTR publication.120
in some low-resource settings.
Prior Treatment Recommendations (2010)
Knowledge Gaps
There is insufficient evidence to alter the current recommen-
• No studies examined the pediatric or in-hospital
dations to use the largest size paddles that fit an infant’s or
setting.
child’s chest without touching each other or to recommend
• The effectiveness of different pad positions com-
one paddle or pad position or type over another.110,121
pared with standard positions in any patient popula-
Treatment Recommendations (2025) tion, in the first 3 shocks
For Manufacturers • The relative effectiveness of different pad sizes
Manufacturers could consider the standardization of • The interaction between pad size and pad orientation
pad size for infants, children, and adults (good practice • The effectiveness of a vector change strategy in
statement). children
Manufacturers of AEDs should standardize pad • The effectiveness of paddles as compared with
placement in an anteroposterior position for infants and pads in children
young children (with 1 pad anteriorly, over the left pre-
cordium, and the other pad posteriorly to the heart just
Single or Stacked Shocks for Pediatric
inferior to the left scapula) (good practice statement).
Manufacturers should include instructions to ensure Defibrillation (PLS 4080.19, SysRev 2025)
adequate contact between the pad and the skin and ensure Rationale for Review
that their pad position diagrams clearly indicate the ILCOR- Before 2005, guidelines recommended 3 stacked
recommended pad position (good practice statement). shocks for shockable rhythms because of low first-shock

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

efficacy with monophasic waveforms and the theo- cardiovascular life support recommendations in adults.
retical reduction in transthoracic impedance after each The 1-shock strategy has not been directly studied
shock.123 However, with the advent of biphasic defibril- against a 3-shock strategy in pediatric VF/pVT but the
lators, which show high first-shock success and minimal 2005 recommendation129 that those providing CPR
transthoracic impedance reduction, the 2005 guidelines should give a single shock followed immediately by CPR
shifted to a single-shock strategy followed by immediate (beginning with chest compressions) rather than the 3
chest compressions.124,125 successive (“stacked”) shocks in pediatric VF or pVT was
Current ILCOR guidelines, unchanged since 2010, based on the evidence that
endorse a single-shock approach followed by CPR for • First-shock success rate of currently used biphasic
pediatric VF or pVT, before reassessing rhythm. EvUps defibrillators is up to 90%.130,131
done in 2023 found no new pediatric studies, and adult • In a 3-shock sequence (stacked) the delay between
studies were excluded because of physiological differ- delivery of the first shock and delivery of the first
ences between children and adults.126,127 The PLS Task post-shock compression is up to 37 seconds.132,133
Force prioritized this SysRev to enable confirmation of • Interruption of chest compressions reduces coro-
current recommendations through a systematic search. nary perfusion pressure.134
The SysRev was registered before initiation (PROS- • If the first shock fails, intervening chest compres-
PERO Registration: CRD42024559428) and the full sions may improve oxygen and substrate delivery
CoSTR is available online.128 to the myocardium, making the subsequent shock
more likely to result in defibrillation.
Population, Intervention, Comparator, Outcome, and
• Data from animal studies document harmful effects
Time Frame
from interruptions to chest compressions.135
• Population: Infants and children (excluding newborn
infants) who are in VF or pVT during out-of-hospital Knowledge Gaps
or in-hospital cardiac arrest There are no randomized controlled trials directly com-
• Intervention: More than 1 (stacked) shocks for the paring 3-shock (stacked) strategy with single biphasic
initial or subsequent defibrillation attempt shocks in pediatric defibrillation.
• Comparison: A single shock for each defibrillation
attempt
• Outcomes: Any clinical outcome Lay Rescuer Use of AEDs (PLS 4080.01,
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• Time frame: All years to May 15, 2024 SysRev 2022, EvUp 2025)
Population, Intervention, Comparator, Outcome, and
Consensus on Science
Time Frame
No studies comparing single versus stacked shock in
• Population: Infants and children (excluding newborn
children with out-of-hospital or in-hospital cardiac arrest
infants) with nontraumatic OHCA
with VF or pVT were identified.
• Intervention: Application of or shock delivery from
Prior Treatment Recommendations (2005, an AED by lay rescuers
Withdrawn) • Comparators: Standard care by lay rescuer without
A single-shock strategy followed by immediate CPR (be- AED application
ginning with chest compressions) is recommended for • Outcomes: Any clinical outcome
children with out-of-hospital or in-hospital VF or pVT. • Time frame: November 3, 2021, to May 22, 2024
The prior treatment recommendation of 2005 is
Summary of Evidence
unsupported due to the lack of any available direct or
The complete EvUp is provided in Appendix B. A SysRev
indirect evidence. The PLS Task Force therefore with-
of this topic was last done for the 2022 CoSTR summa-
draws the prior treatment recommendation and replaces
ry.70–72 This EvUp identified no new pediatric studies on
it with a good practice statement.
this subject that would potentially alter the current treat-
Treatment Recommendations (2025) ment recommendation. There is insufficient evidence to
In infants and children with out-of-hospital or in-hospital support the conduct of a SysRev.
cardiac arrest in VF or pVT, we suggest a single-shock
Treatment Recommendations (2022)
strategy followed by immediate CPR (beginning with
We suggest the use of an AED by lay rescuers for
chest compressions) (good practice statement).
all children >1 year of age who have nontraumatic
Justification and Evidence-to-Decision Framework OHCA (weak recommendation, very low–certainty
Highlights evidence).70–72
The 3-shock (stacked) strategy used in pediatric VF We cannot make a recommendation for or against the
or pVT before the 2005 American Heart Association use of an AED by lay rescuers for all children <1 year of
guideline was based on an extrapolation from advanced age with nontraumatic OHCA.70–72

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

INTRA-ARREST: MONITORING pressure monitoring blinded for the participants.140 In

this study, only 39% (60/153) of the participants de-
Pulse Check Accuracy in Pediatrics During cided on the presence of a pulse within 10 seconds.
Resuscitation (PLS 4080.18, SysRev 2025) The median duration until any decision was made was
Rationale for Review 18 seconds, with an accuracy of 85%. Inexperienced
Guidelines recommend a manual pulse check during participants took longer to make their decisions. This
rhythm analyses to detect ROSC, with different anatomi- indirect evidence indicates that there is a reasonable
cal sites for different age groups.136 With the increasing concern about prolonged chest compression pauses,
availability of ultrasound and arterial lines, the PLS Task especially in inexperienced clinicians. This evidence
Force prioritized this topic and conducted the first Sys- was gained in a less critical setting with perfused chil-
Rev based on a previous EvUp in 2023.127 The SysRev dren with warm skin temperature and brisk capillary re-
was registered before initiation (PROSPERO Registra- fill time.
tion CRD42024549535). The full CoSTR can be found Any Clinical Outcome
on the ILCOR website.138 No studies in infants and children were identified that
Population, Intervention, Comparator, Outcome, and assessed any clinical outcome.
Time Frame Prior Treatment Recommendations (2020)
• Population: Infants and children in any setting (out- Palpation of a pulse (or its absence) is not reliable as the
of-hospital or in-hospital) with suspected cardiac sole determinant of cardiac arrest and need for chest
arrest when assessing whether to start or continue compressions. If the victim is unresponsive, and not
CPR breathing normally, and there are no signs of life, lay res-
• Intervention: Any other site for pulse check (eg cuers should begin CPR.110
femoral pulse) OR method (including but not limited
to cardiac auscultation, pulse oximetry, ultrasonog- Withdrawn Treatment Recommendation
raphy, rise in end-tidal CO2 values above specific In infants and children with no signs of life, health care
thresholds, invasive monitoring) providers should begin CPR unless they can definitely
• Comparators: Pulse check as per current guide- palpate a pulse within 10 seconds.
lines for health care professionals (brachial pulse
for infants and carotid pulse for children and Treatment Recommendations (2025)
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adolescents) We suggest that the palpation of a pulse (or its absence)

• Outcomes: Any outcome including but not limited to is unreliable as the sole determinant of cardiac arrest
– Accuracy, defined as sensitivity and specificity of and the need for chest compressions (weak recommen-
detecting a perfusing rhythm dation, very low certainty on evidence).
– Duration of cardiac compression pauses In unresponsive children, not breathing normally and
– Any clinical outcome without signs of life, lay rescuers and health care profes-
• Time frame: All years to April 24, 2024 sionals should begin CPR (good practice statement).

Consensus on Science Justification and Evidence-to-Decision Framework

Accuracy Highlights
For the critical outcome of accuracy (defined as sen- The complete Evidence-to-decision table is provided in
sitivity and specificity), this SysRev identified 3 studies Appendix A.
with 39 patients and 376 pulse checks, providing very The task force justified including the 2 previously
low certainty of evidence.139–141 All studies had a seri- included studies in the SysRev, downgrading those stud-
ous risk of bias. Two studies were further downgraded ies for indirectness.139,140 One additional case series
for imprecision and indirectness. These studies assessed showed good accuracy when ultrasound was performed
clinicians’ ability to accurately palpate a pulse (brachial or by trained health care professionals for emergency
femoral) for children with LVADs or on ECMO, but with- department resuscitation of children with cardiac arrest
out cardiac arrest. Sensitivity ranged from 76% to 100%, during pulse checks.141 Very experienced clinicians per-
and specificity 64% to 79%.139,140 The studies did not formed the intervention in this case series. The task force
directly compare different pulse palpation sites. concluded that evidence was insufficient to make a treat-
ment recommendation. The duration of pulse checks was
Duration of Cardiac Compression Pauses not reported in this case series.
No studies in infants and children were identified that The previous treatment recommendation limited the
directly assessed this outcome. One study evaluated the pulse check duration to 10 seconds.121 However, in 1
time until a decision was made about whether a pulse study, only 39% (60/153) of the participants decided on
was present or not. However, this study was performed the presence of a pulse within 10 seconds.140 Given the
in children with LVADs or on ECMO with arterial blood indirect evidence in this SysRev, the task force withdrew

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

the Treatment Recommendation regarding pulse palpa- • Intervention: A specific blood pressure target during
tion within 10 seconds. arrest
• Comparators: A different blood pressure target or
Knowledge Gaps no blood pressure target
• No randomized controlled trials were identified com- • Outcomes: Critical: ROSC; survival to hospital dis-
paring ultrasound, arterial blood pressure or differ- charge; survival to hospital discharge with good
ent pulse check sites with guideline recommended neurological outcome
pulse check sites in children with cardiac arrest. • Time frame: All years to July 19, 2024
• The effect of pulse palpation attempts on hands-off
time and impact on outcome Consensus on Science
• Future studies would benefit from including out- Five observational cohort studies were included.144,148–151
come measures consistent with the P-COSCA Three were analyses of the same cohort (Pediatric In-
recommendations.4 tensive Care Quality of CPR study) but examined differ-
ent subpopulations or different outcomes.148,150,151

Blood Pressure Monitoring and Targets During Diastolic Blood Pressure

Pediatric In-Hospital Cardiac Arrest (PLS For the critically important outcomes of ROSC, survival to
hospital discharge, and survival with favorable neurologi-
4160.08, SysRev 2025) cal outcome, we identified 2 observational studies enroll-
Rationale for Review ing 577 patients with IHCA and invasive arterial blood
In children who have intra-arterial catheters in place, pressure monitoring in place at the time of arrest,144,148
hemodynamic data may be used to provide information which showed benefit from exposure to diastolic blood
about the quality of chest compressions during cardiac pressure (DBP) of ≥25 mm Hg for infants <1 and ≥30
arrest.142 Since the PLS Task Force ScopRev in 2020,143 mm Hg for children ≥1 for the first 10 minutes of CPR,
subsequent studies on the topic144,145 have been pub- when compared with lower DBP. A summary of the out-
lished, prompting this SysRev. The SysRev was regis- comes of the included studies examining DBP targets is
tered with PROSPERO prior to initiation (Registration shown in Table 4.
CRD42024590080), and the full CoSTR can be found There was no difference in median DBP between
on the ILCOR website.147 subjects with new substantive morbidity after arrest
and those without (30.5 mm Hg versus 30.9 mm Hg,
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Population, Intervention, Comparator, Outcome, and

P=0.5).150 This was a subpopulation of the subjects in
Time Frame
Berg et al (2018).148
• Population: Infants and children receiving resuscita-
tion after in-hospital cardiac arrest with intra-arterial Diastolic Blood Pressure: Subgroups
blood pressure monitoring in place at the time of For the critically important outcome of survival to hospi-
arrest tal discharge, we identified very low–certainty evidence

Table 4. Summative Results of Studies: Pediatric Diastolic BP Targets

Anticipated absolute effect* (95% CI)

Certainty Risk with a DBP of 25 mm Hg

Participants (studies), of evidence Risk with no for infants <1 year and 30
Outcomes (importance) n (GRADE) RR (95% CI) BP target mm Hg for children ≥1 year
Return of spontaneous circulation 577 Very low RR, 1.33 528 per 1000 703 per 1000
(critical)
(2 nonrandomized (1.12–1.59) (592–840)
studies)144,148
Survival to hospital discharge (critical) 577 Very low RR, 1.55 407 per 1000 630 per 1000
(2 nonrandomized (1.18–1.91) (480–776)
studies)144,148
Survival with favorable neurological 577 Very low RR, 1.37 390 per 1000 535 per 1000
outcome (PCPC 1-3 or no change from
(2 nonrandomized (1.04–1.69) (406–660)
baseline) (critical)
studies)144,148
Functional status scale152 increase by 77 Very low RR, 1.69 222 per 1000 376 per 1000
3 or increase by 2 in single domain (in
(1 nonrandomized (0.83–3.42) (184–760)
survivors) (critical)
study)150

*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI indicates confidence interval; DBP, diastolic blood pressure; GRADE, Grading of Recommendations, Assessment, Development, and Evaluation; PCPC, Pediatric
Cerebral Performance Category; and RR, risk ratio.

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

from a single observational study enrolling children with mm Hg for children 1 to 18 years of age with invasive
invasive arterial BP monitoring in place at the time of blood pressure monitoring in place at the time of car-
IHCA, and either medical cardiac disease (n=24) or sur- diac arrest (weak recommendation, very low–certainty
gical cardiac disease (n=88).151 Only patients with sur- evidence).
gical cardiac disease had improved survival to hospital
discharge (RR, 1.64; 95% CI, 1.06–2.54) from exposure Justification and Evidence-to-Decision Framework
to a DBP of ≥25 mm Hg for infants <1 and ≥30 mm Hg Highlights
for children ≥1 for the first 10 minutes of CPR when The complete Evidence-to-decision table is provided in
compared with patients with lower DBP. Appendix A.
Measurement of intra-arrest blood pressure is gen-
Systolic Blood Pressure erally available only in high-resource settings, and all
For the critically important outcomes of survival to hos- studies examined patients with invasive BP monitoring in
pital discharge and survival with favorable neurological place at the time of arrest. While this limits the scope of
outcome, we identified no difference from exposure to the recommendation, children with invasive BP monitor-
a systolic blood pressure of ≥60 mm Hg for infants <1 ing may be at higher risk of cardiac arrest, thus making a
and ≥80 mm Hg for children ≥1 for the first 10 minutes recommendation valuable.
of CPR (I) when compared with lower systolic blood No randomized controlled trials were identified in the
pressure.144,148 A summary of the outcomes of the included search. We found only very low–certainty evidence from
studies examining systolic BP targets is shown in Table 5. 5 observational trials, all of which were from cohorts in
There was no difference between the median systolic the United States (ICU-RESUSCITATION,145 Pediatric
blood pressure between subjects with new substantive Intensive Care Quality of CPR study,148 and Get With
morbidity and those without (76.3 mm Hg versus 63 The Guidelines-Resuscitation). Other studies148,150,151 all
mm Hg, P=0.2).150 This was a subpopulation of the sub- used the Pediatric Intensive Care Quality of CPR study
jects in Berg et al (2018).148 cohort but with different subpopulations or outcome
measures.
Presence of Monitoring
The task force noted that in Berg et al (2018), the
A single study149 examining the effect of clinician-
same population was used to both generate and validate
reported use of invasive blood pressure monitoring on
the cutoffs of 25 mm Hg and 30 mm Hg for infants and
CPR quality found no difference in any of the outcomes
children, respectively.148 Berg et al (2023)144 examined
when compared with no use of invasive blood pressure
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other cutoffs but found 25 mm Hg and 30 mm Hg to be

monitoring.
most predictive. We noted that while Berg et al (2018)
Prior Treatment Recommendations (2020) showed a benefit in functional neurological outcome
The confidence in effect estimates is so low that the (aRR, 1.6; 95% CI, 1.1–2.5), Berg et al (2023) did not
panel decided a recommendation was too speculative. (aRR, 1.14; 95% CI, 0.93–1.39). The pooled estimate
suggested benefit (aRR, 1.37; 95% CI, 1.04–1.69).
Treatment Recommendations (2025) Lastly, we noted that certain subgroups were under-­
We suggest targeting an intra-arrest diastolic blood represented, including children with heart disease and
pressure of ≥25 mm Hg for infants <1 year and ≥30 older children.

Table 5. Summative Results of Studies-Pediatric Systolic BP Targets

Anticipated absolute effect* (95% CI)

Risk with a SBP of 60

Certainty of Risk with no BP mm Hg for infants <1 and
Outcomes (importance) Participants (studies), n evidence (GRADE) RR (95% CI) target 80 mm Hg for children ≥1
Survival to hospital discharge (critical) 577 Very low RR, 1.12 507 per 1000 568 per 1000
(2 nonrandomized (0.95–1.32) (482–670)
studies)144,148
Survival with favorable neurological 164 Very low RR, 1.0
outcome (PCPC 1-3 or no change)
(1 nonrandomized (0.7–1.4)
(critical)
study)148
Functional status scale increase by 3 77 Very low RR, 0.70 489 per 1000 342 per 1000
or increase by 2 in single domain (in
(1 nonrandomized (0.40–1.24) (196–606)
survivors) (critical)
study)150

*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI indicates confidence interval; GRADE, Grading of Recommendations, Assessment, Development, and Evaluation; PCPC, Pediatric Cerebral Performance Category;
RR, risk ratio; and SBP, systolic blood pressure.

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Since the evidence is both indirect and imprecise, as Intra-arrest End-Tidal Carbon Dioxide (PLS
described above, the task force limited the recommenda- 4160.07, ScopRev 2020, EvUp 2025)
tion to children with invasive BP monitoring in place at
the time of arrest. Population, Intervention, Comparator, Outcome,
Study Design, and Time Frame
Knowledge Gaps • Population: Infants and children (excluding newborn
• Randomized trial data comparing the benefits or infants) with in-hospital or out-of-hospital cardiac
harms of specific BP targets during arrest arrest
• Use of noninvasive methods to measure BP during • Intervention: The presence of variables (images, cut-
arrest off values or trends) during CPR (intra-arrest) that
• Whether different blood pressure targets would be can provide physiologic feedback to guide resuscita-
more appropriate for older children or adolescents tion efforts, namely: end-tidal carbon dioxide (ETCO2)
• The utility of initiating invasive BP monitoring • Comparators: The absence of such variables
intra-arrest (images, cut-off values or trends)
• Blood pressure targets in children with heart disease • Outcomes: Any clinical outcome
• The importance of diastolic and systolic BP in lon- • Time frame: July 2020 to June 26, 2024
ger arrests, as studies have focused primarily on BP
in the first 10 minutes of CPR Summary of Evidence
• The effect of mean arterial pressure on outcomes This topic was previously reviewed in a ScopRev for
2020,110–112 with an EvUp in 2023126,127 and for 2025.
The complete 2025 EvUp is provided in Appendix B. One
observational study published in 2022 demonstrated an
Intra-arrest Echocardiography (Point-of-Care ­association between ETCO2 monitoring and ROSC in ado-
Cardiac Ultrasound) (PLS 4160.05, ScopRev lescents.154 A propensity weighted cohort study149 conclud-
2020, EvUp 2025) ed that clinician reported use of ETCO2 intra-arrest was
Population, Intervention, Comparator, Outcome, and not associated with ROSC in children. The ICU-­R ESUS
Time Frame trial was a large multicenter prospective observational co-
• Population: Infants and children (excluding newborn hort study. A secondary analysis study of ICU-RESUS trial
infants) with cardiac arrest. found no association between ETCO2 in first 10 minutes
Downloaded from [Link] by on October 27, 2025

• Intervention: The presence of variables (images, CPR event and survival with favorable neurologic out-
cut-off values or trends) during CPR (intra-arrest) come.155 However, an ancillary study of children in ICU-
that can provide physiologic feedback to guide RESUS trial (CPR-NOVA)156 found a higher incidence of
resuscitation efforts, namely: echocardiography/ ROSC and survival to hospital discharge in patients with
point-of-care cardiac ultrasound ETCO2 target >20 mm Hg. It is the first pediatric study to
• Comparators: The absence of such variables support use of ETCO2 monitoring intra-arrest and defines
(images, cut-off values or trends) an intra-arrest ETCO2 target. A SysRev may be justified
• Outcomes: Any clinical outcome following future studies assessing this question.
• Time frame: July 2020 to June 26, 2024 Prior Treatment Recommendation (2020,
Summary of Evidence Unchanged From 2015)
A ScopRev was done in 2020,110–112 with an EvUp in The confidence in effect estimates is so low that the pan-
2023126,127 and for 2025. The 2025 EvUp is included el decided that a recommendation was too speculative.157
in Appendix B, and neither EvUp since 2020 identified Treatment Recommendation (2025)
any new pediatric studies on this subject that would in- For children in cardiac arrest monitoring ETCO2 may help
form a treatment recommendation. There is insufficient achieve quality CPR; however, specified values to guide
evidence to support a SysRev. intra-arrest interventions have not been well established
Good Practice Statement (2025) (good practice statement).
The Treatment Recommendation of 2010,121,153 which
was reiterated in 2020,110–112 has been downgraded to
Intra-arrest Near-Infrared Spectroscopy (PLS
a good practice statement based the lack of evidence.
For children in cardiac arrest, echocardiography may 4160.09, ScopRev 2020, EvUp 2025)
be considered to identify potentially treatable condi- Population, Intervention, Comparator, Outcome, and
tions when appropriately skilled personnel are available, Time Frame
but the benefits must be carefully weighed against the • Population: Infants and children (excluding newborn
known deleterious consequences of interrupting chest infants) with in-hospital or out-of-hospital cardiac
compressions (good practice statement). arrest

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

• Intervention: The presence of variables (images, cut- • Comparators: No vasopressor use

off values or trends) during CPR (intra-arrest) that • Outcomes:
can provide physiologic feedback to guide resusci- – Critical: Short-term and long-term survival or neu-
tation efforts, namely near infrared spectroscopy rological outcomes.
• Comparators: The absence of such variables – Important: ROSC.
(images, cut-off values or trends) • Time frame: All years to July 16, 2024
• Outcomes: Any clinical outcome
• Time frame: July 2020 to June 26, 2024 Consensus on Science
Two propensity score matched observational studies
Summary of Evidence were identified,161,163 providing very low– to low-certainty
This topic was last reviewed in a ScopRev for the 2020 evidence. Both studies were in the out-of-hospital set-
CoSTR. The complete EvUp is provided in Appendix B. We ting and compared outcomes of children who received
identified 1 additional abstract158 and a single center ob- epinephrine with children who did not.
servational study by the same authors utilizing data from For favorable neurological outcomes at 1 month, 1
3 hospitals in the Pediatric Resuscitation Quality Collab- study163 involving 608 patients found no significant dif-
orative.159 Both studies concluded that higher median ce- ference when epinephrine was administered compared
rebral regional oxygen saturation measured with cerebral with no epinephrine (15 more patients with favorable
near infrared spectroscopy during IHCA in children was neurological survival at 1 month per 1000 resuscitations;
associated with increased rate of ROSC and survival to 95% CI, 11 fewer to 92 more).163
hospital discharge. A SysRev is not indicated at this time. For favorable neurological outcome at hospital dis-
charge, the second study,161 involving 1432 patients, found
Good Practice Statement (2025) no significant difference when epinephrine was adminis-
The treatment recommendation of 2020110–112 has been tered compared with no epinephrine (9 more patients with
downgraded to a good practice statement based on the favorable neurological survival at hospital discharge per
lack of evidence. 1000 resuscitations; 95% CI, 13 fewer to 50 more).
Monitoring cerebral oxygenation during cardiopulmo- For survival at 1 month, 1 study163 involving 608
nary resuscitation is a noninvasive metric that does not patients found no significant difference when epineph-
require pulsatile signal and may be beneficial to monitor. rine was administered compared with no epinephrine
However, there is no consensus about a cut-off thresh- (10 more survivors per 1000 resuscitations; 95% CI, 27
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old for cerebral oxygenation that can be used to guide or fewer to 78 more).
terminate resuscitation during in-hospital cardiac arrest For survival to hospital discharge, 1 study161 involving
in children (good practice statement). 1432 patients found no significant difference when epi-
nephrine was administered compared with no epineph-
rine (19 more survivor per 1000 resuscitations; 95% CI,
INTRA-ARREST: DRUGS AND DRUG 7 fewer to 64 more).
ADMINISTRATION For prehospital ROSC, 2 studies161,163 involving 2034
Vasopressor Use During Cardiac Arrest in patients found a benefit when epinephrine was adminis-
tered, compared with no epinephrine (63 more patients
Children (PLS 4080.21, SysRev 2025)
with ROSC per 1000 resuscitations; 95% CI, 28 more
Rationale for Review to 145 more).
Since the SysRev published by the ILCOR PLS Task Force
CoSTR in 2020 on timing of epinephrine initial dose and Prior Treatment Recommendations (2020)
dose interval during CPR in children,110–112 a systematic We suggest that the initial dose of epinephrine in pediat-
review160 and 3 observational studies161–163 have been ric patients with nonshockable IHCA and OHCA be ad-
published examining the effects of Epinephrine in pediat- ministered as early in the resuscitation as possible (weak
ric cardiac arrest. The PLS Task Force therefore prioritized recommendation, very low–certainty evidence).
an updated SysRev, which was registered before initiation We cannot make a recommendation for the timing of
(PROSPERO Registration CRD42024596959). The full the initial epinephrine dose in shockable pediatric car-
CoSTR is available on the ILCOR website.164 diac arrest. The confidence of the effect estimates is
so low that we cannot make a recommendation about
Population, Intervention, Comparator, Outcome, and the optimal interval for subsequent epinephrine doses in
Time Frame pediatric patients with IHCA or OHCA.
• Population: Infants and children (<18 years) in car-
diac arrest who received chest compression in any Treatment Recommendations (2025)
setting We suggest the use of epinephrine in pediatric out-of-
• Intervention: Any use of vasopressors (epinephrine, hospital cardiac arrest (weak recommendation, very low–
vasopressin, combination of vasopressors) certainty evidence).

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

There is insufficient evidence to generate a treatment recommendations; or administration of epinephrine

recommendation for the use of epinephrine in pediatric more or less frequently than every 3 to 5 minutes
in-hospital cardiac arrest. However, the task force con- following the initial dose
siders the indirect evidence from OHCA to support the • Comparators: Timing of administration of epineph-
administration of epinephrine in pediatric in-hospital car- rine in line with current guideline recommendations
diac arrest (good practice statement). • Outcomes: Any clinical outcome
• Time frame: July 2019 to April 25, 2024
Justification and Evidence-to-Decision Framework
Highlights Summary of Evidence
The complete evidence-to-decision table is provided in The complete EvUp is provided in Appendix B. This topic
Appendix A. was last updated by a SysRev for the 2020 CoSTR.110–112
The task force acknowledged that the included stud- This EvUp identified 5 new pediatric observational stud-
ies were from settings with advanced emergency medi- ies on this subject since the last review.161,168–171 Given
cal services. In similar settings, the administration of the lack of a recommendation for epinephrine dosing in-
epinephrine as part of advanced pediatric life support tervals, a future SysRev may be warranted. However, no
for pediatric OHCA should be continued but also further evidence for the time to first dose epinephrine in shock-
evaluated. able rhythms was identified and a SysRev for this ques-
However, there are very few studies looking at tion is not justified.
resources required to train, maintain skillsets, and pro-
Treatment Recommendation (2020)
vide the necessary equipment for emergency medical
We suggest the initial dose of epinephrine in pediatric
services systems to administer epinephrine in pediatric
patients with both nonshockable IHCA and OHCA be ad-
OHCA.
ministered as early in the resuscitation as possible (weak
The task force acknowledged that the ALS Task
recommendation, very low–certainty evidence).110–112
Force currently recommends the use of epinephrine in
We cannot make a recommendation for the timing of
adult cardiac arrest. The PLS Task Force did not include
the initial epinephrine dose in shockable pediatric car-
indirect evidence from adults because of differences in
diac arrest.
etiologies of cardiac arrest in children.161,163,166
The confidence of the effect estimates is so low that
Knowledge Gaps we cannot make a recommendation regarding the opti-
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• The effect of potential undesirable effects of epi- mal epinephrine interval for subsequent epinephrine
nephrine. Adverse outcomes from administration of doses in pediatric patients with IHCA or OHCA.
epinephrine have been reported.162
• Whether specific subpopulations might potentially
benefit (or not) from administration of epinephrine Calcium Use During Cardiac Arrest (PLS
in the prehospital setting. 4090.01, SysRev 2023, EvUp 2025)
• Cost-effectiveness and feasibility of the provision
Population, Intervention, Comparator, Outcome, and
of advanced pediatric life support in the prehospi-
Time Frame
tal settings (across resource rich and limited emer-
• Population: Infants and children (excluding newborn
gency medical services systems) to facilitate the
infants) with in-hospital or out-of-hospital cardiac
administration of epinephrine in pediatric OHCA
arrest
while ensuring high-quality basic life support.
• Intervention: Calcium administration
• Effect of vasopressors during cardiac arrest in the
• Comparators: No calcium administration
inpatient setting, especially in the context of initial
• Outcomes: Any clinical outcome
resuscitation of pediatric cardiac arrest patients
• Time frame: November 2019 to October 26, 2024
prior to ECPR.167,168
Summary of Evidence
A SysRev on this topic was published172 for the 2023
Epinephrine Administration Timing in Cardiac CoSTR summary.126,127 The 2025 EvUp is provided in Ap-
Arrest (PLS 4090.02, SysRev 2020, EvUp 2025) pendix B. We identified 2 additional observational studies
Population, Intervention, Comparator, Outcome, and in children, both of which found a significantly lower rate of
Time Frame sustained ROSC, lower survival rate to hospital discharge
• Population: Infants and children (excluding newborn and lower survival to discharge with favorable neurologic
infants) with in-hospital or out-of-hospital cardiac outcome associated with use of calcium in arrest.173,174
arrest There is insufficient evidence to support a new SysRev.
• Intervention: Administration of the initial dose of The use of calcium for documented hypocalce-
epinephrine earlier or later than current guideline mia, hypermagnesemia, or suspected calcium channel

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

blocker overdose was not included in this review. Further • Comparators: Administration of another anti-
evaluation of the use of calcium in these special circum- arrhythmic or placebo
stances is required. The use of calcium in hyperkalemia • Outcomes: Any clinical outcome
is reviewed separately. • Time frame: July 5, 2022, to October 1, 2024
Treatment Recommendation (2020) Summary of Evidence
Routine use of calcium for infants and children with car- This topic was last reviewed with a SysRev in 2018177–179
diopulmonary arrest is not recommended in the absence and EvUp in 2023.126,127 The complete EvUp is provid-
of hypocalcemia, calcium channel blocker overdose, hy- ed in Appendix B. Our EvUp identified no new pediatric
permagnesemia, or hyperkalemia.110–112 studies on this subject. There is insufficient evidence to
support the conduct of a systematic review.

Sodium Bicarbonate Administration in Cardiac Treatment Recommendation (2018)

We suggest that amiodarone or lidocaine may be
Arrest (PLS 4090.04, EvUp 2020, EvUp 2025) used for the treatment of pediatric shock-resistant
Population, Intervention, Comparator, Outcome, and VF/pVT (weak recommendation, very low–quality
Time Frame evidence).178,179
• Population: Infants and children (excluding newborn
infants) with in-hospital or out-of-hospital cardiac
arrest IO Versus IV in Cardiac Arrest (PLS 4080.15,
• Intervention: Use of sodium bicarbonate with a cer- EvUp 2022, EvUp 2025)
tain dose and timing
Population, Intervention, Comparator, Outcome, and
• Comparators: No sodium bicarbonate
Time Frame
• Outcomes: Any clinical outcome
• Population: Infants and children (excluding newborn
• Time frame: December 1, 2020, to October 21,
infants) with in-hospital or out-of-hospital cardiac
2024
arrest
Summary of Evidence • Intervention: Placement of an IO cannula and drug
An EvUp was done for the 2020 CoSTR,110–112 and the administration through this IO during cardiac arrest
treatment recommendation from 2010 was maintained. • Comparators: Placement of an IV cannula and drug
Downloaded from [Link] by on October 27, 2025

The current EvUp identified 2 pediatric studies, 1 a administration through this IV during cardiac arrest
meta-analysis175 and the other, a secondary analysis of • Outcomes: Any clinical outcome
a ­prospective RCT.176 Both found sodium bicarbonate • Time frame: December 1, 2021, to May 10, 2024
administration during pediatric cardiac arrest was as-
sociated with a significantly decreased rate of survival Summary of Evidence
to hospital discharge. The complete EvUp is provided in A SysRev on this topic was last conducted in 2020, and
Appendix B. Based on this EvUp, we plan to conduct a no evidence in children was found at that time so the
systematic review. 2010 recommendation was maintained.110–112 An EvUp
included in the 2022 CoSTR summary70,72 identified 2
Treatment Recommendation (2010) registry studies180,181 that were not thought sufficient to
Routine administration of sodium bicarbonate is not warrant updating the SysRev and treatment recommen-
recommended in the management of pediatric cardiac dations. The EvUp for 2025 identified no new pediatric
arrest.110–112,121,153 studies. The ALS Task Force conducted a SysRev182 for
this PICOST for 2025, but the PLS Task Force agreed
that the adult evidence is too indirect to be considered
Anti-Arrhythmic Drugs in Cardiac Arrest With relevant to the infant and child population. The adult
Shockable Rhythms (PLS 4080.04, SysRev evidence may have some relevance to the adolescent
2018, EvUp 2023, EvUp 2025) population and may be explored by the task force in
the future.
Population, Intervention, Comparator, Outcome, and
Time Frame Treatment Recommendation (2020, Unchanged
• Population: Infants and children (excluding newborn From 2010)
infants) with in-hospital or out-of-hospital cardiac Intraosseous cannulation is an acceptable route of
arrest and a shockable rhythm at any time during vascular access in infants and children with cardiac ar-
CPR or immediately after ROSC rest. It should be considered early in the care of criti-
• Intervention: Administration (IV or IO) of an anti- cally ill children whenever venous access is not readily
arrhythmic drug available.110–112

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

INTRA-ARREST: SPECIAL Task Force Insights

The evidence identified was limited by conflicting results
CIRCUMSTANCES and differences in outcomes measured. The overall re-
Cardiopulmonary Resuscitation in Obese sults do not suggest a requirement to deviate from stan-
Patients (ScopRev 2025) dard CPR protocols.
Rationale for Review
This topic was chosen as a ScopRev by the PLS and Good Practice Statement (2025)
BLS Task Forces because of the increasing preva- Standard CPR protocols should be used in obese pa-
lence of obesity worldwide and the specific chal- tients (good practice statement).
lenges in providing cardiopulmonary resuscitation to
this patient cohort. This topic has not previously been Knowledge Gaps
reviewed by ILCOR. The full ScopRev report is avail- • Few studies of CPR in obese infants, children, and
able online.183 adolescents
• A standardized definition of obese, or population
Population, Intervention, Comparator, Outcome, and specific definition of obese, for the purpose of
Time Frame resuscitation research
• Population: Adults and children in any setting (in- • More robust adjusted analyses of the impact of obe-
hospital or out-of-hospital) with cardiac arrest sity on CPR outcomes
• Intervention: Cardiopulmonary resuscitation (includ- • The effect of obesity on CPR techniques, CPR qual-
ing mechanical and ECPR) in obese patients (as ity, and time to and delivery of resuscitation inter-
defined in specific papers) ventions in both adults and children
• Comparators: May have no comparator, comparator • Whether the degree of obesity influences CPR
of non-obese patients, or comparator of modified performance, outcomes following CPR including
CPR for obese patients with standard CPR health-related quality of life, or inclusion in CPR
• Outcomes: research
– Critical: survival to hospital discharge with good • The effect of patient obesity on those providing
neurological outcome and survival to hospital CPR (physical exertion, manual handling, fatigue)
discharge.
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– Important: ROSC, CPR quality measures (chest

compression rate, chest compression depth,
IHCA Due to Suspected Cardiac Shunt/Stent
ventilation rate, tidal volume, end-tidal CO2), Obstruction (PLS 4030.25, SysRev 2025)
CPR timing (time to commencement of res- Rationale for Review
cue breaths, first compression, first defibril- Aortopulmonary shunts and patent ductus arteriosus
lation if shockable rhythm), CPR techniques stents are important tools for the palliation of patients
(chest compressions, defibrillation, ventilation with congenital heart disease. Current therapies for acute
and airway management, vascular access and shunt obstruction can include any of the following: (1) in-
medications), health related quality of life and creasing the inspired oxygen concentration to maximize
outcomes for those providing CPR (safety, man- alveolar oxygenation; (2) vasoactive agents to maximize
ual handling). shunt perfusion pressure; (3) anticoagulation with heparin
• Time frame: All years to October 1, 2024 to prevent clot propagation; (4) shunt intervention by cath-
eterization or surgery; (5) stabilization with ECPR/ECMO;
Summary of Evidence (6) sternal re-opening to relieve shunt compression.187–192
Adult evidence is summarized in the BLS CoSTR pa- The PLS Task Force prioritized this SysRev to define
per.120 There were 2 studies of children184,185 and 1 study what specific interventions other than standard CPR
in which patient age was not reported.186 Both pediatric may improve clinical outcomes in pediatric IHCA due to
studies184,185 reported worse neurological outcomes in suspected aortopulmonary shunt/stent obstruction. The
obese children (compared with normal weight children) SysRev was registered before initiation (PROSPERO
at hospital discharge185 and 12 months.184 Registration CRD42017080475). The full CoSTR can
Survival to hospital discharge was reported in one be found on the ILCOR website.193
pediatric study185 in which survival to hospital discharge
was less likely in obese children than normal weight chil- Population, Intervention, Comparator, Outcome, and
dren after cardiac arrest.185 Time Frame
The same study showed that obese children had sig- • Population: Infants and children in cardiac arrest in
nificantly lower chance of ROSC than normal weight chil- the in-hospital setting who have suspected aorto-
dren (IHCA).185 pulmonary shunt/stent obstruction

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

• Intervention: Any intervention (administration of Task Force. The SysRev was registered before initiation
oxygen, vasoactive agents to increase shunt/stent (PROSPERO Registration CRD42024560884). The full
perfusion pressure, ECPR, heparin, sternal opening, CoSTR can be found on the ILCOR website.194
catheter-based intervention, surgical intervention)
or a combination of these interventions Population, Intervention, Comparator, Outcome, and
• Comparison: Standard resuscitation Time Frame
• Outcomes: Any clinical outcome • Population: Infants and children (excluding newborn
• Time frame: Literature search included all years up infants) who are in cardiac arrest due to confirmed
to June 6, 2024 or suspected PE in any setting
• Intervention: Any specific alteration in the treatment
Consensus on Science algorithm (eg, fibrinolysis, embolectomy, thrombec-
There were 15 articles screened in full text and none met tomy, with or without ECPR)
criteria for inclusion. • Comparison: Standard CPR
• Outcomes: Any clinical outcome
Treatment Recommendations (2025) • Time frame: All years to May 15, 2024
There is insufficient evidence to make a treatment rec-
ommendation for infants and children in cardiac arrest Consensus on Science
in the in-hospital setting who have suspected aorto- No pediatric studies were identified that directly com-
pulmonary shunt/stent obstruction other than standard pared standard cardiac arrest care with any specific al-
resuscitation. teration in the treatment algorithm due to confirmed or
suspected PE.
Justification and Evidence-to-Decision Framework Two small single-center case series described a total
Highlights of 10 infants and children where individual or combined
No evidence was identified, and therefore no treatment interventions (fibrinolysis, embolectomy, thrombectomy,
recommendations other than following standard resusci- with or without ECPR) were used in addition to standard
tation recommendations could be made. care for cardiac arrest associated with confirmed or sus-
pected pulmonary embolism.195,196
Knowledge Gaps One single institution case series identified PE as
• There is an absence of RCTs or comparative studies the cause of IHCA in 5 (6.3%) of 79 children who
focused on interventions for IHCA due to aortopul-
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received at least 5 minutes of CPR for an IHCA.195

monary shunt or stent obstruction. They were treated with thrombolysis (IV tissue plas-
• There is an absence of data on the effectiveness minogen activator) in addition to standard CPR; 4 of 5
of individual interventions (eg, vasoactive agents, patients were successfully resuscitated and survived to
heparin) or their combinations in improving clinical hospital discharge. Three patients had intact neurologi-
outcomes. cal outcome.
• More data are needed on the benefit of using ECPR A retrospective cohort study of pediatric PE out-
in patients with specific cardiac anatomies, like comes and risk factors from 2 Canadian pediatric hos-
those with single ventricle physiology status post pitals reported 170 children aged 18 years or younger
shunt or stent. Further research is required to deter- with massive and sub-massive pulmonary embolism, 5 of
mine its effectiveness and potential risks in these whom suffered cardiac arrest.196 Patients were treated
subgroups. with a single or combined interventions (embolectomy,
• Data are lacking on survival rates and neurologi- thrombolysis, and catheter-directed thrombolysis) with
cal outcomes following cardiac arrest due to shunt or without ECMO during or after cardiac arrest for PE
obstruction in pediatric patients. in addition to the standard cardiac arrest algorithm.
• More information is needed on the ideal timing and Five cases achieved ROSC and 4 survived to hospital
combination of therapies (eg, vasoactive agents, discharge.
anticoagulation, surgical intervention).
Treatment Recommendations (2025)
There is insufficient evidence to make a treatment rec-
Cardiac Arrest Due to Pulmonary Embolism ommendation for or against the use of any specific alter-
(PLS 4160.10, SysRev 2025) ation to the cardiac arrest algorithm for pediatric cardiac
arrest due to suspected or confirmed PE.
Rationale for Review
Pulmonary embolism (PE) is a rare and potentially treat- Justification and Evidence-to-Decision Framework
able cause of cardiac arrest in children and adoles- Highlights
cents. This question had not previously been examined The complete evidence-to-decision table is provided in
for children and was prioritized for review by the PLS Appendix A.

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

The task force considered additional data that did not Consensus on Science
meet the SysRev inclusion criteria. A single-center ret- The evidence in children in summarized here. For
rospective study of 33 children with massive and sub- the results in adults, see the ALS CoSTR202 and the
massive PE reported 4 patients who sustained cardiac SysRev.200
arrest. One patient died despite standard cardiac arrest
care, while 1 of the 3 who were also treated with one Change in Potassium Values (Nonarrest)
of (or a combination of) systemic fibrinolysis, catheter- Five neonatal studies, 4 interventional and 1 observa-
directed fibrinolysis, embolectomy or ECMO survived.197 tional, tested insulin and glucose using a weight-based
In 15 pediatric case reports that did not meet the ­SysRev approach.203–207 Two studies reported decrease in potas-
inclusion criteria, 4 patients treated using a standard sium while 2 reported no change. The studies could not
cardiac arrest algorithm did not survive. Seven of the 11 be pooled due to differences in methodology.
patients treated with alterations to the algorithm (fibrino- Four studies in neonates and children (53 patients)
lysis, embolectomy, ECMO) survived to hospital discharge. compared intravenous β2-agonists (salbutamol, 4–5
µg/kg) with no treatment for acute hyperkalemia. Meta-
Knowledge Gaps analysis showed a mean decrease in potassium of 1.0
• Effectiveness of fibrinolysis, embolectomy, throm- mmol (95% CI, 1.5 lower to 0.6 lower) (follow-up range
bectomy with or without ECMO in children who had 60 mins).208–211 Only 1 pediatric study investigated com-
an in-hospital cardiac arrest due to apparent or con- bination therapy of intravenous β-agonists and insulin
firmed PE with glucose which showed a reduction in potassium
level from a mean (SD) 6.8 mmol (0.6) to 5.0 (1.2) after
45 minutes with the intervention.212
Pharmacological Interventions for the Inhaled β2-agonists (400 µg salbutamol as inhalation)
Treatment of Hyperkalemia in Children with were compared with no treatment for acute hyperkale-
Cardiac Arrest (PLS 4160.17, SysRev 2025) mia in 3 studies in neonates (51 patients in total), and
Rationale for Review meta-analysis showed a mean decrease in potassium of
Hyperkalemia is a potentially reversible cause of cardiac 0.9 mmol (95% CI, 1.2 lower to 0.5 lower) in the treat-
arrest in both adults and children. Although alternative ment group (follow-up range 240 mins).204,207,213
approaches to advanced life support in patients with Outcomes in Cardiac Arrest
­hyperkalemia-caused cardiac arrest are recommended
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Two observational studies investigated the treatment of

by resuscitation councils,6,113,198,199 this topic has never hyperkalemia during cardiac arrest. Both studies investi-
been formally reviewed by ILCOR. The SysRev was initi- gated the use of calcium; 1 retrospectively in adult pa-
ated as nodal between ALS and PLS Task Forces.200 The tients214 and 1 as a secondary analysis of a prospective
SysRev was registered before initiation (PROSPERO study (ICU-RESUSCITATION project) in infants and chil-
Registration CRD42023440553). The full CoSTR can dren.174 The adult study found a lower unadjusted rate of
be found on the ILCOR website.201 ROSC with the administration of calcium, sodium bicar-
bonate, or the combination.214 In the pediatric study, cal-
Population, Intervention, Comparator, Outcome, and cium was frequently used during cardiac arrest and was
Time Frame associated with worse outcomes.174 Both studies were
• Population: Adults and children with hyperkalemia in assessed as high risk of bias. No studies were found for
any setting (both with or without cardiac arrest) the use of sodium bicarbonate for hyperkalemia in car-
• Intervention: Acute pharmacological intervention diac arrest in children.
with the aim of mitigating the harmful effect of
hyperkalemia or with the aim of lowering potassium Treatment Recommendations (2025)
values For children in cardiac arrest associated with hyperkale-
• Comparators: No intervention, a different interven- mia, there is insufficient evidence to make a treatment
tion (including a different dose), or placebo recommendation for or against the use of calcium.
• Outcomes: For children in cardiac arrest associated with hyper-
– Critical: survival/survival with a favorable neuro- kalemia, there is insufficient evidence to make a treat-
logical outcome (at hospital discharge, 28 days, ment recommendation for or against the use of sodium
30 days,1 month); survival/survival with a favor- bicarbonate.
able neurological outcome at later times (>90 We suggest using intravenous salbutamol or insulin
days); health-related quality of life. with glucose (or a combination of both) in children with
– Important: change in potassium; use of dialy- cardiac arrest associated with hyperkalemia with the
sis; electrocardiographic changes/arrythmias; aim to lower the potassium values during concurrently
cost-effectiveness ongoing high-quality resuscitation efforts (good practice
• Time frame: All years to September 9, 2024 statement).

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Justification and Evidence-to-Decision Framework INTRA-ARREST: ECPR

Highlights
The complete evidence-to-decision table is provided in ECPR in Children With Single Ventricle
Appendix A. Physiology (PLS 4030.09, 4030.10, SysRev
Based on the current systematic review, there is evi- 2025)
dence that treatment with insulin and glucose or inhaled Rationale for Review
or IV β2-agonists causes an acute reduction in potas- The risk of cardiac arrest in a child with single ventricle
sium levels. For all interventions, the reduction in potas- (SV) physiology is elevated.215 Conventional CPR may
sium was consistently in the range of 0.7 to 1.2 mmol/L. not provide adequate reperfusion in this physiology and
Whether this acute decrease in potassium translates to low likelihood of ROSC.216 There is currently no specific
an improvement in clinical outcomes is unclear. recommendation for ECPR that delineates children with
The rationale for administering calcium during car- SV physiology with IHCA refractory to conventional CPR.
diac arrest caused by hyperkalemia is based on the pre- A new SysRev was registered before initiation (PROS-
sumed ability to prevent arrhythmias. Although calcium PERO Registration CRD42023479671). The full CoSTR
is widely recognized and used for this indication, the can be found on the ILCOR website.217
current review did not find any clinical evidence to sup-
port this. Population, Intervention, Comparator, Outcome, and
After discussion, the PLS Task Force decided not to Time Frame
make any statements about the treatment of children not • Population: Infants, children, and adolescents with
in cardiac arrest, although some evidence for this group cardiac arrest following Stage I (Norwood/Hybrid),
of patients exists and is summarized above. Stage II (Hemi-Fontan/Bidirectional Glenn) or
There is no evidence for the use of bicarbonate to Stage III (Fontan) palliation for congenital heart dis-
manage hyperkalemia in children. In adults, bicarbonate ease with SV physiology in the hospital setting
did not lower potassium values or improve outcomes. • Intervention: ECPR including ECMO or cardiopul-
The very low–certainty evidence suggests an asso- monary bypass during resuscitation of cardiac arrest
ciation of calcium with worse outcomes but there are • Comparators: Conventional or manual CPR
critical risks of bias and high uncertainty mainly due to • Outcomes: Critical: survival to hospital discharge;
resuscitation time (duration of resuscitative efforts) bias. survival with favorable neurologic outcome.
The rationale for use of calcium for assumed myocardial
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Important: decannulation from ECMO

protective effect is being questioned. • Time frame: All years to October 2023
The effects of salbutamol and insulin with glucose
on potassium values in cardiac arrest patients have not Consensus on Science
been studied. However, the task force agreed that the Sixteen observational studies were included218–223 all
potential benefits of these pharmacological interventions with very low–certainty evidence. No studies compared
outweigh potential risks, and their use is therefore justi- children with SV physiology who received ECPR with
fied. Inhalational administration of medications is gener- those receiving conventional or manual CPR. Five stud-
ally not feasible and not recommended during cardiac ies compared children with SV physiology who received
arrest, supporting the suggestion for intravenous admin- ECPR with those receiving ECMO without ECPR (ECMO
istration of salbutamol in this setting. non-ECPR).220,221,224–226
An additional 11 studies described ECPR in SV
Knowledge Gaps patients, but with no comparator group.191,218,219,222,223,227–232
• Optimal strategies for reducing potassium val- Of these, 8 studies were single-center observational
ues in children in cardiac arrest associated with cohorts with a total of 318 SV ECPR patients with a
hyperkalemia survival to hospital discharge rate ranging from 32% to
• Whether any decrease in potassium values (in both 62%.218,223,227–232 The remaining 3 studies were regis-
intra-arrest and periarrest patients) translates into try cohorts from the Extracorporeal Life Support Orga-
meaningful patient-centered outcomes such as sur- nization with a total of 805 SV ECPR patients with a
vival to discharge or survival with favorable neuro- survival to hospital discharge rate ranging from 32% to
logical outcomes 34%.191,219,222
• The role of calcium, if any, in protecting myocardial No studies were identified comparing ECPR with con-
cells from hyperkalemia ventional or manual CPR.
• Management of children at high risk of hyperkale-
mia (eg, children with acute or chronic renal failure, ECPR Versus ECMO Non-ECPR
tumor lysis syndrome, or others), particularly regard- For the critical outcome of survival to hospital dis-
ing the preferred treatment, appropriate dosing, and charge we identified 3 observational studies220,221,226
timing of interventions with 91 pediatric SV patients (pooled OR, 0.445; 95%

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

CI, 0.193–1.024) and 2 registry studies225,231 (OR, how to perform open-chest CPR in the context of
1.09; 95% CI, 0.71–1.71, and OR, 0.665; 95% CI, cannulating to central ECPR
0.26–1.72). Collectively these studies found no sig- • Whether oxygenation targets in conventional CPR
nificant difference in survival to hospital discharge with and at the transition to ECPR in cardiac patients
ECPR compared with ECMO non-ECPR in pediatric who have cyanotic heart disease should be aligned
SV patients. with baseline pre-arrest blood oxygen saturations
For the important outcome of decannulation from • Whether there is a circuit prime and transfusion
ECMO, 1 observational study of 40 pediatric SV patients management strategy at the time of ECPR that is
(OR, 1.75; 95% CI, 0.50–6.09) found no difference in optimal
decannulation from ECMO with ECPR compared with • How best to provide early post cardiac arrest care
ECMO non-ECPR.232 with ECPR (oxygenation, decarboxylation, perfusion
pressure)
Subgroup Analyses
• Whether hypothermic temperature control should
Two observational studies221,225 in pediatric SV patients
be delivered with ECPR
status post Stage I Norwood palliation found no dif-
ference in survival to hospital discharge with ECPR
compared to ECMO non-ECPR (OR, 1.09; 95% CI,
­
0.71–1.71, and OR, 0.52; 95% CI, 0.10–2.54).
ECPR for Cardiac Arrest (PLS 4160.02, SysRev
One observational study in pediatric SV patients post 2023, EvUp 2025)
Stage III Fontan palliation found no difference in survival Population, Intervention, Comparator, Outcome, and
to hospital discharge with ECPR compared with ECMO Time Frame
non-ECPR (OR, 0.66; 95% CI, 0.26–1.72).224 • Population: Infants and children (excluding newborn
There were no studies identified in SV patients’ status infants) with in-hospital or out-of-hospital cardiac
post Stage II Hemi-Fontan/Bidirectional Glenn palliation arrest
comparing ECPR to ECMO non-ECPR. • Intervention: ECPR, including extracorporeal mem-
brane oxygenation or cardiopulmonary bypass dur-
Treatment Recommendations (2025) ing resuscitation of cardiac arrest
There is insufficient evidence to make a treatment rec- • Comparators: Conventional or manual CPR without
ommendation for or against the use of ECPR during car- ECPR
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diac arrest in children with single ventricle physiology. • Outcomes: Any clinical outcome
There is insufficient evidence to make a treatment • Time frame: June 2022 to October 1, 2024
recommendation for or against the use of ECPR com-
Summary of Evidence
pared with ECMO non-ECPR in children with single ven-
A SysRev was last conducted on this topic for the 2023
tricle physiology.
CoSTR summary.126,127 This EvUp identified 4 systematic
Justification and Evidence-to-Decision Framework reviews,233–236 1 narrative review,237 and 21 other manu-
Highlights scripts238–257 studying ECPR in the context of pediatric
There is no published evidence in pediatrics that en- cardiac arrest; the great majority in children with cardiac
ables us to compare ECPR with conventional CPR. disease and ICU cardiac arrest. Notably, 2 publications
The available evidence suggests that when comparing studied noncardiac disease,239,249 and 2 publications
ECPR with ECMO non-ECPR in a child with SV physi- examined pediatric OHCA from the Extracorporeal Life
ology the risk of survival to hospital discharge is not Support Organization registry.240,251 The complete EvUp
statistically different in ECPR compared with ECMO is provided in Appendix B. Given the emerging evidence
non-ECPR. in noncardiac populations with IHCA and OHCA, it may
be reasonable to consider a ScopRev in noncardiac pop-
Knowledge Gaps ulations in the next 2 years.
• Comparative prospective studies or randomized tri-
als of ECPR versus conventional or manual CPR Treatment Recommendation (2023)
• Few data on survival with neurologic outcome fol- We suggest that ECPR may be considered as an inter-
lowing cardiac arrest with ECPR vention for selected infants and children (eg, pediatric
• Outcomes of subgroups of SV patients before cardiac populations) with IHCA refractory to conven-
Stage I, and after Stage I, II and III single ventricle tional CPR in settings where resuscitation systems allow
palliation who undergo ECPR ECPR to be well performed and implemented (weak rec-
• How the transition from conventional CPR to ECPR ommendation, very low–certainty evidence).126,127
alters the quality of resuscitation measures There is insufficient evidence in pediatric OHCA to
• How best to provide closed-chest CPR and transi- formulate a treatment recommendation for the use of
tion to a sternal opening for ECPR cannulation or ECPR.

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

POSTRESUSCITATION pressure >10th percentile for age should be targeted

(weak recommendation, very low–certainty evidence).
Blood Pressure Targets Following Return of
Circulation After Pediatric Cardiac Arrest (PLS Justification and Evidence-to-Decision Framework
Highlights
4190.01, SysRev 2025) The complete evidence-to-decision table is provided in
Rationale for Review Appendix A.
Optimal BP targets in infants and children following re- Measurement of BP is a low-cost intervention and
turn of circulation after cardiac arrest are not well de- available in nearly all resource settings. However, the
fined. New evidence emerged after the ILCOR 2024 Task Force did not review the cost-effectiveness of inter-
SysRev,73,74 prompting an updated systematic review mittent, noninvasive BP measurement compared with
this year. The SysRev was registered before initiation invasive arterial or continuous BP measurement.
(PROSPERO Registration CRD42023483865). The full There were no RCTs comparing different treatment
CoSTR can be found on the ILCOR website.258 approaches or BP targets following cardiac arrest. The
available evidence consisted of observational data dem-
Population, Intervention, Comparator, Outcome, and
onstrating the impact of exposure to different BP thresh-
Time Frame
olds on clinically important outcomes. However, the BP
• Population: Infants and children in any setting (in-
thresholds were chosen either a-priori by investigators
hospital or out-of-hospital cardiac arrest) after
as a clinically important threshold (eg, ≤5th percentile)
ROSC or return of circulation (ROC)
or the cut off value was derived statistically from the
• Intervention: A specific blood pressure target
population data as the most significant inflection point
• Comparators: No blood pressure target or a differ-
(≤10th percentile). The task force focused on the impact
ent blood pressure target
of hypotension on clinical outcomes.
• Outcomes: Critical: survival to hospital discharge;
The PLS Task Force considered the exposure overlap
survival with favorable neurological outcome
of the 2 thresholds of systolic blood pressure <5th cen-
• Time frame: August 2023 to April 3, 2024
tile and <10th centile. It was not statistically possible to
Consensus on Science perform meta-regression to compare the 2 treatment tar-
Seven nonrandomized observational cohort studies were gets. The consensus was that the higher threshold cut off
included, 5 of which were secondary analyses.259–265 BP target (<10th centile) included the population included in
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target definitions (eg, systolic, mean, and diastolic BP; the <5th centile group. Acknowledging the low certainty
and >5th, >10th, and >50th centile for age) and time of evidence, the target of >10th centile systolic BP was
frames for measurement (<20 minutes, 0–6 hours, the more acceptable systolic BP goal and ensured avoid-
within 24 hours, and within 0–72 hours) varied across ance of the 5th to 10th BP centiles that were associated
studies. Two studies were excluded as the definition of with worse outcome in the larger study.259
hypotension could not be ascertained.266,267 Additional Although the effect size from the pooled studies is
unpublished data was provided by 2 authors,259,265 which small, the value of the outcome is high and the potential
enabled meta-analysis including these studies. impact on infants and child survivors globally is therefore
The overall certainty of evidence was rated as very large.
low for all outcomes, downgraded for very serious risk of Knowledge Gaps
imprecision, indirectness, inconsistency, and study design. • Interventional randomized controlled trials compar-
BP cut-offs of systolic BP (5th and 10th percentile) ing benefit or harm of targeting specific BP targets
and mean arterial pressure (5th, 10th, and 25th percen- • Information on impact of prehospital BP measure-
tiles) for 0 to 6 hours after return of circulation were ana- ment or treatment for OHCA
lyzed for both survival to hospital discharge and survival • Whether specific sub-groups (eg, medical or cardiac
with favorable neurological outcomes. The results are surgical patients) post return of circulation require
summarized in Table 6. different BP targets (systolic, mean arterial pres-
Prior Treatment Recommendations (2024) sure, or diastolic)
We suggest in infants and children with return of circu- • Data to demonstrate a causal relationship between
lation after an IHCA or OHCA that a systolic BP >10th treatment interventions to achieve higher BP tar-
percentile for age should be targeted (weak recommen- gets and improved outcomes
dation, very low–certainty evidence).73,74 • The optimal strategy to achieve a BP above the
threshold level and any harm associated with these
Treatment Recommendations (2025) interventions
We suggest in infants and children post return of circu- • Optimal BP targets during extracorporeal life sup-
lation, following an in-hospital or out-of-hospital cardiac port post-cardiac arrest or when cerebral autoregu-
arrest, that a systolic or mean arterial pressure blood lation is impaired

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Table 6. Summative Results of Studies for Postarrest BP Targets Review

Study type, No. Certainty of

Outcomes (importance) participants (n) evidence (GRADE) aRR (95% CI) ARD with higher target
Lower target (≤5th centile for age) versus higher target (> 5 centile for age) systolic BP within 6 hours post ROC
th

Survival to hospital discharge Nonrandomized, Very low 1.41; 173 more patients/1000 [95% CI, 84 more
(critical) n=931260–263 (95% CI, 1.20–1.60) patients/1000 to 253 more patients/1000]
survived with the intervention
Favorable neurologic Nonrandomized, Very low 1.30; 132 more patients/1000 [95% CI, 26 more
outcome at hospital n=1371260,261,265 (95% CI, 1.06–1.60) to 264 more patients/1000] survived with
discharge (critical) favorable neurologic outcome with the
intervention
Lower target (≤10th centile for age) versus higher target (>10th centile for age) systolic BP within 6 hours post ROC
Survival to hospital discharge Nonrandomized, Very Low 1.21; 138 more patients/1000 [95% CI, 66 more
(critical) n=693259 (95% CI, 1.10–1.33); patients/1000 to 219 more patients/1000]
P <0.01 survived with the intervention
Favorable neurologic Nonrandomized, Low 1.22; 116 more patients/1000 [95% CI, 53 more
outcome at hospital n=1480259,265 (95% CI, 1.10–1.35); patients/1000 to 185 more patients/1000]
discharge (critical) P <0.01 survived with favorable neurologic outcome
with the intervention
Lower target (≤5th centile for age) versus higher target (>5th centile for age) mean arterial BP within 6 hours post ROC
Favorable neurologic Nonrandomized, n=787265 Low 1.36; 158 more patients/1000 [95% CI, 79 more
outcome at hospital (95% CI, 1.18–1.58); patients/1000 to 254 more patients/1000]
discharge (critical) P <0.01 survived with favorable neurologic outcome
with the intervention
Lower target (≤10th centile for age) versus higher target (>10th centile for age) mean arterial BP within 6 hours post ROC
Favorable neurologic Nonrandomized, n=787265 Low 1.21 102 more patients/1000 [95% CI, 24 more
outcome at hospital (95% CI, 1.05–1.32); patients/1000 to 156 more patients/1000]
discharge (critical) P <0.01 survived with favorable neurologic outcomes
with the intervention
Lower target (≤25th centile for age) versus higher target (>25th centile for age) mean arterial BP within 6 hours post ROC
Favorable neurologic Nonrandomized, n=787265 Low 1.29 150 more patients/1000 [95% CI, 21 fewer
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outcome at hospital (95% CI, 0.96–1.74) patients/1000 to 382 more patients/1000]

discharge (critical) survived with favorable neurologic outcome
with the intervention

ARD indicates absolute risk difference; aRR, adjusted risk reduction; CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development, and
Evaluation; and ROC, return of circulation.

Prediction of Survival With Poor Neurological CI). A low FPR rate means that few patients who are
Outcome After Return of Circulation Following predicted to have poor outcome will in fact have a favor-
able outcome. The task force considered that for pre-
Pediatric Cardiac Arrest—Combined Prognostic diction of poor outcome, a low FPR (eg, <1%) is more
SysRev (PLS 4220.01, 4220.02, 4220.03, desirable than a high sensitivity. The cut-off of FPR <1%
4220.04, SysRev 2025) (equivalent to 99% specificity) was chosen as the con-
Rationale for Review sequences of false pessimism are substantial and may
The PLS Task Force undertook a SysRev considering result in discontinuation of life-sustaining therapy in
the use of individual prognostic tests including clinical patients who would have had a good outcome.
signs, blood biomarkers, brain electrophysiology, and Except where noted, all PICOST questions for neuro-
brain imaging to predict poor neurological outcome prognostication used the same population, comparator,
(PROSPERO Registration CRD42021279221). This is outcome, study design, and time frame. The timing of the
the second part of a SysRev following the original review intervention/diagnostic test was also the same for each.
of individual prognostic tests for predicting good neuro- These parameters are therefore listed here once and not
logical outcome268 published in the 2023 CoSTR sum- repeated in subsequent sections. For all topics, the avail-
mary).126,127 The full CoSTRs can be found on the ILCOR able evidence had a high risk of bias based on heteroge-
website.269–272 neity across studies, few studies/patients included, lack
We defined poor neurological outcome prediction as of blinding, variation in test assessment and performance,
imprecise when the false positive rate (FPR) was >1%. and variability in outcome measurement. Therefore, no
We defined the evidence as reliable if the FPR was <1% meta-analysis was performed, and evidence is considered
(with upper 95% CIs <10%) and moderately reliable if very low certainty. Overall assessment of test performance
FPR was <1% (without a restriction on width of 95% was based on visual assessment of forest plots. If only 1

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

study was available (with small patient sample size), then a neuro-specific enolase (NSE), S100 calcium-binding
suggestion or recommendation could not be made. protein B (S100b), glial fibrillary acidic protein, neuro-
filament light chain (NfL), or blood markers of inflamma-
Population, Intervention, Comparator, Outcome, and tion or systemic ischemic reperfusion (eg, blood pH or
Time Frame lactate).
• Population: Children (<18 years) who achieve spon-
taneous or mechanical ROC after resuscitation from Consensus on Science
IHCA and OHCA. Blood biomarker accuracy is summarized in Table 7. Lac-
• Intervention: Index prognostic tests, recorded at one tate was evaluated in 6 studies.273–278 Only 2 of the 6
or more of the following time points: <12 hours, 12 identified an FPR <1% for poor outcome prediction.273,278
to 24 hours, 24 to 48 hours, 48 to 72 hours, 72 Persistent acidosis (pH <7.0) had a FPR for poor out-
hours to 7 days, or 7 to 10 days after cardiac arrest come prediction of 5% to 20% and low sensitivity in 4
• Comparators: There was no control group for inter- studies.273,276–278 pH and lactate were not reliable prog-
vention/exposure. The accuracy of the prognostic nostic tests.
index test was assessed by comparing the predicted Three studies reported NSE and S100b in 156 chil-
outcome with the final outcome, which represents dren.278–280 At 24 hours, S100b predicted a poor neuro-
the comparator. logical outcome with an FPR of 0% (95% CI, 0%–20%)
• Outcomes: and a sensitivity of 29%–38%.278–280 Similarly, NSE pre-
– Critical: survival with poor neurological outcome dicted a poor neurological outcome with a FPR of 0%
defined as a Pediatric Cerebral Performance (95% CI, 0%–20%) and a sensitivity of 19%–26%.278–
Category score of >3, or Vineland Adaptive
280
Myelin basic protein was assessed in 1 study at 24
Behavioral Scale-II <70. Pediatric Cerebral and 48 hours, predicting poor neurological outcome
Performance Category score ranges 1 (normal), 2 with low FPR 0% (95% CI, 0%–20%).280 NSE, S100b
(mild disability), 3 (moderate disability), 4 (severe and myelin basic protein all fulfilled reliable test criteria
disability), 5 (coma), and 6 (brain death) but with a wide range of cutoff thresholds in the indi-
– Important: poor neurological outcomes measured vidual studies.
with other assessment tools; Pediatric Cerebral Only 1 study reported ubiquitin C-terminal hydrolase
Performance Category score >2; change in L1 (UCH-L1), NfL, tubulin associated unit (Tau), and glial
Pediatric Cerebral Performance Category score fibrillary acidic protein biomarker prediction of poor neu-
Downloaded from [Link] by on October 27, 2025

>2 from baseline rological outcome at 24, 48, and 72 hours.281 These tests
• Time frame: All years up to August 24, 2024 did not reach pre-specified reliability thresholds.
Treatment Recommendations (2025)
Blood Biomarkers for the Prediction of Poor We recommend that no single blood-based biomarker be
Neurological Outcome After ROC Following used in isolation to predict poor neurological outcome
in children after cardiac arrest (strong recommendation,
Pediatric Cardiac Arrest (PLS 4220.01, SysRev very low–certainty evidence).
2025) Clinicians should use multiple tests in combination
Intervention: Blood biomarkers, including serum biomark- for poor neurological outcome prediction (good practice
ers either specific to central nervous system damage, eg, statement).

Table 7. Blood Biomarker Test for Poor Neurological Outcome Prediction Accuracy

False positive rate

Category Study count Patients n= Threshold and time scale (estimate or range) [95% CI] Sensitivity
Lactate 1 278
94 >28.8 mmol/L at <1 hr <1% [0%–8%] 11%
Lactate 1273 61 >2 mmol/L by 48 hr <1% [0%–11%] 23%
Lactate 4 273,275–277
780 >2 mmol/L at 6, 12, 24, and 48 hr 14%–84% 32%–94%
Lactate 1274 120 >5 mmol/L at 24 hr 11% [5%–19%] 83%
NSE 3 278–280
152 53.1 µg/L, 56 µg/L, 7 and 132.7 µg/L 0% [0%–20%] 19%–26%
at <1 hr or 24 hr
S100b 3278–280 156 0.128 µg/L, 2.0 µg/L, and 2.24 µg/L at 0% [0%–20%] 29%–38%
<1 hr or 24 hr
MBP 1280 43 5.83 µg/L at <1 hr or 24 hr 0% [0%–20%] 4%–12%
UCH-L1, NfL, Tau and 1 281
117 Variable best thresholds at 24, 48, or 4%–5% 12%–61%
GFAP 72 hr

GFAP indicates glial fibrillary acidic protein; MBP, myelin basic protein; NfL, neurofilament light chain; NSE, neuron-specific enolase; S100b, S100 calcium binding
protein B; Tau, tau protein; and UCH-L1, ubiquitin carboxy-terminal hydrolase L1.

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

We suggest against using lactate and pH after return blinding of clinicians to test results and only 1 study had
of circulation for predicting poor neurological outcome blinded outcome assessment.
in children after cardiac arrest at any time point (weak
Knowledge Gaps
recommendation, very low–certainty evidence).
• The prognostic value of potential candidate bio-
There is insufficient evidence to make a recom-
markers that are more specific for neurological
mendation for or against the use of other blood-based
injury (eg, NSE, S100b, NfL, glial fibrillary acidic
biomarkers (eg, S100 beta, neuron specific enolase,
protein, Tau, UCH-L1)
neurofilament light chain, etc) after return of circulation
• Economic cost evaluation and cost-effectiveness of
for predicting poor neurological outcome in children after
biomarker testing
cardiac arrest at any time point.
• Optimal multimodal prognostication, including tim-
Justification and Evidence-to-Decision Framework ing, definitions of testing, accurate outcome timing,
Highlights and outcome definition
The complete evidence-to-decision table is provided in • Wider research and consultation with patients, chil-
Appendix A. dren, parents, guardians and caregivers, health care
Included studies were observational studies and professionals, and members of the wider society on
RCTs, but not primarily designed to test prognosis of understanding survivorship after pediatric cardiac
blood biomarkers. arrest to inform correct definitions and framework
Lactate and pH were nonspecific markers of hypoxia- of neurological outcome for prediction research
ischemia following cardiac arrest. Extreme values (very
high lactate, very low pH) have a low FPR in the included
studies, but frequent outliers and very low sensitivity
Clinical Examination for the Prediction of
were reported. Poor Neurological Outcome After Return of
Four studies identified threshold values across a range Circulation Following Pediatric Cardiac Arrest
of blood-based biomarkers (S100b, NSE, myelin basic (PLS 4220.02, SysRev 2025)
protein, UCH-L1, NfL, Tau, and glial fibrillary acidic protein) Intervention: Clinical examination, including every part
that are known to represent brain injury and are associated of a bedside neurological clinical examination, including
with poor neurological outcome with a low FPR. However, pupillary response (assessed using manual light reflex
sensitivity was low and the wide range of reported thresh- or automated pupillometry), conscious level (eg, Glasgow
Downloaded from [Link] by on October 27, 2025

olds preclude any accurate description of clinical utility. Coma Scale [GCS] score or Full Outline of Unrespon-
Furthermore, they are not widely available for clinical use, siveness score), and brainstem reflexes
even though they only require the patient’s blood.
No studies reported any assessment of the confound- Consensus on Science
ing influence of medication. None of the included studies Summary results of clinical examination tests and predic-
specifically excluded the presence of residual sedation at tive accuracy are in Table 8.
the time clinical examination was assessed. Absence of the pupillary light reflex prior to 24 hours
Lack of blinding is a major limitation of biomarker was not a reliable prognostic test. At 48 and 72 hours
tests, even if the withdrawal of life-sustaining therapy after ROC, FPR was less than 1% but 95% confidence
based on test results has not been documented in any intervals were wide.280,282–287 No studies evaluated infor-
of the studies included in our review. No studies included mation from automated pupillometry.

Table 8. Clinical Examination Test Accuracy for Poor Neurological Outcome Prediction

Patients False positive rate Sensitivity

Test domain No. of studies n= Time scale (estimate or range) [95% CI] (range) or [95% CI]
Pupil reactivity 7280,282–286 312 <1 hr to 24 hr 10%–60% 33%–84%
Pupil reactivity 3280,282,287
139 48 hr and 72 hr <1% [0%–40%] 12%–46%
GCS motor score <4 3282,297,299 252 <1 hr and at 4 to 6 hr 50%–83% 86%–94%
GCS <7 1285
152 24 hr 69% [41%–89%] 94% [73%–100%]
Motor response 1282 27 48 hr 20% [1%–72%] 73% [50%–89%]
Motor response 1282 29 72 hr <1% [0%–28%] 61% [36%–83%]
Pain response 1288
41 6 hr to 12 hr 0% [0%–15%] 33% [13%–59%]
Cough or gag response 2286 153 24 hr 60% [36%–81%] 65%–68%
Pain response 1287
20 72 hr 8% [0%–38%] 75% [35%–97%]

GCS indicates Glasgow Coma Scale.

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Total GCS285 and GCS motor score of less than No studies reported any assessment of the confound-
4279,294,296 as assessments of level of consciousness ing influence of medication.
were not predictive of poor neurological outcome. No studies included blinding of test results from
GCS was an unreliable test and motor response was treating clinicians and only 1 study had blinded out-
moderately reliable in only 1 study at 72 hours.282 come assessment (for pupil light reactivity). Lack of
Presence of other brainstem reflexes (pain, gag reflex, blinding is a major limitation of clinical examination
and cough reflex) were infrequently reported and tests studies.
unreliable.,286–288 The studies inconsistently reported the co-­intervention
of temperature control on the clinical assessments that
Prior Treatment Recommendations (2015) will be affected by hypothermia.
We suggest that practitioners use multiple variables Despite its limitations, given the ease of conducting a
when attempting to predict outcomes for infants and bedside assessment, the balance between the costs and
children after cardiac arrest (weak recommendation, very benefits favors benefits for the functional assessment of
low–quality evidence). pupil light reactivity and coma.
No previous recommendation regarding use of clinical
exam.
Knowledge Gaps
Treatment Recommendations (2025) • Clinical examination for prognostication after car-
We recommend that no single clinical examination test diac arrest appears promising, but more research is
be used in isolation to predict poor neurological outcome required in infants and children.
in children after cardiac arrest (strong recommendation, • The impact of residual medication or temperature
very low–certainty evidence). on pupillary light reflex assessment, coma score and
Clinicians should use multiple tests in combination motor response in infants and children
for poor neurological outcome prediction (good practice • Costs and benefits of the use of automated pupil-
statement). lometry compared with simple pupillary light reflex
The absence of pupil reactivity to light at 48 and 72 assessment
hours after ROC may be considered as part of multi- • Economic cost and cost-effectiveness of clinical
modal testing to predict poor neurological outcome in examination for prognostication of poor neurologic
children after cardiac arrest (good practice statement). outcome
Downloaded from [Link] by on October 27, 2025

We suggest against using absence of pupil reactivity • Optimal approach to prognostication using mul-
to light within 24 hours after ROC to predict poor neu- timodal approaches, timing, definitions of testing,
rological outcome in children after cardiac arrest (weak accurate outcome timing and outcome definition
recommendation, low-certainty evidence). • We encourage wider research and consultation with
We suggest against using GCS within 24 hours after patients, children, parents, guardians and caregiv-
ROC to predict poor neurological outcome in children ers, health care professionals and members of the
after cardiac arrest (weak recommendation, low-­certainty wider society on understanding survivorship after
evidence). pediatric cardiac arrest to inform correct definitions
There is insufficient evidence to make a recommen- and framework of good neurological outcome for
dation for or against the use of other brainstem or motor prediction research.
response tests to predict poor neurological outcome in
children after cardiac arrest at any time point.
Electrophysiology Testing for the Prediction
Justification and Evidence-to-Decision Framework of Poor Neurological Outcome After ROC
Highlights
The complete evidence-to-decision table is provided in
Following Pediatric Cardiac Arrest (PLS
Appendix A. 4220.03, SysRev 2025)
For total GCS, GCS motor score and overall motor Intervention: Electrophysiology testing, including sur-
response, and brain stem tests, only 1 study was avail- face bioelectrical recordings from the central nervous
able (with small patient sample size) for each test and system such as electroencephalogram (EEG) and
time point and therefore a suggestion or recommenda- evoked potentials (EPs) (eg, brainstem auditory evoked
tion could not be made. potentials, and short-latency somatosensory evoked po-
For all clinical examination modalities, the inaccuracy tentials [SSEPs]). We included studies of the interpreta-
of outcome prediction tests may be due to confounding tion of raw signals or summary measures derived from
from the effect of sedatives used for delivery of neuro- processed EEG signals such as amplitude-integrated
protective interventions (eg, hypothermic temperature EEG (aEEG), quantitative EEG (qEEG), or bispectral
control) or to facilitate ventilation. index.

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Consensus on Science however, it was imprecise (at the FPR <1% cut off)
Summary of electrophysiology tests, time scale and pre- in more than 50% of included studies.280,283,286–291,293–298
diction accuracy are in Table 9. Presence of burst suppression, burst attenuation or
Presence of clinical or electrographic seizures in chil- generalized periodic epileptiform discharges after 24 to
dren post-cardiac arrest as a prognostic test was unreli- 72 hours had a FPR <1% (95% CI upper limit range,
able.275–277,283,288–297 Presence of status epilepticus at 4 16%–54%) in 3 of 4 studies and was moderately
to 72 hours predicted poor neurological outcome at ICU reliable.287,288,297
or hospital discharge, with a low FPR of 0%–5% (upper Absence of reactivity,280,283,286–291,293–298 sleep II archi-
limit of 95% CI ranged 13%–41%)287,290,295–297 and pres- tecture or sleep spindles,283,286 or variability on EEG294,296
ence of myoclonic status epilepticus on EEG in 2 studies were unreliable tests for poor outcome prediction. A com-
predicted with a FPR 0% (95% CI, 0%–34%).288,294 Both posite score assessing EEG background from a 24-hour
were moderately reliable tests. monitoring period, obtained from quantitative EEG using
The absence of a benign continuous EEG background the amplitude integrated EEG trace, was assessed in
pattern was an inaccurate and unreliable method for only 1 study and unreliable.299
predicting poor neurological outcome.280,283,286–291,293–298 SSEPs, evaluating bilateral absence of N20 waves,
The presence of an attenuated, isoelectric, or flat EEG reported a FPR 0% (95% CI, 0%–52%) at 24 and 48
after 24 hours had improved prediction accuracy; hours and 17% at 72 hours.300 The test was moderately

Table 9. Electrophysiology Tests Accuracy for Poor Neurological Outcome Prediction

Study count Patients False positive rate

Category (ref) n= Time scale (estimate or range) [95% CI] Sensitivity
Presence of clinical or 11275–277,283,288–297 1308 4 hr–24 hr 0%–20% 2%–38%
electrographic seizure
(3/11 <1% [0%–37%]290,293,294
Presence of clinical or 10275–277,283,288–297 1053 48 hr–72 hr 0%–42% 0%–58%
electrographic seizure
(3/10 <10%) 275,291,294

Presence of status epilepticus 5287,290,295–297 299 4 hr–72 hr 0%–5% [95% CI, upper limit 13%–41%] 9%–25%
on EEG
Presence of myoclonic status 2288,294 61 48 hr 0% [95% CI, 0%–34%] 17%–21%
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epilepticus on EEG
Absence of continuous or normal 14280,283,286–291,293–298 563 4 hr–72 hr 0%–91% 7%–96%
background EEG*
(4/14 studies <10%)
Presence of attenuated, 4286,290,296,298 341 <24 hr 10%–90% 51%–100%
isoelectric or flat EEG
background
Presence of attenuated, 9280,283,288,289,291,293–295,297,298 526 24 hr–6 days 0%–71% (all) 17%–100%
isoelectric or flat EEG
(7/9 <10% [95%
background
CI, upper limit 4%–52%])283,288,289,291,293,294
(4/9 <1% [95% CI, upper limit 4%–
52%]283,288,293,294
Presence of burst suppression, 7286,288–290,294,296,297 395 <24 hr 0%–19% 9%–30%
burst attenuation or GPEDS on
4/7 <1% [95% CI, upper limit 16%–54%]
EEG
Presence of burst suppression, 4287,288,297 98 hours 0%–14% (all) 0%–67%
burst attenuation or GPEDS on
(¾ studies287,288,297 <1% [95% CI, upper limit
EEG
16%–54%])
Absence of reactivity 3294,296,297 222 6 hr–72 hr 0%–93% 36%–100%
Absence of sleep II architecture 2 283,286
123 6 hr–24 hr 20%–43% 84%–92%
Absence of variability 2294,296 162 6 hr–48 hr 0%–80% 21%–82%
Quantitative EEG scoring 1299 30 24 hr 6% [0%–27%] 33%
Somatosensory evoked potential 1 300
12 24 hr and 0% [0%–52%] 100% [29–100]
(SSEPs)† 48 hr
Somatosensory evoked potential 1300 12 72 hr 17% [0%–64%] 100% [29–100]
(SSEPs)†

*Defined as normal, continuous and reactive, continuous and unreactive, and nearly continuous by ACNS definitions.301
†Absence of N20 waves.
ACNS indicates American Clinical Neurophysiology Society; EEG, electroencephalogram; GPEDS, generalized periodic epileptiform discharges; and SSEP, somato-
sensory evoked potential.

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

reliable to predict poor neurological outcome, but only reported limited information on handling of this area and
assessed in 1 small study. further refinement of definitions and application of rec-
ommendation are required.
Prior Treatment Recommendations (2015)
SSEPs have high precision in adult studies of neu-
We suggest that the use of EEG within the first 7 days
roprognostication in comatose patients after cardiac
after pediatric cardiac arrest may assist in prognostica-
arrest.302 The task force recognizes the lack of available
tion (weak recommendation, very low–quality evidence).
data in children and strongly encourages further multi-
Treatment Recommendations (2025) center evaluation.
We recommend that no single electrophysiology test be
Knowledge Gaps
used in isolation to predict poor neurological outcome
• Electrophysiology tests for prognostication after
in children after cardiac arrest at any time point (strong
cardiac arrest appear promising but more research
recommendation, very low–certainty evidence).
is required in infants and children.
Clinicians should use multiple tests in combination
• More research is required on type of monitoring,
for poor neurological outcome prediction (good practice
intermittent or continuous EEG, use of reduced
statement).
channel monitoring, quantitative EEG systems, and
The presence of status epilepticus between 24 to 72
duration and timing of prognostic assessment.
hours after ROC, presence of burst suppression, burst
• Validation needed of ACNS301 or other international
attenuation or GPEDs between 24 to 72 hours after
definitions of EEG indices within the pediatric ICU
ROC, all had moderate reliability and may be considered
environment for infants and children after cardiac
as part of multimodal testing to predict poor neurological
arrest.
outcome in children after cardiac arrest (good practice
• Further work is needed on multimodal prognostica-
statement).
tion, timing, definitions of testing, accurate outcome
We suggest against using the following EEG fea-
timing and definition.
tures for predicting poor neurological outcome: presence
• We encourage wider research and consultation with
of clinical or electrographic seizures; absence of sleep
patients, children, parents, guardians and caregiv-
spindle and sleep II architecture on EEG, continuous or
ers, health care professionals and members of the
normal background EEG, EEG reactivity and EEG vari-
wider society on understanding survivorship after
ability, at any time point (weak recommendation, very
pediatric cardiac arrest to inform correct definitions
Downloaded from [Link] by on October 27, 2025

low–certainty evidence).
and framework of good neurological outcome for
There was insufficient evidence to make a recom-
prediction research.
mendation for or against the use of presence of attenu-
ated, isoelectric, or flat EEG, absence of N20 response
on SSEPs, presence of myoclonic status epilepticus, or Brain Imaging for the Prediction of Poor
quantitative EEG score to predict poor neurological out- Neurological Outcome After Return of
come in children after cardiac arrest at any time point.
Circulation Following Pediatric Cardiac Arrest
Justification and Evidence-to-Decision Framework (PLS 4220.04, SysRev 2025)
Highlights Intervention: Neuroimaging modalities. These modalities
The complete evidence-to-decision table is provided in include head computed tomography (CT) and brain mag-
Appendix A. netic resonance imaging (MRI).
The available scientific evidence had a high risk of bias
based on high heterogeneity across studies, few studies Consensus on Science
and few patients included, lack of blinding, variation in test Head CT reported absence of gray-white matter dif-
assessment and performance, and variability in outcome ferentiation or reversal sign at 24 hours was a mod-
measurement. Overall assessment of test performance erately reliable test for poor neurological outcome
was based on visual assessment of forest plots. ­prediction.297,303 All other CT reported tests (presence
Electrophysiology monitoring may enable reversible of effacement of sulci or basal cisterns, presence of CT
events (eg, seizures) to be identified, as well as provid- lesions, oedema, or intracranial hemorrhage) were unre-
ing prognostic information. Treatment of seizures may liable for poor neurological outcome prediction.280,297,303
prevent additional secondary injury following a hypoxic- MRI apparent diffusion coefficient threshold
ischemic insult. The role of electrophysiology monitoring <650x10-6 mm2/s in ≥10% of brain volume (indicat-
was not assessed for this purpose. ing high ischemic burden), at a median of 4 days after
The complex interpretation of normality in background ROC, predicted poor neurological outcome with FPR
EEG patterns in preterm and term infants, and the impact 0% to 6% (95% CI, 1%–21%) and sensitivity of 49% to
of brain maturation on EEG patterns in infancy and child- 52%.289,291,304 One study reached threshold for moderate
hood, requires expert neurophysiology input. Studies reliability.304

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

Any region of abnormality on restricted diffusion, or abnormal MRI predicts a poor neurological outcome. FPR
individual regions of diffusion restriction did not meet our <1% was only recorded for 1 study for global assess-
threshold for reliability.287,291,304–306 ment of brain injury. Low FPR was identified during
Table 10 summarizes results from CT and MRI regional brain assessment, however in only a few cases,
imaging. and with wide confidence limits on the point estimate.
The sensitivity of abnormal MRI or CT to predict a
poor neurological outcome is moderate to high, but up to
Treatment Recommendations (2025)
40% may be falsely categorized and a falsely pessimistic
We recommend no single imaging test be used alone
prediction made.
to predict poor neurological outcome in children after
The precision of MRI and CT is affected by the timing
cardiac arrest at any time point (strong recommendation,
of the investigation and is at risk of pseudonormalization.
very low–certainty evidence).
The definition of a presence diffusion-weighted imaging
Clinicians should use multiple tests in combination
or cut off values for apparent diffusion coefficient level
for poor neurological outcome prediction (good practice
on MRI, or gray-to-white matter ratio on CT was incon-
statement).
sistent in the included studies.
An abnormal MRI showing high ischemic burden on
MRI and CT are both expensive tests and require spe-
apparent diffusion coefficient mapping at 72 hours and
cialist equipment, training, interpretation and most often,
beyond after ROC or CT scan showing loss of gray-white
patient transport to obtain the information. This may be
matter differentiation within 24 hours after ROC may be
prohibitive in physiologically unstable patients, or some
considered as part of multimodal testing to predict poor
health care settings.
neurological outcome in children after cardiac arrest
(good practice statement).
Task Force Knowledge Gaps
• Neuro-imaging for prognostication after cardiac
Justification and Evidence-to-Decision Framework arrest appears promising, but more research is
Highlights required in infants and children.
The complete evidence-to-decision table is provided in • Standardization of definitions and assessment of
Appendix A. optimal thresholds for gray-to-white matter ratio
The available scientific evidence had a high risk of bias calculation on CT, and diffusion-weighted imaging,
based on high heterogeneity across studies, few studies apparent diffusion coefficient thresholds on MRI
Downloaded from [Link] by on October 27, 2025

and few patients included, lack of blinding, variation in test • The optimal timing for prognostication using CT and
assessment and performance, and variability in outcome MRI after cardiac arrest
measurement. Overall assessment of test performance • The role of assessing regional areas of the brain for
was based on visual assessment of forest plots. predicting outcome, or the use of magnetic reso-
The low FPR (high specificity) for abnormal MRI nance spectroscopy
on global assessment for predicting poor neurological • Economic cost evaluation and cost-effectiveness
outcome reduces the chance of false pessimism if an studies on the use of CT and MRI for prognostication

Table 10. Brain Imaging for the Prediction of Poor Neurological Outcome

False positive rate

Category Study count Patients n= Time scale (estimate or range) [95% CI] Sensitivity
Head CT absence of GWM differentiation 2297,303 142 24 hr 0%–36% 20%–30%
Head CT presence of reversal sign 1303 78 24 hr 0% [0%–12%] 65%
Head CT presence of effacement of sulci or basal cisterns 2297,303
142 24 hr 0–7 [95% CI, upper limit 27%–68%
0%–30%]
Head CT presence of CT lesions, oedema, or intracranial 3280,297,303 173 24 hr 7%–17% 11%–68%
hemorrhage
Magnetic resonance imaging (MRI) ADC threshold 3289,291,304 250 4–7 days 0%–6% [1%–21%] 49%–52%
<650x10-6 mm 2/s in ≥10% of brain volume
Magnetic resonance imaging (MRI) ADC threshold for high 1304 90 4–7 days <1% [0%–21%] 80%
ischemic burden [44%–97%]
Magnetic resonance imaging (MRI) 2287,291 97 4–7 days 12%–58% 98%–100%
Any region of abnormality on restricted diffusion
Magnetic resonance imaging (MRI)—14 individual regions 3287,305,306 67 4–7 days 0%–33% [95% CI, upper limit 0%–57%
of the brain on DWI, T1, T2 weighted imaging 23%–60%]

ADC indicates apparent diffusion coefficient; CT, computed tomography; DWI, diffusion-weighted imaging; GWM, gray-white matter; and MRI, magnetic resonance
imaging.

Circulation. 2025;152(suppl 1):S116–S164. DOI: 10.1161/CIR.0000000000001362 October 21, 2025 S147

 Scholefield et al Pediatric Life Support: 2025 CoSTR

A summary of the treatment recommendation and good hours to <72 hours, 72 hours to <7 days, or 7 days
practice statements is illustrated in the Figure. to 10 days after cardiac arrest
• Comparator: There was no control group for inter-
vention/exposure. The accuracy of the prognostic
Prediction of Survival With Good Neurological index test was assessed by comparing the predicted
Outcome After Return of Circulation Following outcome with the final outcome, which represents
Pediatric Cardiac Arrest—Combined Prognostic the comparator.
SysRev (PLS 4220.05, 4220.06, 4220.07, • Outcome: Critical: prediction of survival with good
4220.08, SysRev 2023) neurological outcome (defined as a Pediatric
Cerebral Performance Category score of 1, 2, or 3
The PLS Task Force conducted a SysRev of prognosti- or Vineland Adaptive Behavioral Scale-II ≥70) at the
cation of favorable neurologic outcome in 2023.268 De- pediatric intensive care unit or hospital discharge, 1
tails of this CoSTR can be found in the 2023 CoSTR month or later
summary.126,127 • Time frame: January 1, 2010, to December 31,
Population, Intervention, Comparator, Outcome, and 2022
Time Frame (for All Neuroprognostication)
• Population: Children (<18 years of age) who Treatment Recommendations (2023)
achieve a return of circulation (ROC, which includes All evaluated tests were used in combination with other
ROSC or mechanical circulation) after resuscitation tests by clinicians in these studies. Although the predic-
from IHCA and OHCA, from any cause tive accuracy of tests was evaluated individually, we rec-
– Studies that included newborn infants or patients ommend that no single test should be used in isolation
in hypoxic coma from causes without a cardiac for prediction of good neurological outcome (good prac-
arrest (eg, respiratory arrest, toxidromes, drown- tice statement).
ing, hanging) were excluded, except when a sub- We suggest using pupillary light reflex within 12 hours
population of cardiac arrest patients could be after ROC for predicting good neurological outcome in
evaluated separately. children after cardiac arrest (weak recommendation, very
• Intervention: Index prognostic tests, recorded at one low–certainty evidence).
or more of the following time points: <12 hours, We cannot make a recommendation for or against
Downloaded from [Link] by on October 27, 2025

12 hours to <24 hours, 24 hours to <48 hours, 48 using total GCS, GCS motor score, or motor response

Figure. Summary of treatment recommendations and good practice statement for poor outcome prediction after pediatric
cardiac arrest.

S148 October 21, 2025 Circulation. 2025;152(suppl 1):S116–S164. DOI: 10.1161/CIR.0000000000001362

 Scholefield et al Pediatric Life Support: 2025 CoSTR

after ROC for predicting good neurological outcome in Effect of Prophylactic Antiseizure Medication or
children after cardiac arrest. Treatment of Seizures on Outcome of Children
We cannot make a recommendation for or against
the use of other brainstem tests after ROC for predicting
Following Cardiac Arrest (PLS 4210.02: SysRev
good neurological outcome in children after cardiac arrest. 2024 CoSTR Summary)
We suggest using a normal plasma lactate value (<2 Administration of prophylactic anti-seizure medication to
mmol/L) up to 12 hours following ROC for predict- prevent seizures or treatment of seizures was addressed
ing good neurological outcome of children after car- in a SysRev in 2024, and details can be found in the
diac arrest (weak recommendation, very low–certainty 2024 CoSTR summary.73,74
evidence).
Population, Intervention, Comparator, Outcome, and
We cannot make a recommendation for or against
Time Frame
using time–to–lactate clearance within 48 hours follow-
• Population: Adults or children in any setting (IHCA
ing ROC for predicting good neurological outcome.
or OHCA) with ROC
We suggest against using pH following ROC for pre-
• Intervention: One strategy for prophylactic anti-­
dicting good neurological outcome after cardiac arrest
seizure medication OR seizure treatment
(weak recommendation, very low–certainty evidence).
• Comparators: Another strategy or no prophylactic
We cannot make a recommendation for or against the
anti-seizure medication OR seizure treatment
use of blood neuro-biomarkers (eg, S100b, NSE) after
• Outcomes: Critical: survival; survival with favorable
ROC for predicting good neurological outcome in chil-
neurological outcome
dren after cardiac arrest.
• Time frame: All years up to September 11, 2023
We suggest using EEG within 6 to 72 hours after
ROC for predicting good neurological outcome in chil- Treatment Recommendations (2024)
dren after cardiac arrest (weak recommendation, low- We suggest against the routine use of prophylactic anti-
certainty evidence). seizure medication in children post–cardiac arrest (good
We suggest using the following EEG features after practice statement).
ROC for predicting good neurological outcome: pres- We suggest the treatment of seizures in children
ence of sleep spindle and sleep II architecture at 12 post–cardiac arrest (good practice statement).
to 24 hours, or continuous or normal background EEG
between 1 and 72 hours, or EEG reactivity between 6
Downloaded from [Link] by on October 27, 2025

to 24 hours (weak recommendation, very low–certainty Post-ROSC Oxygenation and Ventilation (PLS
evidence). 4180.01 and PLS 4180.02, SysRev 2019, EvUp
We suggest against using the following EEG fea- 2025)
tures after ROC to predict good neurological outcome:
Population, Intervention, Comparator, Outcome, and
absence of clinical or electrographic seizures; absence
Time Frame
of status epilepticus; absence of myoclonic epilepsy;
• Population: Infants and children (excluding newborn
absence of burst suppression, burst attenuation, or gen-
infants) who achieve ROC after out-of-hospital or
eralized periodic epileptiform discharges; or absence of
in-hospital cardiac arrest
attenuated, isoelectric, or flat EEG (weak recommenda-
• Intervention: A ventilation and oxygenation strategy
tion, very low–certainty evidence).
targeting a specific oxygen saturation as measured
We cannot make a recommendation for or against the
by a pulse oximeter (Spo2), Pao2, or Paco2
use of the presence or absence of N20 response SSEPs
• Comparators: Treatment without specific targets or
after ROC for predicting good neurological outcome.
with an alternate target to the intervention
We cannot make a recommendation for or against
• Outcomes: Any clinical outcome
the use of EEG variability or EEG voltage or quantitative
• Time frame: July 1, 2019, to June 20, 2024
EEG score for predicting good neurological outcomes.
We suggest against using normal CT imaging at 24 Summary of Evidence
to 48 hours from ROC for predicting good neurologi- Our EvUp identified 4 new observational pediatric stud-
cal outcome (weak recommendation, very low–certainty ies307–310 on this topic. One study309 found an associa-
evidence). tion between hypoxemia and hypercapnia and the critical
We suggest using normal MRI between 72 hours and outcomes of favorable neurologic outcome and survival
2 weeks after ROC for predicting good neurological out- to hospital discharge, while the other studies found no
come (weak recommendation, low-certainty evidence). overall association. In 1 study,307 increased cumulative
We cannot make a recommendation for or against Paco2 exposure was associated with lower survival to
the use of transcranial Doppler ultrasound for predicting hospital discharge among infants. An updated SysRev is
good neurological outcome. warranted.

Circulation. 2025;152(suppl 1):S116–S164. DOI: 10.1161/CIR.0000000000001362 October 21, 2025 S149

 Scholefield et al Pediatric Life Support: 2025 CoSTR

Table 11. Topics Not Reviewed With a SysRev of ScopRev Table 12. PLS Task Force PICOSTs Retired 2025
Since 2020
PLS 4010.01 Atropine use for emergency intubation
PLS 4030.01 Adenosine use in SVT during resuscitation (EvUp 2023) PLS 4010.02 Formulas for ETT size
PLS 4030.04 Cardiogenic shock and inotropes PLS 4020.01 Negative pressure ventilation in congenital heart disease
PLS 4030.08 Drugs for unstable tachycardia (SVT or wide complex) patients

PLS 4030.19 Prearrest care of pediatric dilated cardiomyopathy or PLS 4020.02 Optimal ventilation strategy for Fontan or hemi-Fontan/
myocarditis (EvUp 2024) bidirectional Glenn physiology in periarrest state
PLS 4020.03 Ventilation target for infants with congenital heart disease
PLS 4030.31 Pre-arrest IV/IO bolus vasopressor (epinephrine)
preoperatively
PLS 4050.03 Pediatric METs and RRTs (EvUp 2022)
PLS 4030.05 Corticosteroids for septic shock
PLS 4070.01 FIO2 titrated to oxygenation during cardiac arrest (EvUp
PLS 4030.06 Diagnostic tests for shock
2023)
PLS 4030.07 Distributive shock and inotropes
PLS 4070.04 Timing of intubation for IHCA
PLS 4030.12 Etomidate and septic shock
PLS 4080.02 Adhesive pads versus paddles for defibrillation
PLS 4030.13 Fluid resuscitation in septic shock
PLS 4080.06 Chest compression depth
PLS 4030.14 Graded volume resuscitation for traumatic shock
PLS 4080.07 Chest compression only CPR versus conventional CPR
(EvUp 2022) PLS 4030.15 Timing of Intubation for shock
PLS 4030.16 Low cardiac output stage post-congenital heart disease
PLS 4080.08 CPR feedback device
surgery blood pressure management
PLS 4080.1 Chest compression rate
PLS 4030.17 Medical treatment of excessive QP:QS circulation in
PLS 4080.11 Effect of chest compression pause duration neonatal congenital heart disease
PLS 4080.13 Heads up CPR PLS 4030.18 Postoperative care of child with pulmonary hypertension

PLS 4080.14 Interposed abdominal compression CPR PLS 4030.24 Shock vasoconstrictors

PLS 4080.16 One hand versus 2 hand compressions (and PLS 4030.26 Treatment of high-risk myocarditis patients
circumferential) PLS 4030.27 Type of fluid for septic shock
PLS 4080.2 Synced/nonsynced shock for ventricular tachycardia PLS 4030.28 Volume of fluid for septic shock
PLS 4080.23 Chest compression recoil PLS 4030.32 Cardioversion for SVT
PLS 4080.24 Chest compression-to-ventilation ratios PLS 4050.01 Cervical spine management
Downloaded from [Link] by on October 27, 2025

PLS 4080.25 Tidal volumes (chest rise) PLS 4080.05 Chest compression only CPR for intubated neonates
outside of delivery room
PLS 4100.01 Family presence during resuscitation
PLS 4090.03 ET versus IV drugs
PLS 4120.01 Ventilation rate in pediatric respiratory arrest with a
perfusing rhythm present (EvUp 2024) PLS 4110.01 Cricoid pressure for kids

PLS 4150.01 Methods of calculating pediatric drug doses for cardiac PLS 4110.02 Cuffed versus uncuffed ETTs
arrest PLS 4110.03 Verification of airway placement
PLS 4160.01 Channelopathy and consideration of etiology of arrest PLS 4160.04 Infants and children in cardiac arrest with sepsis
PLS 4160.06 Intracardiac arrest monitoring clinical prognostic factors for ET indicates endotracheal; ETT, endotracheal tube; IV, intravenous; and SVT,
cardiac arrest in infants and children supraventricular tachycardia.
PLS 4160.12 Resuscitation of the pediatric patient with a single
ventricle, post Stage I repair (EvUp 2023) Treatment Recommendation (2020)
PLS 4160.13 Resuscitation of the pediatric patient with hemi-Fontan/ We suggest that rescuers measure Pao2 after ROSC and
bidirectional Glenn circulation (EvUp 2023)
target a value appropriate to the specific patient condi-
PLS 4160.14 Resuscitation of the pediatric patient with single-ventricle, tion. In the absence of specific patient data, we suggest
status-post Stage III/Fontan/total cavopulmonary
connection/anastomosis (EvUp 2023)
rescuers target normoxemia after ROSC (weak recom-
mendation, very low–quality evidence).110–112
PLS 4160.16 Point of care ultrasound for identification of reversible
causes Given the availability of continuous pulse oximetry,
PLS 4190.02 Post-ROSC inotrope approach
targeting an oxygen saturation of 94% to 99% may be
a reasonable alternative to measuring Pao2 for titrating
PLS 4210.01 Monitor kidney function and urine output as dialysis may
be required
oxygen when feasible to achieve normoxia (based on
expert opinion).110–112
PLS 4210.03 Post-ROSC targeted temperature management
(EvUp 2022) We suggest that rescuers measure Paco2 after ROSC
PLS 4210.06 Follow-up clinics to improve survivorship
and target normocapnia (weak recommendation, very
low–certainty evidence).110–112
PLS 4221.01 Multimodal prognostic model for neuroprognostication
Consider adjustments to the target Paco2 for specific
CPR indicates cardiopulmonary resuscitation; IHCA, in-hospital cardiac arrest; patient populations where normocapnia may not be desir-
IO, intraosseous; IV, intravenous; MET, medical emergency team; ROSC, return
of spontaneous circulation; RRT, rapid response team; and SVT, supraventricular
able (eg, chronic lung disease with chronic hypercapnia,
tachycardia. congenital heart disease with single-ventricle physiology,

S150 October 21, 2025 Circulation. 2025;152(suppl 1):S116–S164. DOI: 10.1161/CIR.0000000000001362

 Scholefield et al Pediatric Life Support: 2025 CoSTR

increased intracranial pressure with impending hernia- rosawa H, Myburgh MC, del Castillo J, Rossano J, Djakow J, Guerguerian A-M,
Nadkarni VM, Bittencourt Couto T, Schexnayder SM, Nuthall G, Tijssen JA, Ong
tion) (good practice statement).110–112 GY-K, Gray JM, Lopez-Herce J, Ambunda ES, Nolan JP, Berg KM, Morrison LJ,
Atkins DL, de Caen AR; on behalf of the Pediatric Life Support Task Force Col-
laborators. Pediatric Life Support: 2025 International Liaison Committee on Re-
PLS Task Force PICOSTs Not Reviewed by suscitation Consensus on Science With Treatment Recommendations. Circulation.
SysRev or ScopRev (2021 to 2025) 2025;152(suppl 1):S116–S164. doi: 10.1161/CIR.0000000000001362
This article has been copublished in Resuscitation. Published by Elsevier Ire-
A list of topics not reviewed with a SysRev of ScopRev land Ltd. All rights reserved.
since 2020 is provided in Table 11. In cases where an This article has been copublished in Pediatrics.

EvUp was conducted since 2020 this is indicated. Sev- Acknowledgments

eral topics reviewed by other ILCOR task forces have The Pediatric Life Support Task Force acknowledges the assistance of Jaylen I.
included children in their search, in some cases generat- Wright in manuscript and appendix preparation and editing throughout the pub-
lication process.
ing statements that include children. A list of these topics
and the year they were last reviewed, and by which task Collaborators
force, is provided in Appendix C. The authors thank the following individuals (the Pediatric Life Support Task Force
Topics retired in 2025 are listed in Table 12. Collaborators) for their contributions: Antonio Rodriguez-Nunez, Florian Hoffman,
Elliott Acworth, Ashley Bach, Akash Bang, Niklas Breindahl, Michael Adam
Carlisle, Genie Castellino, Kaustabh Chaudhuri, Jessie Cunningham, Gurpreet
S. Dhillon, Lars Eriksson, Maria Frazier, Saptharishi L. Ganesan, Lara Goldstein,
ARTICLE INFORMATION Seth Gray, Prakriti Gupta, Martha Keinzle, Mirjam Kool, Javier J. Lasa, Suzanne
The American Heart Association requests that this document be cited as fol- Laughlin, Jaime Lawton, Daniel Loeb, Will McDevitt, Michael Alice Moga, Amanda
lows: Scholefield BR, Acworth J, Ng K-C, Tiwari LK, Raymond TT, Christoff A, O’Halloran, Debra Pirrello, Sara-Pier Piscopo, Leandra Rech, Catherine Ross, A.
Katzenschlager S, Escalante-Kanashiro R, Bansal A, Topjian A, Kleinman M, Ku- Sahai, Raghavendra Vanaki, George Sam Wang, Mike Wells, Aidan Wilkinson.

Disclosures
Writing Group Disclosures

Other
Writing Group Research Research Speakers’ Bureau/ Expert Ownership Consultant/
Member Employment Grant Support Honoraria Witness Interest Advisory Board Other
Barnaby R. Hospital for None None None None None None None
Scholefield Sick Children
(Canada)
Downloaded from [Link] by on October 27, 2025

Jason Acworth University of None None None None None None None
Queensland,
Children’s Health
Clinical Unit
(Australia)
Jerry P. Nolan Warwick None None None None None None None
Medical School,
University
of Warwick,
Coventry (United
Kingdom)
Katherine M. Beth Israel None None None None None AHA/ILCOR† None
Berg Deaconess
Medical Center
and Harvard
Medical School
Laurie J. St. Michael’s None None None None None None None
Morrison Hospital and
University of
Toronto (Canada)
Dianne L. University of None None None None None None None
Atkins Iowa
Allan R. de Alberta Health None None None None None None None
Caen Services and
University of
Alberta (Canada)
Ester Windhoek None None None None None None None
Shambekela Central Hospital
Ambunda (Namibia)

(Continued )

Circulation. 2025;152(suppl 1):S116–S164. DOI: 10.1161/CIR.0000000000001362 October 21, 2025 S151

 Scholefield et al Pediatric Life Support: 2025 CoSTR

Writing Group Disclosures Continued

Other
Writing Group Research Research Speakers’ Bureau/ Expert Ownership Consultant/
Member Employment Grant Support Honoraria Witness Interest Advisory Board Other
Arun Bansal Post Graduate None None None None None None None
Institute
of Medical
Education and
Research (India)
Andrea Sydney None None None None None None None
Christoff Children’s
Hospitals
Network
(Australia)
Thomaz Hospital None None None None None None None
Bittencourt Israelita Albert
Couto Einstein AND
Universidade
de São Paulo
(Brazil)
Jimena del Hospital General Zoll* None Speakers’ Bureau: None None None None
Castillo Universitario Zoll*
Gregorio
Maranon (Spain)
Jana Djakow Masaryk None None None None None None None
University
(Czechia)
Raffo Inter-American None None None None None None None
Escalante- Heart Foundation
Kanashiro and Instituto
Nacional de
Salud del Niño
(Peru)
Downloaded from [Link] by on October 27, 2025

James M. Gray Cincinnati None None None None None None None
Children’s
Hospital Medical
Center
Anne-Marie The Hospital for None None None None None None None
Guerguerian Sick Children
(Canada)
Stephan Heidelberg None None None None None None None
Katzenschlager University
Hospital
(Germany)
Monica Boston None None None None None American Heart Boston
Kleinman Children’s Association*; Children’s
Hospital International Hospital†
Liaison
Committee on
Resuscitation*;
Boston
MedFlight*
Hiroshi Hyogo None None None None None None None
Kurosawa Prefectural
Kobe Children’s
Hospital (Japan)
Jesus Lopez- Hospital General None None None None None None None
Herce Universitario
Gregorio
Maranon (Spain)
Michelle C. University of None None None None None None None
Myburgh the Free State
(South Africa)

(Continued )

S152 October 21, 2025 Circulation. 2025;152(suppl 1):S116–S164. DOI: 10.1161/CIR.0000000000001362

 Scholefield et al Pediatric Life Support: 2025 CoSTR

Writing Group Disclosures Continued

Other
Writing Group Research Research Speakers’ Bureau/ Expert Ownership Consultant/
Member Employment Grant Support Honoraria Witness Interest Advisory Board Other
Vinay M. Children’s Zoll Medical*; None None None None None Citizen CPR
Nadkarni Hospital Nihon-Kohden;* Foundation*;
Philadelphia, Laerdal Society of
University of Foundation*; Simulation in
Pennsylvania American Heart Healthcare*
Perelman School Association*
of Medicine
Kee-Chong Ng KK Women’s None None None None None None None
and Children’s
Hospital
(Malaysia)
Gabrielle Starship Child Children’s Hospital None None None None None None
Nuthall Health, Te Toka of Philidelphia*
Tumai, Auckland,
Te Whatu Ora/
Health New
Zealand (New
Zealand)
Gene Yong- KK Women’s None None None None None None None
Kwang Ong and Children’s
Hospital
(Malaysia)
Tia T. Raymond Medical City None None None None None None None
Children’s
Hospital
Stephen M. University of None None None Love & None American Heart None
Schexnayder Arkansas/ Kirschenbaum Association†
Arkansas LLLC†; Best
Children’s and Sharp*
Hospital
Downloaded from [Link] by on October 27, 2025

Janice A. London Health Thrasher Research None None None None None None
Tijssen Sciences Center Fund*; AMOSO
(Canada) Innovation Fund*;
Heart and Stroke
Foundation of
Canada GIA*; PSI
Grant*
Lokesh Kumar All India Institute Indian Council of None Speakers’ Bureau: None None None AIIMS
Tiwari of Medical Medical Research*; AIIMS Rishikesh*; Rishikesh†;
Sciences, Cipla* Speakers’ Bureau: ILCOR*;
Rishikesh (India) Indian Resuscitation IRCF*; IAP
Council Federation*; ALS BLS
Speakers’ Bureau: Group*
Indian Academy of
Pediatrics*
Alexis Topjian Children’s NIH* None None None None None Elsevier†
Hospital of
Philadelphia &
University of
Pennsylvania
School of
Medicine

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Circulation. 2025;152(suppl 1):S116–S164. DOI: 10.1161/CIR.0000000000001362 October 21, 2025 S153

 Scholefield et al Pediatric Life Support: 2025 CoSTR

Reviewer Disclosures

Speakers’ Consultant/
Research Other Research Bureau/ Expert Ownership Advisory
Reviewer Employment Grant Support Honoraria Witness Interest Board Other
Jacqueline Lurie Children’s Hospital of Chicago None None None None None None None
Corboy
Rakesh Lodha All India Institute of Medical Sciences None None None None None None None
(India)
Jayashree PGIMER, PICU and Emergency Units, None None None None None None None
Murlidharan Advanced Pediatrics Centre (India)
Ron W. Reeder University of Utah None None None None None None None
Pediatrics
Ameila Reis Inter-American Heart Foundation (Brazil) None None None None None None None
Ken Tegtmeyer Cincinnati Children’s Hospital None None None None None None None
Critical Care Medicine

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-
tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any
12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of
the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

10. Al-Eyadhy A, Almazyad M, Hasan G, Alkhudhayri N, Alsaeed AF, Habib

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 Scholefield et al Pediatric Life Support: 2025 CoSTR

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S164 October 21, 2025 Circulation. 2025;152(suppl 1):S116–S164. DOI: 10.1161/CIR.0000000000001362

 Circulation

Neonatal Life Support: 2025 International Liaison

Committee on Resuscitation Consensus on
Science With Treatment Recommendations
Helen G. Liley, Chair; Gary M. Weiner, Vice Chair; Myra H. Wyckoff; Yacov Rabi; Georg M. Schmölzer; Maria Fernanda de Almeida;
Daniela T. Costa-Nobre; Peter G. Davis; Jennifer A. Dawson; Walid El-Naggar; Jorge G. Fabres; Joe Fawke; Elizabeth E. Foglia;
Ruth Guinsburg; Tetsuya Isayama; Mandira Daripa Kawakami; Henry C. Lee; R. John Madar; Christopher J.D. McKinlay;
Victoria J. Monnelly; Firdose L. Nakwa; Mario Rϋdiger; Anne Lee Solevåg; Takahiro Sugiura; Daniele Trevisanuto;
Viraraghavan Vadakkencherry Ramaswamy; Nicole K. Yamada; Marlies Bruckner; Emer Finan; David Honeyman;
Daniel Ibarra Rios; Justin B. Josephsen; C. Omar Kamlin; Vishal Kapadia; Anup Katheria; Bin Huey Quek; Shalini Ramachandran;
Charles Christoph Roehr; Anna Lene Seidler; Marya L. Strand; Enrique Udaeta-Mora; Katherine M. Berg, Senior Editor; on behalf
of the Neonatal Life Support Task Force Collaborators

ABSTRACT: The International Liaison Committee on Resuscitation continually reviews new, peer-reviewed cardiopulmonary
resuscitation science and publishes comprehensive reviews every 5 years. The Neonatal Life Support chapter of the 2025
International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations addresses all published
resuscitation evidence reviewed by the Neonatal Life Support Task Force science experts since 2020. This summary addresses
40 questions on population, intervention, comparator, and outcomes, addressing all parts of the Neonatal Resuscitation Algorithm.
The summary includes 4 new systematic reviews, 2 new scoping reviews, and evidence updates for other topics. Members of
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the Neonatal Life Support Task Force have assessed, discussed, and debated the quality of the evidence on the basis of Grading
of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment
recommendations. Insights into the deliberations of the task force are provided in the Justification and Evidence-to-Decision
Framework Highlights sections. In addition, the task force lists priority knowledge gaps for further research.

Key Words: Scientific Statements ◼ cardiopulmonary resuscitation ◼ ILCOR ◼ infant ◼ neonatal resuscitation

INTRODUCTION out resuscitation, but interventions to support or achieve

these adaptations can be critical to achieving survival
Resuscitation of the Newborn Infant and preventing morbidity.
The physiological adaptations that take place during and National data from 2022 to 2023 from Australia indi-
immediately after birth are interdependent and critical to cated that among over 600 000 live-born infants, 10.3%
survival and good health. They include the establishment received continuous positive airway pressure, 4.5%
of air breathing, closure of fetal cardiovascular shunts, received positive-pressure ventilation, 0.8% were intu-
and functional adaptations to increase pulmonary blood bated, and 0.2% received chest compressions.1 However,
flow while maintaining or increasing systemic flows and although these results are from a country where neonatal
pressures. Additional adaptations that are critical to sur- resuscitation training is widely accessible and the neona-
vival of the immediate newborn period include the main- tal mortality rate is low (2.3/1000), the data reflect those
tenance of body temperature and of a consistent supply who received various resuscitation interventions and do
of glucose and substrates for metabolism of vital organs. not define the optimal proportions who would benefit.
The majority of newborns adapt to extrauterine life with- The need for resuscitation interventions may be affected

Supplemental Material is available at [Link]

© 2025 American Heart Association, Inc., European Resuscitation Council, International Liaison Committee on Resuscitation, and American Academy of Pediatrics, Inc.
Circulation is available at [Link]/journal/circ

Circulation. 2025;152(suppl 1):S165–S204. DOI: 10.1161/CIR.0000000000001363 October 21, 2025 S165

 Liley et al Neonatal Life Support: CoSTR 2025

by various factors including maternal health, the quality gaps, and ScopRevs summarize task force insights on
of antenatal and intrapartum care, rates of prematurity, specific topics. Links to the published reviews and full
and other risk factors. Higher intervention rates may be online CoSTRs are provided in the corresponding sec-
needed to optimize survival without major morbidity when tions. Evidence-to-decision tables for SysRevs are pro-
high-quality pregnancy and birth care are unavailable. vided in Appendix A, and the complete EvUp worksheets
As consistently recommended by the Neonatal Life are provided in Appendix B.
Support (NLS) Task Force,2,3 newborn infants who are Topics are presented using the PICOST format.
breathing or crying and have good tone and an ade- To minimize redundancy, PICOST wording has been
quate heart rate may undergo deferred cord clamping removed from EvUps and reviews published previously,
and should be placed skin-to-skin with their mothers, and the study designs have been removed from all
using methods to maintain a normal body temperature. reviews except in cases where the designs differed from
Ongoing observation is needed because the low oxygen the ILCOR standard criteria. The standard study designs
saturations that are normal in the first few minutes after included were randomized controlled trials (RCTs) and
birth can persist or recur, apnea can occur, and breath- nonrandomized studies (non-RCTs, interrupted time
ing difficulties are common. When respiratory effort is series, controlled before-and-after studies, and cohort
inadequate, escalation should be undertaken by using studies). Case series, case reports, animal studies, and
the steps of the Neonatal Resuscitation Algorithm (Fig- unpublished studies (conference abstracts, trial proto-
ure 1), which is unchanged from 2015 and 2020.2,5 cols) were excluded. All languages were included pro-
This NLS Task Force chapter of the 2025 International vided they had an English abstract.
Liaison Committee on Resuscitation (ILCOR) Consensus The following topics are addressed in this NLS Task
on Science With Treatment Recommendations (CoSTR) Force CoSTR summary. The order reflects the steps in
includes 4 systematic reviews (SysRevs) and 2 scoping the Neonatal Resuscitation Algorithm. Importance of all
reviews (ScopRevs) conducted by the NLS Task Force outcomes was in accord with Strand et al12 and (where
in the previous year. Another 22 reviews conducted and stated) Webbe et al,13 or by consensus of the task force
published6–9 since the 2020 publication are also summa- for outcomes specific to each review.
rized to provide a single reference document for readers,
along with evidence updates (EvUps) for these reviews
and for 12 reviews conducted in 2020 or earlier. Thus, Anticipation and Preparation
the NLS Task Force work presented here encompasses • Effect of briefing before neonatal resuscitation
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40 PICOST (population, intervention, comparator, out- (NLS 5002: EvUp 2025)

come, study design, time frame) questions. Draft CoSTRs
for all topics evaluated with SysRevs were posted on a
rolling basis on the ILCOR website,10 with public com- Umbilical Cord Management
ments accepted for at least 2 weeks after posting and • Umbilical cord management at birth for nonvigor-
considered before final versions were posted. ous term and late preterm infants (NLS 5050[a]:
Although only SysRevs can generate a full CoSTR SysRev 2025)
and new treatment recommendations, many other top- • Umbilical cord management at birth for vigorous
ics were evaluated with more streamlined processes, term and late preterm infants (NLS 5050[b]: SysRev
including ScopRevs and EvUps. Good practice state- 2021, EvUp 2025)
ments, which represent the opinion of task force • Umbilical cord management at birth for preterm
experts in light of very limited or no direct evidence, infants (NLS 5051: SysRev 2024, EvUp 2025)
can be generated after ScopRevs and occasionally
after EvUps in cases where the task force thinks pro-
viding guidance is especially important. A separate arti- Initial Steps
cle in this issue includes the full details of the evidence • Maintaining normal temperature immediately after
evaluation process.11 birth in term and late preterm infants (NLS 5100:
This summary statement contains the final wording SysRev 2022, EvUp 2025)
of the treatment recommendations and good practice • Maintaining normal temperature immediately after
statements as approved by the ILCOR NLS Task Force. birth in preterm infants (NLS 5101: SysRev 2023,
The year that treatment recommendations or good EvUp 2025)
practice statements were generated or last updated by • Suctioning of clear amniotic fluid at birth (NLS
a SysRev is provided in parentheses. In cases where 5120: SysRev 2022, EvUp 2025)
existing treatment recommendations have changed for • Tracheal suctioning of meconium-stained amniotic
2025, the prior recommendations are also presented so fluid (NLS 5130: SysRev 2022, EvUp 2025)
the reader can easily see what has changed. SysRevs • Tactile stimulation (NLS 5140: SysRev 2022, EvUp
include evidence-to-decision highlights and knowledge 2025)

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 Liley et al Neonatal Life Support: CoSTR 2025
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Figure 1. Neonatal Resuscitation Algorithm.

CPAP indicates continuous positive airway pressure; ECG, electrocardiographic; HR, heart rate; IV, intravenous; PPV, positive-pressure ventilation;
and TT, tracheal tube.

Assessment of Heart Rate Ventilation and Oxygenation

• Heart rate assessment methods in the deliv- • Devices for administering positive-pressure
ery room—diagnostic characteristics (NLS 5200: ventilation (NLS 5300: SysRev 2021, EvUp
SysRev 2023, EvUp 2025) 2025)
• Heart rate assessment methods in the delivery • Continuous positive airway pressure versus positive-
room—clinical outcomes (NLS 5201: SysRev 2022, pressure ventilation for preterm infants (NLS 5310:
EvUp 2025) SysRev 2015, EvUp 2025)

Circulation. 2025;152(suppl 1):S165–S204. DOI: 10.1161/CIR.0000000000001363 October 21, 2025 S167

 Liley et al Neonatal Life Support: CoSTR 2025

• Continuous positive airway pressure for term and Postresuscitation Care

late preterm infants with respiratory distress (NLS
• Rate of rewarming hypothermic newborns (NLS
5312: SysRev 2022, EvUp 2025)
5700: SysRev 2024, EvUp 2025)
• Sustained inflations during newborn resuscitation
• Therapeutic hypothermia in limited-resource set-
(NLS 5320: EvUp 2025)
tings (NLS 5701: SysRev 2024, EvUp 2025)
• Supraglottic airway device versus face mask (NLS
5340: SysRev 2022, EvUp 2025)
• Supraglottic airway device versus tracheal tube Prognostication During CPR
(NLS 5341: EvUp 2025)
• Impact of duration of intensive resuscitation (NLS
• Use of a supraglottic airway device during chest
5800: EvUp 2025)
compressions (NLS 5342: ScopRev 2025)
• Exhaled CO2 monitoring to guide noninvasive venti-
lation (NLS 5350: SysRev 2023, EvUp 2025) Family Presence
• Video versus traditional laryngoscope (NLS 5351:
• Family presence during neonatal resuscitation (NLS
SysRev 2025)
5900: SysRev 2021, EvUp 2025)
• Respiratory function monitoring during resuscitation
at birth (NLS 5360: SysRev 2022, EvUp 2025) Readers are encouraged to monitor the ILCOR web-
• Near-infrared spectroscopy during positive- site10 to provide feedback on planned SysRevs and to
pressure ventilation (NLS 5362: SysRev 2025) provide comments when additional draft reviews are
• Oxygen concentration for initiating resuscitation in posted.
preterm infants (NLS 5400: SysRev 2025)
• Oxygen concentration for initiating resuscitation in
late preterm and term infants (NLS 5401: EvUp ANTICIPATION AND PREPARATION
2025)
Effect of Briefing Before Neonatal
Resuscitation (NLS 5002: EvUp 2025)
Circulatory Support Rationale for Review
• Heart rate for commencing chest compressions A ScopRev addressed both briefing and debriefing to de-
(NLS 5500: ScopRev 2023, EvUp 2025) termine whether they improve outcomes for infants, fam-
Downloaded from [Link] by on October 27, 2025

• Chest compressions with 2 thumbs versus other ilies, and health care professionals for the 2020 CoSTR
techniques (NLS 5501: ScopRev 2023, EvUp and concluded that there was insufficient evidence to
2025) make a treatment recommendation.5,14 This EvUp only as-
• Supplemental oxygen during chest compressions sessed briefing because debriefing has been addressed
(NLS 5503: ScopRev 2023, EvUp 2025) in a recent SysRev by the Education, Implementation,
• Compression-to-ventilation ratio (NLS 5504: and Teams Task Force.15 The complete EvUp, including
ScopRev 2023, EvUp 2025) the full PICOST, can be found in Appendix B.
• Use of feedback cardiopulmonary resuscitation Time frame: December 1, 2019, to December 30,
(CPR) devices for neonatal cardiac arrest (NLS 2024
5505: ScopRev 2023, EvUp 2025)
Summary of Evidence
• Depth of chest compressions (NLS 5506: ScopRev
Four new studies including observational data from be-
2023, EvUp 2025)
fore and after implementation of an intervention to in-
• Chest compression location on sternum (NLS 5507:
crease or improve aspects of briefing before newborn
EvUp 2025)
resuscitation were identified.16–19 The studies were gen-
erally supportive of the use of briefing, but there is insuf-
Drug and Fluid Administration ficient new evidence to justify a new SysRev.
• Epinephrine (adrenaline) for neonatal resuscitation
(NLS 5600: EvUp 2025) Treatment Recommendation (2025)
• Sodium bicarbonate during neonatal resuscitation There was no previous treatment recommendation on
(NLS 5601: EvUp 2025) the topic. The task force considered that the following
• Glucose management during or immediately after statement was justified:
resuscitation (NLS 5602: ScopRev 2025) Whenever the need for resuscitation of a newborn is
• Blood volume expansion during neonatal resuscita- anticipated, there should be a briefing of the neonatal
tion (NLS 5650: EvUp 2025) team that includes communication with the obstetric and
• Intraosseous versus intravenous cannulation for midwifery team to inform the neonatal management plan
emergency access (NLS 5652: EvUp 2025) (good practice statement).

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 Liley et al Neonatal Life Support: CoSTR 2025

UMBILICAL CORD MANAGEMENT of the umbilical cord and transfer to a resuscitation trolley
for the commencement of assisted ventilation. Alternative
For umbilical cord management, the previous reviews
strategies to enable placental transfusion before or dur-
for preterm and term infants used definitions that do
ing resuscitation have since been investigated. The task
not adequately reflect more recent research studies and
force updated the previous SysRev for term and late pre-
routine definitions used in clinical practice. These terms
term infants for the specific subgroup of infants who are
have been replaced, as noted in Table 1, in the following
not vigorous at birth. The review was registered before
3 summaries of reviews of umbilical cord management.
initiation (PROSPERO 2024 CRD42024562012). The
There is also some variation in how individual clinical tri-
full online CoSTR can be found on the ILCOR website.23
alists or previous reviews have used these terms. Where
essential to interpretation of results, we will point this out.
Population, Intervention, Comparator, Outcome, and
Adherence to the intended intervention may also vary be-
Time Frame
tween the arms of different studies.
• Population: Term and late preterm infants (≥34
weeks’ gestation) who are not vigorous at birth
Umbilical Cord Management at Birth for • Intervention: Any cord management strategy
Nonvigorous Term and Late Preterm Infants designed to improve fetal to neonatal cardiorespi-
(NLS 5050[a]: SysRev 2025) ratory transition, including deferred cord clamping,
intact cord resuscitation, intact umbilical cord milk-
Rationale for Review ing, and cut umbilical cord milking
Clamping the umbilical cord at birth is a key event af- • Comparator: Immediate cord clamping, early cord
fecting adaptation to extrauterine life, particularly in the clamping, or between-intervention comparisons (eg,
seconds and minutes immediately after birth. If cord deferred cord clamping versus intact umbilical cord
clamping is deferred, umbilical venous return contrib- milking or cut umbilical cord milking)
utes to hemodynamic stability for several minutes after • Outcome:
birth.20,21 Placental transfusion also reduces later need Infant
for red cell transfusion in preterm infants and helps to − Neonatal mortality (critical)
prevent anemia and iron deficiency in term infants.9 − Moderate to severe neurodevelopmental impair-
A 2021 SysRev conducted for ILCOR with the ment at 18 to 24 months (critical)
Cochrane Collaboration found substantial evidence to sup- − Any component of neurodevelopmental impair-
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port a recommendation suggesting deferred cord clamp- ment at 18 to 24 months (critical) (cerebral palsy,
ing for ≥60 seconds.9,22 Because of a paucity of evidence significant mental developmental delay, blind-
at the time, this recommendation excluded the important ness as defined by the World Health Organization
subgroup of infants who are not vigorous at birth. Their [<20/200 visual acuity] or the author’s definition,
treatment has traditionally involved immediate clamping hearing deficit [aided or <60 dB on audiometric
testing])
− Moderate to severe hypoxic ischemic encepha-
Table 1. Abbreviations and Definitions of Terms Related to lopathy (Sarnat 2 or 324) (critical)
Umbilical Cord Management − Proportion of infants receiving chest compres-
Time-based Physiology-based sions in the delivery room (important)
decisions decisions Cord milking − Admission to a neonatal intensive care unit
ICC: Immediate cord Intact cord resuscitation: I-UCM: Intact (NICU) (important)
clamping (usually Any time to cord clamping umbilical cord milking;
− Jaundice: Treated with exchange transfusion
≤15 s) without (usually ≥60 s) but when repeated compression
initiation of respira- respiratory support (eg, of the cord from the (critical) or phototherapy (important)
tory support supplemental oxygen, placental side toward − Hematologic outcomes including peak hemoglo-
high-flow, CPAP, PPV) the baby with the
ECC: Early cord bin or hematocrit concentration during hospital
is provided before cord connection to the
clamping (usually admission (important) and anemia or iron defi-
clamping placenta intact
<60 s) without
initiation of respiratory PBCC: Physiologically C-UCM: Cut umbilical ciency at 4 to 6 months (important)
support; may include based cord clamping; cord milking; drainage − Unintended hypothermia within the first hour of
infants who had ICC cord clamping not based of the cord by life (important)
on a specific time but on compression from the
DCC: Deferred cord
physiological observa- cut end toward the Mother
clamping (usually
≥60 s), before
tions such as a defined baby after clamping − Postpartum hemorrhage, estimated as at least
duration of breathing or and cutting a long 1000 mL (critical), postpartum infection (critical),
respiratory support
effective PPV segment
death or severe morbidity (composite), major sur-
CPAP indicates continuous positive airway pressure; C-UCM, cut umbilical gery, organ failure, intensive care unit admission
cord milking; DCC, deferred cord clamping; ECC, early cord clamping; I-UCM, in-
tact umbilical cord milking; ICC, immediate cord clamping; PBCC, physiologically
(critical)
based cord clamping; and PPV, positive-pressure ventilation. • Time frame: January 1, 2019, to July 10, 2024

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 Liley et al Neonatal Life Support: CoSTR 2025

Consensus on Science Two other small single-arm studies examining resus-

Intact Umbilical Cord Milking Compared With Early Cord citation with an intact cord concluded that intact cord
Clamping resuscitation was feasible in 12 nonvigorous infants ≥32
One eligible cluster-randomized multicenter crossover weeks’ gestation31 and 20 infants with congenital dia-
trial including 1730 infants,25 of whom 971 were fol- phragmatic hernia.32
lowed up to 2 years of age,26 was identified. Infants were
eligible if they had poor tone, pallor, or were not breathing Prior Treatment Recommendations (2021; see NLS
despite stimulation. For those in the intact umbilical cord 5050[b])
milking arm, the infant was held below the level of the There are none for this subgroup of nonvigorous term
incision (for caesarean births) or on the mother’s abdo- and late preterm infants.
men (for vaginal births) while a 20 cm length of umbili-
cal cord was milked for 2 seconds per time a total of 4 Treatment Recommendations (2025)
times before cord clamping. For those in the early cord Intact Umbilical Cord Milking Compared With Early Cord
clamping arm, the cord was clamped within 60 seconds Clamping
after birth (median interquartile range, 20 [10–30] s). In term and late preterm infants who remain nonvigor-
Key outcomes are summarized in Table 2. For additional ous despite stimulation, we suggest intact cord milking in
outcomes, see the full online CoSTR.23 Statistical results preference to early cord clamping (weak recommenda-
are reported conforming to analytical methods that were tion, low-certainty evidence).
used in the study because of the cluster randomization
Intact Cord Resuscitation Compared With Early Cord
(eg, modified odds ratio instead of relative risk).
Clamping or Immediate Cord Clamping
There is currently insufficient evidence to recommend ei-
Intact Cord Resuscitation Compared With Early Cord ther for or against intact cord resuscitation for term and
Clamping or Immediate Cord Clamping late preterm infants who are nonvigorous at birth.
Three studies were included,27–29 and 2-year follow-up
data30 were available for one.28 In all 3 studies, the in-
Justification and Evidence-to-Decision Framework
tervention group received respiratory support, if required,
Highlights
using a T-piece resuscitator27,29 or self-inflating bag28
The complete evidence-to-decision table is provided in
with the umbilical cord intact. Two studies aimed for at
Appendix A.
least 180 seconds before cord clamping27,28 and the oth-
Downloaded from [Link] by on October 27, 2025

er at least 2 minutes and until ≥60 seconds after change Intact Umbilical Cord Milking Compared With Early Cord
in color of a CO2 detector placed between the face mask Clamping
and T-piece.29 Timing of clamping of the umbilical cord The use of intact umbilical cord milking in preference to
in the control arm of each study was generally within 1 early cord clamping in infants who remain nonvigorous
minute. From these studies, clinical benefit or harm could despite stimulation is justified by the reduction in mod-
not be excluded for any of the critical or important short- erate or severe hypoxic ischemic encephalopathy and
and long-term outcomes. improvement in early hemoglobin, given that there was

Table 2. Milking of the Intact Umbilical Cord Compared With Early Cord Clamping: Critical and Important Outcomes

Anticipated absolute effect (95% CI)

Certainty of
Outcome Participants evidence, Relative effect Risk difference with
(importance*) (studies), n GRADE (95% CI) Risk with ECC I-UCM
Mortality (critical) 1730 (1 RCT)25 (follow-up Low RR 0.11 (0.01–2.03) 5/1000 4 fewer per 1000
to hospital discharge) (5 fewer to 5 more)
Moderate or severe HIE (critical) 1634 (1 RCT)25 Moderate RR 0.49 (0.25–0.97) 30/1000 15 fewer per 1000
(22 fewer to 1 fewer)
Admission to NICU (important) 1730 (1 RCT)25 Moderate mOR,† 0.69 (0.41–1.14) 279/1000 68 fewer per 1000
(142 fewer to 27 more)
Hemoglobin (g/dL) (important) 1730 (1 RCT)25 Moderate – Median hemoglobin mMD† 0.7 g/L higher
(g/dL) was 17.3 g/L (0.3 higher to 1.1 higher)
Survival with typical development 971 (1 RCT)26 (follow-up Low mOR,† 0.76 (0.54–1.08) 829/1000 42 fewer per 1000
(ASQ domains normal range) to 2 y of age) (105 fewer to 11 more)

*Outcome importance according to Strand et al.12

†Modeled odds ratios or modeled mean differences were as reported by study authors (modeling to account for the cluster-randomized study design).
ASQ indicates Ages & Stages Questionnaires; ECC, early cord clamping; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; HIE,
hypoxic ischemic encephalopathy; I-UCM, intact cord milking; mMD, modelled mean difference; mOR, modeled odds ratio; NICU, neonatal intensive care unit; RCT,
randomized controlled trial; and RR, relative risk.

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 Liley et al Neonatal Life Support: CoSTR 2025

no evidence of adverse effects. It also allows a uniform • The effect of other techniques to facilitate placental
suggestion for intact cord milking as an alternative to transfusion including milking of a long segment of
early cord clamping for all infants ≥28 weeks’ gestation,9 clamped-and-cut umbilical cord
bearing in mind that deferred cord clamping is still the
preferred option for all vigorous infants. The rationale
differs depending on gestation, but the certainty of evi- Umbilical Cord Management for Vigorous Term
dence and strength of recommendation are similar.9 The and Late Preterm Infants (NLS 5050(b): SysRev
strategy is simple, does not require additional equipment, 2021, EvUp 2025)
and appears safe and feasible. Although no formal cost- Various methods of umbilical cord management for all
benefit analysis has been performed, any reduction in term and late preterm infants were addressed by a 2021
moderate or severe hypoxic ischemic encephalopathy is SysRev and included in the 2021 CoSTR summary, al-
likely to result in cost savings both in relation to the costs though the studies found for inclusion included few in-
of NICU care and the lifetime costs of adverse outcomes fants who were nonvigorous.9,22 An EvUp was conducted
of this condition. for 2025 to determine whether, in vigorous infants, any
An additional observational study reported that in of these methods compared with early cord clamping (or
newborn infants who were not yet crying, providing tac- any other method) improved neonatal or infant outcomes
tile stimulation while the cord remained intact (deferred without causing any harm to mothers. The complete EvUp,
cord clamping) was associated with a higher proportion including the full PICOST, can be found in Appendix B.
who breathed spontaneously, a decrease in use of bag- • Time frame: July 26, 2019, to July 10, 2024
mask ventilation, fewer Apgar scores ≤3, and increased
odds of spontaneous breathing than providing stimulation Summary of Evidence
after early cord clamping,33 supporting the role of tactile Forty-two eligible RCTs or quasi RCTs reported in 43 arti-
stimulation during deferred cord clamping and indicating cles since the last SysRev were identified.35–77 The studies
that the task force treatment recommendation for tactile each compared two or more methods of umbilical cord man-
stimulation to stimulate breathing should apply regard- agement including ECC, DCC of various durations, I-UCM,
less of the method of umbilical cord management.34 C-UCM and PBCC. Twenty-four trials focused on infant
hematologic outcomes,37–39,41–43,45,47–51,53–56,60,61,66,70,71,74,76,77
Intact Cord Resuscitation Compared With Early Cord 8 on various physiological measurements,35,40,46,57,67,69,72,75
Clamping or Immediate Cord Clamping 3 on risk of postpartum hemorrhage,58,62,65 3 on jaundice,
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The task force considered that because clinical ben- phototherapy59,64,68 and 3 on neurodevelopmental or brain-
efit or harm cannot be excluded for any outcome, and imaging outcomes.36,52,63 One trial assessed breastfeeding
certainty of evidence was low, no general or conditional scores.44 Seven of the trials examined specific subgroups
treatment recommendation can be made at this time. Re- of infants, including those at risk of Rh hemolytic disease,66
suscitation of infants still attached to the umbilical cord infants of mothers with diabetes or large-for-gestational
can be accomplished by using a variety of strategies and age infants,48,59,76 and infants who were small for gesta-
devices. These include purpose-built resuscitation tables tional age, had fetal growth restriction, or whose mothers
that may include equipment to provide an external heat had preeclampsia.35,39,65
source, assisted ventilation, and monitoring. Given that in Based on the amount of evidence, the task force will
many cases, the finding that an infant is not vigorous at
prioritize an updated SysRev.
birth is unexpected, these devices may only be available
for a small proportion of high-risk births, and potentially Treatment Recommendation (2021)
not in locations where resources are limited. For term and late preterm infants born at ≥34 weeks’
No studies were found to inform a treatment recom- gestation who are vigorous or deemed not to require
mendation about any other form of umbilical cord man- immediate resuscitation at birth, we suggest later (de-
agement in late preterm and term infants who are not ferred) clamping of the cord at ≥60 seconds (weak rec-
vigorous at birth, or to compare intact umbilical cord milk- ommendation, very low–certainty evidence).
ing to intact cord resuscitation.
Knowledge Gaps Umbilical Cord Management at Birth for
• The need for large multicenter RCTs evaluating both
Preterm Infants (NLS 5051: SysRev 2023, EvUp
intact umbilical cord milking and intact cord resus-
citation, including high-quality follow-up with formal 2025)
assessment of cognition, motor development, hear- Umbilical cord management for preterm infants was ad-
ing, and vision dressed by a 2021 SysRev,9,78 which was updated for
• The safety, useability, and cost-effectiveness of dif- the 2024 CoSTR summary7 by adolopment of a large,
ferent devices to support resuscitation with an intact individual patient data pairwise meta-analysis79 and net-
cord work meta-analysis80—the iCOMP (Cord Management of

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 Liley et al Neonatal Life Support: CoSTR 2025

Preterm Birth) study. An EvUp was conducted for 2025. maternal and neonatal risk (weak recommendation, very
The complete EvUp, including the full PICOST, can be low–certainty evidence).
found in Appendix B. Whenever circumstances allow, the plan for umbilical
• Study design: The iCOMP individual patient data cord management should be discussed between mater-
meta-analysis and network meta-analysis included nity and neonatal providers and parents before delivery
RCTs comparing umbilical cord management strat- and should take into account individual maternal and
egies for which individual patient data were avail- infant circumstances (good practice statement).
able but excluded trials with missing data, integrity
issues, those not fitting intervention categories, and
cluster- and quasi-randomized trials.81 The updated INITIAL STEPS
search included RCTs whether or not individual
patient data were available. Maintaining Normal Temperature Immediately
• Time frame: June 6, 2023, to June 6, 2024 After Birth in Term and Late Preterm Infants
(NLS 5100: SysRev 2022, EvUp 2025)
Summary of Evidence
The search found 8 eligible RCTs35,82–88 and 1 SysRev.89 A previous ILCOR SysRev reported a dose-responsive
Most of the clinical trials had insufficient sample size for association between hypothermia and increased risk
critical and important outcomes, but overall, they support- of mortality and other adverse outcomes,2 and another
ed the use of deferred cord clamping or umbilical cord SysRev found that hypothermia was very common in
milking compared with early cord clamping or immediate infants born in hospitals and homes, even in tropical
cord clamping, with no new adverse effects reported. The environments.90 Hence, the effect of various interven-
task force concluded that they would not change the cur- tions to maintain normal temperature immediately after
rent treatment recommendations or justify updating the birth on survival, on the response to resuscitation, and
SysRev at this time. on temperature outcomes was addressed in a 2022
SysRev,91 details of which can be found in the 2022
Treatment Recommendations (2024) CoSTR summary.8 An EvUp was conducted for 2025.
In preterm infants born at <37 weeks’ gestation who The complete EvUp, including the full PICOST, can be
are deemed not to require immediate resuscitation at found in Appendix B.
birth, we recommend deferring clamping of the umbilical • Time frame: July 20, 2022, to July 20, 2024
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cord for at least 60 seconds (strong recommendation,

moderate-certainty evidence). Summary of Evidence
In preterm infants born at 28 + 0 to 36 + 6 weeks’ The update found 1 SysRev establishing a national
gestation who do not receive deferred cord clamp- guideline that had extensive overlap with the previous
ing, we suggest umbilical cord milking as a reasonable ILCOR SysRev,92 3 RCTs, 2 observational studies, and
alternative to immediate cord clamping to improve infant 1 quality improvement study. There was insufficient new
hematologic outcomes. Individual maternal and infant evidence for most interventions to justify an updated
circumstances should be taken into account (conditional SysRev. However, 1 cluster RCT comparing different am-
recommendation, low-certainty evidence). bient temperatures in the operating room was thought to
We suggest against intact cord milking for infants justify an updated SysRev for this specific intervention,
born at <28 weeks’ gestation (weak recommendation, which the task force will prioritize.93
low-certainty evidence). There is insufficient evidence to
make a recommendation regarding cut-cord milking in Treatment Recommendations (2022)
this gestational age group. In late preterm and term newborn infants (≥34 weeks’
In preterm infants born at <37 weeks’ gestation who gestation), we suggest the use of room temperatures of
are deemed to require immediate resuscitation at birth, 23 ºC compared to 20 ºC at birth in order to maintain
there is insufficient evidence to make a recommendation normal temperature (weak recommendation, very low–
with respect to cord management (weak recommenda- certainty evidence).
tion, low-certainty evidence). In late preterm and term newborn infants (≥34 weeks’
There is insufficient evidence to make recommenda- gestation) at low risk of needing resuscitation, we sug-
tions on cord management for maternal, fetal, or placen- gest the use of skin-to-skin care with a parent imme-
tal conditions that were considered exclusion criteria in diately after birth rather than no skin-to-skin care to
many studies (monochorionic multiple fetuses, congeni- maintain normal temperature (weak recommendation,
tal anomalies, placental abnormalities, alloimmunization, very low–certainty evidence).
fetal anemia, fetal compromise, and maternal illness). In some situations where skin-to-skin care is not pos-
In these situations, we suggest individualized decisions sible, it is reasonable to consider the use of a plastic
based on severity of the condition and assessment of bag or wrap, among other measures, to maintain normal

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 Liley et al Neonatal Life Support: CoSTR 2025

temperature (weak recommendation, very low–certainty a thermal mattress, but there is a risk of hyperthermia
evidence). (conditional recommendation, low-certainty evidence).
In late preterm and term newborn infants ≥34 weeks’ In preterm infants (<34 weeks’ gestation) immedi-
gestation, for routine use of a plastic bag or wrap in addi- ately after birth, we recommend the use of a plastic bag
tion to skin-to-skin care immediately after birth compared or wrap to maintain normal temperature (strong recom-
with skin-to-skin care alone, the balance of desirable and mendation, moderate-certainty evidence).
undesirable effects was uncertain. Furthermore, the val- Temperature should be carefully monitored and man-
ues, preferences, and cost implications of the routine use aged to prevent hyperthermia (good practice statement).
of a plastic bag or wrap in addition to skin-to-skin care In preterm infants (<34 weeks’ gestation) immedi-
are not known; therefore, no treatment recommendation ately after birth, we suggest the use of a head covering
can be formulated. to maintain normal temperature (strong recommenda-
tion, moderate-certainty evidence).
In preterm infants (<34 weeks’ gestation) immedi-
Maintaining Normal Temperature Immediately ately after birth, we suggest that heated and humidified
After Birth in Preterm Infants (NLS 5101: gases for respiratory support in the delivery room can be
SysRev 2023, EvUp 2025) used when an audit shows that admission hypothermia is
Recent observational studies94–97 confirm the associa- a problem and resources allow (conditional recommen-
tion between hypothermia on admission to a neonatal dation, very low–certainty evidence).
unit and increased mortality and other adverse out- In preterm infants (<34 weeks’ gestation) immedi-
comes,2 and also suggest there is potential harm from ately after birth, there is insufficient published evidence
hyperthermia on admission. Therefore, a SysRev on the to suggest for or against the use of a radiant warmer in
effect of various methods for maintaining normal tem- servo-controlled mode compared with manual mode for
perature immediately after birth on critical and import maintaining normal temperature.
neonatal outcomes was conducted98 and included in the In preterm infants (<34 weeks’ gestation), there is
2023 CoSTR summary.6 An EvUp was also conducted insufficient published evidence to suggest for or against
for 2025. The complete EvUp, including the full PICOST, the use of skin-to-skin care immediately after birth. Skin-
can be found in Appendix B. to-skin care may be helpful for maintaining normal tem-
• Time frame: The literature search was updated from perature when few other effective measures are available
(good practice statement).
Downloaded from [Link] by on October 27, 2025

July 20, 2022, to July 20, 2024.

Summary of Evidence
One SysRev92 that addressed the PICOST had exten- Suctioning of Clear Amniotic Fluid at Birth (NLS
sive overlap in included studies with the ILCOR Sys- 5120: SysRev 2022, EvUp 2025)
Rev98 and similar conclusions. In addition, 1 cluster Since 2010, ILCOR treatment recommendations and
RCT addressed ambient operating room temperature many guidelines have advised selective rather than
(24 °C versus 20 °C) at birth93 and 2 RCTs assessed routine oropharyngeal or nasopharyngeal upper airway
aspects of plastic bag or wrap versus no plastic bag suctioning, with use only if the airway appears obstruct-
or wrap.99,100 These studies do not warrant an updated ed or when positive-pressure ventilation is required.105
SysRev. To update the assessment of evidence using Grading
Some additional studies provided evidence on admis- of Recommendations Assessment, Development, and
sion temperatures in relation to skin-to-skin care after Evaluation methods, the topic was prioritized for a Sys-
delivery room resuscitation.101–104 These may justify a Rev,106 details of which can be found in the 2022 CoSTR
ScopRev or SysRev to consider the role of skin-to-skin summary.8 An EvUp was conducted for 2025. The com-
care during transfer from delivery room to NICU after plete EvUp, including the full PICOST, can be found in
resuscitation. Appendix B.
• Time frame: September 21, 2021, to June 23, 2024
Treatment Recommendations (2023)
In preterm infants (<34 weeks’ gestation), as for late Summary of Evidence
preterm and term infants (≥34 weeks’ gestation), we A new quality improvement study that focused on re-
suggest the use of room temperatures of ≥23 °C com- ducing unnecessary suctioning of clear amniotic fluid
pared with 20 °C at birth in order to maintain normal in the delivery room included 999 infants, of whom
temperature (weak recommendation, very low–certainty 12% received oropharyngeal suctioning in the first
evidence). phase of the study and 4% in the second.107 The study
In preterm infants (<34 weeks’ gestation) immediately found no disadvantages of the more selective suction-
after birth, where hypothermia on admission is identified ing approach. An updated SysRev is not justified at
as a problem, it is reasonable to consider the addition of this time.

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 Liley et al Neonatal Life Support: CoSTR 2025

Treatment Recommendations (2022) was conducted for 2022 examining whether—in infants
We suggest that suctioning of clear amniotic fluid from with absent, intermittent, or shallow breathing immedi-
the nose and mouth should not be used as a routine step ately after birth—tactile stimulation improved survival or
for newborn infants at birth (weak recommendation, very other critical and important outcomes, including response
low–certainty evidence). to resuscitation. Details can be found in the 2022 CoSTR
Airway positioning and suctioning should be consid- summary.8 An EvUp was conducted for 2025. The com-
ered if airway obstruction is suspected (good practice plete EvUp, including the full PICOST, can be found in
statement). Appendix B.
• Time frame: September 17, 2021, to June 30, 2024

Tracheal Intubation and Suctioning of Summary of Evidence

Meconium-Stained Amniotic Fluid (NLS 5130: One narrative review125 and 4 observational stud-
EvUp 2025) ies33,126–128 were identified. All the observational studies
supported use of tactile stimulation to promote spon-
ILCOR guidance has progressively changed for infants taneous breathing, but none specifically addressed the
exposed to meconium-stained amniotic fluid, from rec- PICOST. There is insufficient new evidence to justify up-
ommending routine tracheal suctioning in all infants with dating the SysRev.
depressed respirations and decreased muscle tone to
prevent meconium aspiration syndrome and reduce risk Treatment Recommendations (2022)
of death,108 to concluding that there was insufficient We suggest it is reasonable to apply tactile stimulation
evidence for this practice,4 to suggesting against it as in addition to routine handling with measures to maintain
a result of a 2020 ILCOR SysRev.8,109 An EvUp was con- temperature in newborn infants with absent, intermittent,
ducted for 2025. The complete EvUp, including the full or shallow respirations during resuscitation immediately
PICOST, can be found in Appendix B. after birth (weak recommendation, very low–certainty
• Time frame: November 1, 2018, to June 3, 2024 evidence).
Tactile stimulation should not delay the initiation of
Summary of Evidence positive-pressure ventilation for newborn infants who
A meta-analysis of RCTs110 included the same studies as continue to have absent, intermittent, or shallow respira-
the previous ILCOR SysRev109 and supported its conclu- tions after birth (good practice statement).
sions, as did a meta-analysis of observational studies.111
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Eight single-center observational studies were identi-

fied.112–119 All were retrospective or prospective with his- ASSESSMENT OF HEART RATE AT BIRTH
torical controls and were considered unlikely to change
the existing treatment recommendation or to justify a Heart Rate Assessment Methods in the Delivery
new SysRev at this time. Room—Diagnostic Characteristics (NLS 5200:
SysRev 2023, EvUp 2025)
Treatment Recommendations (2020)
For nonvigorous newborn infants delivered through The diagnostic characteristics of methods to assess heart
meconium-stained amniotic fluid, we suggest against rate were addressed in a SysRev129 that was included
routine immediate direct laryngoscopy with or without in the 2023 CoSTR summary.6 Note that the treatment
tracheal suctioning when compared with immediate re- recommendations for NLS 5200 are combined with and
suscitation without direct laryngoscopy (weak recom- supersede those of NLS 5201. A companion review
mendation, low-certainty evidence). (NLS 5201) examined the effects of different methods
Meconium-stained amniotic fluid remains a signifi- of heart rate measurement on survival and other critical
cant risk factor for receiving advanced resuscitation in and important outcomes.130 For this review of diagnostic
the delivery room. Rarely, an infant may require intuba- characteristics, heart rate measured by electrocardiog-
tion and tracheal suctioning to relieve airway obstruction raphy (ECG) was considered the gold standard against
(good practice statement). which the relative accuracy and precision of other meth-
ods were assessed. The time to first heart rate assess-
ment from the device placement and from birth was also
Tactile Stimulation (NLS 5140: SysRev 2022, compared. An EvUp was conducted for 2025. The com-
EvUp 2025) plete EvUp, including the full PICOST, can be found in
Appendix B.
Tactile stimulation as an initial step in resuscitation im- • Time frame: August 16, 2023, to June 30, 2024
mediately after birth was included in ILCOR neonatal
resuscitation treatment recommendations since 1999, Summary of Evidence
largely based on expert opinion.5,105,120,121 A SysRev124 No new studies were identified.

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 Liley et al Neonatal Life Support: CoSTR 2025

Treatment Recommendations (2023) VENTILATION AND OXYGENATION

Where accurate heart rate estimation is needed for a
newborn infant immediately after birth and resources Devices for Administering Positive-Pressure
permit, we suggest that the use of ECG is reasonable Ventilation (NLS 5300: SysRev 2021, EvUp
(conditional recommendation, low-certainty evidence). 2025)
Pulse oximetry and auscultation may be reasonable Establishing lung aeration and tidal ventilation is essential
alternatives to ECG for heart rate assessment, but the in newborn infants who remain apneic or are not breath-
limitations of these modalities should be kept in mind ing effectively. A 2021 ILCOR ScopRev identified possi-
(conditional recommendation, low-certainty evidence). ble differences in the effectiveness and safety of T-piece
There is insufficient evidence to make a treatment resuscitators versus self-inflating bags for administering
recommendation regarding use of any other device for positive-pressure ventilation.132 A subsequent SysRev in
heart rate assessment of a newborn infant immediately the same year addressed this question.133 Details of this
after birth. review can be found in the 2021 CoSTR summary.9 An
Auscultation with or without pulse oximetry should be EvUp was conducted for 2025. The complete EvUp, in-
used to confirm the heart rate when ECG is unavailable, cluding the full PICOST, can be found in Appendix B.
not functioning, or when pulseless electrical activity is • Time frame: December 30, 2020, to July 1, 2024
suspected (good practice statement).
Summary of Evidence
Two new SysRevs were identified that included RCTs
Heart Rate Assessment Methods in the Delivery
and cohort studies, most of which were already included
Room—Clinical Outcomes (NLS 5201: SysRev in the 2021 ILCOR review,134,135 and which, in general,
2022, EvUp 2025) concurred with the previous ILCOR SysRev.133 Two addi-
Because heart rate is considered a critical indicator of tional small RCTs136,137 provide insufficient new evidence
both the need for and the response to resuscitation in to justify a new SysRev.
newborn infants, fast and accurate measurement is de-
sirable.129 However, heart rate should be considered in Treatment Recommendations (2021)
the context of other characteristics, such as tone and Where resources permit, we suggest the use of a T-piece
breathing effort, and with an awareness of the time it resuscitator over the use of a self-inflating bag in infants
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takes for the heart rate to improve after any interven- receiving positive-pressure ventilation at birth (weak rec-
tion. Fixation on heart rate alone could lead to too many ommendation, very low–certainty evidence).
or too few resuscitation interventions. Because evalu- However, a self-inflating bag should be available as
ation of test characteristics and the effects on clinical a backup device for the T-piece resuscitator in case of
outcomes required different methods, clinical outcomes gas-supply failure (technical remark).
were addressed by a separate SysRev130 included in the There are no data to make a treatment recommenda-
2022 CoSTR summary,8 and an EvUp was conducted for tion for use of a T-piece resuscitator compared with a
2025. The complete EvUp, including the full PICOST, can flow-inflating bag.
be found in Appendix B. There are no data to make a treatment recommen-
• Time frame: August 16, 2023, to June 30, 2024 dation for use of a flow-inflating bag compared with a
self-inflating bag.
Summary of Evidence The confidence in effect estimates is so low that any
One new retrospective observational study compared the recommendation for the use of self-inflating bags fitted
frequency of resuscitation interventions before and after with positive end-expiratory pressure valves compared to
implementation of ECG in the delivery room and reported those without them would be speculative.
an initial increase in the use of chest compressions at
birth and a decrease in frequency of tracheal intubation. Continuous Positive Airway Pressure Versus
These changes were reversed by a focused educational
intervention highlighting the importance of achieving ef-
Positive-Pressure Ventilation for Preterm
fective ventilation.131 This study was not deemed to jus- Infants (NLS 5310: EvUp 2025)
tify a new SysRev. Continuous positive airway pressure is a well-established
method of respiratory support during NICU care for pre-
Treatment Recommendations (2022, Superseded– term infants whose breathing is spontaneous but labored
See NLS 5200) because of lung immaturity, or as part of treatment for
Recommendations for NLS 5201 were superseded in apnea of prematurity. A 2015 SysRev2 addressed the
2023 by those for heart rate assessment methods— use of continuous positive airway pressure compared
diagnostic characteristics (NLS 5200, see previous sec- with tracheal intubation and positive-pressure ventila-
tion), which reflect conclusions of both reviews. tion immediately after birth for mortality and critical and

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 Liley et al Neonatal Life Support: CoSTR 2025

important neonatal morbidity outcomes. An EvUp was Treatment Recommendation (2022)

undertaken for the 2020 CoSTR5 and again in 2025. The For spontaneously breathing late preterm and term new-
complete EvUp, including the full PICOST, can be found born infants in the delivery room with respiratory distress,
in Appendix B. there is insufficient evidence to suggest for or against
• Time frame: November 1, 2019, to September 30, routine use of continuous positive airway pressure com-
2024 pared with no continuous positive airway pressure.
Summary of Evidence
No new studies were identified. A new SysRev conclud- Sustained Inflations During Newborn
ed that in spontaneously breathing, very preterm infants, Resuscitation (NLS 5320: EvUp 2025)
nasal continuous positive airway pressure (within the
Whether initial sustained inflations, with longer inspiratory
first 15 minutes) compared with mechanical ventilation
times than those used for subsequent positive-pressure
reduces the incidence of bronchopulmonary dysplasia,
ventilation, improve critical or important outcomes from
the combined outcome of death and bronchopulmonary
resuscitation of newborn infants was addressed with a
dysplasia, and mechanical ventilation but does not affect
SysRev included in the 2020 CoSTR.5,141 An EvUp was
neurodevelopmental impairment at 18 to 22 months of
undertaken for 2025. The complete EvUp, including the
age.138 In the absence of new evidence, there is no justi-
full PICOST, can be found in Appendix B.
fication for an updated SysRev.
• Time frame: January 1, 2020, to July 2, 2024
Treatment Recommendation (2015)
Summary of Evidence
For spontaneously breathing preterm infants with re-
One RCT including 160 participants found no differ-
spiratory distress requiring respiratory support in the
ences in outcomes.142 The task force concluded that this
delivery room, we suggest initial use of continuous posi-
single new study did not justify updating the SysRev at
tive airway pressure rather than tracheal intubation and
this time.
positive-pressure ventilation (weak recommendation,
moderate-certainty evidence). Treatment Recommendation (2020)
For preterm newborn infants who receive positive-
pressure ventilation due to bradycardia or ineffective
Continuous Positive Airway Pressure for Term
respirations at birth, we suggest against the routine use
and Late Preterm Infants With Respiratory
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of initial sustained inflation(s) >5 seconds (weak recom-

Distress (NLS 5312: SysRev 2022, EvUp 2025) mendation, low-certainty evidence). A sustained inflation
Although it has become increasingly common to use may be considered in research settings.5
continuous positive airway pressure for respiratory dis- For term or late preterm infants who receive positive
tress immediately after birth in late preterm and term in- pressure ventilation due to bradycardia or ineffective
fants, the evidence for it is not as well established as for respirations at birth, it is not possible to recommend any
preterm infants. The effect of continuous positive airway specific duration for initial inflations due to the very low
pressure for late preterm and term infants with respira- confidence in the estimates of effect.
tory distress on mortality, major neonatal morbidity, and
response to resuscitation was addressed in a SysRev139
Supraglottic Airway Device Versus Face Mask
included in the 2022 CoSTR summary.8 An EvUp was
conducted for 2025. The complete EvUp, including the (NLS 5340: SysRev 2022, EvUp 2025)
full PICOST, can be found in Appendix B. Positive-pressure ventilation administered via a face
• Time frame: October 8, 2021, to August 28, 2024 mask may be ineffective because of mask leak or fail-
ure to achieve airway patency. The effect of the use
Summary of Evidence of supraglottic airway devices compared with face
One new retrospective observational study compared masks for administering positive-pressure ventilation
outcomes before and after introduction of local guide- on mortality, morbidity, and response to resuscitation
lines to avoid the use of continuous positive airway was assessed by a SysRev143 included in the 2022
pressure in certain late preterm and term infants. It CoSTR summary.8 An EvUp was conducted for 2025.
suggested no harm and a possible benefit from reduc- The complete EvUp, including the full PICOST, can be
ing the use of continuous positive airway pressure for found in Appendix B.
term and late preterm infants immediately after birth • Time frame: December 9, 2021, to July 2, 2024
who have signs of respiratory distress (eg, grunting, re-
tractions or tachypnea) but whose blood oxygen satu- Summary of Evidence
rations are reaching target ranges.140 Given the limited One new quasi-RCT (67 participants) was found,144
new evidence, there is no justification for an updated which provided insufficient evidence to justify updating
SysRev. the SysRev at this time.

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 Liley et al Neonatal Life Support: CoSTR 2025

Treatment Recommendation (2022) Use of a Supraglottic Airway Device During

Where resources and training permit, we sug- Chest Compressions (NLS 5342: ScopRev
gest that a supraglottic airway device may be used
in place of a face mask for newborn infants ≥34
2025)
weeks’ gestation receiving intermittent positive- Rationale for Review
pressure ventilation during resuscitation immediate- Despite being one of the most common neonatal resus-
ly after birth (weak recommendation, low-certainty citation interventions, positive-pressure ventilation via
evidence). a face mask can be compromised by leaks around the
mask or upper airway obstruction leading to inadequate
tidal volume.143 Reduced tidal volume and minute volume
with positive-pressure ventilation via a face mask during
Supraglottic Airway Device Versus Tracheal chest compressions have been reported.155 Because im-
Tube (NLS 5341: EvUp 2025) mediate availability of a clinician with skills to intubate the
Tracheal intubation can be a lifesaving intervention trachea cannot be assured in all locations where advanced
during resuscitation of newborn infants, but it is a resuscitation is needed, the task force prioritized a new
difficult, complex task. There are limited opportuni- ScopRev addressing whether a supraglottic airway de-
ties and a lack of well-defined pathways for health vice would provide an effective alternative to face mask
care professionals to consolidate simulation-based positive-pressure ventilation during chest compressions.
training with guided clinical practice.145 Supraglottic The full review is available on the ILCOR CoSTR website.23
airway devices do not require laryngoscopy and are
Population, Intervention, Comparator, Outcome, and
used in resuscitation in other age groups, albeit with
Time Frame
low certainty of evidence.146,147 Until recently, devices
• Population: Newborn infants of ≥34 weeks’ gesta-
small enough for infants <34 weeks’ gestation were
tion receiving chest compressions despite optimized
not available. The effect of the use of supraglottic air-
positive-pressure ventilation
way devices in newborns as an alternative to tracheal
• Intervention: Positive-pressure ventilation with a
intubation on mortality, major morbidity, and response
supraglottic airway device
to resuscitation was last assessed by the NLS Task
• Comparator: Positive-pressure ventilation with a
Force in 2015.2 An EvUp was undertaken for 2025.
face mask or tracheal tube
The complete EvUp, including the full PICOST, can be
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• Outcome:
found in Appendix B.
– Delivery room outcomes:
• Time frame: January 1, 2014, to November 4, 2024
▪ Death in the delivery room (critical)
▪ Time to heart rate ≥60 beats per minute (bpm)
Summary of Evidence and time to heart rate ≥100 bpm (important)
Two SysRevs,148,149 3 new RCTs (2 of which were in- ▪ Duration of advanced airway placement
cluded in the SysRevs, together enrolling 223 partici- attempt and duration of interruption of CPR
pants),150–152 and 1 observational study of 86 infants153 (important)
addressed the comparison for this PICOST. ▪ Number of attempts to insert advanced airway
The evidence was considered unlikely to change (important)
the current treatment recommendation but may jus- ▪ Epinephrine (adrenaline) administration
tify updating the SysRev to reevaluate the certainty (important)
of evidence. The terms laryngeal mask and low-quality ▪ Team preference (important)
evidence have been updated to reflect current termi- ▪ Failure of primary device (important)
nology (supraglottic airway device and low-certainty evi- ▪ Physiologic pulmonary outcomes (eg, tidal vol-
dence, respectively). ume, peak inspiratory pressure) (important)
– NICU outcomes:
Treatment Recommendations (2015, Updated to ▪ Survival to hospital discharge (critical)
Reflect Current Terminology) ▪ Incidence of hypoxic ischemic encephalopathy
We suggest using a supraglottic airway device as an al- (critical)
ternative to tracheal intubation during resuscitation of ▪ Air leak (eg, pneumothorax, pneumomediasti-
the late preterm and term newborn (≥34 weeks) if face num) during first 48 hours of life (important)
mask ventilation is unsuccessful (weak recommendation, ▪ Airway injury (important)
low-certainty evidence). ▪ Length of hospital stay (important)
A supraglottic airway device should be considered − Long-term outcomes:
during newborn resuscitation if face mask ventilation is ▪ Neurodevelopmental impairment at ≥18
unsuccessful and tracheal intubation is unsuccessful or months (critical)
not feasible (good practice statement). • Time frame: All years to July 15, 2024

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 Liley et al Neonatal Life Support: CoSTR 2025

Summary of Evidence 1.6–3.4 min less; high certainty), and the use of a supra-
Neonatal or Infant Studies glottic airway device likely led to more ROSC (relative risk,
No studies addressed the PICOST in human infants in 1.09; 95% CI, 1.02–1.15; moderate certainty).166
the delivery room or during the neonatal period. Indirect
Epinephrine Administration During CPR
evidence was available from 2 studies that addressed the
For the outcome of epinephrine administration, no stud-
use of supraglottic airway devices during chest compres-
ies addressed whether epinephrine use was reduced by
sions in newborn animals,156,157 2 in adult animals,158,159
using a supraglottic airway device during chest compres-
and 1 assessing resuscitator performance in a neonatal
sions. For efficacy of epinephrine via supraglottic airway
manikin study.160
devices, 2 studies in adult pigs (not in cardiac arrest)
In lambs that were asphyxiated before the transi-
concluded that epinephrine administration via a catheter
tion from intrauterine to extrauterine life, similar rates of
passed through the supraglottic airway device had simi-
return of spontaneous circulation (ROSC) were achieved
lar effects to epinephrine administration via tracheal tube.
within similar time frames with a supraglottic airway
But if administering epinephrine from the top of the su-
device and a tracheal tube.156 No differences in peak
praglottic airway devices, higher doses would be needed.
inspiratory pressure, positive end-expiratory pressure,
In the same model, 5 different routes and doses of
tidal volume, or mean airway pressure were found, lead-
epinephrine were compared.159 The authors again con-
ing the authors to conclude that use of the supraglottic
cluded that higher doses of epinephrine may be needed
airway device is noninferior to the use of a tracheal tube
if administering the epinephrine at the top of the supra-
during chest compressions. In piglets asphyxiated after
glottic airway device to produce an equivalent effect to
the transition to air breathing, similar tidal volumes and
epinephrine administered via tracheal tube.
peak inspiratory pressures were achieved during venti-
lation with a supraglottic airway device or tracheal tube
during neonatal chest compressions.157 Task Force Insights
A crossover manikin study evaluating single-rescuer The task force noted the lack of studies in newborn in-
CPR found that peak inspiratory pressures much closer fants but concluded that the few animal studies suggest
to the pressure that was set for the T-piece resuscita- that the use of a supraglottic airway device compared with
tor were achieved with the supraglottic airway compared a tracheal tube achieves similar rates of ROSC and that
with a face mask.160 The time taken to complete 30 ventilation of the lungs is not compromised. The pediat-
compression-to-ventilation cycles was shorter with the ric and adult (human) studies suggest benefits including
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supraglottic airway device than with a face mask (60.6 reduced time to airway placement and increased rates of
± 3.4 s versus 66.2 ± 6.1 s; [mean ± SD] P  <0.0001), ROSC, without evidence of any adverse effects attribut-
which enabled better adherence to recommendations for able to supraglottic airway devices. The animal studies of
completing 120 events in 60 seconds.161 epinephrine administration suggest that doses given via
Because of the paucity of human infant evidence, indi- a catheter down a supraglottic airway device may be as
rect evidence from other age groups was also evaluated. effective as administration via a tracheal tube. However,
no human infant studies are available, and the task force
Indirect Evidence From Studies in Children or Adolescents noted that intravascular administration remains the pre-
A registry study reported improved 30-day survival when ferred route for epinephrine.5,167 The task force concluded
a supraglottic airway device was used compared with a that there was insufficient evidence to justify a SysRev
tracheal tube.162 Other pediatric studies have also re- but that it was reasonable to generate a new good prac-
ported worse outcomes with tracheal intubation during tice statement based on the results of this ScopRev.
CPR.163,164
Treatment Recommendations (2025)
Indirect Evidence From Studies in Adults In newborn infants ≥34 weeks’ gestation who are re-
A 2020 SysRev and network meta-analysis (of 11 stud- ceiving chest compressions despite optimized positive-
ies including 8 RCTs) compared effectiveness of different pressure ventilation, if placement of a tracheal tube is not
airway interventions for out-of-hospital cardiac arrest.165 possible or is unsuccessful, ventilation via a supraglottic
The study reported increased ROSC with the use of a airway device during compressions is reasonable (good
supraglottic airway device compared with a tracheal tube practice statement).
(odds ratio, 1.11; 95% CI, 1.03–1.20) or compared with
bag-mask ventilation (odds ratio, 1.35; 95% CI, 1.11–
1.63). No differences in survival or long-term neurological Exhaled CO2 Monitoring to Guide Noninvasive
outcomes were found. A later SysRev and meta-analysis
comparing the use of a supraglottic airway with tracheal
Ventilation (NLS 5350: SysRev 2023, EvUp
intubation in adults with out-of-hospital cardiac arrest 2025)
concluded that it took less time to place a supraglottic The effectiveness of noninvasive positive-pressure ven-
airway device (mean difference 2.5 min less; 95% CI, tilation can be difficult to judge objectively. There may be

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 Liley et al Neonatal Life Support: CoSTR 2025

a delay in improvement in heart rate and blood oxygen • Intervention: Tracheal intubation using video
saturation, even after positive-pressure ventilation is es- laryngoscopy
tablished.168 Therefore, the effect of exhaled CO2 moni- • Comparator: Tracheal intubation using traditional
toring to guide noninvasive positive-pressure ventilation laryngoscopy
on survival, major morbidity, and response to resuscita- • Outcome:
tion was addressed by a SysRev169 included in the 2023 – Mortality in-hospital (critical)
CoSTR summary.6 An EvUp was undertaken for 2025. – Successful tracheal intubation (important)
The complete EvUp, including the full PICOST, can be – Successful tracheal intubation at the first attempt
found in Appendix B. (important)
• Time frame: August 1, 2022, to July 3, 2024 – Number of attempts to achieve successful tra-
cheal intubation (important)
Summary of Evidence – Time taken to successfully intubate (important)
One small pilot RCT addressed the PICOST, providing – Adverse events around the time of laryngoscopy,
insufficient evidence to justify updating the SysRev. eg, airway trauma, bradycardia, desaturation,
Treatment Recommendation (2023) esophageal intubation, pneumothorax (important)
There is insufficient evidence to suggest for or against – Perception of intubating clinician, eg, intubation
the use of exhaled CO2 to guide noninvasive intermit- difficulty (as defined by the author) (important)
tent positive-pressure ventilation using interfaces, such – Any intraventricular hemorrhage (IVH) (preterm
as face masks, supraglottic airways, and nasal cannulas only) (important)
in infants immediately after birth. • Time frame: All years to August 22, 2024
Consensus on Science
Video Versus Traditional Laryngoscope (NLS The SysRev identified 6 RCTs including 817 infants and
5351: SysRev 2025) 862 tracheal intubations,173–178 as well as 4 observational
studies involving 3289 infants who received 3342 tra-
Rationale for Review
cheal intubations.175–177,179 The evidence was considered
Aspects of neonatal anatomy (including the small mouth
indirect because approximately 80% of the infants were
and airway, the large tongue, epiglottis, and arytenoids, and
intubated in the NICU, not the delivery room. Outcomes
appearance of the glottis) make tracheal intubation diffi-
were described by intubation, not by infant.
cult, especially in preterm infants. Delivery room intubation
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Key results from RCTs are summarized in Table 3. The

for resuscitation is a time-critical procedure with a relatively
full online CoSTR can be found on the ILCOR website.23
low first-attempt success rate.170 Video laryngoscopes pro-
For the number of attempts to intubate and time to
vide indirect visualization of the glottis using a screen that
successful intubation, meta-analysis was not performed
(depending on the device) may also be visible to an instruc-
because of heterogeneity in how these results were
tor or assistant. Some video laryngoscopes also may be
reported. For other critical and important outcomes for
used for direct visualization. In contrast, traditional laryngo-
which data were available, clinical benefit or harm could
scopes enable only a direct view, which may be impeded
not be excluded.
by airway anatomy. Performance of and training in neonatal
intubation may be improved by using video laryngoscopes Treatment Recommendations (2025)
instead of traditional laryngoscopes.145,171 Therefore, the Where resources and training allow, in infants being intu-
NLS Task Force prioritized a SysRev,172 of which full details bated at birth or on a neonatal unit, we suggest the use
are available on the CoSTR website.23 The protocol was of video laryngoscopy in comparison to traditional laryn-
registered on PROSPERO CRD42023467940. goscopy, especially in settings where less-experienced
• Population: Infants receiving tracheal intubation at clinicians are intubating (conditional recommendation,
birth or on a neonatal unit moderate-certainty evidence).

Table 3. Video Laryngoscopy Compared With Traditional Laryngoscopy for Tracheal Intubation at Birth or in a Neonatal Unit: RCTs

Anticipated absolute effect (95% CI)

Intubations, n Certainty of evidence, Relative effect Risk with traditional Risk difference with video
Outcomes (importance*) (studies) GRADE (95% CI) laryngoscopy laryngoscopy
Successful intubation— 567 Moderate RR 1.43 513/1000 220 more intubations per 1000
overall (%) (important) (4 RCTs)173–175,178 (1.15–1.77) (77 more to 395 more)
Successful intubation—first 610 High RR 1.57 394/1000 225 more intubations per 1000
attempt (%) (important) (4 RCTs)175–178 (1.33–1.85) (130 more to 335 more)

*Outcome importance according to task force consensus.

GRADE indicates Grading of Recommendations Assessment, Development, and Evaluation; RCT, randomized controlled trial; and RR; relative risk.

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 Liley et al Neonatal Life Support: CoSTR 2025

Traditional laryngoscopy remains a reasonable option, insufficient or excessive tidal volumes during resuscita-
as no increased harm was shown compared with video tion, such as airway obstruction or ventilation pressures
laryngoscopy (weak recommendation, very low–certainty that are too high or too low for the respiratory mechan-
evidence). ics of the infant’s lungs. Therefore, the effect of the use
A traditional laryngoscope should always be available of respiratory function monitors during neonatal resus-
as a backup device (good practice statement). citation on mortality, neonatal morbidity, and response
to resuscitation was addressed by a SysRev184 included
Justification and Evidence-to-Decision Framework in the 2022 CoSTR summary.8 An EvUp was conducted
Highlights for 2025. The complete EvUp, including the full PICOST,
The complete evidence-to-decision table is provided in can be found in Appendix B.
Appendix A. • Time frame: December 31, 2021, to September 30,
The task force noted the moderate-certainty evi- 2024
dence for successful intubation overall and high-cer-
tainty evidence for first attempts. Although the RCT Summary of Evidence
evidence was used to formulate the treatment recom- No new studies were found to alter the current treat-
mendations, the observational studies were broadly ment recommendation or to justify a new SysRev. The
consistent. For adverse effects, from RCTs, there task force is currently undertaking a SysRev of the use
were either no data or clinical benefit or harm could of respiratory function monitors during simulation-based
not be excluded (low- to very low–certainty evidence). training.
Of note, for the critical outcomes of mortality and IVH,
the combined sample size was well below the optimal Treatment Recommendation (2022)
information size to detect clinical benefit or harm. The There is insufficient evidence to make a recommenda-
RCTs mainly included infants without airway anomalies, tion for or against the use of a respiratory function moni-
and they were intubated by trainees or other relatively tor in newborn infants receiving respiratory support at
inexperienced clinicians. In previous studies, success birth (low-certainty evidence).
rates using traditional laryngoscopes were proportional
to experience.180–183 So, for clinicians who are already
very experienced, benefits may be smaller. The cost of Near-Infrared Spectroscopy During Positive-
video laryngoscopes is higher than for traditional laryn-
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Pressure Ventilation (NLS 5362: SysRev

goscopes (although no studies have assessed cost-
effectiveness), and they are unlikely to be available in all 2025)
locations where infants needing resuscitation are born. Rationale for Review
Therefore, there is a potential to decrease health equity. Oxygenation is a determinant of morbidity and mortality
in preterm infants. Evidence suggests that even when
Knowledge Gaps preterm infants reach early peripheral oxygen satura-
• Efficacy, effectiveness, and safety of video laryn- tion targets, cerebral regional oxygen saturation (crSo2)
goscopy compared with traditional laryngoscopy measured with near-infrared spectroscopy may remain
in different gestational ages, in emergency intu- low. A low crSo2 may be a risk factor for IVH.185 Re-
bation (including for infants immediately after cent studies have addressed whether the use of near-
birth), and in the delivery room compared with infrared spectroscopy accompanied by a treatment
other settings guideline that suggests adjustments to inspired oxy-
• The usability, feasibility, comparative effectiveness, gen or positive-pressure ventilation for out-of-range
and cost-effectiveness of different types of video crSo2 values, compared with standard care, improves
laryngoscopes outcomes for infants receiving positive-pressure ven-
• Effect of video laryngoscopy in those who are tilation for resuscitation in the delivery room. This
already experienced in intubation, compared with SysRev186 was registered on PROSPERO 2024
the effect in less-experienced practitioners and in CRD42024511496. The full online CoSTR can be
training settings found on the ILCOR website.10

Respiratory Function Monitoring During Population, Intervention, Comparator, Outcome, and

Time Frame
Resuscitation at Birth (NLS 5360: SysRev 2022,
• Population: Newborn infants receiving continuous
EvUp 2025) positive airway pressure, positive-pressure ventila-
Respiratory function monitors have the potential to help tion, or both (any interface) during stabilization or
resuscitation teams to recognize problems that cause resuscitation at birth

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 Liley et al Neonatal Life Support: CoSTR 2025

• Intervention: Delivery room monitoring of crSo2 with 0 to 32 + 6 weeks gestation for the outcomes of sur-
a dedicated treatment guideline in addition to clini- vival, severe IVH, or periventricular leukomalacia. There
cal assessment, pulse oximetry, or ECG were insufficient data for other preplanned subgroup
• Comparator: Clinical assessment, pulse oximetry, or analyses.
ECG only
Treatment Recommendation (2025)
• Outcome:
In newborn infants receiving continuous positive airway
– Survival without neurodevelopmental impairment
pressure or positive-pressure ventilation immediately af-
(critical)
ter birth, there is insufficient evidence to recommend for
– Survival (critical)
or against use of delivery room monitoring of regional
– Neurodevelopmental impairment (critical)
cerebral oxygen saturation with a dedicated treatment
– Response to resuscitation (important): crSo2
guideline in addition to (and compared with) clinical as-
<10th or >90th centile, maximum fraction of
sessment and pulse oximetry with or without ECG (very
inspired oxygen (Fio2) used, total oxygen exposure
low–certainty evidence).
– Morbidity outcomes in infants <34 weeks (criti-
cal): Severe IVH (Papile grade III or IV),187 peri- Justification and Evidence-to-Decision Framework
ventricular leukomalacia Highlights
• Time frame: All years to November 5, 2024 The complete evidence-to-decision table is provided in
– Potential subgroups were defined a priori: meth- Appendix A.
ods of near-infrared spectroscopy (including Concerns about clinical effectiveness, resources,
brand, manufacturer); continuous positive air- equity, acceptability, and feasibility led the task force to
way pressure versus positive-pressure ventila- conclude that in the absence of evidence of benefit or
tion; cord management strategy, ie, immediate or harm, delivery room monitoring of crSo2 with a dedicated
deferred cord clamping or cord milking; sex, ges- treatment guideline should only be considered where
tation at birth: <28 weeks; 28 to 33 weeks; and resources permit and ideally in the context of a research
≥34 weeks’ gestation. trial to close knowledge gaps.
Consensus on Science Knowledge Gaps
Two RCTs188,189 reporting outcomes for a total of 667 in- • The effectiveness of interventions in response to
fants were included, and additional follow-up data were out-of-range crSo2 values
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available for one.190 The studies examined a similar inter- • Prioritized research that includes human factors,
vention, but there were some differences in which out- opportunities to reduce inequity, and cost-benefit
comes were reported. Key results from included RCTs analysis
are summarized in Table 4. Additional details can be • The training requirements needed to achieve and
found on the ILCOR website.23 maintain competency in interpretation of and
For all other critical and important outcomes, there response to monitoring of crSo2 during neonatal
were either no data or clinical benefit or harm could resuscitation
not be excluded. For the preplanned subgroup analysis • Cost-benefit analysis of monitoring of crSo2, taking
by gestation, there were no significant differences in into account both critical short-term outcomes and
effect size by gestation groups <28 weeks versus 28 + also long-term neurodevelopmental disability

Table 4. Comparison of the Use of Near Infrared Spectroscopy With a Dedicated Treatment Guideline Versus Standard Care
During PPV in the Delivery Room: RCTs

Anticipated absolute effect (95% CI)

Participants, n Certainty of
(studies) evidence, Relative effect Risk with clinical Risk difference with NIRS plus a
Outcomes (importance*) follow-up GRADE (95% CI) assessment dedicated treatment guideline
Survival (critical) 667 Low RR 1.02 (0.99–1.05) 946/1000 19 more infants per 1000
(2 RCTs)188,189 (9 fewer to 47 more)
In infants <34 wk—severe IVH (critical) 667 Very low RR 0.76 (0.3–1.54) 51/1000 12 fewer infants per 1000
(2 RCTs)188,189 (32 fewer to 28 more)
In infants <34 wk—periventricular 667 Very low RR 1.93 (0.66–5.70) 15/1000 14 more infants per 1000
leukomalacia (critical) (2 RCTs)188,189 (5 fewer to 71 more)
Regional cerebral tissue oxygenation 60 (1 RCT)188 Very low RR 1.00 (0.78–1.29) 800/1000 0 fewer infants per 1000
(crSo2 <10th centile) (important) (176 fewer to 232 more)

*Outcome importance according to Strand et al12 or task force consensus.

crSo2 indicates cerebral regional oxygen saturation; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; IVH, intraventricular hemor-
rhage; NIRS, near-infrared spectroscopy; PPV, positive-pressure ventilation; RCT, randomized controlled trial; and RR, relative risk.

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 Liley et al Neonatal Life Support: CoSTR 2025

Oxygen Concentration for Initiating • Outcome:

Resuscitation in Preterm Infants (NLS 5400: – All-cause mortality in-hospital or by 28 days
(critical)
SysRev 2025) – All-cause mortality before 1 to 3 years (critical)
Rationale for Review – Neurodevelopmental impairment at 1 to 3 years
A 2019 ILCOR SysRev reviewed 10 RCTs and 4 of age (critical)
cohort studies including 5697 participants and con- – Major IVH (grade III or IV)187 (critical)
cluded that there were no clear benefits or harms – Retinopathy of prematurity (important)
from starting with lower compared with higher Fio2 for – Necrotizing enterocolitis (Bell’s stage II or III206)
short-term mortality, long-term mortality, neurodevel- (important)
opmental impairment, or key preterm morbidities.191 As – Bronchopulmonary dysplasia (chronic neonatal
a result of these findings, the task force suggested lung disease) (important)
starting with a lower oxygen concentration (Fio2 0.21– – Number with heart rate >100 bpm at 5 minutes;
0.30) compared with a higher concentration (0.60– time from birth to peripheral oxygen saturation
1.00) for preterm infants <35 weeks’ gestation, with ≥80% (important)
subsequent titration of oxygen concentration using – Advanced resuscitation (chest compressions with
pulse oximetry.192 or without epinephrine [adrenaline]) (important)
Recently, an individual patient data network meta- • Study design: In addition to standard criteria, individ-
analysis (NetMotion)193 obtained individual patient data ual patient data SysRevs were eligible for inclusion.
for 1055 infants included in 8194–201 of the 12 RCTs • Time frame: August 10, 2018, to August 7,
included in the previous ILCOR SysRev191 and 4 addi- 2024. Articles included in the previous review
tional trials.202–205 The authors concluded that “high initial were assumed to be eligible for inclusion in
Fio2 (≥0.90) may be associated with reduced mortality meta-analyses.191
in preterm infants born at <32 weeks’ gestation com-
pared to low initial Fio2 (low certainty). High initial Fio2 A priori subgroups included those based on gestational
is possibly associated with reduced mortality compared age, level of initial supplemental oxygen delivered, wheth-
to intermediate initial Fio2 (very low certainty), but more er there was oxygen saturation targeting, and method of
evidence is required.” umbilical cord management as well as sensitivity analysis
Given the discordance between the conclusions by high versus low risk of bias.
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of these 2 SysRevs, the task force concluded that an

updated ILCOR SysRev was required to consider the fol- Consensus on Science
lowing: The NetMotion individual patient data network meta-
• Evidence from study-level meta-analysis of eligible analysis193 evaluated 1055 infants from 12 of 13 eligible
RCTs, including those in the previous SysRev191 plus studies198–203,205,207–210 and was deemed suitable for ado-
any published since the last search date lopment by using the AMSTAR2 checklist.211 It included
• Evidence from large observational studies judged to only infants <32 weeks’ gestation, whereas the ILCOR
provide similar or higher certainty of evidence to the PICOST and the previous SysRev includes infants <35
RCTs weeks’ gestation. NetMotion used individual patient data,
• Results of the NetMotion individual patient data which enabled adjustment for various important modifi-
network meta-analysis,193 by adolopment. Key ers such as gestation at birth and birthweight,212 so it
results from NetMotion and of the study-level should provide greater precision of estimates than the
meta-analysis of RCTs are described in text. The study-level meta-analysis.
full online CoSTR can be found on the ILCOR web- The study-level meta-analysis (new search plus stud-
site.23 The review was registered on PROSPERO ies included in the previous SysRev191) identified 18
(CRD42024589330). articles,127,194–202,204,205,207,208,210,213–215 reporting results
from 14 RCTs. There were also 4 observational stud-
Population, Intervention, Comparator, Outcome, ies209,216–218 (all included in the previous SysRev) that
Study Design, and Time Frame included 4437 infants.
• Population: Newborn infants <35 weeks’ estimated The updated study-level meta-analysis included 3
gestational age who receive respiratory support at RCTs published after the previous ILCOR SysRev191 (all
delivery included in NetMotion193) and 1 additional cluster-RCT214
• Intervention: Lower initial oxygen concentration (excluded from NetMotion). The study-level meta-analysis,
(Fio2 ≤0.5) therefore, included 1289 infants (compared with the
• Comparator: Higher initial oxygen concentration 1007 included in the previous ILCOR meta-analysis).219
(Fio2 >0.5) It was thought unlikely that any differences in the results

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 Liley et al Neonatal Life Support: CoSTR 2025

of the NetMotion and the task force study-level meta- all-cause mortality (in-hospital or by 28 days),194,196–
analyses are accounted for by study exclusions. 202,204,205,207,210,213,214
long-term all-cause mortality,195,215
neurodevelopmental impairment (at 1–3 years),195,215
Results of the Individual Patient Network Meta-Analysis
major IVH (grade III or IV),195–198,200–202,204,205,213,214 severe
The NetMotion study compared low (≤0.3), intermedi-
retinopathy of prematurity,195–198,200,204,205,213,214 necrotiz-
ate (0.5–0.65) and high (≥0.9) initial Fio2. For the critical
ing enterocolitis,195–198,200,204,205,213,214 bronchopulmonary
outcome of mortality, there was low certainty evidence
dysplasia,195–198,200,204,213,214 or advanced resuscitation.196,1
from 8 RCTs197,199–203,206 enrolling 833 infants of lower 98,199,201,204,205,208
All comparisons yielded evidence of very
mortality with high initial Fio2 compared with low ini-
low certainty, and tests for subgroup differences were
tial Fio2 (aOR, 0.45; 95% CI, 0.23–0.86). The adjusted
not significant for any comparison.
absolute risk difference was that 67 more infants per
1000 survived with high initial Fio2 (95% CI), 15 more Observational Studies
to 100 more infants survived, NNTB 16 infants (95% CI, There were no new observational studies found for inclu-
10–66). There was very low certainty evidence from 4 sion in this updated review; hence, the evidence is the
RCTs206,207,210,213 enrolling 652 infants that could not ex- same as that from the previous ILCOR SysRev, which
clude benefit or harm with intermediate initial Fio2 com- included 4 observational studies. For long-term mortal-
pared with low initial Fio2 (aOR for mortality, 1.33; 95% ity, 2 observational cohort studies included 1225 preterm
CI, 0.54–3.15). There was very low certainty evidence newborns who received respiratory support at birth and
from an indirect comparison of 519 infants of lower mor- found a possible benefit of starting with lower compared
tality with high initial Fio2 compared with intermediate ini- with higher Fio2 (relative risk, 0.77; 95% CI, 0.59–0.99;
tial Fio2 (aOR, 0.34; 95% CI, 0.11–0.99). The prediction I2, 6%; very low–certainty evidence).191 For the outcome
intervals crossed the line of no effect for both the high of neurodevelopmental impairment, 2 studies including
compared with low and high compared with intermediate 930 infants could not exclude benefit or harm from start-
initial Fio2 comparisons. Prediction intervals describe the ing with lower compared with higher Fio2 (relative risk,
range within which the results of future studies would be 0.89; 95% CI, 0.66–1.20; I2, 59%; very low–certainty
expected to lie. This was interpreted by the authors as evidence).191
evidence of inconsistency and reduced the certainty of
evidence for these comparisons.193 Prior Treatment Recommendation (2018)
For the critical outcomes of severe IVH and the impor- For preterm newborn infants (<35 weeks’ gestation)
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tant outcomes of chronic neonatal lung disease and reti- who receive respiratory support at birth with subsequent
nopathy of prematurity, clinical benefit or harm could not titration of oxygen concentration using pulse oximetry,
be excluded for the comparison between high (>0.90) we suggest starting with a lower oxygen concentration
and low (≤0.30) Fio2. In each case, the evidence was of (21%–30%) rather than higher oxygen concentration
very low certainty. For these outcomes, the comparisons (60%–100%) (weak recommendation, very low–cer-
between high (>0.90) and intermediate (0.50–0.65) Fio2 tainty evidence).
are even more imprecise because fewer infants were
included. Numeric results are therefore not presented.193 Treatment Recommendations (2025)
For subgroup analyses, the NetMotion authors Among newborn infants <32 weeks’ gestation, it is rea-
reported that “there was no evidence of differential sonable to begin resuscitation with ≥30% oxygen (weak
effects of treatment across gestational ages or accord- recommendation, low-certainty evidence).
ing to infant sex (post hoc, primary outcome only) when For infants born at 32 to 34 + 6 weeks’ gestation,
examining treatment-covariate interactions” and that there is insufficient evidence to make a recommendation.
there was limited statistical power to detect such inter-
actions.193 The authors also reported that there were too
Justification and Evidence-to-Decision Framework
few participants from low-or middle-income countries
Highlights
to perform prespecified subgroup analysis according to
The complete evidence-to-decision table is provided in
country income classification, and they considered that
Appendix A. Evidence from NetMotion, which was includ-
oxygen concentration titration strategies were too heter-
ed by adolopment, suggested benefit from higher con-
ogenous to explore faster versus slower titration.193
centrations of oxygen and that a high Fio2 (0.90–1.00)
Other critical and important outcomes of the PICOST
may result in the lowest mortality.193 However, the task
were not reported.
force concluded that the overall certainty of evidence
From the Study-Level Meta-Analysis was very low, mainly because of concerns that the total
Clinical benefit or harm could not be excluded for the sample for each comparison was substantially below the
comparison of lower initial oxygen concentration (Fio2 optimal information size for all outcomes. The updated
≤0.5) with higher initial oxygen concentration (Fio2 >0.5) study-level meta-analysis found that benefit or harm
for any of the following critical or important outcomes: could not be excluded for any outcome for lower versus

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 Liley et al Neonatal Life Support: CoSTR 2025

higher concentrations of oxygen for commencing resus- who were resuscitated with an initial Fio2 of 0.5 and
citation, with low to very low certainty of evidence for all compared with historical controls who received Fio2
outcomes. 1.0, reported similar outcomes for both groups.221
There are still concerns about unmeasured adverse Although the limited new evidence is insufficient to
effects of hyperoxia and hypoxia. As a result, 2 pend- justify an updated SysRev, the task force will priori-
ing multicenter trials are using Fio2 of 0.30 versus tize updating the SysRev. We have concerns that the
0.60 for their treatment arms (clinical trial registration certainty of evidence would now be judged insuffi-
ACTRN12618000879268 and NCT03825835220). cient to make the previous strong recommendation
Whichever initial oxygen concentration was used, oxy- against commencing resuscitation for term and late
gen saturation monitoring and individualized adjustments of preterm infants with 100% oxygen.192 We, therefore,
inspired oxygen concentration were used in most of the clin- withdraw this recommendation in the interim. The task
ical trials and are likely to be needed to optimize outcomes. force strongly encourages additional research on this
important topic.
Knowledge Gaps Treatment Recommendation (2019)
• Comparison of oxygen saturation target levels and For newborn infants at ≥35 weeks’ gestation receiving
strategies to achieve them by adjusting inspired respiratory support at birth, we suggest starting with
oxygen concentrations or other aspects of respira- 21% oxygen (weak recommendation, low-certainty evi-
tory support in the first 10 to 20 minutes after birth dence).
in preterm infants
• Optimal oxygen concentration for commencing
resuscitation in preterm newborn infants CIRCULATORY SUPPORT
• The performance of resuscitation teams (eg, in Chest Compressions in Newborn Infants (NLS
titrating oxygen concentration and other resuscita-
5500–5507: ScopRev 2023, EvUp 2025)
tion interventions to the infant’s response) in the
setting of various initial oxygen concentrations Chest compressions are used in only a few newborn in-
• Effect of initial oxygen concentrations and titra- fants in every thousand but can be lifesaving for infants
tion targets and strategies on biomarkers of both who are asystolic or severely bradycardic and who are
hypoxic and hyperoxic injury to organs including the not responding to effective positive-pressure ventila-
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brain, lungs, and retinas tion. Various aspects of chest compressions for new-
born infants were addressed in 2023 using ScopRev
The task force concluded that the uncertainty over the methods because prior surveillance of the literature in-
optimal initial oxygen concentration means that it is rea- dicated that there was very little available human infant
sonable to study a full range of oxygen concentrations evidence; hence, a broad search would be needed to
(21%–100%) within a research protocol. evaluate indirect evidence.222 Details of this review can
be found in the 2023 CoSTR summary.6 An EvUp was
conducted for 2025. The results are summarized here
Oxygen Concentration for Initiating
by individual PICO questions. The complete EvUp, in-
Resuscitation in Late Preterm and Term Infants cluding the full PICOST, for each of the questions can
(NLS 5401: EvUp 2025) be found in Appendix B.
The oxygen concentration for commencing resuscitation
in late preterm and term infants was reviewed in 2010 Heart Rate for Commencing Chest
and 2019.105,192,219 Both reviews concluded that there
was improvement in survival and other outcomes from
Compressions (NLS 5500: ScopRev 2023, EvUp
commencing resuscitation with Fio2 0.21 compared with 2025)
Fio2 1.0. An EvUp was conducted for 2025. The com- This question addresses neonates who are being resus-
plete EvUp, including the full PICOST, can be found in citated who have a slow heart rate and compares the ef-
Appendix B. fect of starting chest compressions when the heart rate
• Time frame: July 1, 2018, to August 7, 2024 is <60 bpm with any other heart rate on survival, neuro-
A priori subgroup analyses: gestational age (≥35 logic outcomes, and ROSC.
weeks, ≥37 weeks); grouped lower and higher oxygen • Time frame: November 22, 2021, to June 16, 2024
concentrations; explicit oxygen saturation targeting ver-
sus no oxygen saturation targeting Summary of Evidence
No further studies addressing this PICOST were iden-
Summary of Evidence tified in the EvUp. The task force considered that (de-
One retrospective observational study that included spite the lack of evidence for any specific threshold),
68 infants with congenital diaphragmatic hernia, given the need to provide resuscitation teams with a

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 Liley et al Neonatal Life Support: CoSTR 2025

standardized approach to clinical practice, formulation Summary of Evidence

of a good practice statement was justified. This new Two animal studies compared Fio2 0.21 with Fio2 1.0
good practice statement replaces the commentary pro- during chest compression after asphyxial cardiac ar-
vided in lieu of a treatment recommendation after the rest.233,234 One was in older piglets233 rather than in neo-
2023 ScopRev. natal animals. The new evidence does not justify a new
SysRev.
Prior Treatment Recommendation (2023)
ILCOR has not developed an evidence-based treatment Treatment Recommendation (2015 Updated to
recommendation on heart rate threshold to initiate chest Reflect Current Terminology)
compressions previously. However, ILCOR guidance By the time resuscitation of a newborn infant has
since 1999 has been to initiate chest compressions if reached the stage of chest compressions, the steps
the heart rate is <60 bpm despite adequate assisted of trying to achieve ROSC using effective ventila-
ventilation for 60 seconds. tion should have been completed. It is reasonable to
increase the supplementary oxygen concentration
Treatment Recommendation (2025) (good practice statement). Once the heart rate has
In neonates being resuscitated who have a slow heart recovered, supplementary oxygen should be titrated
rate even after optimizing ventilation, initiating cardiac to oxygen saturation targets (good practice state-
compressions when the heart rate is <60 bpm is reason- ment).
able (good practice statement).

Compression-to-Ventilation Ratio (NLS 5504:

Chest Compressions With 2 Thumbs Versus ScopRev 2023, EvUp 2025)
Other Techniques (NLS 5501: ScopRev 2023,
This question compares the effect of using a compression-
EvUp 2025) to-ventilation ratio of 3:1 with using any other ratio,
This question compares the effect of using 2 thumbs with including chest compressions during sustained lung in-
hands encircling the chest with using any other method flation, on survival, neurologic outcomes, ROSC hemody-
on survival, neurologic outcomes, and ROSC. namic measures, and compressor fatigue.
• Time frame: November 22, 2021, to June 16, 2024 • Time frame: November 22, 2021, to June 16, 2024
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Summary of Evidence Summary of Evidence

Ten simulation studies,223–230 1 RCT in piglets,231 and 1 The updated EvUp search identified 1 clinical and 7 ani-
prospective observational study in children in cardiac ar- mal studies comparing various ratios. The new evidence
rest, of whom 16 were <1 year of age232 overall, sup- does not justify a new SysRev at this time.
ported the findings of the ScopRev. This ScopRev found
Treatment Recommendation (2015, Updated in
that the 2-thumb technique resulted in greater chest
2023 CoSTR summary)
compression depth, less fatigue, and higher proportion
We suggest continued use of a 3:1 compression-to-
of correct hand placement compared with the 2-finger
ventilation ratio for CPR in newborn infants immediately
technique.222 The new studies identified in the 2025
after birth (weak recommendation, very low–certainty
EvUp do not provide sufficient evidence to justify a new
evidence).
SysRev.
Treatment Recommendation (2015)
We suggest that chest compressions in newborn in- Use of Feedback CPR Devices for Neonatal
fants immediately after birth should be delivered by the Cardiac Arrest (NLS 5505: ScopRev 2023, EvUp
2-thumb, hands-encircling-the-chest method as the pre- 2025)
ferred option (weak recommendation, very low–certainty
This question compares the effect of using any type of
evidence).
feedback device, including end-tidal CO2 monitoring,
pulse oximeters, or automated compression feedback
Supplemental Oxygen During Chest devices on survival, neurologic outcomes, ROSC and
Compressions (NLS 5503: ScopRev 2023, EvUp hands-off time, and measures of perfusion.
• Time frame: November 22, 2021, to June 16, 2024
2025)
This question compares the effect of using an Fio2 of 1.0 Summary of Evidence
once chest compressions have been commenced with Three studies in animals235 or manikins236,237 assessed
using any lower oxygen concentration on survival, neuro- the use of chest compression feedback devices in-
logic outcomes, and ROSC. cluding a chest compression machine,235 real-time vi-
• Time frame: November 22, 2021, to June 16, 2024 sual feedback,237 and a new smart ring–based chest

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 Liley et al Neonatal Life Support: CoSTR 2025

compression–depth feedback device.236 While each sug- recent studies using chest radiographs248 or chest com-
gested potential benefits, no studies assessed improve- puted tomography249 have largely confirmed their results.
ments in resuscitation practice or outcomes in human The task force concluded that, because these studies
infants. The studies do not justify a new SysRev. had not been evaluated using Grading of Recommen-
dations Assessment, Development, and Evaluation as-
Treatment Recommendation (2023) sessment of certainty of evidence, the 2010 treatment
In newborn infants with asystole or bradycardia, we sug- recommendation should be reworded as a good practice
gest against the routine reliance on any single feedback statement.
device such as end-tidal CO2 monitors or pulse oxime-
ters for detection of ROSC until more evidence becomes Treatment Recommendation (2025)
available (weak recommendation, very low–certainty evi- Neonatal chest compressions should be centered over
dence). the lower third of the sternum but above the xiphoid
(good practice statement).
Depth of Chest Compressions (NLS 5506:
EvUp 2025) DRUG AND FLUID ADMINISTRATION
This EvUp adds to information published in the ILCOR Epinephrine (Adrenaline) for Neonatal
ScopRev222 but not reported in the 2023 CoSTR sum-
Resuscitation (NLS 5600: EvUp 2025)
mary on whether the use of any other chest compression
depth than one third the anteroposterior diameter of the In the 2020 ILCOR SysRev, studies of epinephrine in
chest improves survival, neurologic outcomes, or time to human infants were mostly observational cohort stud-
ROSC.6 The results from all years were described in the ies or case series.167 Therefore, studies in asphyxiated
EvUp worksheet. newborn animals receiving effective positive-pressure
• Time frame: All years to June 16, 2024 ventilation and chest compressions that showed that
epinephrine (especially when given intravenously)
Summary of Evidence can achieve ROSC more effectively and sooner than
Two animal physiology studies238,239 and 3 human infant control treatments contributed to the 2020 ILCOR
studies that used computed tomography scans240,241 or treatment recommendations about epinephrine dose,
laser distance meters242 to estimate chest compres- route, and timing.5,167 A 2025 EvUp was performed
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sion depths in infants were identified. The 2023 ILCOR and also included relevant animal studies. The com-
ScopRev included some of these studies.222 No studies plete EvUp, including the full PICOST, can be found
were found that addressed survival rates or other critical in Appendix B.
or important outcomes in newborn infants. A new SysRev • Time frame: March 6, 2019, to August 20, 2024
was not thought to be warranted.
Summary of Evidence
Treatment Recommendation (2010, Now Worded as The only new human infant evidence was from obser-
a Good Practice Statement) vational studies.250–253 Eight animal studies (and an ad-
Compress the chest one third the anterior-posterior di- ditional one published just after the search completion
ameter (good practice statement). date254) examined various comparisons, including epi-
nephrine versus no epinephrine as well as dose and
Chest Compression Location on Sternum (NLS route.255–262 The task force concluded that the PICOST
5507: EvUp 2025) question deserves an updated SysRev, mainly to assess
new indirect evidence from animal studies that refines
This question has not been addressed since 2010105; understanding of dose, route, and potential harms of
hence, a literature search was used for the EvUp that epinephrine, particularly when given in high cumulative
included contemporary search terms and was conduct- doses.
ed without a start-date restriction. In infants receiving
chest compressions, the PICOST compared whether Treatment Recommendations (2020)
any other location on the sternum than the lower one If the heart rate has not increased to ≥60/minute af-
third improved survival, neurologic outcomes, or time to ter optimizing ventilation and chest compressions, we
ROSC. suggest the administration of intravascular epinephrine
• Time frame: All years to June 16, 2024 (0.01–0.03 mg/kg) (weak recommendation, very low–
certainty evidence).
Summary of Evidence If intravascular access is not yet available, we sug-
Studies considered before 2010 included observational gest administering endotracheal epinephrine at a
studies in small numbers of human infants,243,244 cadav- larger dose (0.05–0.1 mg/kg) than the dose used for
ers,245 or predictions from chest radiographs.244–247 More intravascular administration (weak recommendation,

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 Liley et al Neonatal Life Support: CoSTR 2025

very low–certainty of evidence). The administration of ventilation is established and there is no response to
endotracheal epinephrine should not delay attempts to other therapies.265
establish vascular access (weak recommendation, very Although this treatment recommendation was included
low–certainty evidence). in previous consensus statements (2005–2020), it can
We suggest the administration of further doses of epi- no longer be supported. Based on current methods of
nephrine every 3 to 5 minutes, preferably intravascularly, evaluating the certainty of evidence, the task force has
if the heart rate remains <60 bpm (weak recommenda- concluded there is neither direct nor indirect evidence
tion, very low–certainty evidence). to inform a treatment recommendation. As a result, this
If the response to endotracheal epinephrine is inad- treatment recommendation has been withdrawn and will
equate, we suggest that an intravascular dose be given be reconsidered if new evidence becomes available.
as soon as vascular access is obtained, regardless of the
interval after any initial endotracheal dose (weak recom-
mendation, very low–certainty evidence). Glucose Management During or Immediately
After Resuscitation (NLS 5602: ScopRev 2025)
Sodium Bicarbonate During Neonatal Rationale for Review
Resuscitation (NLS 5601: EvUp 2025) Glucose management in neonatal resuscitation was last
In infants (newborn or in the neonatal period) requir- addressed for the 2010 CoSTR, which concluded that
ing resuscitation, the question of whether sodium bi- newborns who had hypoglycemia in the setting of hypoxic
carbonate administration compared with no sodium ischemic encephalopathy had worse outcomes than those
bicarbonate improves survival, ROSC, or critical or im- who were normoglycemic, and that hyperglycemia might be
portant neonatal morbidity outcomes was last reviewed protective, although a specific target blood glucose concen-
in 2005.120 An EvUp was done in 2020.5 The complete tration range could not be identified at that time.105 An EvUp
2025 EvUp, including the full PICOST, can be found in in 2020 prompted the task force to conduct this ScopRev.
Appendix B. Complete details are available on the ILCOR website.23
• Time frame: January 1, 2020, to June 17, 2024 Population, Intervention, Comparator, Outcome,
Summary of Evidence Study Design, and Time Frame
No new evidence was found to support the use of so- • Population: Newborn infants (preterm and term)
who receive resuscitation at birth in all health care
Downloaded from [Link] by on October 27, 2025

dium bicarbonate in neonatal resuscitation. One study

in 2- to 5-day-old anesthetized, nonasphyxiated piglets settings that provide birthing services
suggested a potential mechanism of harm, particularly – Question 1. When and how should blood glu-
when vasoconstrictors were also administered.263 One cose be monitored in newborn infants receiving
study of sodium bicarbonate treatment for acidosis in resuscitation?
pediatric intensive care units suggested sodium bicar- • Intervention: Strategy of monitoring glucose or
bonate treatment was beneficial in the setting of hyper- metabolites (lactate, ketones, insulin) or postresus-
chloremia but harmful if chloride values were normal (as citation care bundles that include such monitoring
will usually be the case in newborn infants).264 The overall • Comparator: No monitoring or no defined strategy
evidence from the current and the previous EvUp (2019) or alternative monitoring strategy
is insufficient to justify a new SysRev. – Question 2. When and how should glucose (or
The previous treatment recommendation (2005) was other treatments to control blood glucose con-
not supported by a SysRev using contemporary ILCOR centration) be used during and after neonatal
methods of evidence appraisal. The conditions suggested resuscitation?
in the previous treatment recommendation for the use of • Intervention: Glucose (administered via intrave-
sodium bicarbonate (after adequate ventilation is estab- nous, intraosseous, or buccal route) or glucagon or
lished and there is no response to other therapies) are postresuscitation care bundles to control blood glu-
rare and unexpected in human infants needing resuscita- cose concentration
tion immediately after birth, meaning that human infant • Comparator: No glucose (or other treatment to con-
trials would be difficult to conduct and might take many trol blood glucose concentrations) or an alternative
years to complete. The animal studies assessed in previ- strategy
ous ILCOR worksheets have not addressed these cir- – Question 3. What is the optimal blood glucose
cumstances. concentration range for newborn infants during
and after resuscitation?
Prior Treatment Recommendation (2005, • Exposure: Dysglycemia or defined blood glucose
Withdrawn) target range
Sodium bicarbonate is discouraged during brief CPR, but • Comparator: Normoglycemia or alternative target
it may be useful during prolonged arrests after adequate range

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 Liley et al Neonatal Life Support: CoSTR 2025

• Outcome: In studies assessing the risk of hypoglycemia at dif-

– All Questions ferent times after resuscitation, 1 study including 60
▪ Success of resuscitation (critical) term infants with Apgar scores ≤6 at 5 minutes (of whom
▪ Neonatal brain injury (critical) 73% had subsequent hypoxic ischemic encephalopathy)
▪ Long-term neurological function (critical) reported that 92% of the 12 patients with blood glucose
▪ Neonatal morbidity (important) measurement recorded in the delivery room were hypo-
– Questions 1 and 2 glycemic.269 In studies reporting glucose measurements
▪ Dysglycemia: referring to episode(s) of either on NICU admission, the proportions of infants with hypo-
hypoglycemia (blood glucose concentration glycemia ranged from 8% to 23%.268,273–275,279,286 The
≤2.5 mmol/L [≤45 mg/dL]) and hyperglycemia proportions with hyperglycemia ranged from 19% to
(blood glucose concentration ≥7 mmol/L [≥126 53%.274,275,279 In 6 studies reporting results in the first 6
mg/dL]), or both, for the purposes of this review hours after birth, the proportion of infants with hypogly-
(important) cemia ranged from 7% to 24%.270,276,277,282–284
▪ Metabolite levels: blood lactate, ketone, and Question 2. When and how should glucose (or other
insulin concentrations (important) treatments to control blood glucose concentration) be
▪ Feasibility (important) used during and after neonatal resuscitation?
• Study design: Because this was a ScopRev, animal There were no human studies directly addressing
trials, human trials (randomized, nonrandomized, control of blood glucose during resuscitation, and evi-
historically controlled), and human observational dence from animal studies was inconsistent, with some
studies (cohort, before-and-after, case-control, case studies suggesting neuroprotection when glucose was
series if ≥6 participants) were eligible for inclu- infused during asphyxia or during recovery from hypoxia-
sion. Studies were considered eligible for inclusion ischemia280,292–312 and others suggesting harm or no ben-
if they directly or indirectly addressed the review efit.313–318
questions but were excluded if they had not been During postresuscitation care, routine commence-
peer reviewed or published in full text. All years and ment of intravenous glucose infusions was a common
all languages were included provided there was an practice in infants admitted to NICU, typically at infusion
English abstract. rates of 4 mg/kg per minute, but no studies defined an
• Time frame: All years to October 6, 2024 optimal strategy to achieve euglycemia (and avoid iatro-
genic hyperglycemia) during the treatment of hypoglyce-
Downloaded from [Link] by on October 27, 2025

Summary of Evidence mia after resuscitation at birth.

Question 1. When and how should blood glucose be Question 3. What is the optimal blood glucose con-
monitored in newborn infants receiving resuscitation? centration range for newborn infants during and after
Twenty-five articles reporting 24 observational stud- resuscitation?
ies described serial monitoring of blood glucose con- No studies directly investigated the optimal blood glu-
centrations, commencing at NICU admission or at ≤2 cose target range for infants immediately after resusci-
hours of age to assess the frequency of neonatal dys- tation at birth. Whether a lower or higher target is better
glycemia.266–290 Apart from 1 study in which 35% of remains unknown.
infants were born at ≤32 weeks’ gestation,250 all other
studies included only infants born at ≥34 weeks’ ges- Task Force Insights
tation. For infants needing advanced resuscitation at birth, it
Two studies used continuous glucose monitoring,282,285 remains unknown if empiric use of glucose during re-
and all others used intermittent blood glucose sampling, suscitation improves the success of the resuscitation
with variation in whether the sampling site or analytic interventions.
method was specified. The definitions of hypoglycemia As a whole, the studies addressed only a subgroup
and hyperglycemia also varied. Hypoglycemia was most of the infants intended in the ScopRev questions (eg,
often defined as blood glucose values <2.2 mmol/L term and late preterm already defined to have—or be at
(<40 mg/dL) or <2.6 mmol/L (<46 mg/dL). Hypergly- high risk for—hypoxic ischemic encephalopathy), rather
cemia was most often defined as ≥1 blood glucose val- than including all infants who had received resuscitation,
ues >8.3 mmol/L (>150 mg/dL). regardless of gestation. There was also considerable
Only 9 studies provided information about specific variation in study design and methods. Hence, for infants
resuscitation interventions received by infants that who have received resuscitation, the task force consid-
might be associated with increased risk of dysglyce- ered that meta-analysis would not accurately determine
mia.250,268,273,275,281,283,286,288,289 Three studies suggested a the risk of hypo- or hyperglycemia at specific times in the
lower risk of hypoglycemia or higher blood glucose levels first few hours or the extent to which hypo- or hypergly-
in infants who had received epinephrine compared with cemia affects outcomes. No studies compared outcomes
those who had not.250,268,289 from any specific strategy for blood glucose monitoring

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 Liley et al Neonatal Life Support: CoSTR 2025

to any other strategy in a way that allowed determination Summary of Evidence

of an optimal approach. Nevertheless, in the first hours One narrative review that included a few previously un-
after resuscitation, the evidence that was available sug- published animal data was identified for inclusion.319
gested that both hypo- and hyperglycemia are common Because the sparse available evidence from previous
and that both may be associated with harm. Research is reviews has not been evaluated using Grading of Rec-
needed to define an optimal target range for blood glu- ommendations Assessment, Development, and Evalu-
cose in the aftermath of resuscitation, optimal strategies ation methods, the existing recommendation is now
for monitoring, and management strategies that improve reworded as good practice statements, pending an up-
outcomes and avoid overtreatment or undertreatment. dated SysRev.
Treatment Recommendations (2025)
Prior Treatment Recommendation (2010) Early volume replacement with crystalloid or red cells is
Intravenous glucose infusion should be considered as indicated for newborn infants with blood loss who are
soon as practical after resuscitation, with the goal of not responding to resuscitation (good practice state-
avoiding hypoglycemia.105 ment).
This recommendation was not supported by a Sys- There is insufficient evidence to support the routine
Rev of the literature using Grading of Recommendations use of volume administration in newborn infants with no
Assessment, Development, and Evaluation methods and blood loss who are refractory to ventilation, chest com-
should be regarded as superseded. Until sufficient evi- pressions, and epinephrine. Because blood loss may be
dence is available to justify a SysRev, the task force gen- occult, a trial of volume administration may be considered
erated the following good practice statements. in newborn infants who do not respond to resuscitation
Treatment Recommendations (2025) (good practice statement).
Among newborn infants receiving resuscitation, blood
glucose concentration should be measured early in the
Intraosseous Versus Intravenous Cannulation
postresuscitation period and monitored with serial mea-
surements until maintained within a normal range. Infants for Emergency Access (NLS 5652: EvUp 2025)
at greatest risk of hypo- and hyperglycemia during the A 2020 SysRev for all age groups identified that in-
postresuscitation period include preterm infants, infants traosseous administration of medications and fluids
receiving chest compressions or epinephrine, and those could be accomplished during cardiac arrest, including
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with hypoxic ischemic encephalopathy (good practice during neonatal resuscitation but with some potential
statement). for serious complications in newborns.320 A 2025 EvUp
Treatment with intravenous glucose infusions should was performed, focusing only on newborn infants. The
be guided by the infant’s blood glucose concentration complete EvUp, including the full PICOST, is provided
with the goal of avoiding both hypoglycemia and hyper- in Appendix B.
glycemia (good practice statement). • Time frame: December 1, 2019, to July 15, 2024
Summary of Evidence
Blood Volume Expansion During Neonatal Three new observational studies that reported results
Resuscitation (NLS 5650: EvUp 2025) of intraosseous access in newborns and infants in the
neonatal period were included, but none specifically
The previous ILCOR assessment of the role of fluids compared intraosseous with intravenous access.321–323
to expand blood volume during neonatal resuscitation Two studies identified cases from databases,321,323 and
focused on the risk of harm if fluid boluses are given 1 study322 used self-reported results of questionnaires.
to all infants, while recognizing that a few infants have The proximal tibia was the most commonly used insertion
experienced critical blood loss immediately before or site.321,322 Success rates for intraosseous insertion varied
during resuscitation and may benefit from volume resus- from 50% to 86% between studies,321–323 and complica-
citation.105 Surveillance of the literature and an EvUp in tion rates varied from 10.8%323 to 35%.321 Complications
2020 concluded that the 2010 treatment recommen- included extravasation, necrosis, compartment syndrome,
dation was still supported.5 A further EvUp addressing subperiosteal infusion, tibial fracture, broken intraosse-
whether blood volume expansion with any blood prod- ous needle, osteomyelitis, and soft tissue infection.
ucts or crystalloids (eg, sodium chloride 0.9%) compared The new studies support the current treatment rec-
with no blood volume expansion improved survival, neu- ommendations and appear insufficient to justify a new
rodevelopmental outcomes, serious morbidity, or short- SysRev at this time.
term outcomes of resuscitation was conducted for 2025.
The complete EvUp, including the full PICOST, can be Treatment Recommendations (2020)
found in Appendix B. We suggest umbilical venous catheterization as the pri-
• Time frame: January 1, 2021, to July 2, 2024 mary method of vascular access during newborn infant

Circulation. 2025;152(suppl 1):S165–S204. DOI: 10.1161/CIR.0000000000001363 October 21, 2025 S189

 Liley et al Neonatal Life Support: CoSTR 2025

resuscitation in the delivery room. If umbilical venous cluded post hoc when the task force recognized some
access is not feasible, the intraosseous route is a rea- inconsistences that raised concerns about trustworthi-
sonable alternative for vascular access during newborn ness of the findings.324 Another article325 was found to
resuscitation (weak recommendation, very low–certainty have reported additional outcomes for a subset of par-
evidence). Outside the delivery room setting, we suggest ticipants in a previous RCT326 and so is now only included
that either umbilical venous access or the intraosseous as a single trial. Amended versions of the online CoSTR
route may be used to administer fluids and medications and evidence-to-decision table have been posted on the
during newborn resuscitation (weak recommendation, ILCOR website, but the task force concluded that the
very low–certainty evidence). The actual route used may revised evidence still supports the 2024 treatment rec-
depend on local availability of equipment, training, and ommendations and certainty of evidence.
experience.
Treatment Recommendations (2024)
We suggest the use of therapeutic hypothermia in com-
POSTRESUSCITATION CARE parison with standard care alone for term (≥37 + 0
weeks’ gestational age) newborn infants with evolving
Rate of Rewarming Hypothermic Newborns moderate-to-severe hypoxic-ischemic encephalopathy
(NLS 5700: SysRev 2024, EvUp 2025) in low- and middle-income countries in settings where
The effect of the rate of rewarming on outcomes of new- a suitable level of supportive neonatal care is available
borns who are unintentionally hypothermic after delivery (weak recommendation, low-certainty evidence).
was addressed by a 2024 SysRev, and details of this For late preterm infants, 34 + 0 to 36 + 6 weeks’ ges-
review, including the complete PICOST, can be found in tational age infants, a recommendation cannot be made
the 2024 CoSTR summary.7 The literature search was due to insufficient evidence.
updated from July 1, 2023, to June 13, 2024, during Therapeutic hypothermia should only be considered,
the process of preparing the SysRev for submission for initiated, and conducted under clearly defined protocols
publication. with treatment in neonatal care facilities with the capabil-
ities for multidisciplinary care and availability of adequate
Treatment Recommendations (2024) resources to offer intravenous therapy, respiratory sup-
In newborn infants who are unintentionally hypother- port, pulse oximetry, antibiotics, antiseizure medication,
mic after birth, rewarming should be started, but there transfusion services, radiology (including ultrasound),
Downloaded from [Link] by on October 27, 2025

is insufficient evidence to recommend either rapid (≥0.5 and pathology testing, as required. Treatment should be
°C/h) or slow (<0.5 °C/h) rates of rewarming. consistent with the protocols used in RCTs. Most proto-
Regardless of the rewarming rate chosen, a protocol cols included commencement of cooling within 6 hours
for rewarming should be used. Frequent or continuous after birth, strict temperature control to a specified range
monitoring of temperature should be undertaken, partic- (typically 33 °C–34 °C), and most commonly for a dura-
ularly if using a supraphysiological set temperature point tion of 72 hours with rewarming over at least 4 hours.
to accelerate the rewarming rate, because of the risk of Adoption of hypothermia techniques without close moni-
causing hyperthermia. In any hypothermic infant, monitor toring, without protocols, or without availability of com-
blood glucose because there is a risk of hypoglycemia prehensive neonatal intensive care may lead to harm
(good practice statement). (good practice statement).

Therapeutic Hypothermia in Limited-Resource

PROGNOSTICATION DURING CPR
Settings (NLS 5701: SysRev 2024, EvUp 2025)
Therapeutic hypothermia for the treatment of moder-
Impact of Duration of Intensive Resuscitation
ate or severe hypoxic ischemic encephalopathy in neo- (NLS 5800: EvUp 2025)
nates is now the well-established standard of care in Deciding how long to continue resuscitative efforts in a
high-income countries, but its efficacy in low-resource newborn with no heart rate or a very low heart rate with
settings had been unclear.2 The task force was aware absent respirations after sustained resuscitative efforts is a
of several new studies in low- and middle-income coun- critical decision. If such a decision is made too early, some
tries and considered it a sufficiently important aspect of newborns with potential to survive without severe neurode-
postresuscitation care to prioritize a SysRev. Details of velopmental impairments may die. If made too late, parental
this review, including the complete PICOST, can be found engagement during end-of-life care may be impeded. This
in the 2024 CoSTR summary.7 The literature search was topic was previously addressed in a 2020 SysRev.5,327 A
updated from July 1, 2023, to September 30, 2024, dur- 2025 EvUp was conducted, and complete details, includ-
ing the process of preparing the SysRev for submission ing the full PICOST, can be found in Appendix B.
for publication. During this process, one study was ex- • Time frame: October 17, 2019, to July 4, 2024

S190 October 21, 2025 Circulation. 2025;152(suppl 1):S165–S204. DOI: 10.1161/CIR.0000000000001363

 Liley et al Neonatal Life Support: CoSTR 2025

Summary of Evidence Treatment Recommendation (2021)

One SysRev328 (with included studies that extensively We suggest it is reasonable for mothers/fathers/part-
overlapped with those in the ILCOR SysRev) was identi- ners to be present during the resuscitation of neonates
fied. There was 1 additional population-based study329 where circumstances, facilities, and parental inclination
and 3 cohort studies nested within RCTs of advanced allow (weak recommendation, very low–certainty evi-
resuscitation.330–332 Overall, these studies confirm that, dence).
for infants who receive resuscitation, survival without There is insufficient evidence to indicate an interven-
severe neurodevelopmental impairment is possible after tional effect on patient or family outcome. Being pres-
prolonged asystole or bradycardia. However, this may ent during the resuscitation of their infant seems to be a
vary with gestational age, the availability of therapeutic positive experience for some parents but concerns about
hypothermia, resuscitation practices, and access to other an adverse effect upon performance exist among both
intensive or complex care. The new evidence is not suf- health care professionals and family members.
ficient to justify a new SysRev at this time.
Treatment Recommendation (2020) Topics Not Included in the 2025 Review
Failure to achieve ROSC in newborn infants despite 10
The following PICOSTs are not included in this summary:
to 20 minutes of intensive resuscitation is associated
▪ Anticipation and Preparation
with a high risk of mortality and a high risk of moderate-
– Effect of neonatal resuscitation team composi-
to-severe neurodevelopmental impairment among sur-
tion on outcomes (NLS 5000): not previously
vivors. However, there is no evidence that any specific
reviewed
duration of resuscitation consistently predicts mortality
– Checklists and cognitive aids for neonatal resus-
or moderate-to-severe neurodevelopmental impairment.
citation (NLS 5001): addressed by Education,
If, despite provision of all the recommended steps of re-
Implementation, and Teams Task Force as EIT
suscitation and excluding reversible causes, a newborn
6400
infant requires ongoing CPR after birth, we suggest dis-
– Prediction of the need for resuscitation at birth
cussion of discontinuing resuscitative efforts with the
(NLS 5003): not previously reviewed
clinical team and family. A reasonable time frame to con-
– Prediction of outcome after extremely preterm
sider this change in goals of care is around 20 minutes
birth (NLS 5004): SysRev underway
after birth (weak recommendation, very low–certainty
– Prediction of outcome if mother has intrapartum
Downloaded from [Link] by on October 27, 2025

evidence).
hypothermia or hyperthermia (NLS 5005): not
previously reviewed
FAMILY PRESENCE ▪ Initial Steps
– Prediction of outcomes based on infant tempera-
Family Presence During Neonatal Resuscitation ture during or immediately after resuscitation
(NLS 5900: SysRev 2021, EvUp 2025) ▪ Ventilation and Oxygenation
A SysRev conducted with the Pediatric Life Support Task – Upright resuscitator for administering positive-
Force in 2021 addressed the impact of family presence pressure ventilation at birth (NLS 5301): not pre-
during resuscitation of infants and children on outcomes viously reviewed
of resuscitation, on families, or on those providing resus- – High flow nasal cannula for initial respiratory sup-
citation.9,333,334 A 2025 EvUp assessed whether there port (NLS 5302): not previously reviewed
were new studies specific to the presence of parents at – Mouth techniques for administering positive-
the resuscitation of newborn infants. The complete EvUp, pressure ventilation in very low resource settings
including the full PICOST, can be found in Appendix B. (NLS 5303): not previously reviewed
• Time frame: September 1, 2019, to September 5, – Interfaces for noninvasive positive-pressure ven-
2024 tilation (NLS 5304): not previously reviewed
– Strategies for positive-pressure ventilation (NLS
Summary of Evidence 5325): ScopRev underway
Five studies specifically addressing parental presence – Respiratory function monitoring during simulation
during resuscitation at birth were included, all from high- training (NLS 5361): SysRev underway
income countries and all addressing caregiver percep- – Oxygen saturation targeting (NLS 5402):
tions.335–339 There is a continued absence of studies from ScopRev underway
culturally diverse settings or where resources are limited, – Oxygen use after ROSC (NLS 5403): not previ-
and none of the new studies interviewed parents. The ously reviewed
new evidence does not appear sufficient to change the ▪ Drug and Fluid Administration
current treatment recommendation or to justify a new – Caffeine administration for preterm infants during
SysRev until more studies have accumulated. stabilization (NLS 5311): not previously reviewed

Circulation. 2025;152(suppl 1):S165–S204. DOI: 10.1161/CIR.0000000000001363 October 21, 2025 S191

 Liley et al Neonatal Life Support: CoSTR 2025

– Surfactant administration during or immedi- ARTICLE INFORMATION

ately after neonatal resuscitation (NLS 5370): The American Heart Association requests that this document be cited as follows:
ScopRev underway Liley HG, Weiner GM, Wyckoff MH, Rabi Y, Schmölzer GM, de Almeida MF, Cos-
ta-Nobre DT, Davis PG, Dawson JA, El-Naggar W, Fabres JG, Fawke J, Foglia EE,
▪ Postresuscitation Care Guinsburg R, Isayama T, Kawakami MD, Lee HC, Madar RJ, McKinlay CJD, Monnelly
– Therapeutic hypothermia, how to identify infants VJ, Nakwa FL, Rϋdiger M, Solevåg AL, Sugiura T, Trevisanuto D, Ramaswamy VV,
who may benefit (NLS 5702): not previously Yamada NK, Bruckner M, Finan E, Honeyman D, Rios DI, Josephsen JB, Kamlin CO,
Kapadia V, Katheria A, Quek BH, Ramachandran S, Roehr CC, Seidler AL, Strand
reviewed ML, Udaeta-Mora E, Berg KM; on behalf of the Neonatal Life Support Task Force
– Therapeutic hypothermia, commencement dur- Collaborators. Neonatal life support: 2025 International Liaison Committee on Re-
ing resuscitation (NLS 5703): not previously suscitation Consensus on Science With Treatment Recommendations. Circulation.
2025;152(suppl 1):S165–S204. doi: 10.1161/CIR.0000000000001363
reviewed This article has been copublished in Resuscitation. Published by Elsevier Ire-
– Alternatives to therapeutic hypothermia (NLS land Ltd. All rights reserved.
5704): not previously reviewed This article has been copublished in Pediatrics.
▪ Other and Special Considerations Acknowledgment
– Resuscitation for infants with specific congeni- The writing group would like to acknowledge Jaylen I. Wright for his organizational
tal anomalies (NLS 5960): ScopRev planned and administrative assistance in preparing the manuscript.

2025 Collaborators
– Face-to-face versus remote or distance learning: The authors thank the following individuals (the Neonatal Life Support Collabora-
new question tors) for their contributions: Maha Aly, Jasmine Antoine, Khalid Aziz, Jenny Bua,
Peter S. Cunningham, Hege Ersdal, Qi Feng, Janene H. Fuerch, Calum Gately, Lou-
is Halamek, Eiji Hirakawa, Cameron P. Hurst, Stuart Hooper, Tina Leone, Richard
Readers are encouraged to monitor the ILCOR web- Mausling, Lindsay Mildenhall, Susan Niermeyer, Somashekhar Marutirao Nimbalkar,
site10 to provide feedback on planned SysRevs and to Sian Oldham, Yuri Ozawa, Jeffrey Perlman, Graeme R. Polglase, Siren Irene Ret-
tedal, Taylor Sawyer, Birju A. Shah, Qian Hui Soh, Roger Soll, Amuchou Soraisham,
provide comments when additional draft reviews are Angela Spencer, Alex Staffler, Edgardo Szyld, Arjan te Pas, Marta Thio-Lluch, Ja-
posted. cinta Trang, Berndt Urlesberger (deceased), Jonathan Wyllie, Cheo Lian Yeo

Disclosures

Writing Group Disclosures

Other Speakers’ Consultant/

Writing group Research research bureau/ Expert Ownership advisory
Downloaded from [Link] by on October 27, 2025

member Employment grant support honoraria witness interest board Other

Helen G. Liley The University of None None None None None None None
Queensland (Australia)
Gary M. Weiner University of Michigan None None None None None None None
Katherine M. Beth Israel Deaconess None None None None None AHA/ILCOR† None
Berg Medical Center and
Harvard Medical School
Marlies Medical University Graz Grant of “Initiative für None None None None None None
Bruckner (Austria) Früh- und
Neugeborene”*
Daniela T. Universidade Federal de None None None None None None None
Costa-Nobre Sao Paulo (Brazil)
Peter G. Davis The Royal Women’s None None None None None None None
Hospital (Australia)
Jennifer A. The Royal Women’s None None None None None None None
Dawson Hospital (Australia)
Maria Fernanda Universidade Federal de None None None None None None None
de Almeida São Paulo (Brazil)
Walid Dalhousie University Aerogen Pharma*; None None None None None None
El-Naggar (Canada) National Heart, Lung
and Blood Institute
(NHLBI)/National Insti-
tutes of Health (NIH)†
Jorge G. Pontificia Universidad None None None None None None None
Fabres Catolica de Chile (Chile)
Joe Fawke University Hospitals None None None None None None None
Leicester NHS Trust
(United Kingdom)
Emer Finan Mount Sinai Hospital; Uni- None None None None None None None
versity of Toronto (Canada)
(Continued )

S192 October 21, 2025 Circulation. 2025;152(suppl 1):S165–S204. DOI: 10.1161/CIR.0000000000001363

 Liley et al Neonatal Life Support: CoSTR 2025

Writing Group Disclosures Continued

Other Speakers’ Consultant/
Writing group Research research bureau/ Expert Ownership advisory
member Employment grant support honoraria witness interest board Other
Elizabeth E. Children’s Hospital of None None None None None Chiesi USA* Chiesi USA*
Foglia Philadelphia
Ruth Federal University of Sao None None None None None None None
Guinsburg Paulo (Brazil)
David The University of None None None None None None None
Honeyman Queensland (Australia)
Tetsuya National Center for Child None None None None None None None
Isayama Health and Development
(Japan)
Justin B. Saint Louis University None None None None None None None
Josephsen
C. Omar Orphalan, London, Eng- None None None None None None None
Kamlin land (United Kingdom)
Vishal Kapadia UT Southwestern National Institute of None None None None None None
Health†; Monivent*;
Masimo*
Anup Katheria Sharp Mary Birch Hospital None None None None None None None
for Women & Newborns
Mandira Daripa Universidade Federal de None None None None None None None
Kawakami São Paulo (Brazil)
Henry C. Lee University of California None None None None None None None
San Diego
R. John Madar University Hospitals None None None None None None European
Plymouth National Health Resuscitation
Services Trust (United Council*;
Kingdom) Resuscitation
Council UK*
Downloaded from [Link] by on October 27, 2025

Christopher University of Auckland None None None None None None None
J.D. McKinlay (New Zealand)
Victoria J. The University of Edinburgh None None None None None None None
Monnelly (United Kingdom)
Firdose L. University of the Witwa- None None None None None None None
Nakwa tersrand, Johannesburg
(South Africa)
Bin Huey Quek KK Women’s and None None None None None None None
Children’s Hospital
(Singapore)
Yacov Rabi University of Calgary None None None None None None None
(Canada)
Shalini UT Southwestern None None None None None None None
Ramachandran
Viraraghavan Ankura Hospital for None None None None None None None
Vadakkencherry Women and Children
Ramaswamy (India)
Daniel Ibarra Instituto Nacional de None None None None None None None
Rios Perinatología (Mexico)
Charles University of Bristol (Unit- None None Speakers’ Bu- None None None None
Christoph ed Kingdom), Faculty of reau: Chiesi
Roehr Health and Life Sciences Pharmaceuti-
cals, Italy
Relationship
Myself
Compensa-
tion Com-
pensated
Level Modest
($5000 or
5%)
(Continued )

Circulation. 2025;152(suppl 1):S165–S204. DOI: 10.1161/CIR.0000000000001363 October 21, 2025 S193

 Liley et al Neonatal Life Support: CoSTR 2025

Writing Group Disclosures Continued

Other Speakers’ Consultant/
Writing group Research research bureau/ Expert Ownership advisory
member Employment grant support honoraria witness interest board Other
Mario Rϋdiger TU Dresden, Medical None None None None None None None
Faculty Carl Gustav
Carus (Germany)
Georg M. University of Alberta Research Grant to None None None None None None
Schmölzer (Canada) compare 30% vs
60% oxygen in 29 wk
gestation - Hilo-Trial†
Anna Lene German Center for Child Australian National None None None None None None
Seidler and Adolescent Health Health and Medical
(DZKJ) (Germany) Research Council*
Anne Lee Oslo University Hospital None None None None None None None
Solevåg (Norway)
Marya L. Strand Akron Children’s Hospital None None None None None Mayo Clinic*; None
Children’s
Hospital of
Philadelphia*
Takahiro Nagoya City University None None None None None None None
Sugiura Graduate School of Medi-
cal Sciences (Japan)
Daniele University of Padova None None None None None None None
Trevisanuto (Italy)
Enrique Asociacion Mexicana de None None None None None None None
Udaeta-Mora Pediatria (Mexico)
Myra H. UT Southwestern None None None None None None None
Wyckoff
Nicole K. Stanford University None None None None None None None
Yamada
Downloaded from [Link] by on October 27, 2025

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Reviewer Disclosures

Speakers’ Consultant/
Research bureau/ Expert Ownership advisory
Reviewer Employment grant Other research support honoraria witness interest board Other
Marilyn B. University of None None None None None None None
Escobedo Oklahoma
Noah St. Louis Uni- None None None None None None None
Hillman versity School
of Medicine
Satyan University of NIH (Evalua- None None None None None None
Lakshminrusimha California, tion of oxygen
Davis in neonatal
lung injury
including
resuscitation)†
Rob Moonen Zuyderland None None None None None None None
Medical
Center,
Heerlen (The
Netherlands)

(Continued )

S194 October 21, 2025 Circulation. 2025;152(suppl 1):S165–S204. DOI: 10.1161/CIR.0000000000001363

 Liley et al Neonatal Life Support: CoSTR 2025

Reviewer Disclosures Continued

Speakers’ Consultant/
Research bureau/ Expert Ownership advisory
Reviewer Employment grant Other research support honoraria witness interest board Other
Colm P.F. National Ma- None Karl Storz Endoskop, Tuttlingen, None None None None None
O’Donnell ternity Hospi- Germany (Loan equipment, funding
tal (Ireland) for statistical support for NEU-
VODE trial [NCT06757543])†;
Chiesi Farmaceutici (Providing sur-
factant free-of-charge and funding
for statistical support for the pro-
TeCt trial [NCT06557551])†; Karl
Storz Endoskop, Tuttlingen, Ger-
many (Provided two video laryn-
goscopes on loan for 10 months
for the purposes of the VODE trial
(N Engl J Med 2024;390: 1885-
1894) that were purchased by the
hospital at a 40% reduction at the
conclusion of the study)†
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-
tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any
12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of
the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

ric Life Support; Neonatal Life Support; Education, Implementation, and

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1997;72:255–264. doi: 10.1159/000244491 10.1136/archdischild-2020-320059
319. Sankaran D, Lane ECA, Valdez R, Lesneski AL, Lakshminrusimha S. Role 336. Karlsson L, Gustafsson U, Thernstrom Blomqvist Y, Wallstrom L, Brostrom
of Volume Replacement during Neonatal Resuscitation in the Delivery A. Neonatal resuscitation: a critical incident technique study exploring
Room. Children (Basel). 2022;9:1484. doi: 10.3390/children9101484 pediatric registered nurses’ experiences and actions. Adv Neonatal Care.
320. Granfeldt A, Avis SR, Lind PC, Holmberg MJ, Kleinman M, Maconochie 2023;23:220–228. doi: 10.1097/ANC.0000000000001063
I, Hsu CH, Fernanda de Almeida M, Wang TL, Neumar RW, et al. 337. Patriksson K, Andersson O, Stierna F, Haglund K, Thies-Lagergren L.
Intravenous vs. intraosseous administration of drugs during cardiac ar- Midwives’ experiences of intact cord resuscitation in nonvigorous neo-
rest: A systematic review. Resuscitation. 2020;149:150–157. doi: nates after vaginal birth in Sweden. J Obstet Gynecol Neonatal Nurs.
10.1016/[Link].2020.02.025 2024;53:255–263. doi: 10.1016/[Link].2023.12.003
321. Schwindt E, Pfeiffer D, Gomes D, Brenner S, Schwindt JC, Hoffmann 338. Patriksson K, Andersson O, Thies-Lagergren L, Ronnerhag M. Neonatal
F, Olivieri M. Intraosseous access in neonates is feasible and safe - An healthcare professionals’ experiences of intact cord resuscitation in the
analysis of a prospective nationwide surveillance study in Germany. Front mother’s bed- an interview study. BMC Pregnancy Childbirth. 2024;24:362.
Pediatr. 2022;10:952632. doi: 10.3389/fped.2022.952632 doi: 10.1186/s12884-024-06558-0
322. Mileder LP, Urlesberger B, Schwaberger B. Use of intraosseous vascu- 339. Zehnder E, Law BHY, Schmolzer GM. Does parental presence affect
lar access during neonatal resuscitation at a tertiary center. Front Pediatr. workload during neonatal resuscitation? Arch Dis Child Fetal Neonatal Ed.
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S204 October 21, 2025 Circulation. 2025;152(suppl 1):S165–S204. DOI: 10.1161/CIR.0000000000001363

 Circulation

Education, Implementation, and Teams: 2025

International Liaison Committee on
Resuscitation Consensus on Science With
Treatment Recommendations
Robert Greif, Chair; Adam Cheng, Vice Chair; Cristian Abelairas-Gómez; Katherine S. Allan; Jan Breckwoldt; Andrea Cortegiani;
Aaron J. Donoghue; Kathryn J. Eastwood; Barbara Farquharson; Ming-Ju Hsieh; Tracy Kidd; Ying-Chih Ko; Kasper G. Lauridsen;
Yiqun Lin; Andrew S. Lockey; Tasuku Matsuyama; Sabine Nabecker; Kevin J. Nation; Alexander Olaussen; Sebastian Schnaubelt;
Taylor Sawyer; Chih-Wei Yang; Joyce Yeung; on behalf of the Education, Implementation, and Teams Task Force Collaborators

ABSTRACT: The International Liaison Committee on Resuscitation conducts continuous reviews of new, peer-reviewed,
published cardiopulmonary resuscitation science and publishes more comprehensive reviews every 5 years. The Education,
Implementation, and Teams chapter of the 2025 International Liaison Committee on Resuscitation Consensus on Science With
Treatment Recommendations describes all published resuscitation evidence reviewed by the International Liaison Committee
on Resuscitation’s Education, Implementation, and Teams Task Force science experts since 2020. This summary addresses
the evidence in 4 subchapters: (1) training populations, (2) faculty development, (3) knowledge translation and implementation,
and (4) instructional design. Members from the Education, Implementation, and Teams Task Force have assessed, discussed,
and debated the quality of the evidence, based on Grading of Recommendations, Assessment, Development, and Evaluation
Downloaded from [Link] by on October 27, 2025

criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task
force are provided in the Justification and Evidence-to-Decision Framework Highlights sections. Priority knowledge gaps for
further research are listed.

Key Words: Scientific Statements ◼ cardiopulmonary resuscitation ◼ educational status ◼ emergency treatment
◼ faculty ◼ health personnel ◼ ILCOR

INTRODUCTION between December 1, 2024, and January 15, 2025, on

the ILCOR website.1 Each draft CoSTR includes the data
This International Liaison Committee on Resuscitation (IL- reviewed and draft treatment recommendations, with
COR) Education, Implementation, and Teams (EIT) Task public comments accepted for 2 weeks after posting.
Force 2025 ILCOR Consensus on Science With Treatment EIT Task Force members considered public feedback and
Recommendations (CoSTR) publication includes all the provided responses. All CoSTRs are now available online,
reviews conducted by the EIT Task Force in the previ- adding to the existing CoSTR statements.
ous year. Reviews conducted and published since the Although only SysRevs can generate a full CoSTR
2020 publication are also summarized to provide a single, and new treatment recommendations, many other topics
more comprehensive reference document for readers. were evaluated with more streamlined processes, includ-
New work from the past year encompasses 12 PICOST ing scoping reviews (ScopRevs) and evidence updates
(population, intervention, comparator, outcome, study de- (EvUps). Good practice statements, which represent the
sign, and time frame) studies reviewed in some capacity, opinion of task force experts in light of very limited or no
including 10 systematic reviews (SysRevs). Draft CoSTRs direct evidence, can be generated after ScopRevs and
for all 2025 topics evaluated with SysRevs were posted occasionally after EvUps in cases where the task force

Supplemental Material is available at [Link]

© 2025 American Heart Association, Inc., European Resuscitation Council, and International Liaison Committee on Resuscitation.
Circulation is available at [Link]/journal/circ

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

thinks providing guidance is especially important. A sep- – Emergency Medical Services (EMS) Experience
arate publication in this issue includes the full details of and Exposure (EIT 6104, EvUp 2025)
the evidence evaluation process.2 – Basic Life Support (BLS) Training for Likely
This summary statement contains the final wording Rescuers of High-Risk Populations (EIT 6105,
of the treatment recommendations and good practice SysRev 2022, EvUp 2025)
statements as approved by the ILCOR EIT Task Force, – Patient Outcome of Team Member Attending
as well as summaries of the evidence identified. The Cardiopulmonary Resuscitation (CPR) Course
year that treatment recommendations or good practice (EIT 6106, SysRev 2022, EvUp 2025)
statements were generated or last updated by a Sys- – CPR Education Tailored for Specific Populations
Rev is provided in parentheses. In cases where existing (EIT 6108, ScopRev 2024, EvUp 2025)
treatment recommendations have changed for 2025, • Faculty Development
the prior recommendations are also presented so that – Approaches for CPR Instructors (EIT 6200,
the reader can easily see what has changed. SysRevs ScopRev 2022, EvUp 2025)
include evidence-to-decision highlights and knowledge • Knowledge Translation and Implementation
gaps, and ScopRevs summarize task force insights on – Debriefing of Resuscitation Performance (EIT
specific topics. Links to the published reviews and full 6307, SysRev 2025)
online CoSTRs are provided in the corresponding sec- – Rapid Response Systems for Adults (EIT 6309,
tions. Evidence-to-decision tables for SysRevs are pro- SysRev 2025)
vided in Appendix A, and the complete EvUp worksheets – Systems Performance Improvements (EIT 6310,
are provided in Appendix B. SysRev 2025)
Topics are presented using the Grading of Recom- – Prehospital Critical Care for Out-of-Hospital CA
mendations, Assessment, Development, and Evaluation Patients (EIT 6313, SysRev 2025)
(GRADE) approach3 in the PICOST format. To minimize – CPR Coaching During Adult and Pediatric Cardiac
redundancy, the study designs have been removed from Arrest (EIT 6314, SysRev 2025)
the text except in cases where the designs differed from – Out-of-Hospital Cardiac Arrest Termination of
the EIT standard criteria. Standard study designs included Resuscitation (TOR) Rules (EIT 6303, SysRev
are randomized controlled trials (RCTs) and nonrandom- ADOLOPMENT 2025)
ized studies (nonrandomized controlled trials, interrupted – Community Initiatives to Promote BLS
time series, controlled before-and-after studies, cohort Implementation (EIT 6306, ScopRev 2025)
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studies), and all languages were included provided there – Family Presence in Adult Resuscitation (EIT
was an English abstract. Unpublished studies (eg, con- 6300, SysRev 2024, EvUp 2025)
ference abstracts, trial protocols), letters, editorials, com- – Cardiac Arrest Centers (EIT 6301, SysRev 2024,
ments, and case reports were excluded. EvUp 2025)
From 2020 onward, the EIT Task Force grouped its – Technology to Summon Responders (EIT 6302,
PICOST questions in 4 categories and identified some EvUp 2025)
topics to exclude because the content was either out- – Willingness to Provide CPR (EIT 6304, EvUp
dated or irrelevant due to more modern teaching or 2025)
methods of implementation. The 4 categories and the – Clinical Decision Rules to Facilitate In-Hospital
topics addressed in this EIT Task Force CoSTR sum- Do-Not-Attempt CPR (EIT 6305, SysRev 2022,
mary are delineated in Table 1. All EIT PICOST questions EvUp 2025)
reviewed since 2020 have been reviewed in some form – Termination of Resuscitation for In-hospital
for 2025. The type of review done this year and the most Cardiac Arrest (EIT 6308, EvUp 2025)
recent preceding review are summarized in Table 1. Sup- – Chain of Survival (EIT 6311, ScopRev 2024,
plemental Table S1 lists previous and updated treatment EvUp 2025)
recommendations from 2021 to 2025 and includes the – Impact of Support on Mental Health in Cosurvivors
corresponding knowledge gaps. of Cardiac Arrest Patients (EIT 6315, EvUp 2025)
Readers are encouraged to monitor the ILCOR web- • Instructional Design
site1 to provide feedback on planned systematic reviews – CPR Feedback Devices During Training (EIT
and to provide comments when additional draft reviews 6404, SysRev 2025)
are posted. – CPR Self-Instruction versus Instructor Guided
(EIT 6406, SysRev 2025)
– In Situ Training (EIT 6407, SysRev 2025)
CONTENTS – Manikin Fidelity in Resuscitation Education (EIT
• Training Populations 6410, SysRev 2025)
– Disparities in Education (EIT 6102, ScopRev – Cognitive Aids During Resuscitation (EIT 6400,
2023, EvUp 2025) SysRev 2024, EvUp 2025)

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Table 1. Overview of PICOSTs Addressed From 2021 to 2025

PICOST Type of review for Year of previous Type of previous

Topic number 2025 review review
Training Populations
 Disparities in education EIT 6102 EvUp 2023 ScopRev
 EMS experience and exposure EIT 6104 EvUp 2020 SysRev
 BLS training for likely rescuers of high-risk populations EIT 6105 EvUp 2022 SysRev
 Patient outcomes when team member attended CPR course EIT 6106 EvUp 2022 SysRev
 CPR education tailored for specific populations EIT 6108 EvUp 2024 ScopRev
Faculty Development
 Faculty development approaches for CPR instructors EIT 6200 EvUp 2022 ScopRev
Knowledge Translation and Implementation
 Debriefing of resuscitation performance EIT 6307 SysRev 2020 SysRev
 Rapid response systems for adults EIT 6309 SysRev 2020 SysRev
 Systems performance improvements EIT 6310 SysRev 2020 SysRev
 Prehospital critical care for OHCA patients EIT 6313 SysRev new in 2025
 CPR coaching during adult and pediatric cardiac arrest EIT 6314 SysRev new in 2025
 OHCA termination of resuscitation rules EIT 6303 Adolopment 2020 SysRev
 Community initiatives to promote BLS implementation EIT 6306 ScopRev 2020 ScopRev
 Family presence in adult resuscitation EIT 6300 EvUp 2023 SysRev
 Cardiac arrest centers EIT 6301 EvUp 2024 SysRev
 Technology to summon responders EIT 6302 EvUp 2020 SysRev
 Willingness to provide CPR EIT 6304 EvUp 2020 ScopRev
 Clinical decision rules to facilitate in-hospital DNACPR EIT 6305 EvUp 2022 SysRev
 Termination of resuscitation for IHCA EIT 6308 EvUp 2020 SysRev
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 Chain of survival EIT 6311 EvUp 2024 ScopRev

 Impact of support on mental health in cosurvivors of CA patients EIT 6315 EvUp new in 2025
Instructional Design
 CPR feedback devices during training EIT 6404 SysRev 2020 SysRev
 CPR self-instruction versus instructor-guided EIT 6406 SysRev 2021 SysRev
 In situ training EIT 6407 SysRev 2020 EvUp
 Manikin fidelity in resuscitation education EIT 6410 SysRev 2020 EvUp
 Cognitive aids during resuscitation EIT 6400 EvUp 2024 SysRev
 Clinician workload and stress during resuscitation EIT 6401 EvUp 2024 ScopRev
 Stepwise approach to skills training in resuscitation EIT 6402 EvUp 2023 SysRev
 Immersive technologies–virtual and augmented reality EIT 6405 EvUp 2024 SysRev
 Blended learning approach for life-support education EIT 6409 EvUp 2022 SysRev
 Gamified learning versus nongamified learning EIT 6412 EvUp 2024 SysRev
 Scripted debriefing versus nonscripted debriefing EIT 6413 EvUp 2024 ScopRev
 Rapid-cycle deliberate practice in resuscitation training EIT 6414 EvUp 2024 SysRev
 Team competencies in resuscitation training EIT 6415 EvUp 2024 SysRev

BLS indicates basic life support; CPR, cardiopulmonary resuscitation; DNACPR, do not attempt cardiopulmonary resuscitation; EMS, emergency medical services;
IHCA, in-hospital cardiac arrest; OHCA, out-of-hospital cardiac arrest; and PICOST, population, intervention, comparator, outcome, study design, and time frame. Adolop-
ment refers to use of a published SysRev that meets predefined ILCOR criteria for quality rather than conducting a new SysRev.

– Clinician Workload and Stress During – Immersive Technologies–Virtual and Augmented

Resuscitation (EIT 6401, ScopRev 2024, EvUp Reality (EIT 6405, SysRev 2024, EvUp 2025)
2025) – Blended Learning Approach for Life-Support
– Stepwise Approach to Skills Training in Education (EIT 6409, SysRev 2022, EvUp 2025)
Resuscitation (EIT 6402, SysRev 2023, EvUp – Gamified Learning versus Nongamified Learning
2025) (EIT 6412, SysRev 2024, EvUp 2025)

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

– Scripted Debriefing versus Nonscripted • Outcomes: Improved OHCA patient outcome (good
Debriefing (EIT 6413, ScopRev 2024, EvUp neurological outcome at discharge/30 days; survival
2025) to hospital discharge/30 days; survival to hospital
– Rapid Cycle Deliberate Practice in Resuscitation [event survival]; return of spontaneous circulation
Training (EIT 6414, SysRev 2024, EvUp 2025) [ROSC]); EMS personnel confidence/satisfaction
– Team Competencies in Resuscitation Training with OHCA procedures/training
(EIT 6415, SysRev 2024, EvUp 2025) • Time frame: April 10, 2020, to May 6, 2024
• Topics Not Included in the 2025 Review
– Resuscitation Training in Low-Income Countries Summary of Evidence
(EIT 6100, ScopRev In 2020, task force state- A SysRev was performed for 2020 and details can be
ment 2023) found in the 2020 CoSTR.9–11 The complete EvUp is
– Spaced Learning (EIT 6408, SysRev 2020, EvUp provided in Appendix B. No further relevant papers were
2022) identified; therefore, a SysRev is not required.
Treatment Recommendations (2020)
TRAINING POPULATIONS We suggest that EMS systems (1) monitor their clinical
personnel’s exposure to resuscitation and (2) implement
Disparity in Layperson Resuscitation Education strategies, where possible, to address low exposure or
(EIT 6102, ScopRev 2023, EvUp 2025) ensure that treating teams have members with recent
A ScopRev was performed for 2023, and details can be exposure (weak recommendation, very low–certainty
found in the 2023 CoSTR summary.4–6 The complete ­evidence).
EvUp is provided in Appendix B.
BLS Training for Likely Rescuers of High-Risk
Population, Intervention, Comparator, Outcome, and
Time Frame Populations (EIT 6105, SysRev 2022, EvUp
• Population: Laypersons (defined as non–health 2025)
care professional) A SysRev was performed for 2022, and details can be
• Intervention (Exposure): Presence of any specific found in the 2022 CoSTR summary.12,13 The complete
factor EvUp is provided in Appendix B.
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• Comparator: Absence of the specific factor

• Outcome: Likelihood of undertaking resuscitation Population, Intervention, Comparator, Outcome, and
education, including adult/pediatric BLS, and neo- Time Frame
natal resuscitation program • Population: Adults and children at high risk of OHCA
• Time frame: January 1, 2023, to October 31, 2024 • Intervention: Targeted BLS training of likely rescu-
ers (eg, family members or caregivers)
Summary of Evidence • Comparator: No such targeting
Two new observational studies were found investigating • Outcomes
disparities in layperson resuscitation training.7,8 The fac- – Patient: Favorable neurological outcome at hos-
tors identified in the 2 studies align with the categories pital discharge or to 30 days, survival at hospital
outlined in the previous scoping review, specifically per- discharge or to 30 days, ROSC, rates of bystander
sonal factors, socioeconomic status and education, and CPR (subsequent use of skills), bystander CPR
geographic factors. An updated SysRev was not thought quality during an OHCA (any available CPR met-
to be warranted, but there is a need for further research rics), and rates of automated external defibrillator
to explore overlooked aspects that may be associated (AED) use (subsequent use of skills)
with these disparities. – Educational: CPR quality and correct AED use
at end of training and within 12 months of train-
EMS Experience and Exposure (EIT 6104, ing, CPR and AED knowledge at end of training
EvUp) and within 12 months after training, confidence
and willingness to perform CPR at end of train-
Population, Intervention, Comparator, Outcome, and ing and within 12 months after training, and CPR
Time Frame training of others
• Population: Adults and children with out-of-hospital • Time frame: January 1, 2014, to July 31, 2024
cardiac arrest (OHCA)
• Intervention: Resuscitation by experienced emer- Summary of Evidence
gency medical service practitioners or practitioners The 5 new observational studies identified are consistent
with higher exposure to resuscitation in supporting previous findings and do not substantially
• Comparator: Resuscitation by less-experienced or change the weight of evidence.14–18 A SysRev for studies
lower-exposed practitioners before 2010 will be considered.

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Treatment Recommendations (2022) We have made a discordant recommendation (strong

We recommend BLS training for likely rescuers of pop- recommendation despite very low–certainty evidence)
ulations at high-risk of out-of-hospital cardiac arrest because we have placed a very high value on an uncer-
(strong recommendation, low- to moderate-certainty tain but potentially life-preserving benefit, and the inter-
­evidence). vention is not associated with prohibitive adverse effects.
We recommend health care professionals encour-
age and direct likely rescuers of populations at high risk
of cardiac arrest to attend BLS training (good practice CPR Education Tailored for Specific
statement). Populations (EIT 6108, ScopRev 2023, EvUp
2025)
Patient Outcomes When CPR Team Member The complete EvUp is provided in Appendix B. A ScopRev
Attended a CPR Course (EIT 6106, SysRev was performed in 2023, and details can be found in the
2022, EvUp 2025) 2023 CoSTR summary.4,5,20

A SysRev was performed in 2022 and details can be Population, Intervention, Comparator, Outcome,
found in the 2022 CoSTR summary.12,13,19 The complete Study Design, and Time Frame
EvUp is provided in Appendix B. • Population: Specific adult layperson populations or
groups (defined below) participating in BLS training
Population, Intervention, Comparator, Outcome,
• Intervention: Tailored BLS training
Study Design, and Time Frame
• Comparator: Generic BLS training
• Population: Patients of any age requiring in-hospital
• Outcomes:
cardiac arrest (IHCA) resuscitation
– Patient: ROSC, survival to hospital discharge, 30
• Intervention: Prior participation of ≥1 members of
days, and 12 months; neurological outcome
the resuscitation team in an accredited advanced
– Clinical: Starting CPR in case of real cardiac
life support (ALS) course
arrest, performance during real CPR
• Comparator: No such participation
– Educational: knowledge and skills acquisition,
• Outcomes: ROSC, survival to hospital discharge or
willingness to perform CPR, barriers to perform-
to 30 days, survival to 1 year, and survival with favor-
ing CPR, participant satisfaction or knowledge
able neurological outcome
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and skills retention at end of the respective

– Additional outcomes for Neonatal Resuscitation
course and later (eg, 3 months, 1 year), imple-
Training: stillbirth rate, neonatal and perinatal
mentation success, resource implications, and
mortality
cost-effectiveness
• Study designs: In this review we excluded studies of
• Study designs: Research aimed at teaching BLS to
the impact of individual components of courses (eg,
children, research on CPR training for various health
airway, drug therapy, defibrillation), studies relating
care professionals (both sufficiently covered else-
to BLS and first aid courses, studies on dedicated
where) were excluded.
trauma courses (eg, Advanced Trauma Life Support,
• Time frame: January 1, 2023, to October 22, 2024
European Trauma Course), and studies relating to
OHCA. Summary of Evidence
• Time frame: June 1, 2022, to July 31, 2024 Insights from the 2023 review included that tailored BLS
Summary of Evidence education for specific populations is probably feasible
No relevant studies were identified, and no new SysRev and that groups that may otherwise have been left out
is indicated. (eg, individuals with disabilities) can be added into the
pool of potential bystander CPR providers. Specific tai-
Treatment Recommendations (2022) lored courses for first responders with and without a duty
We recommend the provision of accredited ALS train- to respond need to be explored. In this EvUp search, no
ing (advanced cardiovascular life support, ALS) for health relevant studies were found. There is too little evidence
care providers who provide ALS care for adults (strong on the topic of tailored BLS training for specific popu-
recommendation, very low–certainty evidence). lation groups to perform a SysRev, but the task force
We recommend the provision of accredited courses thought a good practice statement was important to en-
in neonatal resuscitation training (neonatal resuscitation courage progress in this area.
training, neonatal resuscitation programs) and Helping
Babies Breath for health care providers who provide ALS Treatment Recommendations (2025)
care for newborns and babies (strong recommendation, The task force encourages resuscitation councils to
very low–certainty evidence). develop, offer, and implement tailored BLS courses for

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

specific populations based on their needs and specific Summary of Evidence

educational approach (good practice statement). Two studies identified in this evidence update found
that instructor courses with reduced face-to-face time
were not inferior to traditional instructor courses.22,23 Two
FACULTY DEVELOPMENT other studies incorporating techniques for identifying
Faculty Development Approaches for and correcting common student errors improved student
BLS performance.24,25 This suggests that integrating
Resuscitation Instructors (EIT 6200, ScopRev techniques for recognizing common student mistakes
2022, EvUp 2025) in instructor courses may enhance the effectiveness
A ScopRev was conducted for 2022,21 and details of that of teaching. This ScopRev has not identified sufficient
review can be found in the 2022 CoSTR summary.12,13 evidence to support a SysRev. A task force opinion pub-
The complete EvUp is provided in Appendix B. lished with the 2022 ScopRev has been formalized as a
good practice statement for 2025.
Population, Intervention, Comparator, Outcome,
Treatment Recommendations (2025)
Study Designs and Time Frame
The task force encourages resuscitation councils to
• Population: Instructors of accredited life-support
implement faculty development programs for the teach-
courses, including basic life support (BLS), pediatric
ing staff of their accredited resuscitation courses (good
basic life support, ALS, pediatric advanced life sup-
practice statement).
port, and neonatal resuscitation programs
• Intervention: Any faculty development approach to
improve instructional competence in accredited life-
support courses KNOWLEDGE TRANSLATION AND
• Comparator: No such approach or any other faculty IMPLEMENTATION
development approach
• Outcomes: Debriefing of Clinical Resuscitation
– Patient outcomes: Performance (EIT 6307, SysRev 2025)
■ Critical: outcome of patients resuscitated by Rationale for Review
students of the instructors, including favorable Strategies to provide debriefing to improve CPR team
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neurological outcome, survival to discharge, performance and optimize delivery of care are available
short-term survival, ROSC, sustained ROSC, and often common practice. However, there are few data
and survival to admission showing either improved patient outcome or negative
– Educational outcomes: side effects (eg, cost, emotional impact on professionals).
■ Critical: Skill performance of students of the The last review of this topic was in 2020, and awareness
instructors in actual resuscitation of new data prompted this SysRev, which was r­ egistered
■ Important: Knowledge, skill performance, atti- in Prospective Register of Systematic Reviews (PROS-
tudes, willingness to perform resuscitation, PERO) (CRD42024595033). The full CoSTR is avail-
and confidence of students of the instructors able on the ILCOR website.26
immediately after the course or at defined peri-
ods of time after course completion Population, Intervention, Comparator, Outcome, and
– Instructors outcome: Time Frame
■ Important: Knowledge, instructional skills, and • Population: Health care professionals performing
attitudes of instructors at end of instructor resuscitation in any clinical setting
training course; knowledge, instructional skills, • Intervention: Postevent clinical debriefing
and attitudes of instructors at defined periods • Comparator: No debriefing
of time after end of instructor training course; • Outcomes:
confidence of instructors to teach students at – Clinical: Resuscitation skills performance (in clini-
end of instructor training course at defined cal contexts, eg, CPR quality, time to medication
periods of time after course completion; administration, initiation of CPR, time to defibrilla-
instructor acceptance of a faculty development tion, chest compression fraction, etc.), and resus-
approach; cost of faculty development citation knowledge
• Study designs: In addition to standard criteria, grey – Patient: Favorable neurological outcome at hos-
literature, non–peer-reviewed studies, unpublished pital discharge/30 days, survival at hospital dis-
studies, conference abstracts, and trial protocols charge/30 days, survival to hospital admission,
were eligible for inclusion. event survival
• Time frame: January 1, 2022 (after last research), • Time frame: January 1, 2014, to September 26,
to June 30, 2024 2024

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Consensus on Science • The effect of debriefing by subgroups such as

Six studies in adults,27–32 1 in children,33 and 3 in neona- adult versus pediatric cardiac arrest, in-hospital
tal cardiac arrests34–36 were identified. All were nonran- versus out-of-hospital setting, or hot versus cold
domized studies providing very low certainty of evidence. debriefing
Interventions included postresuscitation debriefings27;
­ • Cost-effectiveness of debriefing or effect of poste-
audiovisual feedback plus weekly postevent debrief- vent debriefings in low-resource settings are
ings28; short, individual oral debriefings29; hot or cold de- warranted
briefings30; weekly debriefing sessions with audiovisual • Whether there are any negative effects of debrief-
feedback during cardiac arrest31 after-training workshops ing on the resuscitation team
with debriefing;34 video-assisted, performance-focused
debriefings36; positive-pressure ventilation refresher
and performance debriefings35; and postresuscitation Rapid Response Systems for Adult In-Hospital
interdisciplinary team debriefings.33 One study stratified Patients (EIT 6309, SysRev 2025)
­hospitals by debriefing frequency.32 Because of this het- Rationale for Review
erogeneity, no meta-analyses could be performed. Key Patients admitted to hospital might be at risk of deterio-
study findings are presented in Table 2. ration, which can lead to cardiac arrest. These patients
often have symptoms and signs of deterioration hours
Prior Treatment Recommendations (2020) before cardiac arrest.37 A rapid response system includes
We suggest data-driven, performance-focused debrief- an afferent component to identify such deterioration
ing of rescuers after IHCA for both adults and children early to prevent serious adverse events and an efferent
(weak recommendation, very low–certainty evidence). component, which is a rapid response team or a medical
We suggest data-driven, performance-focused emergency team.38,39 Because there is uncertainty if rap-
debriefing of rescuers after OHCA in both adults and id response or medical emergency teams improve ­patient
children (weak recommendation, very low–certainty outcomes after cardiac arrest, this SysRev was initiated
­evidence). by the EIT Task Force. It was registered at PROSPERO
(CRD42024615077), and the CoSTR is available on the
Treatment Recommendations (2025)
ILCOR website.40
We suggest performing postevent debriefing after adult,
pediatric, and neonatal cardiac arrest in all settings (weak
Population, Intervention, Comparator, Outcome, and
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recommendation, very low–certainty evidence).

Time Frame
Justification and Evidence-to-Decision Framework • Population: Adults at risk of cardiac or respiratory
Highlights arrest in hospital
The complete evidence-to-decision table is provided in • Intervention: Rapid response system (includes rapid
Appendix A. response team or medical emergency team)
Performance of postevent debriefing was either • Comparator: No rapid response system
associated with no effect or with improved outcome • Outcomes: Survival to hospital discharge with good
(favorable neurological outcome, survival to discharge, neurological outcome; survival to hospital discharge;
ROSC, chest compression depth, chest compression in-hospital incidence of cardiac/respiratory arrest
rate, chest compression fraction, adherence to guide- • Time frame: All years to September 9, 2024
lines). Because of the high heterogeneity across studies
Consensus on Science
(variation in debriefing design, patient population [adults,
Because of extensive heterogeneity between the
children, neonates], outcome measures) no statement
studies, no meta-analyses were performed. How-
can be made about the most effective type of debrief-
ever, the summary of available evidence indicates
ing. No undesirable effects (eg, emotional trauma to the
reduced incidence of cardiac arrest in those hos-
debriefed team, needed resources–including costs) have
pitals that implemented a rapid response system,
been identified, but neutral to positive effects on resus-
and a dose-response effect. Table 3 presents data
citation outcomes were reported. Hence, we consider
on the incidence of cardiac arrest, and survival to
that the reported positive effects outweigh any possible
­discharge or 30 days. We did not find any study re-
undesirable effects. This treatment recommendation is
porting data for survival with favorable neurological
based on nonrandomized studies. No study compared
outcome. Of the 56 nonrandomized studies reporting
debriefing with no debriefing after CPR in a randomized
the incidence of cardiac arrest after implementation
controlled trial, resulting in serious risk of bias.
of a rapid response system,41–96 39 showed improve-
Knowledge Gaps ment,41–43,45,49,51–57,59,61–65,67,68,71,73–77,81–90,94,95 and 17
• RCTs on debriefing after CPR are needed. showed no improvement.44,46–48,50,58,66,69,70,72,78,80,91–93,96

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Table 2. Key Findings of Included Studies on Postevent Debriefing

Favorable Chest Chest Chest Adherence to

Outcome neurological Survival to hospital compression compression compression resuscitation
of interest outcome discharge ROSC depth rate fraction guidelines
Number of 5 nonrandomized 6 nonrandomized 7 nonrandomized 3 4 4 2 studies35,36
studies studies28–30,32,33 studies27–29,32,33 studies28–31,33,34 nonrandomized nonrandomized nonrandomized
studies28,29,31 studies27–29,31 studies27–29,31
Number of 46 145 46 269 46 459 1773 1897 1897 381
patients
Evidence 1 study favored hot 1 study favored hot 1 study30 found 48% 1 study31 1 study27 found 1 study27 1 study36
debriefings30—using a debriefings,30 finding probability that hot found that CC that CC rate found that found a medi-
Bayesian hierarchical 67% probability of debriefings increase depth was 50 was 93/min CCF was 79% an total NRPE
logistic regression increased odds of the odds of ROSC mm (10) with with debriefing (70%–85%) score of 89%
model—77% prob- survival with hot de- (OR, 0.99; 95% CI, debriefing and (9) and 81/min with debrief- (86, 93) with
ability of increased briefings (OR, 1.06; 0.80–1.21) and 89% 44 mm (10) (13) without ing and 86% debriefing
odds of favorable 95% CI, 0.81–1.37). probability that cold without debrief- (P =0.03). No (82%–89%) and 77% (75,
neurological outcome However, 11% prob- debriefings increase ing (P <0.001). effect size without. No 81) without
with hot debriefings ability of increased the odds of ROSC No effect size reported effect size or P (P <0.001).
(OR, 1.11; 95% CI, odds of survival with (OR, 1.15; 95% CI, reported value reported
0.83–1.44). cold debriefings 0.90–1.43).
(OR, 0.83; 95% CI,
However, 1% prob-
0.62–1.11)
ability of increased
odds of favorable
neurological outcome
with cold debriefings
(OR, 0.69; 95% CI,
0.49–0.93)
1 study33 found de- 1 study33 found no as- 1 study31 reported a 1 study31 found 1 study31 1 study35
briefing was associ- sociation between de- ROSC rate of 59% a CC rate of found a no- found a me-
ated with improved briefing and improved with debriefing, and 105/min (10) flow fraction dian NRPE
favorable neurologic survival in univariate 45% without (P =0.03). with debriefing of 0.13 (0.10) score of 89%
outcome. Univariate: analysis (52% versus No effect size reported and 100/min with debrief- (86%–92%)
(50% versus 29%; 33%; P =0.054); (13) without ing and 0.20 with debrief-
P =0.036); multi- after controlling for (P =0.003). (0.13) without ing and 77%
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variate: (aOR, 2.75; potential confounders No effect size (P <0.001). (75%–81%)

95% CI, 1.01–7.5; (aOR, 2.5; 95% CI, reported No effect size without
P =0.047) 0.91–6.8; P =0.075) reported (P <0.001).
1 study34 showed no
significant differences
between groups for
time of neonate’s color
to return to normal,
and Apgar scores at
1, 5, and 10 min were
higher in the debrief-
ing group compared
with those reported for
other groups. No effect
sizes reported.
3 studies showed no 4 studies showed no 4 studies showed no 2 studies 2 studies 2 studies
effect.28,29,32 effect.27–29,32 effect.28,29,32,33 showed no showed no showed no
effect.28,29 effect.28,29 effect.29,30

aOR indicates adjusted odds ratio; CC, chest compressions; CCF, chest compression fraction; NRPE, Neonatal Resuscitation Performance Evaluation; OR, odds ratio;
and ROSC, return of spontaneous circulation.

Treatment Recommendations (2025) In making these recommendations, the task force

We suggest that hospitals consider the introduction emphasizes the importance of outcomes such as pre-
of a rapid response system to reduce the incidence of venting in-hospital cardiac arrests and increasing sur-
in-­hospital cardiac arrest (weak recommendation, low-­ vival to hospital discharge, despite the considerable
quality evidence). costs associated with these systems. Numerous health
care institutions globally have effectively adopted rapid
Justification and Evidence-to-Decision Framework response systems,102 and it is recommended by the Insti-
Highlights tute for Healthcare Improvement.103
The complete evidence-to-decision table is provided in Implementing an effective rapid response system
Appendix A. requires strong afferent (detection and activation) and

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Table 3. Summary of Findings of Studies on Effect of Rapid System Performance Improvement (EIT 6310,
Response Systems on Incidence and Outcome of In-hospital
Cardiac Arrest SysRev 2025)
Study Total number of Rationale for Review
design studies Evidence The clinical outcomes of patients with cardiac arrest
RCTs 3 RCTs97–99 on 1 study reported cardiac arrest rates of 1.3 differ around the world. There is a need for a sys-
incidence of versus 1.0/1000 admissions (OR, 0.71; 95% tematic review of system-wide interventions to better
cardiac arrest CI, 0.33–1.52) with or without RRS.97
­understand their impact. System performance improve-
After implementation of RRS, the proportion ment is defined as hospital-level, community-level, or
of patients admitted to the ward who received
CPR decreased from 4.86% to 3.61% country-level advancements related to structure, care
(unadjusted OR, 0.73; 95% CI, 0.64–0.85). pathways, processes, and quality of care. This can
There was no difference after adjustment include single interventions or multidisciplinary ap-
(aOR, 1.00; 95% CI, 0.69–1.48).98
proaches deployed to improve outcomes of cardiac ar-
Cardiac arrest incidence 1.64/1000 in
patients without RRS versus 1.31/1000 with
rest patients. As the last systematic review on this topic
RRS (P =0.306; 95% CI, –0.264 [–2.449 to was in 2020 the EIT Task Force initiated a new review,
1.921]99) which was registered in PROSPERO under the num-
Non- 11 8 studies41–44,46–48,100 reported no ber CRD42020161882. The full CoSTR is available on
RCTs nonrandomized improvement in survival to discharge after the ILCOR website.105
studies on cardiac arrest.
survival41–49,100,101 Population, Intervention, Comparator, Outcome, and
1 pre/post-RRS implementation study found
no difference in survival 30 d after cardiac Time Frame
arrest.45
• Population: Resuscitation systems caring for patients
1 pre/poststudy showed increased long-term in cardiac arrest in any setting
survival postsurgery in hip fracture patients:
71.8 mo pre-RRS versus 75.0 mo post RRS • Intervention: System performance improvement ini­
(P =0.008).101 tiative(s)
1 study found RRS did not impact overall • Comparator: No system performance improvement
survival to discharge for female patients. initiative(s)
However, an increase was reported for
• Outcomes: Survival with favorable neurologic out-
females 18–34 y of age.49
come at discharge, survival to hospital discharge,
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CPR indicates cardiopulmonary resuscitation; RCT, randomized controlled trial; skill performance in actual resuscitations, survival to
and RRS, rapid response system.
admission, system-level variables
• Time frame: July 1, 2020, to June 30, 2024
efferent (response by the rapid response team/medi-
cal emergency team team) limbs. These are supported Consensus on Science
by administrative and quality improvement measures,104 This systematic review found 15 new studies,106–120
which include comprehensive staff training on consistent which added to the 27 publications31,33,121–145 from the
and appropriate monitoring of vital signs, clear protocols previous CoSTR in 2020.9,10
on early warning scores to facilitate early detection, and The interventions investigated in the 15 new studies
a tiered clinical response structure. are summarized in Table 4. Those 27 described previ-
ously were included in the earlier publication.146 Key
Knowledge Gaps results from these studies are summarized in Table 5.
• Effect of rapid response systems on long-term sur-
vival with positive neurological outcome Prior Treatment Recommendations (2020)
• Role of technology in enhancing rapid response We recommend that organizations or communities that
systems treat cardiac arrest evaluate their performance and target
• Essential components of the afferent limb in rapid key areas with the goal to improve performance (strong
response systems (eg, which vital signs, clinical recommendation, very low–certainty evidence).
observations, and laboratory parameters should Treatment Recommendations (2025)
be monitored, as well as the optimal frequency for We recommend that organizations or communities that
these assessments) treat cardiac arrest use system- improvement strategies
• Optimal design of education programs to improve to improve patient outcome (strong recommendation,
the recognition of patient deterioration very low–certainty evidence).
• Ideal composition of the efferent limb, or the
response team Justification and Evidence-to-Decision Framework
• Most effective mechanism for escalating assistance Highlights
• Cost-effectiveness of rapid response systems in The complete evidence-to-decision table is provided in
practice Appendix A.

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Table 4. Interventions in Included Studies The EIT Task Force decided to exclude studies inves-
Study (author, tigating extracorporeal CPR, which were included previ-
year, setting) Interventions ously, because the prevalence of extracorporeal CPR is
Blewer 2020 National bystander-focused public health interventions increasing, and several RCTs were reviewed in another
(OHCA)107 including DA-CPR, CPR training programs, and the CC PICOST. In making this recommendation, the task force
application
prioritized the benefits of system performance improve-
Lee 2020 Citywide interventions including (1) mandatory CPR and ments, recognizing that they present no known risks
(OHCA)113 AED training, DA-CPR, and the establishment and actions
of the Daegu cc and (2) public-access defibrillation and hold substantial potential for positive impact. The
program; team CPR program; dual-patch system; task force recognized that the evidence supporting this
standardized post-CA treatment; education program recommendation is derived from studies with very low
for medical staff; regional OHCA registry; and public
reporting and feedback to provinces, hospitals, and EMTs certainty across all evaluated outcomes, primarily due to
Kim 2020 Implementing the PDSA model for quality improvement:
risks of bias and inconsistencies. However, most studies
(OHCA)111,112 (1) bystander CPR education and dispatcher training, (2) found that interventions to improve system performance
regular skills training sessions for EMTs, (3) detailed data not only improve system-level variables and skill perfor-
collection instrument, (4) medical director assignment
mance in actual resuscitations among rescuers, but also
Kim 2020 A multidisciplinary approach including (1) re-education of clinical outcomes of patients with out-of-hospital or in-
(OHCA)110 BLS, (2) simulation training for real-time medical direction
via video call, (3) 2-tier dispatch
hospital cardiac arrest. We acknowledge that these inter-
ventions demand funding, personnel, and stakeholder
Auricchio 2020 Statewide initiatives including recording of OHCAs;
(OHCA)106 initiatives on AED density, bystander and layperson support to improve system performance. Varying levels
recruitment; first responder network of resources across settings may influence the effective-
Nehme 2021 High-performance CPR focusing on team dynamics ness of implementing these performance improvements.
(OHCA)118 and communication, with emphasis on optimizing
resuscitation flow and minimizing delays Knowledge Gaps
Dong 2022 Citywide quality improvement program consisting of (1) • Cost-effectiveness of individual interventions aimed
(OHCA)108 standardized ambulance treatment protocol adopted, (2)
at improving systems
ambulance crew targeted training, (3) quality monitoring,
feedback, and postevent debriefing • Feasibility of implementing community interventions
Kim 2022 SALS protocol incorporating changes in CPR assistance
across diverse resource settings
(OHCA)111 and coaching by physicians via real-time video calls • Effects of individual and bundled interventions
across diverse resource settings
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Lin 2022 Citywide bundle initiative including (1) commencement of

(OHCA)115,117 medical direction and public-access defibrillation project,
(2) digitized Utstein-based registry, (3) public involvement
and continuous QA process, (4) proactive CPR
promotion and PAD, (5) built and implemented culture of
Prehospital Critical Care for Out-of-Hospital
excellence and smart technology Cardiac Arrest (EIT 6313, SysRev 2025)
McCoy 2023 Bundled intervention on IHCA survival in patients on Rationale for Review
(IHCA)117 centralized telemetry: (1) telemetry hotline for telemetry
technicians to reach nursing staff, (2) empowerment of
The emergency medical service (EMS) system re-
telemetry technicians to directly activate the IHCA response sponse is a critical element in the pathway of care for
team, and (3) standardized escalation system for automated OHCA patients.147,148 Prehospital critical care teams
critical alerts within the nursing mobile phone system
as part of a tiered EMS response are emerging.149–151
Freedman Bundled intervention on IHCA including EMC These are specialists in the care of critically ill patients
2023 restructuring, CPR coach, replacing defibrillators,
(IHCA)109 defibrillator data review, training program, metronomes, requiring resuscitation,152 and they have competen-
code documentation, debriefing, and event reviews cies in advanced life support beyond that of standard
Li 2023 RQI HeartCode Complete program, designed to enhance EMS teams.153 Understanding the clinical efficacy of
(OHCA)114 CPR training by using real-time feedback manikins prehospital critical care teams may inform the decision
Lyngby 2023 Real-time feedback displayed on the defibrillator screen, to implement this into practice. This SysRev on pre-
(OHCA)116 presenting compression depth, compression rate, and hospital critical care teams for nontraumatic OHCA154
audible rate guidance
was registered in PROSPERO under the number
Riyapan 2024 CQI low-dose, high-frequency training interventions
CRD42023478216. The full CoSTR is available on the
(OHCA)119 included advanced airway management, high-performance
CPR, and postevent debriefing with video recording ILCOR website.155
Vaillancourt Implementation of medical directive allowing nurses to
2024 (IHCA)120 use defibrillators in AED mode for IHCA Population, Intervention, Comparator, Outcome, and
Time Frame
AED indicates automated external defibrillator; BLS, basic life support; CPR,
cardiopulmonary resuscitation; CQI, Continuous Quality Improvement; DA-CPR,
• Population: Adults and children with OHCA and
dispatcher-assisted cardiopulmonary resuscitation; EMC, Emergency Manage- attempted resuscitation. Traumatic cardiac arrest
ment Committee; EMT, emergency medical technician; IHCA, in-hospital cardiac was excluded.
arrest; OHCA, out-of-hospital cardiac arrest; PAD, public access defibrillation;
PDSA, Plan-Do-Study-Act; RQI, Resuscitation Quality Improvement; and SALS,
• Intervention: Attendance of a prehospital critical
Smart Advanced Life Support. care team. Prehospital critical care was defined as

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Table 5. Summary of Outcomes Reported in Studies About System Interventions

Survival with favorable

neurologic outcome at Skill performance in actual
discharge Survival to hospital discharge resuscitations Survival to admission System-level variables
1 cluster-randomized 1 cluster-randomized trial showed 1 cluster-randomized trial 1 cluster-randomized
trial showed survival with survival to hospital discharge was showed that rescuer skill trial showed survival
favorable neurologic not higher after interventions.130 performance improved after to admission was
outcome at discharge interventions.130 not higher after
was not higher after interventions.130
interventions.130
17 non-RCTs showed 20 non-RCTs showed 16 non-RCTs reported 3 non-RCTs 18 non-RCTs achieved all or
significantly higher survival significantly higher survival that improved rescuer showed significantly partial goals from individual
with favorable neurologic to hospital discharge after skill performance after higher survival to interventions or improved specific
outcome at discharge after interventions.33,106,107,111,113, interventions.31,33,110,114,116,118,120, admission after system-level variables (including
interventions.33,110,111,113,115, 115,118,122,125–128,131,133–135,137,139,140,143 123,128,131–133,135,136,141,145
interventions.126,137,140 rate of bystander CPR or AED,
122,125–128,131,133,134,139,140,142,143
rate of prehospital or in-hospital
hypothermic temperature
7 non-RCTs showed 14 non-RCTs showed no 2 non-RCTs showed no 6 non-RCTs showed
control, use of automatic CPR
no significant significant improvement after significant improvement after no significant
devices, CPR feedback devices,
improvement after interventions.28,31,109,110,112,116,117, interventions.28,138 improvement after
or percutaneous coronary
interventions.28,106,112,123,129, 119,120,123,129,141,142,144
interventions.110,115,116,
135,144 119,129,142
intervention).106,107,110,112,113,
115,116,121,125,126,128,129,133,134,137,139,

142,144

AED indicates automated external defibrillation; CPR, cardiopulmonary resuscitation; and RCT, randomized controlled trial.

any clinician with clinical competencies beyond that teams.150–153,160,163 A single non-RCT in pediatric OHCA
of standard paramedics using ALS algorithms and did not find a benefit from prehospital critical care
dedicated dispatch to critically ill patients. teams.157 (Figure 3).
• Comparator: Advanced life support by any other Favorable neurological outcome at hospital discharge
prehospital health care professional was addressed in 1 nontraumatic OHCA study enrolling
• Outcomes: Clinical outcomes of survival, favorable 973 patients, showing no significant difference (OR, 1.35;
neurological outcome, and ROSC; resource and 95% CI, 0.71–2.60).158 No pediatric study addressed this
cost implications outcome.
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• Time frame: All years to April 20, 2024 Favorable neurological outcome at 30 days was
addressed in 6 nontraumatic OHCA studies, which
Consensus on Science found a benefit from prehospital critical-care teams.150–
Out of 15 articles included,147–153,156–163 no randomized 153,160,163
A single non-RCT in pediatric OHCA found an
studies were identified. A total of 1 188 287 patients association of prehospital critical-care teams with better
were included in the non-RCTs, and 1 included chil- ­outcome157 (Figure 4).
dren only.157 Seven studies came from Japan, 3 from
the UK, and 1 each from Australia, Iceland, Norway, Treatment Recommendations (2025)
Poland, and the USA. In 14 studies prehospital critical We recommend that prehospital critical-care teams attend
care teams included physicians,147–153,156–158,160–163 includ- adults with nontraumatic, out-of-hospital cardiac arrest
ing specialists in emergency medicine,148–150,156,157,160,162 within EMS systems with sufficient resource infrastruc-
anesthesia,156,158,162 or critical/intensive care medi- ture (weak recommendation, low certainty of evidence).
cine.148,150,156,160,162 Four studies included specially trained We suggest that prehospital critical-care teams attend
critical care paramedics,147,159,161,162 3 from the United children with out-of-hospital cardiac arrest within EMS
Kingdom,147,161,162 and 1 from Australia that included systems with sufficient resource infrastructure (weak
solely critical-care paramedics.159 For the combined out- recommendation, very low certainty of evidence).
come of ROSC and survival to hospital admission, pooled
results from 6 adult non-RCTs found a benefit from pre- Justification and Evidence-to-Decision Framework
hospital critical care teams.147,148,150,156,160,162 A single non- Highlights
RCT in pediatric OHCA enrolled 1187 patients and also The complete evidence-to-decision table is provided in
found an association of prehospital critical-care teams Appendix A.
with better outcome157 (Figure 1). The EIT Task Force has made a recommendation
For survival to hospital discharge, pooled results from alongside low-certainty evidence for adults in light of
5 adult non-RCTs found a benefit from prehospital critical consistent benefits across clinical outcome from a vari-
care teams.147,148,156,161,162 No study on children included ety of different health care systems. One study including
this outcome (Figure 2). 1187 children also found benefit; hence the EIT Task
For survival at 30 days, pooled results from 6 adult Force also made a treatment recommendation favoring
non-RCTs found a benefit from prehospital critical care prehospital critical-care teams for children.

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Figure 1. Survival to hospital admission/return of spontaneous circulation with prehospital critical-care teams compared with
standard advanced life support.
ALS indicates advanced life support; and CCT, critical-care team.
Adapted from Boulton et al.154 This is an Open Access article under the CC BY 4.0 license.
Downloaded from [Link] by on October 27, 2025

This SysRev demonstrated that many settings have menting these services in other health care systems is
already implemented prehospital critical-care teams. likely to incur additional resources, training, and EMS infra-
Expanding prehospital critical-care services and imple- structure costs, and hence may not be universally available.

Figure 2. Survival to hospital discharge with prehospital critical-care teams compared with standard advanced life support.
ALS indicates advanced life support; and CCT, critical care team.
Adapted from Boulton et al.154 This is an Open Access article under the CC BY 4.0 license.

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Figure 3. Survival at 30 days with prehospital critical-care teams compared with standard advanced life support.
ALS indicates advanced life support; and CCT, critical care team.
Adapted from Boulton et al.154 This is an Open Access article under the CC BY 4.0 license.
Downloaded from [Link] by on October 27, 2025

Knowledge Gaps vide real-time coaching on resuscitation quality. The EIT

• RCTs investigating prehospital critical-care teams Task Force initiated this SysRev focusing on coaching
for OHCA are needed. where the coach is an active resuscitation team mem-
• Evidence about children with out-of-hospital cardiac ber. The SysRev167 was registered on PROSPERO
arrest is based on only 1 study. (CRD42017080475), and the full CoSTR is available on
• Which patient groups would benefit most from pre- the ILCOR website.168
hospital critical-care teams
• Optimal composition of prehospital critical-care
Population, Intervention, Comparator, Outcome, and
teams, their professional background, and training
Time Frame
requirements
• Population: Health care teams managing adult or
• Associated resource costs, cost-effectiveness,
pediatric cardiac arrest
impact on health equity, and feasibility of implemen-
• Intervention: CPR coach as a resuscitation team
tation of prehospital critical-care teams
member
• Comparator: No CPR coach on the resuscitation
team
CPR Coaching During Adult and Pediatric • Outcomes:
Cardiac Arrest (EIT 6314, SysRev 2025) – Simulation-based clinical skills: CPR skill perfor-
Rationale for Review mance, adherence to guidelines, teamwork, team
Despite CPR training, adherence to guidelines is poor member workload
during cardiac arrest. Visual feedback devices during – Real-life clinical performance: CPR skill perfor-
CPR can improve chest compression (CC) quality, but mance, adherence to guidelines
compliance for CC depth is still <40%.164 To implement – Patient survival: ROSC, survival to hospital dis-
well-known evidence into clinical practice, the integra- charge or 30 days, survival with favorable neuro-
tion of a CPR coach within the resuscitation team has logical outcome, survival beyond discharge or 30
been proposed.165,166 A CPR coach is a resuscitation days
team member whose primary responsibility is to pro- • Time frame: All years to October 11, 2024

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Figure 4. Favorable neurological outcome at 30 days with prehospital critical-care teams compared with standard advanced life
support.
ALS indicates advanced life support; and CCT, critical-care team.
Adapted from Boulton et al.154 This is an Open Access article under the CC BY 4.0 license.
Downloaded from [Link] by on October 27, 2025

Consensus on Science a CPR Coach may be considered a specific way of using

We identified 7 studies investigating the use of a CPR shared leadership in resuscitation teams. Shared leader-
coach versus no use of a CPR coach as a resuscita- ship has been suggested to be useful in several studies
tion team member.165,169–174 One study investigated use on IHCA.175–177 CPR Coaches are already implemented
of CPR coaches in a clinical setting,171 and 6 were as part of the resuscitation teams in many hospitals,178
simulation studies.165,169,170,172–174 Five of the simulation suggesting that staff members are often available to fill
studies were based on the same randomized controlled this role.175 This may differ in low-resource settings and
trial.165,170,172–174 The outcomes of the included studies out-of-hospital settings.
are presented in Table 6. The outcomes of adherence to Most of the evidence was based on 1 randomized
guidelines in a clinical setting and patient survival were simulation-based trial.174
not reported in any studies.
Knowledge Gaps
• Identified evidence was limited (from 1 RCT simula-
Treatment Recommendations (2025) tion,165 1 clinical observational study,171 1 pilot RCT
We recommend considering the inclusion of a CPR simulation169). Further evidence on CPR Coaching
Coach as a member of the resuscitation team during from RCTs is needed.
cardiac arrest resuscitation in settings with adequate • Effect of CPR coaches on real cardiac arrest and
staffing (weak recommendation, very low–certainty patient survival outcome
evidence). • Effect of CPR coaches on prespecified subgroups
(eg adult versus pediatric patients, trained versus
Justification and Evidence-to-Decision Framework untrained CPR Coaches, use of CPR feedback
Highlights devices versus no CPR feedback devices)
The complete evidence-to-decision table is provided in • Optimal role and effectiveness of a CPR Coach in
Appendix A. out-of-hospital settings and in-hospital settings
CPR Coaches were generally associated with improved • Cost-effectiveness or utilization of CPR Coaches in
outcomes, and no harmful effects were observed. Use of limited resource settings

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Table 6. Study Outcomes and Certainty of Evidence for Use by CPR Coaches During Resuscitation

Outcome Evidence with CPR coach implementation Certainty of evidence

Clinical CPR CCF at adequate depth improved from 69.8%–80.4%. Very low (downgraded for
performance risk of bias, indirectness,
Compression depth increased from 43.6 mm to 47.2 mm.
imprecision)
Time to defibrillation decreased from 13.2 s–7.2 s.171
CPR performance in a Higher fraction of excellent chest compressions (63% versus 31%; Diff, 31.8 [17.7, 45.9]), higher Very low (downgraded for
simulated setting fraction of compressions within guideline recommendations (38.0% versus 69.5%; Diff, 31.5 [15.7, risk of bias, imprecision)
47.4]), higher guideline compliance rate (88% versus 80%; P =0.07), higher CCF (82% versus 77%; no significantly higher
P =0.04) for coached versus noncoached teams165
Shorter total mean pause duration (98.6 s versus 120.85 s; 95% CI of mean Diff, 0.6 s–43.9 s,
P =0.04)173
Shorter time to backboard placement (22 s versus 55 s; P =0.02). No difference in compression rate,
no-flow time, time to first epinephrine, time to perishock, peri shock pause duration169
Adherence to guidelines Clinical performance tool scores were higher (73.4 versus 68.3; Diff, 5.2 points; 95% CI, 1.0–9.3; Low (downgraded for
in a simulated setting P =0.016).170 risk of bias, indirectness,
imprecision)
Teamwork in a simulated Coached teams used more words/min (160 versus 134; P <0.05) driven by more directives on chest Very low (downgraded for
setting compression rate and depth, and positive verbal cues from the CPR coach to the team; team leaders risk of bias, indirectness,
and others said fewer words/min (70 versus 88 and 30 versus 46; P <0.05).172 imprecision)

Workload in a simulated One study found no significant difference for overall workload for team leaders; chest compressors had Very low (downgraded for
setting lower mental demand but higher physical demand in coached teams.174 risk of bias, inconsistency,
and indirectness)
Another study showed no differences on any NASA Task Load index subscales for team leader.169

CCF indicates chest compression fraction; Diff, difference; and NASA, National Aeronautics and Space Administration.

Out-of-Hospital Cardiac Arrest Termination • Outcomes: Ability of TOR to predict death in

of Resuscitation Rules (EIT 6303, SysRev hospital or unfavorable neurologic outcome.
Cost-effectiveness
Adolopment 2025) • Time frame: January 1, 2023, to October 19, 2024
Rationale for Review
Consensus on Science
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A systematic review on prehospital TOR rules was first

published as part of the 2020 ILCOR CoSTR.9,10 Sub- The 2020 ILCOR CoSTR identified several studies ad-
sequently, a systematic review including these findings dressing the use of TOR rules, but a meta-­ analysis
was published, including a literature update in Janu- was not possible because of high risk of bias and
ary 2024 that reviewed additional literature on cost-­ ­heterogeneity.9,10
effectiveness.180 The EIT Task Force conducted an The updated review published in 2024 identified 10
adolopment (utilizing an existing SysRev that meets pre- new observational studies on the validation of different
defined ILCOR criteria for quality) of the recently pub- TOR rules from historical cohorts.182–191 These stud-
lished review, searched recent literature from January ies, grouped by outcome reported, are summarized in
2023 to October 2024, and conducted data extraction Tables 7 through 9. Several studies validated more than
and risk of bias assessment for any paper published af- 1 score or applied the same score in different cohorts.
ter the initial review. We considered papers on prehos- Following the 2024 publication, we identified 3 addi-
pital TOR rules used in the prehospital setting. Studies tional studies, 2 investigating cost-effectiveness of dif-
addressing TOR for patients arriving at the emergency ferent TOR rules192,193 and 1 on the derivation of a new
department by ambulance in-hospital TOR were exclud- TOR rule for pediatric OHCA.194
ed. The adoloped review was registered in PROSPERO One study estimated quality-adjusted life years for
(CRD42019131010), and the full online CoSTR is avail- survivors following OHCA in the United Kingdom.192
able on the ILCOR website.181 The most cost-effective strategies were the European
Resuscitation Council TOR rule (incremental cost-
Population, Intervention, Comparator, Outcome, and effectiveness ratio (ICER) of £8,111), the Korean Car-
Time Frame diac Arrest Research Consortium 2 (KOC 2) TOR rule
• Population: Adults and children in cardiac arrest (ICER of £17,548), and the universal Basic Life Sup-
who do not achieve ROSC in the out-of-hospital port (BLS) TOR rule (ICER of £19,498,216).192 The
environment. KOC 2 TOR rule was cost-effective at the established
• Intervention: (Index test) TOR rules cost-effectiveness threshold of £20,000 to £30,000
• Comparator: (Reference standard) In-hospital out- per quality-adjusted life year (providing the most
come: survival, favorable or unfavorable neurologic ­quality-adjusted life years being below the established
outcome ICER threshold).

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Table 7. Prediction of No Return of Spontaneous Circulation

Study TOR rule Population TP FP FN TN Sensitivity Specificity

Harris 2021183 MIEMS Child (trauma, 0–17 y of age) 27 4 71 36 0.28 [0.19–0.37] 0.90 [0.76–0.97]
Harris 2021183 MIEMS Child (trauma, 0–14 y of age) 39 4 107 50 0.27 [0.20–0.35] 0.93 [0.82–0.98]
Harris 2021183 MIEMS Child (medical, 0–17 y of age) 44 1 1028 322 0.04 [0.03–0.05] 1.00 [0.98–1.00]

FP indicates false positive; FN, false negative; MIEMS, Maryland Institute for Emergency Medical Services Systems; TN, true negative; and TP, true positive.

Another study investigated the cost-effectiveness A new pediatric TOR rule to predict no survival or
of implementation of TOR rules in Singapore based on unfavorable neurological outcome was included,194 which
cases terminated in the field and all cases eligible for was derived from a dataset spanning 2013 to 2019 and
TOR but transported to hospital.193 They found that ter- validated during 2020 to 2022 (including the period
minating CPR on all patients eligible for the TOR rule of COVID-19). The specificity was 99.1% (sensitivity
would result in 31 additional deaths per 10 000 patients 29.6%) in the derivation cohort and 99.7% in the valida-
compared with no TOR. If TOR is exercised for every tion cohort (sensitivity 30.4%).
eligible case, it could save approximately $400,440 per
quality-adjusted life year loss compared with no TOR, Prior Treatment Recommendations (2020)
and $821,151 per quality-adjusted life year loss com- We conditionally recommend the use of TOR rules to as-
pared with the actual observed rate of TOR in the field. sist clinicians in deciding whether to discontinue resus-
citation efforts out of hospital or to transport to hospital
with ongoing CPR (conditional recommendation/very
TOR Rules for Pediatric Out-of-Hospital Cardiac low–certainty evidence).
Arrest Treatment Recommendations (2025)
We identified 3 studies assessing TOR rules for the pre- For adult out-of-hospital cardiac arrest, we conditionally
diction of death in children.183,189,194 One study applied recommend that emergency medical service systems
adult TOR rules in children,189 another, a derivation of the may implement termination of resuscitation (TOR) rules
Maryland Institute for Emergency Medical Services Sys- to assist clinicians in deciding whether to discontinue re-
tems (MIEMSS) score,183 and the third, a derivation of suscitation efforts at the scene or to transport to hospital
Downloaded from [Link] by on October 27, 2025

the pediatric TOR score.194 All studies were downgraded with ongoing CPR. We suggest that TOR rules may only
for risk of bias, imprecision, and indirectness, and the evi- be implemented following local validation of the TOR
dence was rated as very low certainty. rule with acceptable specificity considering local culture,

Table 8. Prediction of Death in Hospital

Study TOR rule Population TP FP FN TN Sensitivity Specificity

Park 2023 190
KoCARC 1 Adult (medical) 668 7 1039 113 0.39 [0.37–0.41] 0.94 [0.88–0.98]
Park 2023190 KoCARC 2 Adult (medical) 687 11 1020 109 0.40 [0.38–0.43] 0.91 [0.84–0.95]
Park 2023 190
KoCARC 3 Adult (medical) 524 6 1183 114 0.31 [0.29–0.33] 0.95 [0.89–0.98]
Hreinsson 2020185 uTOR Adult (cardiac) 202 0 252 113 0.44 [0.40–0.49] 1.00 [0.97–1.00]
Hsu 2022 186
uTOR Adult (medical) 40 904 657 10 873 2630 0.79 [0.79–0.79] 0.80 [0.79–0.81
Hreinsson 2020185 ALS Adult (cardiac) 35 0 414 113 0.08 [0.05–0.11] 1.00 [0.97–1.00]
Hsu 2022186 ALS Adult (medical) 25 164 385 26 613 2902 0.49 [0.48–0.49] 0.88 [0.87–0.89]
Smits 2023 191
ALS Adult (cardiac, male) 3834 6 15 240 2728 0.20 [0.20–0.21] 1.00 [1.00–1.00]
Smits 2023191 ALS Adult (cardiac, female) 2301 3 7704 764 0.23 [0.22–0.24] 1.00 [0.99–1.00]
Matsui 2023 189
ALS Child (medical and trauma) 299 21 1319 190 0.18 [0.17–0.20] 0.90 [0.85–0.94]
Matsui 2023189 BLS Child (medical and trauma) 5474 440 869 657 0.86 [0.85–0.87] 0.60 [0.57–0.63]
Hsu 2022 186
GOTO 1 Adult (medical) 27 856 283 23 921 3004 0.54 [0.53–0.54] 0.91 [0.90–0.92]
Jabre 2016187 JABRE Adult (cardiac) 2799 1 3435 728 0.45 [0.44–0.46] 1.00 [0.99–1.00]
Hreinsson 2020 185
JABRE Adult (cardiac) 215 0 240 113 0.47 [0.43–0.52] 1.00 [0.97–1.00]
Glober 2020182 Glober 1 Adult (medical and trauma) 290 0 3407 344 0.08 [0.07–0.09] 1.00 [0.99–1.00]
House 2018 184
PEA Adult (cardiac, transported) 829 3 955 328 0.46 [0.44–0.49] 0.99 [0.97–1.00]

ALS indicates Advanced Life Support; BLS, Basic Life Support; FN, false negative, FP, false positive; KoCARC, Korean Cardiac Arrest Research Consortium; PEA,
Pulseless Electrical Activity; TN, true negative; TP, true positive; and uTOR, Universal Termination of Resuscitation.

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Table 9. Death or Survival With Unfavorable Neurological Outcome

Study TOR rule Population TP FP FN TN Sensitivity Specificity

Lin 2022188 uTOR Adult (2015 cohort) 738 19 113 13 0.87 [0.84–0.89] 0.41 [0.24–0.59]
Lin 2022 188
uTOR Adult (2020 cohort) 430 8 116 18 0.79 [0.75–0.82] 0.69 [0.48–0.86]
Lin 2022188 ALS Adult (2015 cohort) 122 2 231 22 0.35 [0.30–0.40] 0.92 [0.73–0.99]
Lin 2022 188
ALS Adult (2020 cohort) 104 0 279 24 0.27 [0.23–0.32] 1.00 [0.85–1.00]
Park 2023190 KoCARC 1 Adult (medical) 672 3 1074 78 0.39 [0.36–0.41] 0.96 [0.90–0.99]
Park 2023 190
KoCARC 2 Adult (medical) 695 3 1051 78 0.40 [0.38–0.42] 0.96 [0.90–0.99]
Park 2023190 KoCARC 3 Adult (medical) 527 3 1183 78 0.31 [0.29–0.33] 0.96 [0.90–0.99]

ALS indicates Advanced Life Support; FN, false negative, FP, false positive; KoCARC, Korean Cardiac Arrest Research Consortium; TN, true negative; TP, true positive;
and uTOR, Universal Termination of Resuscitation.

v­alues, and setting (conditional recommendation, very applying adult TOR rules to children, and the 2 TOR
low–certainty evidence). rules derived specifically for children have yet to be
For pediatric out-of-hospital cardiac arrest because externally validated.
of insufficient evidence, we suggest against the use of
TOR rules to decide whether to terminate resuscitation Knowledge Gaps
efforts (conditional recommendation, very low–certainty • Accuracy of TOR rules in clinical practice
evidence). • Compliance with out-of-hospital TOR rules currently
in use
• Evidence-based implementation strategies for TOR
Justification and Evidence-to-Decision Framework rules for EMS
Highlights • Societal perceptions and acceptability of TOR rules
The complete evidence-to-decision table is provided in • Validation of TOR rules in children
Appendix A. • Impact of TOR rules on non–heart-beating organ
The task force made a conditional recommendation donation
for the use of TOR rules for adult OHCA in line with the • Risk associated with emergent transport of futile
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last CoSTR on TOR. The values in making this recom- cases with ongoing resuscitation
mendation remain largely unchanged. The certainty of
evidence is limited by a lack of clinical validation stud-
ies. The task force recognizes that application of TOR Community Initiatives to Promote BLS
rules may result in missed survivors but has the poten- Implementation (EIT 6306, ScopRev 2025)
tial to reduce variation in practice associated with clini- Rationale for Review
cian judgment and prevent premature terminations by Rapid BLS interventions significantly increase survival
clinicians. rates and improve neurological outcome for OHCA
In making this recommendation, the EIT Task Force patients. Various community-based initiatives have
recognizes variation in patient values, resources avail- emerged, ranging from dispatcher-assisted CPR to
able, and performance of TOR rules in different settings, public access defibrillation programs, AED distribution,
and that the performance of TOR rules varies depend- simplification of CPR techniques, and applications locat-
ing on the EMS system, the setting, and the survival ing first responders and AEDs.195–198 The impact of such
rate in the population. Therefore, TOR rules should not initiatives on BLS implementation is less clear, especially
be implemented without assessing the local validity of a regarding public education and training. Given these un-
TOR rule, and the validity should be reassessed as sur- certainties, the EIT Task Force undertook a ScopRev of
vival outcome changes over time. this topic. The full report of this ScopRev is available on
The task force recognizes that TOR rules are already the ILCOR website.199
implemented in some EMS systems. In settings where
EMS personnel will transport all patients to the hospi- Population, Intervention, Comparator, Outcome, and
tal, the use of TOR rules may reduce costs. In contrast, Time Frame
the potential economic benefit in EMS systems with • Population: People who have an out-of-hospital car-
­physician-staffed ambulances already making decisions diac arrest
about terminating CPR may be absent. • Intervention (exposure): Community initiatives to
The task force considered pediatric OHCA sepa- promote BLS implementation
rately and acknowledged that missed survivors in this • Comparator: Current practice
population may be valued differently from the adult • Outcomes: Survival to hospital discharge with good
population. Several missed survivors were seen when neurological outcome, survival to hospital discharge,

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

ROSC, time to first compressions, bystander CPR PICOSTs. Therefore, we excluded studies on public ac-
rate, and proportion of population trained cess defibrillation programs, dispatched or telephone
• Time frame: January 1, 2019, to July 31, 2024 CPR and apps, the impact of social or economic factors
on bystander engagement, and the effect of different
Summary of Evidence CPR techniques or protocols including guideline changes.
The scoping review included 21 studies,133,200–219 con- Findings strongly suggest that community initiatives are
ducted in the United States (47.6%),200–206,211,218 Den- effective and able to improve response to OHCA. However,
mark (23.8%),207,212,213,219 Korea (19.0%),133,215,216 for patient outcomes such as survival and neurological out-
­Japan (4.8%),214 Singapore (4.8%),217 UK (4.8%),210 come, the results did not clearly favor the intervention.
and China (4.8%).209 Design included cohort stud- In 2020 the focus of this PICOST was changed
ies (42.9%),201,203,206,207,210–214 before-and-after stud- to investigate system interventions in general, which
ies (28.6%),112,133,201,209,217,218 cross-sectional studies resulted in a scoping review,220 subsequently updated for
(23.8%),204,215,216,219 RCT (4.8%),205 and 1 nonrandomized this CoSTR. However, the EIT Task Force values commu-
controlled trial (4.8%).200 More than half were prospective nity initiatives to promote BLS implementation as highly
(57.1%),133,200,204,205,207,209,212–215,217,219 and the others were important because the identified studies reported posi-
retrospective (42.9%).112,201–203,210,211,216,218 All studies in- tive signals without any negative or detrimental effects.
volved adult OHCA, with interventions implemented in Thus, in addition to maintaining the existing treatment
workplaces, schools, government offices, public events, recommendation from 2015, the EIT Task Force gener-
and shared community spaces. ated a good practice statement in 2025 for this PICOST.
The community initiatives, summarized in Table 10,
were grouped into 3 categories: Treatment Recommendations (2015 and 2025)
1. Community CPR training programs ([n=11)201, We recommend implementation of resuscitation guide-
202,204–207,211–213,217,218
: (52.3% of studies)] lines within organizations that provide care for patients
2. Mass-media campaigns [(n=1)200: (4.8%)] on pub- in cardiac arrest in any setting (strong recommendation,
lic awareness through media outlets very low–certainty evidence).
3. Bundle interventions [(n=9)112,133,203,209,210,214–216,219: We propose that community initiatives to promote
(42.9% of studies)], defined as efforts combining BLS implementation should be endorsed and supported
CPR training with other community-based strate- (good practice statement).
gies (eg, public awareness campaigns, guideline
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implementation, legislative changes, and manda- Knowledge Gaps

tory training for driver’s license applicants). • Effect of community initiatives to promote BLS
Time to first compressions was not reported as an implementation in more diverse geographic areas,
outcome in any of these studies. including low resource settings
The full study characteristics and detailed results are • Effect of community initiatives to promote BLS imple-
provided in Supplemental Table S2. mentation on neonatal and pediatric resuscitations
• More well-designed RCTs are needed to report key
Task Force Insights patient outcome and enable a systematic review
Initially, the EIT Task Force refined the inclusion and ex- • Effect of public campaigns such as World Restart A
clusion criteria to avoid overlap with other more specific Heart in regions beyond the United Kingdom

Table 10. Community Initiatives to Promote BLS Implementation

Community CPR training programs Mass-media Bundle interventions

Outcome type (n=11)201,202,204–207,211–213,217,218 campaigns (n=1)200 (n=9)112,133,203,209,210,214–216,219
Bystander CPR rate 7 studies reported an Reported increase Reported increase in 6
increase201,202,204,211–213,217 following television studies133,209,210,215,216,219 of combinations of
public service instructor-led training, guideline implementation,
announcements and public initiatives
3 studies reported no change205,207,218 3 studies reported no
Change112,203,214
Proportion of population trained 3 studies, all reporting increase201,204,207 3 studies, all reporting increase133,209,214
ROSC 2 studies,217,218 1 reported increase217 1 study reporting increase209
Survival to hospital discharge after 2 studies reported increase 206,217
1 study reported increase209
instructor-led training
4 studies reported no change202,212,213,218 1 study reported no increase214
Survival with good neurological 1 study reported increase 211

outcome after instructor-led training

2 studies reported no change206,213 1 study reported no change214

CPR indicates cardiopulmonary resuscitation; and ROSC, return of spontaneous circulation.

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

• Influence of specific legal regulations on CPR Cardiac Arrest Centers (EIT 6301, SysRev 2024,
uptake in countries other than China EvUp 2025)
• How specific laws and regulations affect community
response to cardiac arrest A SysRev was conducted in 2024,231 and details of that
• Cost-effectiveness of each intervention for BLS review can be found in the 2024 CoSTR summary.232,233
implementation, and its specific impact on clinical The complete EvUp is provided in Appendix B.
outcomes
Population, Intervention, Comparator, Outcome, and
Time Frame
Family Presence in Adult Resuscitation (EIT • Population: Adults with attempted resuscitation
6300, SysRev 2022, EvUp 2025) after nontraumatic IHCA or OHCA
• Intervention: Care at a specialized cardiac arrest
A SysRev was conducted for 2022,221 and details of that
center
review can be found in the 2022 CoSTR summary.12,13
• Comparator: Care in an institute not designated as
The complete EvUp is provided in Appendix B.
a specialized cardiac arrest center
Population, Intervention, Comparator, Outcome, and • Outcomes: Survival with favorable neurological out-
Time Frame come at 30 days and at hospital discharge; survival
• Population: Adults requiring resuscitation in any at 30 days and at hospital discharge; ROSC post-
setting hospital admission for patients with ongoing CPR
• Intervention: Family presence during resuscitation • Time frame: December 31, 2023, to November 18,
• Comparator: No family presence during resuscitation 2024
• Outcomes: Patient outcomes (short- and long-term),
family-centered outcomes (short- and long-term psy- Summary of Evidence
chological stress, perception of the resuscitation), Three new observational studies were found in this
and health care professional–centered outcomes EvUp.234–236 The new data does not warrant a new SysRev.
(psychological stress, perception of the resuscitation) Treatment Recommendations (2024)
• Time frame: May 10, 2022, to April 28, 2024 We suggest adults with OHCA should be cared for in
Summary of Evidence cardiac arrest centers (weak recommendation, very low–
certainty evidence).
Downloaded from [Link] by on October 27, 2025

The evidence update identified 7 new primary stud-

ies222–228 and 2 systematic reviews.229,230 Patient out-
comes were lacking. A dedicated family support role led Technology to Summon Responders (EIT 6302,
to a more positive view of family presence. Family mem-
ber outcomes demonstrated mixed positive and negative
EvUp)
responses. Given the number of new studies, an escala- Population, Intervention, Comparator, Outcome, and
tion to a new SysRev might be considered. Time Frame
• Population: Adults and children with OHCA
Treatment Recommendations (2022) • Intervention: Having a citizen CPR responder noti-
We suggest that family members be provided with the fied of the event via mobile technology or social
option to be present during in-hospital adult resuscita- media
tion from cardiac arrest (weak recommendation; very • Comparator: No such notification
low–certainty evidence). • Outcomes:
We suggest that family members be provided with the – Patient outcomes: survival to hospital discharge
option to be present during out-of-hospital adult resusci- with good neurological function, 30-day survival,
tation from cardiac arrest, acknowledging that providers survival to hospital discharge, Hospital admission,
are often not able to control this (weak recommendation; ROSC
very low–certainty evidence). – Nonpatient outcomes: bystander CPR rates,
Policies or protocols about family presence during time to first compression, response time, acti-
resuscitation should be developed to guide and support vation rate, system reliability, user satisfaction,
health care professional decision-making (good practice cost-effectiveness
statement). • Time frame: October 21, 2021, to October 27, 2024
When implementing family presence procedures,
health care providers should receive education about Summary of Evidence
family presence during adult cardiac arrest resuscitation, A SysRev was conducted in 2020, and details of that
including how to manage these stressful situations, fam- review can be found in the 2020 CoSTR; an EvUp was
ily distress and their own responses to these situations done in 2021.9,10,237,238 The complete 2025 EvUp is pro-
(good practice statement). vided in Appendix B. Given the absence of RCTs, the 4

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

newly identified observational studies do not warrant a should be instructed to continue compression-only
new SysRev.239–242 CPR.
EMS dispatchers should provide CPR instructions to
Treatment Recommendations (2020)
callers who report cardiac arrest. When providing CPR
We recommend that citizen/individuals who are in close
instructions, EMS dispatchers should include recognition
proximity to a suspected out-of-hospital cardiac ar-
of gasping and abnormal breathing.
rest event and are willing to be engaged/notified by a
smartphone app with mobile positioning system or text Treatment Recommendations (2025)
message-alert system should be notified (strong recom- The task force encourages resuscitation councils, com-
mendation, very low–certainty evidence). munities, and emergency medical services to provide
easy access to BLS courses, raise awareness about car-
diac arrest and its treatment, and utilize training, public
Willingness to Provide CPR/AED (EIT 6304, outreach, and social media to increase laypersons’ will-
EvUp) ingness to perform CPR (good practice statement).
Population, Intervention, Comparator, Outcome, and
Time Frame
• Population: Bystanders (laypersons) in actual situa- Clinical Decision Rules to Facilitate In-hospital
tion of adult or pediatric patients with OHCA Do-Not-Attempt CPR (EIT 6305, SysRev 2022,
• Intervention (Exposure): Factors (barriers or facilita- EvUp 2025)
tors) that affected the willingness of bystanders to A SysRev was conducted in 2022,244 and details of
perform CPR or use an AED that review can be found in the 2022 CoSTR summa-
• Comparator: No such factor or any other factor that ry.9,10,237,238 The complete EvUp is provided in Appendix B.
affected the willingness of bystanders to perform
CPR or use an AED Population, Intervention, Comparator, Outcome, and
• Outcomes: Bystander CPR rate, rate of bystander Time Frame
defibrillation with an AED, willingness to provide • Population: Hospitalized adults and children experi-
CPR in actual situation, willingness to provide defi- encing an in-hospital cardiac arrest
brillation with an AED in actual situation • Intervention: Any pre-arrest clinical prediction rule
• Time frame: August 1, 2022, to June 28, 2024 • Comparator: No clinical prediction rule
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• Outcomes: Return of spontaneous circulation, sur-

Summary of Evidence vival to hospital discharge/30 days or survival with
A ScopRev was conducted for 2020,243 and details of favorable neurological outcome
that review can be found in the 2020 CoSTR. An EvUp • Time frame: January 1, 2021, to November 27,
was done in 2022.9,10,12,13 The complete 2025 EvUp is 2024
provided in Appendix B. Three new observational studies,
like several others included in earlier searches, focused Summary of Evidence
on disparities in receiving CPR rather than factors affect- Four new studies were found.245–248 Overall, there are
ing willingness to perform it. A revised PICOST should still no studies investigating the prospective implementa-
distinguish between factors related to OHCA patients tion of prediction models for do-not-attempt cardiopul-
receiving CPR (such as community-level disparities) and monary resuscitation orders. Therefore, a SysRev is not
factors associated with bystanders performing CPR and warranted.
using AEDs (such as personal-level willingness). Be-
Treatment Recommendations (2022)
cause the recommendation from 2020 was not based
We recommend against using any currently available
on a GRADE SysRev, the EIT Task Force added a new
pre-arrest prediction rule as a sole reason to not resus-
good practice statement to the existing treatment rec-
citate an adult with in-hospital cardiac arrest (strong rec-
ommendations.
ommendation, very low–certainty evidence).
Treatment Recommendations (2020, Unchanged We are unable to recommend for or against any
From 2010) available pre-arrest prediction rule to facilitate do-not-
To increase willingness to perform CPR, laypeople should attempt cardiopulmonary resuscitation discussions with
receive training in CPR. This training should include rec- adult patients or their next of kin as there are no studies
ognizing gasping or abnormal breathing as a sign of car- investigating the effect of clinical implementation of such
diac arrest when other signs of life are absent. score.
Laypeople should be trained to start resuscitation We are unable to provide any recommendation
with chest compressions in adult and pediatric victims. for pediatric patients as no studies on children were
If unwilling or unable to perform ventilation, rescuers ­identified.

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Termination of Resuscitation for In-Hospital Summary of Evidence

Cardiac Arrest (EIT 6308, EvUp 2025) The 7 newly found studies do not add any new informa-
tion to the CoSTR from 2024.252–258 No new SysRev is
Population, Intervention, Comparator, Outcome, and indicated. Task force insights were discussed in detail in
Time Frame the 2024 CoSTR summary.232,233,259
• Population: Adults and children with IHCA
• Intervention: Use of any clinical decision rule
• Comparator: No clinical decision rule Impact of Support on Mental Health in
• Outcomes: No return of spontaneous circulation, Cosurvivors of Cardiac Arrest Patients (EIT
death before hospital discharge, survival with unfa- 6315, EvUp 2025)
vorable neurological outcome, death within 30 days
• Time frame: January 1, 2020, to May 20, 2024 Population, Intervention, Comparator, Outcome, and
Time Frame
Summary of Evidence • Population: Cosurvivors (any age) who witnessed
A SysRev was previously conducted in 2020.249 An EvUp resuscitation of cardiac arrest (any age)
was done in 2025.9,10,237,238 The complete EvUp is pro- • Intervention: Cosurvivors who received support for
vided in Appendix B. This Evidence Update did not iden- their mental health, after the event
tify any new studies. Accordingly, a new SysRev is not • Comparator: No support or any other type of support
warranted. • Outcomes: Mental health (eg, anxiety, depression,
posttraumatic stress disorder), quality of life, socio-
Treatment Recommendations (2020) economic measures
We did not identify any clinical decision rule that was able • Time frame: From inception to October 24, 2024
to reliably predict death following in-hospital cardiac ar-
rest. We recommend against use of the UN10 rule (U– Summary of Evidence
unwitnessed arrest; N–nonshockable rhythm; 10–ROSC The complete EvUp is provided in Appendix B. Cosurvivor
not obtained within 10 minutes) as a sole strategy to ter- is a general term for family members, friends, neighbors,
minate in-hospital resuscitation (strong recommendation, or anyone in a close relationship with the cardiac arrest
very low–certainty evidence). patient. Out of 652 articles identified, none were relevant
to the PICOST. We encourage further research to explore
the effect of support for co-survivors who witnessed a
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Chain of Survival (EIT 6311, SysRev 2024, EvUp cardiac arrest and the effect on their mental health.260 As
2025) this was a new PICOST, no treatment recommendations
A SysRev was conducted in 2024,250 and details of that were generated.
review can be found in the 2024 CoSTR summary.232,233
The complete EvUp is provided in Appendix B.
INSTRUCTIONAL DESIGN
Population, Intervention, Comparator, Outcome,
CPR Feedback Device Use in Resuscitation
Study Designs, and Time Frame
• Population: Literature using the term chain of sur- Training (EIT 6404, SysRev 2025)
vival or similar terms (eg, survival chain, chain of Rationale for Review
[other pathology]) Chest compression skills are an important component
• Intervention (Exposure): Adaptations of the original of effective resuscitation during cardiac arrest. CPR
chain of survival251 feedback devices provide immediate, real-time feed-
• Comparator: The original chain of survival251 back on quality of chest compressions. Use of CPR
• Outcomes: Composition of the specific variations feedback devices during resuscitation skills training
in adapted versions, attitudes, rationale, and views has the potential to enhance CPR skill acquisition and
concerning the adaptation; incentives to develop retention.
novel versions; way of implementation of adapted Recent scientific statements highlight a growing trend
versions; way of using adapted versions in educa- in the use of CPR feedback devices during resuscita-
tion; variations in visualization; effect of the use of tion courses. While earlier reviews showed that these
the chain of survival or variants on teaching, imple- devices can improve short-term educational outcomes,
mentation, and patient outcomes the results have been inconsistent. This topic was last
• Study designs: In addition to standard criteria, reviewed in the 2020 CoSTR9,10 and an updated review
designs such as narrative literature, letters, com- was undertaken. The review261 was registered in PROS-
mentaries, and editorials were included. PERO (CRD42023376751) and the full CoSTR is avail-
• Time frame: January 1, 2023, to October 21, 2024 able on the ILCOR website.262

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Population, Intervention, Comparator, Outcome, and favored use of feedback devices (SMD, 0.44; 95% CI,
Time Frame 0.23-0.66; I2=61%).263,267,270,272–275,281,282 No difference
• Population: All laypersons and health care profes- was found between health care professionals and lay-
sionals in any educational setting persons (P=0.80).
• Intervention: Use of CPR feedback/guidance device
Chest Recoil
during resuscitation training
Ten RCTs involving a total of 3496 participants evalu-
• Comparator: No use of CPR feedback/guidance
ated the effect of CPR feedback devices during training
device during resuscitation training
on chest recoil quantitatively measured as the percent-
• Outcomes: Patient survival, quality of performance
age of compressions with full chest recoil, overall favor-
in actual resuscitations, skill retention (performance
ing feedback devices (SMD, 0.53; 95% CI, 0.31–0.75,
after course conclusion), skill acquisition (perfor-
I2=87%).263,264,267,268,272,274,275,279,281,282 Subgroup analysis
mance at course conclusion)
showed that the effect of the feedback device on recoil
• Time frame: January 1, 2005, to June 13, 2024
compliance was significantly improved in the health care
professionals (SMD, 0.67; 95% CI, 0.52–0.82; I2=0%),
Consensus on Science
but not in the laypersons (SMD, 0.20; 95% CI, 0.24–
Three studies were conducted in laypersons263–265 and
0.64; I2=83%).
17 in health care professionals.266–282 No studies were
identified that examined the impact of using CPR feed- Overall Quality of CPR
back devices during resuscitation training on the out- Eight RCTs involving a total of 3261 participants evalu-
comes of patient survival or quality of performance in ated the effect of CPR feedback devices on overall CPR
actual resuscitation. quality during resuscitation training assessed by com-
puter software integrating all 3 metrics of chest com-
Compression Depth
pression (depth, rate and recoil), with limited validity
Fifteen randomized controlled trials (RCTs) with a to-
evidence favoring feedback devices (SMD, 0.7; 95% CI,
tal of 4185 participants evaluated the effect of CPR
0.40–1.03, I2=86%).263,264,268,272–274,279,281 Subgroup anal-
feedback devices on objectively measured mean com-
ysis showed that the effect of the feedback device use
pression depth, favoring feedback devices (standard-
on the overall CPR score was statistically significantly
ized mean difference [SMD], 0.76; 95% CI, 0.02–1.50,
higher in the health care professionals than in the layper-
P=0.04; I2=94%).263,264,266,268–272,277,279–282 No difference
sons (P=0.02).
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was found between health care professionals and lay-

Three RCTs involving a total of 349 participants evalu-
persons (P=0.10).
ated the effect of CPR feedback devices on overall CPR
Sixteen RCTs involving 4304 participants examined
quality during resuscitation training assessed dichoto-
the effect of CPR feedback devices during resuscitation
mously, based on whether compression depth, rate, and
training on compression depth compliance, quantitatively
recoil all concurrently met guideline standards, favor-
measured as the percentage of compressions meeting
ing feedback devices (SMD, 0.19; 95% CI, 0.01–0.38,
the resuscitation guidelines during assessment, favor-
I2=76%).275,277,280
ing feedback devices (SMD, 0.98; 95% CI, 0.10–1.87,
P=0.03; I2=94%).263–265,267–271,273–277,281–283 No difference Prior Treatment Recommendations (2020)
was found between health care professionals and lay- We suggest the use of feedback devices that provide
persons (P=0.09). directive feedback on compression rate, depth, release,
Compression Rate and hand position during CPR training (weak recommen-
Seventeen RCTs involving a total of 4327 participants dation, low-certainty evidence).
evaluated the effect of CPR feedback devices on objec- If feedback devices are not available, we suggest the
tively measured mean compression rate.263–266,268–273,276– use of tonal guidance (examples include music or metro-
282
Participants trained with CPR feedback devices had nome) during training to improve compression rate only
a significantly lower mean compression rate compared (weak recommendation, low-certainty evidence).
with those trained without them, as participants in the Treatment Recommendations (2025)
nonfeedback group tended to compress too quickly We recommend the use of CPR feedback devices during
(>120 bpm) (SMD, 0.29; 95% CI, 0.48–0.10, I2=3%). resuscitation training for health care professionals and
No difference was found between health care profes- laypersons (strong recommendation, moderate-certainty
sionals and laypersons (P=0.67). evidence).
Nine RCTs involving 905 participants examined the
effect of CPR feedback devices during resuscitation Justification and Evidence-to-Decision Framework
training on compression rate compliance measured as Highlights
the percentage of compressions within the guideline- The complete evidence-to-decision table is provided in
recommended rate of 100 to 120 bpm, and results Appendix A.

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

The results of the meta-analyses of RCTs found evi- discharge or 30 days, ROSC, rates of bystander
dence favoring the use of feedback devices during train- CPR, bystander CPR quality during an OHCA
ing across all CPR quality outcomes with moderate to (any available CPR metrics), rates of automated
strong association. external defibrillator (AED) use
Subgroup analyses showed the effect of feedback – Educational outcomes at end of training and
devices on resuscitation training was greater in health within 12 months: CPR quality (chest compres-
care professionals than in laypersons, but there was still sion depth and rate, chest compression fraction,
a significant effect for most CPR metrics in laypersons. full chest recoil, hand position, ventilation rate)
No undesirable effects were detected in the review, feed- and AED competency; CPR and AED knowl-
back devices are well accepted, and their use is feasible edge; confidence and willingness to perform
with relatively low or negligible costs. CPR
• Time frame: October 11, 2022, to March 28, 2024
Knowledge Gaps
• Relative and synergistic effect of feedback device
use when combined with other educational strate- Consensus on Science
gies and instructional design features No studies were identified for any patient outcome.
• Impact of feedback devices on skill retention beyond For the educational outcomes, we identified 29
the end of a course RCTs.286–314 Because of the high degree of heterogene-
• Impact of improved CPR skills from training with ity in the interventions, comparators, and measurements
feedback devices on patient outcome of outcomes, no meta-analysis was performed.
• Costs associated with implementing feedback Sample sizes ranged from 52 participants314 to 826
devices during resuscitation training, as well as its participants,301 and 14 of the 29 studies had sample sizes
cost-effectiveness less than 140 participants.286–288,297–300,302–304,308,310–312,314
Populations included children; high-school stu-
dents288,291,309,313,314; university students,286,302–304 includ-
Self-Directed, Digital-Based Versus Instructor- ing specific cohorts such as medical287,307,310,311 and
Led Cardiopulmonary Resuscitation Education nursing students294,299; adults,289,290,293,295,296,300,301,306,308,312
and Training in Adults and Children (EIT 6406, including specific cohorts such as those over 60 years of
SysRev 2025) age,305 parents/caregivers of children,298 parents of chil-
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Rationale for Review dren at high risk for sudden cardiopulmonary arrest292;
CPR and AED training is known to improve the willing- university staff and their spouses303; and caregivers of
ness and confidence in someone performing bystander family members with cardiac histories.297 Details of study
CPR.284 Little is known about whether self-directed digi- designs are displayed in Table 11.
tal CPR training is superior to instructor-led training in Only some studies with self-directed training interven-
developing sufficient skills to provide adequate CPR. tions had sufficient numbers for comparison at immediate
This topic was reviewed in 2021 and included RCTs and testing (with video + manikin and video-only self-directed
non-RCTs. Since then, several RCTs on this topic were training). A video + manikin self-directed intervention
published and the EIT Task Force initiated a new system- was used in 15 studies.289,292,293,296,298–302,304,305,307,311–313
atic review that included only RCTs, which was registered Most of these studies demonstrated no difference
in PROSPERO (CRD42020199176). The full CoSTR is between self-directed training using a video with a mani-
available on the ILCOR website.285 kin versus an instructor-led training. Only 1 study favored
We defined self-directed digital-based CPR train- video and manikin self-directed training for compres-
ing as any form of digital education or training for CPR sion rate,312 proportion of compressions at the correct
that can be completed without an instructor. Instructor- rate.296 and hand position.296,300 Instructor-led training
led training was defined as education or training that was favored over video + manikin self-directed training
occurred in the presence of a BLS instructor. for chest compression depth,296 proportion of chest com-
pressions at the correct depth,289 hand position,289,293,304
Population, Intervention, Comparator, Outcome, and knowledge,292 and confidence.307
Time Frame Video-only self-directed training was used in 7
• Population: Adults and children undertaking CPR studies286–288,294,296,297,308 and was the favored arm in 3
training instances for proportion of compressions at the correct
• Intervention: Self-directed digitally based CPR depth,294 chest recoil,294 and confidence.286 Instructor-led
training training was favored over video-only self-directed training
• Comparator: Instructor-led CPR training in other studies for proportion of compressions done at
• Outcomes: the correct rate,296 compression depth,296 knowledge,297
– Patient outcomes: Good neurological outcome at and confidence.297 Across the studies compression rate,
hospital discharge or 30 days, survival at hospital depth, fraction, chest recoil, hand position, ventilation

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Table 11. Self-Directed Digital-Based CPR Training Versus Instructor-Led CPR Training Studies

Willingness Test scores

Confidence to to perform immediately Test scores between 1
Educational CPR quality Knowledge perform CPR CPR to <1 mo and 12 mo of training
outcome 27286–289,291–304,306– AED use 7292,297,302,308,309, 10286,295,297–299, 6289,299,301, 25286–289, 15287,288,290,293,296,297,299,305,
study n 314
10287,290,291,294,303,305–307,309,310 311,312 301,303,305,307,314 303–305 291–304,306–314 307–309,311–314

No. of 8 video- 16 video + manikin practice 1 app-based 1 virtual 1 video + 3 computer 1 interactive computer
studies per only286–288,290,294, approach289,290,292,293,296, self-training reality306 manikin + program/ session309
intervention 296,297,308 298–302,304,305,307,311–313
intervention291 scenario self- online tutorial 1 game-in-film314
training290 + video +
manikin295,
303,310

Details of Video-only Videos used with manikin Not well Not well Not well Not well Not well described
interventions interventions practice ranged from 4–35304 described described described described
ranged from 1 min296,300 to min (length often
min296 to 20 min287 not stated).
in length (length
often not stated).
Comparators 7 formal certified Course length: 9 min (1) up Not well Not well Not well Not well Not well described
courses300,301, to 5 h310 described described described described
303,305,310–312

AED indicates automated external defibrillator; and CPR, cardiopulmonary resuscitation.

rate, AED use, and knowledge and confidence were in adults and in children (weak recommendation, low-
measured a further 19 times, and no difference was certainty evidence).
identified between the video-only self-directed training There was insufficient evidence to make a recom-
and instructor-led groups. mendation on gaming as a CPR or AED training method.
Educational outcomes measured up to 12 months There was insufficient evidence to suggest a treat-
were reported in 14 studies (at 4 months,299 6 months,287 ment effect on bystander CPR rates or patient outcomes.
between 2 and 6 months,311 and between 1 and 6 months)
after the training.288,290,293,296,297,305,307–309,313,314 Many of Treatment Recommendations (2025)
these studies reported a reduction in the quality of the We suggest the use of either instructor-led training or
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skills being performed (compression rate: 2 studies296,313; self-directed digital training for the acquisition of CPR
compression depth: 4 studies296,307,309,313; chest compres- or AED skills in lay adults and high-school–aged (>10
sion fraction: 1 study314; chest recoil: 1 study307; hand years of age) children (weak recommendation, very low–
position: 4 studies296,307,309,313;ventilation rate: 1 study293; certainty evidence).
AED: 1 study305; knowledge: 1 study297; confidence: 1 We suggest self-directed digital training be used when
study307). The opposite of this was seen in 1 study where instructor-led training is not accessible, or when quantity
both the groups were more likely to pass the AED testing over quality of CPR training is needed in adults and chil-
at 2 months than immediately after the training.290 dren (weak recommendation, very low–certainty evidence).
There was insufficient evidence to make a recom-
Prior Treatment Recommendations (2020) mendation on game-in-film, virtual reality, computer pro-
We recommend instructor-led training (with manikin grams, online tutorials or app-based training as a CPR or
practice with feedback device) or the use of self-directed AED training method.
training with video kits (instructional video and manikin
practice with feedback device) for the acquisition of CPR Justification and Evidence-to-Decision Framework
theory and skills in layperson adults and high school- Highlights
aged (more than 10 years of age) children (strong rec- The complete evidence-to-decision table is provided in
ommendation, moderate-certainty evidence). Appendix A.
We recommend instructor-led training (with AED sce- The acquisition of CPR skills may vary across dif-
nario and practice) or the use of self-directed video kits ferent mediums and age groups. However, any form of
(instructional video with AED scenario) for the acquisi- CPR/AED training is likely to improve knowledge, confi-
tion of AED theory and skills in layperson adults and dence and willingness in simulated settings, but this may
high school–aged (more than 10 years of age) children not translate to real-life situations. Digital and instructor-
(strong recommendation, low-certainty evidence). led materials need updating to ensure training complies
We suggest that BLS video education (without mani- with CPR recommendations. Digital training enables
kin practice) be used when instructor-led training or skills to be refreshed at any time, and at no additional
self-directed training with video kits (instructional video cost, and provides the opportunity to teach others. It also
plus manikin with feedback device) are not accessible, enables more people to be educated in periods of need
or when quantity over quality of BLS training is needed (eg, pandemics).

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Cost-effectiveness analysis favored digital self- • Study designs: In addition to standard criteria,
directed training.295,313 This reflects the known barriers reviews and studies with self-assessment as the
that exist to attending instructor-led CPR classes (eg, only outcome were excluded
time, costs, and accessibility) and the need to make CPR • Time frame: From inception to March 25, 2024
training available to everyone.

Knowledge Gaps Consensus on Science

• Standardized outcome measures (educational We identified 4 studies in adults,318–321 3 in children,322–324
and CPR performance outcomes) are needed to and 2 in neonates.325,326 Results globally favored in situ
enable pooling of data. Comparator groups should simulation across all studies. Because of heterogeneity
be aligned using standardized, accepted instructor- in the interventions and outcome definitions, no meta-
led training programs to reduce inconsistency and analysis or formal subgroup analysis according to the
uncertainty. type of training (ie, BLS, advanced cardiovascular life
• The ability of these interventions and comparators support, pediatric advanced life support, neonatal life
to produce findings that meet accepted standards support) was performed.
for adequate CPR that are maintained at defined Patient Survival
time intervals One nonrandomized prospective observational study with
• Effectiveness of specific self-directed digital inter- historical controls135 reported an association between
ventions, such as game-in-film, virtual reality, com- the in situ simulation period and higher odds of survival
puter programs, online tutorials or app-based at hospital discharge in children who experienced cardiac
training arrest [50/124 (40.3%) survival in the pre-intervention
• The treatment effect on bystander CPR rates and period versus 28/46 (60.9%) in the post-intervention
patient outcomes period; (OR, 2.06; 95% CI, 1.02–4.25)].
Other Patient Outcomes
In Situ (Workplace-Based) Simulation-Based One nonrandomized study326 reported a lower inci-
Cardiopulmonary Resuscitation Training (EIT dence of neonatal asphyxia [88 (0.64%) versus 133
(0.84%); P=0.045], severe asphyxia [8 (0.058%) ver-
6407, SysRev 2025)
sus 22 (0.138%); P=0.029], hypoxic-ischemic en-
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Rationale for Review cephalopathy [2 (0.01%) versus 16 (0.1%); P=0.003],

Simulation-based training is traditionally performed in and meconium aspiration syndrome [12 (0.09%) versus
classrooms or laboratories specifically equipped with 31 (0.19%); P=0.014] in the postintervention (in situ
manikins, monitors, and equipment needed for running simulation) versus preintervention period, but no differ-
cardiac arrest scenarios. Providing such training within ence in the composite outcome of neonatal asphyxia
patient care areas has theoretical advantages, with learn- or low Apgar score [111 (0.8%) versus 154 (0.97%);
ing occurring in the context of the real clinical environ- P=0.128], or low Apgar score [23 (0.17%) versus 21
ment and organizational structures. The EIT Task Force (0.13%); P=0.445].
performed a SysRev,316 which was registered in PROS-
PERO (CRD42024521780). The full CoSTR can be Clinical Performance in Actual Resuscitation
found on the ILCOR website.317 Three nonrandomized studies were identified.135,319,322
One before-and-after study135 reported no difference
Population, Intervention, Comparator, Outcome, in neurologic outcome at hospital discharge, the per-
Study Design, and Time Frame formance of chest compressions for heart rate <60/
• Population: Health care professionals second, or the performance of shock <3 minutes from
• Intervention: In situ (workplace-based) simulation- recognized ventricular fibrillation/pulseless ventricular
based CPR training tachycardia, but found improvement in chest compres-
• Comparator: Traditional training sions between rhythm checks with in situ simulation.
• Outcomes: Patient survival and outcome; CPR skill Another before-and-after study319 reported a 12%
performance at course completion and in actual reduction in time to call for help, a 52% reduction in time
resuscitation; CPR skill performance <1 year and elapsed to initiation of chest compressions, and a 37%
≥1 year after course completion; CPR quality (at reduction in time to initial defibrillation, all favoring in situ
course completion, <1 year and ≥1 year after course simulation. A third before-and-after study322 reported a
completion); teamwork competencies (at course 39% decrease in nonadherence to pediatric advanced
completion, <1 year and ≥1 year after course com- life support guidelines for subsequent epinephrine tim-
pletion); resources (time, equipment, cost); clinical ing, favoring in situ simulation, but no significant differ-
performance (adherence to guidelines, time to criti- ence in the administration of epinephrine every 3 to 5
cal interventions, medication errors, etc) minutes.

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Teamwork Competencies in Actual Resuscitation at Justification and Evidence-to-Decision Framework

Course Completion and Less Than 1 Year After the Highlights
Course The complete evidence-to-decision table is provided in
One nonrandomized study135 reported higher adherence Appendix A.
to resuscitation standard operating performance vari- Evidence from RCTs and nonrandomized studies sup-
ables amongst pediatric code teams during the period of ports the effectiveness of in situ simulation to teach CPR.
in situ simulation (38/183 [20.8%] versus 23/64 [35.9]; Critical outcomes, including patient survival and clinical per-
OR, 2.14; 95% CI, 1.15–3.99). formance and teamwork competencies in actual resuscita-
tion, improved with in situ simulation. The balance between
Clinical Performance in Simulation
the benefit and the resources needed may be favorable,
We found 4 RCTs320,321,324,325 and 1 nonrandomized
especially when critical outcomes are considered. Stud-
study.318One RCT324 reported improved skill perfor-
ies addressing patient survival and other clinical outcomes
mance measured by the Clinical Performance Tool [6.2
were found only in the pediatric setting, which provides indi-
(± 4.3) versus 1.2 (± 2.9); P=0.004]. One RCT321 re-
rect evidence for adults. Although the evidence is of very
ported shorter time to call for help and initiation of chest
low certainty, the task force concluded that results were
compression with in situ simulation (P<0.001). The
compelling enough to warrant a strong recommendation.
same study found shorter time to successful defibrilla-
This discordance between recommendation strength and
tion (P<0.001) and improvement in the composite out-
certainty of evidence is permitted when the likelihood of
come of initiation of compressions within 20 seconds of
benefit is high in spite of low or very low–certainty evidence.
cardiac arrest, defibrillation within 180 seconds of de-
tection of a shockable rhythm, and use of a backboard Knowledge Gaps
(P<0.001). • The resources required for implementation of in situ
One RCT325 reported improvement in technical skills training, including direct and indirect costs, work-
and adherence to guidelines with in situ simulation and a load, and equipment needed
higher percentage of scenarios with efficient resuscita- • The feasibility of in situ training in low and middle-
tion at 3 minutes [14 (24%) versus 2 (4%); P=0.003] income countries.
and 5 minutes [40 (68%) versus 25 (47%); P=0.06].
One RCT320 reported better medical management test
scores with in situ simulation (P<0.001), while another318 Manikin Fidelity in Resuscitation Education (EIT
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reported no difference between the 2 groups during 6410, SysRev 2025)

mock code.
Rationale for Review
Higher-fidelity manikins have physical features that make
Teamwork Competencies in Simulation at Course them more realistic, including changes in simulated physi-
Completion and Less Than 1 Year After the Course cal states. Greater realism during life support training
One RCT324 reported no difference in teamwork as- may enhance learner engagement and make it easier to
sessed by the Behavioral Assessment Score [2.8 (±3.6) suspend disbelief. However, using higher-fidelity mani-
versus 3.0 (±4.0); P=0.69]. Other RCTs reported bet- kins depends on the availability of resources to purchase,
ter team performance score325 during in situ simulation properly implement, and maintain them; additionally, cen-
[31.1 (20.8–36.8) versus 19.9 (13.3–25.0); P≤0.001], ters require trained personnel who can operate such man-
while better teamwork with in situ simulation was re- ikins. The EIT Task Force initiated this SysRev327 that was
ported in another RCT320 [10.84 (±3.26) versus 7.87 (± registered in PROSPERO (CRD4202453504), and the
4.14), P<0.001]. full online CoSTR is available on the ILCOR website.328
CPR Skill Performance in Simulation at Course
Completion Population, Intervention, Comparator, Outcome, and
One nonrandomized study318 evaluated CPR fraction as Time Frame
a measure of skill and found improvement favoring in situ • Population: Participants undertaking basic and
simulation (1.8% per time interval of training; P=0.02). advanced life support training in an education setting
No studies were found analyzing resources needed • Intervention: Use of high-fidelity manikins
for in situ simulation, or CPR skill performance in actual • Comparator: Use of low-fidelity manikins
resuscitation. • Outcomes: Patient outcomes, skill performance in
actual resuscitations, skill/knowledge at 1 year,
Treatment Recommendations (2025) skill/knowledge at time between course conclu-
We recommend that in situ simulation may be considered sion and 1 year, skill/knowledge at course conclu-
as an option for CPR training where resources are read- sion, learner confidence, learner preference, cost/
ily available (strong recommendation, very low–certainty resource utilization
evidence). • Time frame: January 1, 2005, to April 30, 2024

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Consensus on Science Skill: CPR Parameters at Course Conclusion

Twenty-one studies were included.329–349 All involved health Two RCTs with 80 intervention subjects and 80 controls
care professionals or trainees and were performed in North were reviewed. One study found greater improvement as
America,330–338 Asia,329,341,343,345Europe,339 and Australia.342 measured at course completion by the American Heart
Association CPR skills checklist among subjects trained
Skill at Course Conclusion
on higher-fidelity manikins.329 The second RCT found
Data were reported in 8 RCTs with a total of 550 partici-
better compression depth and compression fraction im-
pants.331,332,334–336,338,341,346 RCTs assessed performance
mediately posttraining among subjects trained on higher-
in scenarios with manikins: 4 of adults,332,336,338,346 2 of
fidelity manikins.340
children,331,334and 2 of neonates.332,338 Meta-analysis results
of these studies favored high-fidelity manikins (Figure 5). Skill: Clinical Performance at 3 Months or Greater
Two additional RCTs with 107 participants did not Clinical performance was reported in 3 RCTs with 312
report sufficient measures of variance for inclusion in the participants.329,338,346 One RCT in nursing students
meta-analysis. Both found no difference in skill perfor- found better clinical performance in a CPR scenario 3
mance at course completion.333,342 months after training with higher-fidelity manikins329;
Knowledge at Course Completion 2 studies of advanced cardiovascular life support
Data were reported in 7 RCTs with 1016 skills found no difference at 3 months or at 1 year
­participants.329,331,332,336,339,341,346 Five scenarios were in ­posttraining.338,346
adults,329,332,336,339,3461 in children,331 and 1 in neonates.341 Knowledge at 3 Months or Longer
The meta-analysis revealed no significant effect of high-­ Knowledge retained months after training was report-
fidelity manikins (Figure 6). ed in 3 RCTs with 330 participants.329,346,347Two RCTs
Three additional RCTs with 184 participants and found improved knowledge following higher-fidelity
1 observational study of 34 subjects did not report manikin training (3 months after BLS training,329 6
­sufficient measures of variance for inclusion in meta- months after pediatric advanced life support train-
analysis.337,342,344,347 One of these found improved knowl- ing347) and 1 RCT found no difference in advanced car-
edge at course completion342; the others found no diovascular life support knowledge at 6 to 9 months
difference.337,344,347 posttraining.346
Skill: Time-to-Task Performance at Course Conclusion
Attitudes and Preferences
Downloaded from [Link] by on October 27, 2025

Three RCTs with 179 participants330,347,349 were reviewed.

Learner preference and confidence following train-
One found faster time-to-task completion (EMS activa-
ing were reported in 10 RCTs with 818 participa
tion),340 another found shorter time to intervention and
nts.330,332,333,335,336,339,343,345,346,349 Seven RCTs found
assessment,347 and 1 other study found no difference in
greater effectiveness of training with higher-fidelity
time to tracheal intubation during neonatal resuscitation
manikins,330,332,333,339,343,345,349 and 3 RCTs found no
program training.330
­difference.335,336,346
Skill: Teamwork at Course Conclusion
Teamwork performance was reported in 3 RCTs with Prior Treatment Recommendations (2015)
193 participants.331,342,348 Two found improved teamwork We suggest the use of high-fidelity manikins when
behaviors with higher-fidelity manikins,342,348 and 1 found training centers/organizations have the infrastruc-
no difference.331 ture, trained personnel, and resources to maintain the

Figure 5. Skill at completion of courses using high-fidelity manikins.

Circulation. 2025;152(suppl 1):S205–S249. DOI: 10.1161/CIR.0000000000001359 October 21, 2025 S231

 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Figure 6. Knowledge at completion of courses using high-fidelity manikins.

program (weak recommendations, very low–quality

­ sonnel, and resources to use them properly. Educational
­evidence). settings where these resources are less available might
If high-fidelity manikins are not available, we suggest make implementation difficult.
that the use of low-fidelity manikins is acceptable for
standard ALS training in an educational setting (weak Knowledge Gaps
recommendation, low-quality evidence). • Cost-effectiveness and implementation needs for
high-fidelity manikin use in training
• Effect of high-fidelity manikins on longer-term
Treatment Recommendations (2025) educational outcomes (skill, knowledge retention,
We suggest the use of high-fidelity manikins when train- decay)
ing centers or organizations have the infrastructure, • Specific simulation features that are most associ-
trained personnel, and resources to use them (weak rec- ated with improved learning
Downloaded from [Link] by on October 27, 2025

ommendations, very low–certainty evidence). • Effect of high-fidelity manikin use in training on

If high-fidelity manikins are not available, we suggest actual patient-care processes and patient outcomes
that the use of low-fidelity manikins is acceptable for life- • Benefits of high-fidelity manikin use in training in
support training in an educational setting (weak recom- different resource settings
mendation, low-certainty evidence).
Cognitive Aids During Resuscitation (EIT 6400,
Justification and Evidence-to-Decision Framework SysRev 2024, EvUp 2025)
Highlights A SysRev was conducted for 2024350; details can be
The complete evidence-to-decision table is provided in found in the 2024 CoSTR summary.232,233 The complete
Appendix A. 2025 EvUp is provided in Appendix B.
Most studies found a positive impact on skill or knowl-
edge at conclusion of courses with high-fidelity manikins, Population, Intervention, Comparator, Outcome, and
and no study demonstrated a negative effect on educa- Time Frame
tional outcomes. Given that resource use and cost were • Population: Adults, children and neonates in any
not directly studied, and higher-fidelity manikins are likely setting (in-hospital or out-of-hospital) requiring
more expensive to obtain and maintain, we limited our resuscitation provided by laypersons or health care
recommendation to centers where these resources are professionals
available. • Intervention: Use of cognitive aids during
The recommendation for use of low-fidelity manikins resuscitation
when higher-fidelity manikins are not available is based • Comparator: No use of cognitive aids
on studies which found improved performance in post- • Outcomes: Survival to hospital discharge with good
training versus pre-training assessment in all groups irre- neurological outcome and survival to hospital dis-
spective of level of manikin fidelity. charge were ranked as critical outcomes. Quality of
No studies reported on cost or resources needed to performance in actual resuscitations, skill perfor-
implement higher-fidelity manikins. Our recommendation mance 1 year after course conclusion, skill perfor-
is predicated on the higher-fidelity manikins being used mance between course conclusion and 1 year, skill
in a setting with appropriate space, infrastructure, per- performance at course conclusion, and knowledge

S232 October 21, 2025 Circulation. 2025;152(suppl 1):S205–S249. DOI: 10.1161/CIR.0000000000001359

 Greif et al Education, Implementation, and Teams: 2025 CoSTR

at course conclusion were included as important Stepwise Approach to Skills Training in

outcomes. Measures of effect outcomes included Resuscitation (EIT 6402, SysRev 2023, EvUp
adherence to resuscitation guidelines, CPR quality,
and test scores
2025)
• Time frame: June 1, 2023, to April 23, 2024 A SysRev was conducted for 2023,355 and details of that
review can be found in the 2023 CoSTR summary.4,5 The
Summary of Evidence complete EvUp is provided in Appendix B.
The 3 new studies identified are consistent in support-
ing previous findings and do not substantially change the Population, Intervention, Comparator, Outcome, and
weight of evidence.351–353 A further SysRev or ScopRev is Time Frame
not currently warranted. • Population: Adults and children undertaking skills
training related to resuscitation and First Aid in any
Treatment Recommendations (2024) educational setting
We suggest the use of cognitive aids by health care pro- • Intervention: Approaches to skills teaching that
fessionals in resuscitation (weak recommendation, very are not the Peyton 4-steps approach, including
low–certainty evidence). approaches without distinct stages, or modified
We do not recommend the use of cognitive aids for Peyton 4-steps approaches with more or less than
laypersons initiating CPR (weak recommendation, low- 4 steps, or with delivering 1 or more steps by alter-
certainty evidence). native methods (eg, video)
We did not examine the use of cognitive aids in health • Comparator: Peyton’s 4-steps approach for skills
professional or layperson training in resuscitation, so no teaching
recommendation for or against can be made. • Outcomes:
– Improved educational outcomes: Skill perfor-
mance after end of course; skill performance at
Clinician Workload and Stress During
end of course; participants’ confidence to per-
Resuscitation (EIT 6401, ScopRev 2024, EvUp form the skill on patients; participants’ preference
2025) of teaching method
A ScopRev was completed for 2024,354 and details can – Patient outcomes: Skills performed appropriately
be found in the 2024 CoSTR summary.232,233 The com- on real patient after the course.
Downloaded from [Link] by on October 27, 2025

plete EvUp is provided in Appendix B. – Additional outcomes: Teachers’ preference of

teaching method; side effects of teaching
Population, Intervention, Comparator, Outcome, • Time frame: January 1, 2022, to November 20,
Study Design, and Time Frame 2024
• Population: Health care professionals performing
resuscitation on patients in cardiac arrest in clinical Summary of Evidence
settings or on manikins in a simulated setting One new RCT was found,356 which does not add new
• Exposure: Presence of any factors that would pos- evidence to that already known. A SysRev is not currently
sibly impact the health care professional’s perceived warranted.
workload or stress
Treatment Recommendations (2023)
• Comparison: Absence of the specific factor
We suggest that stepwise training should be the method
• Outcomes: Objective or subjective measures of
of choice for skills training in resuscitation (weak recom-
workload and stress experienced by health care
mendation, very low–certainty evidence).
professionals during resuscitations
• Study design: In addition to standard criteria, unpub-
lished studies (eg, conference abstracts, trial pro- Immersive Technologies: Virtual Reality,
tocols), letters, editorials, comments, case reports,
grey literature, and social media were eligible for
Augmented Reality (EIT 6405, SysRev 2024,
inclusion. EvUp 2025)
• Time frame: February 2, 2024, to October 2, 2024 A SysRev was conducted for 2024,357 and details of that
review can be found in the 2024 CoSTR summary.232,233
Summary of Evidence The complete EvUp is provided in Appendix B.
This EvUp found 2 new RCTs in a simulation setting
(1 in neonatal resuscitation, the other in adult simu- Population, Intervention, Comparator, Outcome, and
lation). The evidence in these studies did not add to Time Frame
that already known, and therefore a new SysRev is not • Population: All laypersons and health care profes-
­warranted. sionals in any educational setting

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 Greif et al Education, Implementation, and Teams: 2025 CoSTR

• Intervention: Immersive technologies (virtual reality, Summary of Evidence

augmented reality, mixed reality, extended reality) as No relevant studies were identified and no new SysRev
part of instructional design to train neonatal, pediat- is indicated.
ric, adult basic and advanced life support
Treatment Recommendations (2022)
• Comparator: Other methods of resuscitation train-
We recommend blended-learning as opposed to a non-
ing in basic and advanced life support (eg, tradi-
blended approach for life support training when resourc-
tional manikin-based simulation training, other)
es and accessibility permit its implementation (strong
• Outcomes: Knowledge acquisition and retention,
recommendation, very low–certainty evidence).
skills acquisition and retention, skill performance in
real CPR, willingness to help, bystander CPR rate,
and patients’ survival Gamified Learning Versus Other Forms of
• Time frame: April 4, 2023, to October 10, 2024
Nongamified Learning (EIT 6412, SysRev 2024,
Summary of Evidence EvUp 2025)
No studies on augmented reality were found in this
A SysRev was done for 2024367 and details can be found
updated search. For virtual reality, 5 RCTs358–362 and 2
in the 2024 CoSTR summary.232,233 The complete EvUp is
observational studies363,364 were found. The evidence
provided in Appendix B.
identified continues to support the current recommenda-
tions,365 and the certainty of this evidence remains low. Population, Intervention, Comparator, Outcome, and
The current evidence update does not warrant a new Time Frame
SysRev. • Population: Learners training in basic or advanced
life support
Treatment Recommendations (2024) • Intervention: Instruction using gamified learning (use
We suggest the use of either augmented reality or tradi- of game-like elements in the context of training; eg,
tional methods for basic life support training of layperson point systems, intergroup competition, leaderboards,
and health care professional (weak recommendation, scaffolded learning with increasing challenge, med-
very low–certainty evidence). als or badges)
We suggest against the use of virtual reality-only for • Comparator: Traditional instruction or other forms of
basic and advanced life support training of layperson and nongamified learning
Downloaded from [Link] by on October 27, 2025

health care professional (weak recommendation, very • Outcomes:

low–certainty evidence). – Educational outcomes: Skill (eg CPR performance,
other procedural performance, scores in scenarios,
Blended Learning Approach for Life Support time to task performance) immediately following
Education (EIT 6409, SysRev 2022, EvUp 2025) training (eg end of course), at 3 months, 6 months,
1 year. Knowledge eg test scores immediately fol-
A SysRev was conducted for 2022,366 and details of that lowing training (eg end of course), at 3 months, 6
review can be found in the 2020 CoSTR.9,10 An EvUp months, 1 year. Attitudes: Participant satisfaction,
was done in 2025.12,13 The complete EvUp is provided in learner preference, learner confidence
Appendix B. – Clinical outcomes: Change in health care prac-
Population, Intervention, Comparator, Outcome, and titioner behavior at resuscitation in case of real
Time Frame cardiac arrest (CPR quality, time to task comple-
• Population: Participants undertaking an accred- tion, teamwork/crisis resource management)
ited life support course (eg BLS, ALS, pediatric – Patient outcomes: ROSC, survival to hospital dis-
advanced life support) charge; neurologic intact survival
• Intervention: Blended learning approach – Process: Costs and resources utilization
• Comparator: Nonblended learning approach • Time frame: February 1, 2024, to October 30, 2024
• Outcomes: Summary of Evidence
– Clinical outcomes: Survival (Critical) and neuro- Three new RCTs have been identified.368–370 Including
logical outcome these studies would not alter the strength of the existing
– Knowledge acquisition (end of course, 6 months, recommendation, therefore no new SysRev is warranted.
1 year)
– Skills acquisition (end of course, 6 months, 1 Treatment Recommendations (2024)
year) We suggest the use of gamified learning be considered
– Participant satisfaction (end of course) as a component of resuscitation training for all types of
– Implementation outcomes (cost, time needed) BLS and ALS courses (weak recommendation, very low–
• Time frame: Jan 1, 2021, to Jun 19, 2024 certainty evidence).

S234 October 21, 2025 Circulation. 2025;152(suppl 1):S205–S249. DOI: 10.1161/CIR.0000000000001359

 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Scripted Debriefing Versus Nonscripted real CPR, attitudes, willingness to help, and patients’
Debriefing (EIT 6413, ScopRev 2024, EvUp survival
• Time frame: September 1, 2022, to October 30,
2025) 2024
A ScopRev was conducted for 2024371 and is included in
the 2024 CoSTR summary.232,233 The complete EvUp is Summary of Evidence
provided in Appendix B. This update found 2 additional RCTs that do not change
available evidence.373,374 Therefore, a new SysRev is not
Population, Intervention, Comparator, Outcome, and warranted.
Time Frame
• Population: Health care professionals or lay- Treatment Recommendations (2024)
people receiving resuscitation training (primary), We suggest that it may be reasonable to include rapid
and instructors teaching resuscitation courses cycle deliberate practice in BLS and ALS training (weak
(secondary) recommendation, very low–certainty evidence).
• Intervention: Debriefing with a cognitive aid, check-
list, script or tool
• Comparator: Debriefing without the use of a cogni- Team Competencies in Resuscitation Training
tive aid, checklist, script or tool (EIT 6415, SysRev 2024, EvUp 2025)
• Outcomes: A SysRev was conducted for 2024,375 and details can be
– Primary population: Patient outcomes: Improved found in the 2024 CoSTR summary.232,233 The complete
resuscitation performance in clinical environ- EvUp is provided in Appendix B.
ments; improved learning outcomes (knowledge
and skill acquisition and retention); satisfaction of Population, Intervention, Comparator, Outcome,
learning Study Design, and Time Frame
– Secondary population: Quality of teaching/ • Population: Learners undertaking life support train-
debriefing; workload/cognitive load of instructor/ ing in any setting
debriefer • Intervention: Life support training with a specific
• Time frame: January 1, 2024, to October 10, 2024 emphasis on team competencies training
• Comparator: Life support training without specific
Summary of Evidence
Downloaded from [Link] by on October 27, 2025

emphasis on team competencies training

As there were no new studies identified, this evidence • Outcomes: Patient survival (actual resuscitation),
update does not warrant a SysRev. CPR skill performance at course completion (simu-
Treatment Recommendations (2024) lation), CPR skill performance (in actual resuscita-
Consider using debriefing scripts to support instructors tion and simulation) <1 year and ≥1 year of course
during debriefing in resuscitation programs because they completion; CPR quality (simulation) (at course
may improve learning and performance. Instructors need completion, <1 year and ≥1 year of course comple-
to ensure they have a complete understanding of how the tion); confidence (at course completion and <1 year
debriefing script should be used (good practice statement). and ≥1 year of course completion), teamwork com-
petencies (in actual resuscitation and simulation) (at
course completion, <1 year and ≥1 year of course
Rapid Cycle Deliberate Practice in completion); resources (time, equipment, cost)
Resuscitation Training (EIT 6414, SysRev 2024, • Study design: In addition to the standard criteria,
EvUp 2025) studies evaluating scoring systems (no relevant out-
come), and studies with self-assessment as the only
A SysRev was conducted for 2024,372 and details can be outcome were excluded.
found in the 2024 CoSTR summary.232,233 The complete • Time frame: August 30, 2023, to November 6, 2024
EvUp is provided in Appendix B.
Summary of Evidence
Population, Intervention, Comparator, Outcome, and The 2 new studies identified are consistent in support-
Time Frame ing previous findings; however, they do not substantially
• Population: Learners in training for BLS or ALS change the weight of evidence.376,377 Therefore, a further
• Intervention: Instruction that uses rapid cycle delib- SysRev or ScopRev is not warranted.
erate practice
• Comparator: Traditional instruction or other forms of Treatment Recommendations (2024)
learning without rapid cycle deliberate practice We suggest that teaching teamwork competencies be in-
• Outcomes: Knowledge acquisition and retention, cluded in BLS and all kinds of advanced life support train-
skills acquisition and retention, skill performance in ing (weak recommendation, very low quality of e ­ vidence).

Circulation. 2025;152(suppl 1):S205–S249. DOI: 10.1161/CIR.0000000000001359 October 21, 2025 S235

 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Topics Not Included in the 2025 Review and teams: 2025 International Liaison Committee on Resuscitation Consensus
on Science With Treatment Recommendations. Circulation. 2025;152(suppl
• EIT 6100 Resuscitation training in low- 1):S205–S249. doi: 10.1161/CIR.0000000000001359
This article has been copublished in Resuscitation. Published by Elsevier
income countries (ScopRev in 2020,378 task ­Ireland Ltd. All rights reserved.
force statement 2023)379
• EIT 6408 Spaced Learning (SysRev 2020,380 Acknowledgment
The writing group would like to thank Jaylen I. Wright for his assistance with edit-
EvUp from 2022 in Appendix B available) ing supplemental materials and providing administrative support throughout the
manuscript preparation process.

Collaborators
ARTICLE INFORMATION
The authors thank the following individuals (the Education, Implementation, and
The American Heart Association requests that this document be cited as fol- Teams Task Force Collaborators) for their contributions: Alanowd Alghaith; The-
lows: Greif R, Cheng A, Abelairas-Gómez C, Allan KS, Breckwoldt J, Cortegiani A, resa Aves; Adam Boulton; Natalie Anderson; Emma Buergstein; Aida Carballo-Fa-
Donoghue AJ, Eastwood KJ, Farquharson B, Hsieh M-J, Kidd T, Ko Y-C, zanes; Jon Duff, Bianca Flaim; Heike Geduld; Mariachiara Ippolito; Teruko Kishibe;
Lauridsen KG, Lin Y, Lockey AS, Matsuyama T, Nabecker S, Nation KJ, Olaussen A, Tse-Ying Lee; Julian Lennertz; Brenna Leslie; Kai-Wei Lin; Henry Cheng-Heng Liu;
Schnaubelt S, Sawyer T, Yang C-W, Yeung J; on behalf of the Education, Im- Matthew Olejarz; Timo de Raad; Andrea Scapigliati; Federico Semeraro; Charlotte
plementation, and Teams Task Force Collaborators. Education, implementation, Southern; Devita Stallings; Lorrel Toft; Sandra V
­ iggers

Disclosures
Writing Group Disclosures

Other Speakers’ Consultant/

Writing group research bureau/ Expert Ownership advisory
member Employment Research grant support honoraria witness interest board Other
Robert Greif University of Bern None None None None None None None
(Switzerland)
Adam Cheng Alberta Children’s Hospital Alberta None None None Entity:: The None None
(Canada) Innovates†; Debriefing
Swiss National Academy
Science Relationship::
Foundation† Myself Level::
Significant
(≥$5K or ≥5%)
Cristian University of Santiago de None None None None None None None
Downloaded from [Link] by on October 27, 2025

Abelairas- Compostela (Spain)

Gómez
Katherine S. Unity Health Toronto - St. Zoll Foundation* None None None None None None
Allan Michael’s Hospital (Canada)
Jan Breckwoldt University Hospital of Zurich None None None None None None None
(Switzerland)
Andrea Università degli Studi di None None None None None None None
Cortegiani Palermo (Italy)
Aaron J. The Children’s Hospital Nihon Kohden* None None None None None None
Donoghue of Philadelphia, University
of Pennsylvania School of
Medicine
Kathryn J. Monash University (Australia) None None None None None None None
Eastwood
Barbara University of Stirling (United British Heart None None None None None None
Farquharson Kingdom) Foundation†

Ming-Ju Hsieh National Taiwan University None None None None None None None
Hospital (Taiwan)
Tracy Kidd La Trobe University Rural None None None NSW None College of None
Health School Coroners Emergency
court* Nursing
Australasia†
Ying-Chih Ko National Taiwan University None None None None None None None
Cancer Center (Taiwan)
Kasper G. Aarhus University & Randers Aarhus University None None None None None Resuscitation
Lauridsen Regional Hospital (Denmark) Research Plus, Elsevier*
Foundation*;
Riisfort
Foundation*

(Continued )

S236 October 21, 2025 Circulation. 2025;152(suppl 1):S205–S249. DOI: 10.1161/CIR.0000000000001359

 Greif et al Education, Implementation, and Teams: 2025 CoSTR

Writing Group Disclosures Continued

Other Speakers’ Consultant/
Writing group research bureau/ Expert Ownership advisory
member Employment Research grant support honoraria witness interest board Other
Yiqun Lin Alberta Children’s Hospital None None None None None None None
(Canada)
Andrew S. Calderdale Royal Hospital None None None None None None None
Lockey (United Kingdom)
Tasuku Kyoto Prefectural University of None None None None None None None
Matsuyama Medicine (Japan)
Sabine Mt Sinai Hospital (Canada) None None None None None None None
Nabecker
Kevin J. Nation New Zealand Resuscitation None None None None None None None
Council (New Zealand)
Alexander Monash University (Australia) None None None None None None None
Olaussen
Taylor Sawyer Seattle Children’s Hospital/ None None None None None None None
University of Washington
Sebastian Medical University of Vienna None None None None None None None
Schnaubelt (Austria)
Chih-Wei Yang National Taiwan University None None None None None None None
Hospital (Taiwan)
Joyce Yeung University of Warwick, None None None None None None None
Warwick Medical School
(United Kingdom)

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
Downloaded from [Link] by on October 27, 2025

Reviewer Disclosures

Other Speakers’
research bureau/ Expert Ownership Consultant/
Reviewer Employment Research grant support honoraria witness interest advisory board Other
Patricia The University of Manchester, None None None None None European None
Conaghan School of Health Sciences (United Resuscitation
Kingdom) Council*;
Resuscitation
Council UK*
Garth University of British Columbia, BC None None None None None None None
David Children’s (Canada)
Meckler
Daniel M. Northwell Health Emergency Flosonics Medical None None None None None None
Rolston Medicine (Research Grant)†; Zoll
Foundation (Research
Grant)†
Andrea Catholic University of the Sacred None None None None None None None
Scapigliati Heart Anesthesia and Intensive
Care, Cardiovascular Department
(Italy)

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-
tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any
12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of
the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Circulation. 2025;152(suppl 1):S205–S249. DOI: 10.1161/CIR.0000000000001359 October 21, 2025 S237

 Greif et al Education, Implementation, and Teams: 2025 CoSTR

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 Circulation

First Aid: 2025 International Liaison Committee

on Resuscitation Consensus on Science With
Treatment Recommendations
Therese Djärv, Chair; Matthew J. Douma, Vice Chair; Jestin N. Carlson; Eunice M. Singletary; David C. Berry; Richard N. Bradley;
Pascal Cassan; Wei-Tien Chang; Nathan P. Charlton; Diana Cimpoesu; Craig A. Goolsby; Swee Han Lim; Jen Heng Pek;
Barry Klaassen; Amy Kule; Jorien Laermans; Finlay Macneil; Abel Martinez-Mejias; Daniel Meyran; Masashi Okubo;
Aaron M. Orkin; James Raitt; Heba Shahaed; Anna Maria Subic; Kaushila Thilakasiri; Frances Williamson; on behalf of the
ILCOR First Aid Task Force Collaborators

ABSTRACT: The International Liaison Committee on Resuscitation conducts continuous reviews of new, peer-reviewed,
published first aid and cardiopulmonary resuscitation science and publishes more comprehensive reviews every 5 years.
The First Aid chapter of the 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment
Recommendations addresses all published evidence reviewed by the First Aid Task Force science experts since 2020. This
summary includes new systematic reviews on manual uterine massage for postpartum hemorrhage, unintentional injury
from chest compressions in noncardiac arrests, and treatment of jellyfish stings. There are also new scoping reviews on the
topics of first aid interventions to prevent adverse consequences of postpartum hemorrhage, spinal motion restriction, and
preservation of an amputated body part. Summaries of systematic and scoping reviews included in the 2021 to 2024 annual
summaries are also included to provide a more comprehensive reference for the reader. Members of the First Aid Task Force
have assessed, discussed, and debated the certainty of the evidence, on the basis of the Grading of Recommendations,
Downloaded from [Link] by on October 27, 2025

Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations.
Insights into the deliberations of the task force are provided in the Justification and Evidence-to-Decision Framework
Highlights sections. The task force also lists priority knowledge gaps for further research.

Key Words: Scientific Statements ◼ environmental emergencies ◼ first aid ◼ ILCOR ◼ medical emergencies ◼ trauma ◼ wounds and injuries

T
his First Aid (FA) Task Force chapter of the Inter- for 2 weeks after posting. Task forces considered public
national Liaison Committee on Resuscitation feedback and provided responses. All CoSTRs are now
(ILCOR) International Consensus on Cardiopul- available on the ILCOR website.3
monary Resuscitation (CPR) and Emergency Cardiovas- Although only SysRevs can generate a full CoSTR
cular Care Science With Treatment Recommendations and new treatment recommendations, many other top-
(CoSTR) includes all the reviews conducted by the FA ics were evaluated with scoping reviews (ScopRevs) or
Task Force in the previous year. Reviews conducted and evidence updates (EvUps). Good practice statements,
published since the 2020 publication1,2 are also summa- which represent the opinion of task force experts in light
rized to provide a single, more comprehensive reference of very limited or no direct evidence, can be generated
document for readers. This summary paper comprises 32 after ScopRevs and occasionally after EvUps in cases
topic reviews, including 8 systematic reviews (SysRevs). where the task force thinks providing guidance is espe-
Draft CoSTRs for all topics evaluated with SysRevs were cially important. A separate paper in this issue includes
posted on the ILCOR website3 on a rolling basis. Each the full details of the evidence evaluation process.4
draft CoSTR includes the data reviewed and draft treat- This summary statement contains the final wording
ment recommendations, with public comments accepted of the treatment recommendations and good practice

Supplemental Material is available at [Link]

© 2025 American Heart Association, Inc., European Resuscitation Council, and International Liaison Committee on Resuscitation
Circulation is available at [Link]/journal/circ

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 Djärv et al First Aid: 2025 CoSTR

statements as approved by the ILCOR FA Task Force, help guideline authors and first aid providers under-
as well as summaries of the key evidence identified, key stand how to adapt evidence-based guidelines to various
discussion points and knowledge gaps. The year that emergency situations—from low-resource and remote
treatment recommendations—or good practice state- settings to urban incidents—and across different provider
ments—were generated or last updated by a SysRev is skill levels—from untrained bystanders to health care pro-
provided in parentheses. In cases where existing treat- fessionals. In our future work, we will combine clear rec-
ment recommendations have changed for 2025, the ommendations with practical examples, which will help
prior recommendations are also presented so the reader practitioners to better understand both the applications
can easily see what has changed. Links to the published and limitations of first aid evidence, including when to
reviews and full online CoSTRs are provided in the corre- seek additional help. Since 2024, we have also started
sponding sections. Evidence-to-decision tables for Sys- applying an equity lens on our CoSTRs; included studies
Revs are provided in Appendix A, and the complete EvUp will be screened regarding content in PROGRESS Plus,5
worksheets are provided in Appendix B. and an equity statement will be found in every CoSTR.
Topics are presented using the PICOST (popula- The following topics are addressed in this FA Task Force
tion, intervention, comparator, outcomes, study design, CoSTR chapter. In addition, an overview of changes made
and time frame) format. To minimize redundancy, the in treatment recommendations since 2020 is provided in
study designs have been removed from the text except Supplemental Material Table S1 in the supplement.
in cases where designs included differed from the FA
standard criteria. The standard study designs included
are randomized clinical trials (RCTs) and nonrandomized GENERAL PRINCIPLES
studies (non-RCTs, interrupted time series, controlled • Pulse oximetry (FA 7010, ScopRev 2023)
before-and-after studies, and cohort studies) were eligi- • Use of supplemental oxygen (FA 7030, FA 519, FA
ble for inclusion. Case series, case reports, animal stud- 1549, FA 1649, ScopRev 2023, ScopRev 2024)
ies and unpublished studies (conference abstracts, trial • Recovery position (FA 7040, FA 517, SysRev 2022)
protocols) were excluded. All languages were included
provided there was an English abstract.
Within ILCOR, the FA Task Force highlights the critical FIRST AID FOR MEDICAL EMERGENCIES
role of promoting the helping behaviors of people in emer- • Recognition of anaphylaxis (FA 7110, FA 513,
gencies, emphasizing first aid’s foundational importance ScopRev 2023, EvUp 2025)
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in the Chain of Survival, including preventing, recognizing, • Second dose of epinephrine (FA 7111, FA 500,
and responding to a cardiac arrest. The FA Task Force has ScopRev 2021, EvUp 2025)
developed a framework to improve how we identify and • Removal of foreign-body airway obstruction (FA
evaluate first aid evidence. This framework consists of 4 7113, Basic Life Support [BLS] 368, EvUp 2025)
essential domains that must be considered: the recipient, • Potential harms from bronchodilator administration
the provider, the treatment, and the setting (Table 1). (FA 7122, ScopRev 2023)
Using these domains has strengthened our ability to • Early aspirin for chest pain (FA 7140, FA586, EvUp
conduct focused literature searches, evaluate evidence, 2025)
and translate findings into practice. Moving forward, the • Methods of glucose administration for hypoglyce-
task force may include illustrative case vignettes along- mia (FA 7161, FA 1585, EvUp 2025)
side its recommendations to demonstrate how evidence • Dietary sugar treatment for hypoglycemia (FA 7162,
applies across different scenarios. These examples will FA 795, EvUp 2025)
• Recognition of stroke (FA 7170, FA 801, EvUp
2025)
Table 1. Definition of First Aid (FA 7001) • Recognition of sepsis (FA 7180, ScopRev 2024)
First aid domains for • Interventions administered by lay providers for the
evidence evaluation and treatment of postpartum hemorrhage (FA 7337,
treatment recommendations Examples of characteristics
ScopRev 2025)
First aid recipient Age, sex, gender, health status, capacity • Manual uterine massage for postpartum hemor-
to provide consent
rhage (FA 7336, SysRev 2025)
First aid provider Knowledge, training/education, prepared-
ness, familiarity, duty to respond,
• Use of naloxone during resuscitation for suspected
professional scope, capability opioid-associated emergencies (FA 7442, BLS 811,
Treatment Invasiveness, skill required, technology, EvUp 2025)
efficacy and effectiveness, cost • Prevention of syncope with counter-pressure
Setting and environmental Low or high resource, safety, cultural maneuvers (FA 7550 FA 798, EvUp 2025)
norms and values, urban or remote • Unintentional injury from CPR (FA 7670, BLS 353,
settings
SysRev 2025)

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 Djärv et al First Aid: 2025 CoSTR

FIRST AID FOR TRAUMA EMERGENCIES • Outcome: Any clinical outcome

• Time frame: All years up to November 16, 2022
• Spinal motion restriction (FA 7311, FA 772, ScopRev
2025 including the topic Spinal injury manual stabi- Good Practice Statements (2023)
lization FA 7312, FA 1547) First aid providers who use pulse oximeters for the as-
• Cryotherapy for epistaxis (FA 7151, ScopRev 2021) sessment of acute illness or injuries should be proficient
• Manual pressure and pressure devices for bleeding in their use and understand their limitations, including
(FA 7331, FA 530, SysRev 2021, EvUp 2025) equipment factors, environmental considerations, and
• Type of tourniquets alone or in combinations with patient-specific factors that may produce inaccurate and
other methods of achieving hemostasis (FA 7333, unreliable readings (good practice statement).
FA 768, SysRev 2021, EvUp 2025) The use of a pulse oximeter for first aid assessment
• Types of pediatric tourniquets (FA 7333, FA 768, should not supersede or replace physical assessment
SysRev 2021) (good practice statement).
• Hemostatic dressing (FA 7334, FA 769 EvUp 2025)
• Duration of cooling for burns (FA 7371, FA 770,
SysRev 2021) Use of Supplemental Oxygen in the First Aid
• Dental avulsion (FA 7361, FA794, EvUp 2025) Setting (FA 7030, FA 519, FA 1549, FA 1649,
• Compression wrap for closed extremity joint injuries ScopRev 2023, ScopRev 2024)
(FA 7381, FA 511, EvUp 2025) In the first aid setting, oxygen use has been described for
• Preservation of traumatic, completely amputated or loss of consciousness, diving emergencies, carbon monox-
avulsed body parts (FA 7391, ScopRev 2025) ide poisoning, and during cardiac arrest. A 2015 CoSTR7
and a 2023 ScopRev6 identified evidence of potential harm
with oxygen use in acute exacerbations of chronic obstruc-
FIRST AID FOR ENVIRONMENTAL tive pulmonary disease. A 2024 ScopRev8 expanded the
EMERGENCIES search dates and inclusion criteria. Details of this review
• Exertion-related dehydration and rehydration (FA can be found in the 2024 CoSTR summary.9
7241, FA 584, SysRev 2021)
Population, Intervention, Comparator, Outcome, and
• Tick removal (FA 7231, SysRev 2021)
Time Frame
• Treatment of jellyfish stings (FA 7211, SysRev
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• Population: Adults and children who exhibit symp-

2025)
toms or signs of shortness of breath, difficulty
Readers are encouraged to monitor the ILCOR website3
breathing or hypoxia outside of a hospital
to provide feedback on planned SysRevs and to provide
• Intervention: Administration of oxygen by a first aid
comments when additional draft reviews are posted.
provider
• Comparator: No administration of oxygen
• Outcome: Functional outcome at discharge, 30
GENERAL PRINCIPLES days, 60 days, 180 days, or 1 year, survival only at
Use of Pulse Oximetry (FA 7010, ScopRev discharge, 30 days, 60 days, 180 days, or 1 year,
2023) length of hospital stay, resolution of symptoms or
signs, patient comfort, therapeutic endpoints (eg,
Pulse oximetry has been used for monitoring of hospital-
oxygenation, ventilation)
ized patients at risk of hypoxemia as well as, more recent-
• Time frame: All years to December 2, 2023
ly, for home use during the COVID-19 pandemic. The FA
In 2023, the following good practice statement was for-
Task Force considered it timely to undertake a ScopRev6
mulated based on a limited search (FA 1549): “If first
in 2022 to identify evidence relating to the use of pulse
aid providers, trained to use oxygen, are administering
oximetry as a component of first aid assessment of acute
supplemental oxygen to a person with known chronic ob-
symptoms associated with illness or injury. Details of this
structive pulmonary disease, they should titrate the sup-
review can be found in the 2023 CoSTR summary.6
plemental oxygen to maintain an oxygen saturation by
Population, Intervention, Comparator, Outcome, and pulse oximetry between 88% and 92%.” The intent of the
Time Frame 2024 ScopRev was to look more broadly at the question
• Population: Adults and children in out-of-hospital or of first aid oxygen use for adults and children with short-
home settings with an acute illness or injury ness of breath, difficulty breathing, or hypoxia. No direct
• Intervention: Use of pulse oximetry in addition to evidence was identified to suggest for or against first
standard first aid assessment aid oxygen administration in this general population, and
• Comparator: Standard first aid assessment without this remains a knowledge gap. However, the ScopRev
the use of pulse oximetry yielded indirect evidence of harm with high-flow– or

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 Djärv et al First Aid: 2025 CoSTR

high-concentration–supplemental oxygen in patients with • Study designs: In addition to the standard criteria,
chronic obstructive pulmonary disease in the emergency case reports published in letter form were included.
medical services setting. Based on this 2024 ScopRev, ScopRevs and SysRevs were included for discus-
the good practice statement was slightly changed. sion and to assure no primary papers were missed,
but data were not extracted from these reviews.
Good Practice Statement (2024)
• Time frame: All years to November 17, 2021
When a first aid provider trained in oxygen use admin-
isters oxygen to a person with acute difficulty breathing Treatment Recommendations (2022)
who confirms that they have chronic obstructive pulmo- When providing first aid to a person with a decreased
nary disease, it is suggested that pulse oximetry be used, level of responsiveness of nontraumatic etiology and
and that oxygen be titrated to maintain an oxygen satura- who does not require immediate resuscitative interven-
tion between 88% and 92% (good practice statement). tions, we suggest the use of the recovery position (weak
Although high-flow oxygen should in general be recommendation, very low–certainty evidence).
avoided in patients with chronic obstructive pulmonary When the recovery position is used, monitoring should
disease with difficulty breathing in the out-of-hospital continue for signs of airway occlusion, inadequate or
setting, high-flow oxygen should not be withheld in the agonal breathing, and unresponsiveness (good practice
presence of life-threatening hypoxia (oxygen saturation statement).
<88%) (good practice statement). If body position, including the recovery position, is a
factor impairing the first aid provider’s ability to deter-
The Recovery Position for Maintenance of mine the presence or absence of signs of life, the person
should be immediately positioned supine and reassessed
Adequate Ventilation and the Prevention of (good practice statement).
Cardiac Arrest (FA 7040, FA 517, SysRev 2022) Persons found in positions associated with aspiration
The use of a recovery position for persons with a re- and positional asphyxia such as facedown, prone, or in
duced level of responsiveness has been taught in first neck and torso flexion positions should be repositioned
aid courses for decades, primarily as a means to reduce supine for reassessment (good practice statement).
the risk of aspiration of gastric contents. The original
PICOST wording from a 2015 SysRev10 sought to com-
Recognition of Anaphylaxis (FA 7110, ScopRev
pare a lateral, side-lying recovery position with a supine
2023, EvUp 2025)
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position in adults who are breathing and unresponsive

in an out-of-hospital setting. The revised PICOST word- Population, Intervention, Comparator, Outcome,
ing now clarifies the population of interest as adults and Study Design, and Time Frame
children with a reduced level of responsiveness of non- • Population: Adults and children experiencing
traumatic etiology and who do not require resuscitative anaphylaxis
interventions. A ScopRev was last done in 2020, and this • Intervention: Description of any specific symptoms
SysRev11 was undertaken with involvement of content to the first aid provider
experts from the FA and BLS Task Forces and included • Comparator: Absence of any specific description
in the 2022 CoSTR summary.12 • Outcome: Anaphylaxis recognition (Critical)
• Study designs: In addition to the usual criteria, it was
Population, Intervention, Comparator, Outcome,
anticipated that there would be insufficient studies
Study Designs, and Time Frame
from which to draw a conclusion, so the minimum
• Population: Adults and children in the first aid set-
number of cases for a case series to be included
ting who have a reduced level of responsiveness of
was reduced from the default of 5 to 1 by the team.
nontraumatic etiology and do not require resuscita-
• Time frame: October 28, 2023, to July 3, 2024
tive interventions
• Intervention: Specific positioning (recovery position- Summary of Evidence
ing [ie, various semiprone, lateral recumbent, side- Since the last ScopRev13 in 2022, we identified 734
lying, or three-quarters prone positions of the body]) unique articles, of which 4 articles6,14–16 were relevant.
• Comparator: Supine or other position During the process to screen full text articles, it was
• Outcome: noted that several studies reported an increase in knowl-
– Critical: Survival, incidence of cardiac arrest, edge of how to recognize anaphylaxis after educational
delayed detection of apnea and cardiac arrest interventions, viewing videos, health application (app) use,
– Important: Need for airway management, inci- and coaching. Currently, there is insufficient evidence
dence of aspiration, hypoxia, likelihood of cervi- to justify conducting a SysRev on this topic. However,
cal spine injury, complications (venous occlusion, the available evidence suggests that a future SysRev on
arterial insufficiency, arm discomfort/pain, dis- educational approaches for training lay providers to ef-
comfort/pain, aspiration pneumonia) fectively care for affected individuals is warranted.

Circulation. 2025;152(suppl 1):S250–S282. DOI: 10.1161/CIR.0000000000001358 October 21, 2025 S253

 Djärv et al First Aid: 2025 CoSTR

Treatment Recommendation (2010) Summary of Evidence

First aid providers should not be expected to recognize This EvUp identified 17 new publications20–36 since the
the signs and symptoms of anaphylaxis without repeated previous SysRev20 in 2019. The evidence suggests that
episodes of training and encounters with persons with regardless of which treatment is provided first, it is com-
anaphylaxis (good practice statement). mon for more than one intervention to be required for
relief of a foreign body airway obstruction. One study
suggests that back blows are more effective than chest
Second Dose of Epinephrine for Anaphylaxis or abdominal thrusts.29Airway clearance devices are
(FA 7111, FA 500, ScopRev 2021, EvUp 2025) increasing in prevalence. Currently, there are no treat-
Population, Intervention, Comparator, Outcome, and ment recommendations regarding these devices. An up-
Time Frame dated SysRev is warranted. After discussion, clarification
• Population: Adults and children experiencing severe regarding age range was added to one of the existing
anaphylaxis requiring the use of epinephrine treatment recommendations.
• Intervention: Administration of a second dose of
Treatment Recommendation (BLS 2020)
epinephrine
We suggest that back slaps are used initially in patients with
• Comparator: Administration of only one dose
a foreign body airway obstruction and an ineffective cough
• Outcome: Resolution of symptoms, adverse effects,
(weak recommendation, very low–certainty evidence).
complications
We suggest that abdominal thrusts are used in adults
• Time frame: January 3, 2021, to October 2, 2024
and children (over 1 year of age) with a foreign body
Summary of Evidence airway obstruction and an ineffective cough where back
Since the last ScopRev17 published in 2021, one study18 slaps are ineffective (weak recommendation, very low–
examining methods of administration was identified. certainty evidence).
There was insufficient literature to impact the previ- We suggest that rescuers consider the manual extrac-
ous treatment recommendations. Updated SysRev or tion of visible items in the mouth (weak recommendation,
ScopRev is not recommended at this time. very low–certainty evidence).
We suggest against the use of blind finger sweeps
Treatment Recommendations (2015) in patients with a foreign body airway obstruction (weak
We suggest a second dose of epinephrine be administered recommendation, very low–certainty evidence).
Downloaded from [Link] by on October 27, 2025

by autoinjector to adults and children with severe anaphy- We suggest that appropriately skilled individuals con-
laxis whose symptoms are not relieved by an initial dose sider the use of Magill forceps to remove foreign body
(weak recommendation, very low–certainty evidence). airway obstruction in OHCA patients with a foreign body
airway obstruction (weak recommendation, very low–
certainty evidence).
Removal of Foreign-Body Airway Obstruction We suggest that chest thrusts are used in uncon-
(FA 7113, BLS 368, EvUp 2025) scious patients with a foreign body airway obstruction
This topic was moved from the BLS Task Force to FA (weak recommendation, very low–certainty evidence).
Task Force in 2023 because of its relevance to first aid We suggest that bystanders undertake interventions
providers. A SysRev was last done in 2020 by BLS.19 to support foreign body airway obstruction removal as
soon as possible after recognition (weak recommenda-
Population, Intervention, Comparator, Outcome, tion, very low–certainty evidence).
Study Design, and Time Frame
• Population: Adults and children with foreign body
airway obstruction in any setting Potential Harms From Bronchodilator
• Intervention: Interventions to remove foreign body Administration (FA 7122, ScopRev 2023)
airway obstruction, such as finger sweep, back
Persons with asthma exacerbations benefit from adminis-
slaps, abdominal thrusts, chest thrusts, and suction-
tration of bronchodilators. However, it is unknown wheth-
based airway clearance devices
er first aid providers can appropriately identify asthma
• Comparator: No action
exacerbations, and it is unknown whether bronchodila-
• Outcome: Any clinical outcome
tors could result in harm if administered to individuals
• Study designs: In addition to the standard crite-
with undifferentiated respiratory symptoms. Details of
ria, case reports of injuries or complications were
this review can be found in the 2023 CoSTR summary.6
also eligible. Unpublished studies (eg, conference
abstracts, trial protocols), animal studies, manikin Population, Intervention, Comparator, Outcome, and
studies and cadaver studies were excluded. Time Frame
• Time frame: August 2019 through September 20, • Population: Adults and children in any setting with
2024 acute undifferentiated respiratory problems

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 Djärv et al First Aid: 2025 CoSTR

• Intervention: Administration of any type of inhaled • Intervention: Administration of glucose by any route
bronchodilator (eg, β-agonists, anticholinergics) appropriate for use by first aid providers
• Comparator: No administration of an inhaled • Comparator: Administration of glucose by another
bronchodilator route appropriate for first aid providers
• Outcomes: Survival, dysrhythmia, cardiac isch- • Outcomes: Resolution of symptoms; time to resolu-
emia, hypokalemia, need for emergency depart- tion of symptoms; blood or plasma glucose concen-
ment treatment, need for hospitalization, and time tration at 20 minutes; resolution of hypoglycemia;
to treatment time to resolution of hypoglycemia; any adverse
• Time frame: All years to November 2, 2022 event; administration delay
• Time frame: September 13, 2021, to October 18,
Treatment Recommendation (2015, Unchanged)
2024
When an individual with asthma is experiencing dif-
ficulty breathing, we suggest that trained first aid Summary of Evidence
providers assist the individual with administration of a Since the last SysRev39 in 2021, no relevant new studies
bronchodilator (weak recommendation, very low–cer- were identified. An updated SysRev is not warranted.
tainty evidence).
Treatment Recommendations (2021)
We recommend the use of oral glucose (swallowed) for
individuals with suspected hypoglycemia who are con-
Early Aspirin for Chest Pain (FA 7140, FA 586,
scious and able to swallow (strong recommendation, very
EvUp 2025) low–certainty evidence).
Population, Intervention, Comparator, Outcome, We suggest against buccal glucose administration
Study Designs, and Time Frame compared with oral glucose administration for individu-
• Population: Adults who experience nontraumatic als with suspected hypoglycemia who are conscious and
chest pain able to swallow (weak recommendation, very low–cer-
• Intervention: Early or first aid administration of tainty evidence).
aspirin If oral glucose (for example, tablet) is not immedi-
• Comparator: Later or in-hospital administration of ately available, we suggest a combined oral plus buc-
aspirin cal glucose (for example, glucose gel) administration
• Outcome: Any outcome for individuals with suspected hypoglycemia who are
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• Time frame: October 1, 2019, to September 30, conscious and able to swallow (weak recommenda-
2024 tion, very low–certainty evidence).
We suggest the use of sublingual glucose adminis-
Summary of Evidence
tration for suspected hypoglycemia for children who
Since the last SysRev37 completed for 2019, 98 articles
may be uncooperative with the oral (swallowed) glucose
were screened, and none were relevant for the topic. Of
administration route (weak recommendation, very low–
note, one study38 described increased risk of bleeding
certainty evidence).
in chest pain patients administered aspirin or clopidogrel
(or both) and finally diagnosed as type A aortic dissec-
tion necessitating surgical intervention. A new review is Dietary Sugar Treatment for Hypoglycemia (FA
currently not warranted. 7162, FA 795, EvUp 2025)
Treatment Recommendation (2019) Population, Intervention, Comparator, Outcome, and
For adults with nontraumatic chest pain, we suggest Time Frame
the early administration of aspirin as a first aid inter- • Population: Adults and children with symptomatic
vention compared with late, in-hospital, administration hypoglycemia
of aspirin (weak recommendation, very low–certainty • Intervention: Administration of dietary forms of
evidence). sugar
• Comparator: Standard dose (15–20 g) of glucose
tablets
Methods of Glucose Administration for • Outcomes: Time to resolution of symptoms, compli-
Hypoglycemia (FA 7161, FA 1585, EvUp 2025) cations, blood glucose level after treatment, hypo-
Population, Intervention, Comparator, Outcome, and glycemia (defined as the persistence of symptoms
Time Frame (yes/no) or recurrence of symptomatic hypoglyce-
• Population: Adults and children in any setting mia for more than 15 minutes after treatment), hos-
(in-hospital or out-of-hospital) with (suspected) pital length of stay
hypoglycemia • Time frame: January 1, 2020, to December 8, 2024

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 Djärv et al First Aid: 2025 CoSTR

Summary of Evidence • Study designs: In addition to standard criteria,

Since the last SysRev40 in 2017, we identified 3 relevant because it was anticipated that there would be
studies. One RCT41 with 3 arms in children with diabetes insufficient studies from which to draw a conclusion,
type 1 aged 12 to 16 years trekking for 5 days found no the minimum number of cases for a case series to
difference between any of the 3 arms: 0.3 g glucose prep- be included was reduced from the default of 5 to 1.
aration/kg, sugar fondant candies, and fruit juice. A narra- • Time frame: May 26, 2020, to June 31, 2024
tive review42 explored the optimal dose of carbohydrates in
Summary of Evidence
nonsevere hypoglycemia; their conclusion was that most
Since the last SysRev44 in 2020, we did not identify any
recover after 15 to 20 g, but individual strategies based
relevant articles. An update of the SysRev is not currently
on body weight or type of insulin delivery system might be
indicated.
relevant in future guidelines. One trial43 showed that oral
intake of carbohydrates in patients with type 1 diabetes Treatment Recommendations (2020)
could be beneficial earlier, that is, at higher blood glucose We recommend that first aid providers use stroke as-
levels than traditional cutoffs to avoid hypoglycemia. This sessment scales/tools for adults with suspected acute
might be relevant from a first aid perspective but is out of stroke (strong recommendation, low-certainty evidence).
the scope for the current PICO (population, intervention, For first aid, we suggest the use of the Face, Arms,
comparator, outcome). Based on these studies, additional Speech, Time tool; Melbourne Ambulance Stroke Scale;
reviews (systematic or scoping review) on this specific or Cincinnati Prehospital Stroke Scale; or Los Angeles Pre-
similar topics are not recommended at this time. hospital Stroke Screen for stroke assessment (weak rec-
ommendation, low-certainty evidence).
Treatment Recommendations (2015, Unchanged)
For first aid, we suggest the use of stroke assess-
We recommend that first aid providers administer glu-
ment scales/tools that include blood glucose measure-
cose tablets for treatment of symptomatic hypoglycemia
ment when available, such as the Melbourne Ambulance
in conscious adults and children (strong recommenda-
Stroke Scale or Los Angeles Prehospital Stroke Screen,
tion, low-certainty evidence).
to increase specificity of stroke recognition (weak rec-
We suggest that if glucose tablets are not available,
ommendation, low-certainty evidence).
various forms of dietary sugars such as small candies,
For first aid, we suggest the use of the Face, Arms,
sugar cubes, jelly beans, or orange juice can be used
Speech, and Time tool or Cincinnati Prehospital Stroke
to treat symptomatic hypoglycemia in conscious adults
Scale stroke assessment when blood glucose mea-
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and children (weak recommendation, very low–certainty

surement is unavailable (weak recommendation, low-
evidence).
certainty evidence).
There is insufficient evidence to make a recommenda-
tion on the use of whole milk, cornstarch hydrolysate, and
glucose solution, or glucose gels as compared with glucose Recognition of Sepsis (FA 7180, ScopRev 2024)
tablets for the treatment of symptomatic hypoglycemia.
A significant proportion of preventable deaths worldwide
are caused by sepsis, and early detection and treatment
Recognition of Stroke (FA 7170, FA 801, EvUp is beneficial. No review was undertaken until 2024, when
2025) the task force prioritized a ScopRev on the recognition
and awareness of sepsis by first aid providers evaluating
Population, Intervention, Comparator, Outcome,
adults with an acute illness. The completed ScopRev45
Study Design, and Time Frame
and CoSTR can be found in the 2024 CoSTR summary.8
• Population: Adults with suspected acute stroke
• Intervention: Use of a rapid stroke scoring system or Population, Intervention, Comparator, Outcome,
scale Study Design, and Time Frame
• Comparator: Basic first aid assessment without the • Population: Adults who are being evaluated by a
use of a stroke scale first aid provider for an acute illness
• Outcomes: • Intervention: The presence of any specific signs
– Critical: Time to treatment (eg, symptom onset to or symptoms (ie, pale, blue, or mottled skin, lips,
hospital/emergency department arrival or hospi- tongue, gums, or nails; nonblanching rash; difficulty
tal admission) breathing or rapid respiratory rates; rigors/shiver-
– Important: Recognition of stroke, high sensitiv- ing; lack of urination in a day; muscle pain; confu-
ity and high specificity considered beneficial for sion; or slurred speech)
diagnosis study, discharge with favorable neuro- • Comparator: Fever (≥38 °C [≥100.4 °F]) with signs
logic status (increase considered beneficial), sur- of infection
vival with favorable neurologic outcome (increase • Outcomes: Recognition of a seriously ill person
considered beneficial), increased public/layper- requiring hospitalization or evaluation by a physician
son recognition of stroke signs for sepsis and increased awareness of sepsis

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 Djärv et al First Aid: 2025 CoSTR

• Study designs: In addition to the standard crite- • Study designs: In addition to standard criteria, gray
ria, gray literature, social media posts, non–peer- literature including social media, non–peer-reviewed
reviewed studies, unpublished studies, conference studies, unpublished studies, case reports, confer-
abstracts, and trial protocols were eligible for ence abstracts and trial protocols were eligible for
inclusion. inclusion.
• Time frame: All years to December 2, 2023 • Time frame: All years to October 22, 2024
Good Practice Statement (2024) Summary of Evidence
Those providing first aid should consider an infection in Sixteen articles were included in this ScopRev, includ-
any person who presents with an acute illness, and if the ing 1 opinion article,50 2 observational training or perfor-
illness is associated with any abnormal signs or symp- mance assessment articles,51,52 5 qualitative studies,53–57
toms, they should urgently seek further medical evalua- 3 cross-sectional studies,58–60 2 guidelines,61,62 2 non-
tion (good practice statement). RCTs,63,64 and 1 RCT.49 Interventions in these studies
were primarily implemented by traditional birth atten-
Interventions Administered by Lay Providers for dants or similar persons with minimal formal training.
Three drugs were discussed: misoprostol, oxytocin,
the Treatment of Postpartum Hemorrhage (FA and ergotamine. All medications were administered orally,
7337, ScopRev 2025) rectally, or intramuscularly and were therefore consid-
Rationale for Review ered compatible with first aid practices. Misoprostol was
Postpartum hemorrhage is the leading cause of ma- administered rectally or orally in doses ranging from 400
ternal mortality and morbidity worldwide, particularly to 1000 mcg.60–65 Evidence on misoprostol came from
in low-income countries with limited resources.46 Early the RCT,65 both non-RCTs,63,64 a cross-sectional study,60
recognition and prompt treatment have the ability to and both guidelines.61,62 Oxytocin was discussed in both
prevent many deaths and long term health challeng- guidelines61,62 and 1 cross-sectional study58 in the con-
es.47 The FA Task Force performed a ScopRev to exam- text of a Uniject autoinjector, which keeps the medication
ine interventions for treating postpartum hemorrhage cool and enables lay administration.58,61,62 Ergotamine/
by lay providers, a topic that had not been reviewed by ergometrine was kept and used in lay settings56,58 and
ILCOR before. The full report of the ScopRev can be was further recommended for intramuscular delivery in
found online.49 low-resource settings in both guidelines.61,62
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Controlled cord traction was not recommended for

Population, Intervention, Comparator, Outcome,
use by unskilled birth attendants in both guidelines.61,62
Study Designs, and Time Frame
In lower-resource settings, some unskilled providers
• Population: First aid or emergency care adminis-
applied it in the absence of skilled birth attendants.54
tered by a lay provider to anyone experiencing post-
The use of uterine balloon tamponade was found to
partum hemorrhage
be effective and simple to use by community providers
• Intervention: Interventions that are classified as
in 1 qualitative study.55 A novel intrauterine tamponade
emergency care include those that fall within the
device developed for administration by people with mini-
following 2 categories:
mal training increased usability.51
– Physical interventions: Examples of physical inter-
The use of a compression lower body suit, so-called
ventions administered by a lay provider include
nonpneumatic antishock garment, which forces blood
external uterine massage, bimanual compression,
back to the vital organs, was highlighted by one guide-
aortic compression, antishock garment, manual
line and one opinion article.50,61 These garments are con-
removal of placenta, or manual removal of clots.
ventionally used only in health care facilities but were
– Medications/Pharmaceuticals: Examples of
described as having high potential for application by lay
medical interventions administered by a lay pro-
providers. Herbal medicines commonly used by traditional
vider include iron supplementation, prostaglandin
birth attendants were also addressed in several qualita-
E1/misoprostol, or any other drug that may be
tive and cross-sectional studies and guidelines53,54,56–59
accessible without intervention from a medical
but discouraged based on harms or lack of benefit.56
professional.
• Excluded interventions include those that require Task Force Insights
hospital/clinic support through medical profes- Most birth attendants globally are untrained or trained to
sionals such as a blood transfusion, or any invasive a level that would align with a first aid provider outside
surgical intervention such as curettage, uterine of the birthing or obstetrical domain.67 Determining the
or pelvic artery ligation, uterine tamponade, or difference between preventing and treating postpartum
hysterectomy. hemorrhage can be difficult, especially when interven-
• Comparator: No intervention tions used for prevention and treatment are often the
• Outcomes: Any clinical outcome same (eg, manual external uterine massage, oxytocin).

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 Djärv et al First Aid: 2025 CoSTR

Most studies were qualitative and retrospective in na- tant outcomes of blood loss and blood transfusion (weak
ture, leading to an increased risk of bias and overall low recommendation, very low–certainty evidence).
certainty of evidence. Only 1 RCT65 was performed and
Treatment Recommendation (2025)
evaluated only the efficacy of misoprostol.65
We suggest external uterine massage, including self-
Although we excluded studies on conventional uterine
massage, in the immediate postpartum period in com-
balloon tamponade, we included studies on innovative
parison with no intervention to prevent postpartum
devices useable by nonskilled providers.
hemorrhage, which can lead to maternal death (weak
This ScopRev triggered a SysRev on manual uterine
recommendation, very low–certainty evidence).
massage (FA 7336), which is included below.
Justification and Evidence-to-Decision Framework
Task Force Knowledge Gaps
Highlights
• The effect of first aid interventions for postpartum
The complete evidence-to-decision table is provided in
hemorrhage on long-term outcomes
Appendix A.
• Most studies were qualitative and retrospective
External uterine massage is a ubiquitous standard
in nature, leading to an increased risk of bias and
for professional birth attendants and first responders for
overall low certainty of evidence.
the prevention and management of postpartum hemor-
rhage.68,73,74,77 External uterine massage is a simple and
Manual Uterine Massage for Postpartum safe physical maneuver, equivalent to other physical
Hemorrhage (FA 7336, SysRev 2025) interventions routinely taught to first aid providers (eg,
moving a patient, splinting an injured limb, applying direct
Rationale for Review pressure or a tourniquet to a bleeding wound).
The FA Task Force undertook a SysRev on this topic be- Postpartum hemorrhage is a major source of global
cause many international guidelines and other knowledge morbidity and mortality, especially in settings with lim-
syntheses recommend external uterine massage for the pre- ited or no access to professional health care providers.
vention and management of postpartum hemorrhage.47,68–74 Therefore, recommendations that limit external uterine
Postpartum hemorrhage is a major cause of global morbidity massage to health care professionals would potentially
and mortality, particularly in lower-resource settings where compound health inequities. Although the identified study
most birth attendants have limited professional health edu- did not demonstrate a statistically significant reduction in
cation and may be considered lay or first aid providers.67 blood loss or blood transfusion, it did demonstrate that
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Manual external uterine massage is a simple and safe phys- external uterine massage can be taught to lay providers.
ical maneuver similar to other manual maneuvers taught to
first aid providers and may reduce morbidity and mortality. Task Force Knowledge Gaps
This SysRev was registered in Prospective Register of Sys- • The importance of the pressure and firmness of
tematic Reviews (PROSPERO) (CRD42024572048). The the uterine massage for the effectiveness of the
full CoSTR can be found online.75 intervention; the included study could not measure
or regulate the strength or firmness of the uterine
Population, Intervention, Comparator, Outcome, and massage by study participants and did not describe
Time Frame if or how this was controlled or taught.
• Population: Those experiencing postpartum • More studies examining massage by lay providers,
hemorrhage such as traditional birth attendants, are needed.
• Intervention: Manual external uterine massage • Whether manual uterine massage affects maternal
administered by a lay provider outcome beyond 120 minutes
• Comparator: Any other first aid intervention to treat
postpartum hemorrhaging, or no intervention
• Outcomes: Use of Naloxone During Resuscitation for
– Critical: Maternal survival, blood loss Suspected Opioid-Associated Emergencies (FA
– Important: Future fertility, surgical intervention, 7442, BLS 811, EvUp 2025)
organ dysfunction, pain, and blood transfusion
Population, Intervention, Comparator, Outcome, and
• Time frame: All years to March 22, 2024
Time Frame
Consensus on Science • Population: Adults and children with suspected
We identified a single RCT76 including 127 women who opioid-associated cardiac or respiratory arrest in the
had recently given birth in Kenya and were advised to prehospital setting
perform self-massage cued by an alarm every 15 min- • Intervention: Bystander naloxone administration
utes for the first 120 minutes after birth. The study re- (intramuscular or intranasal), in addition to standard
ported better compliance with an alarm every 15 minutes CPR
but a non–statistically significant difference in the impor- • Comparator: Standard CPR only

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 Djärv et al First Aid: 2025 CoSTR

• Outcomes: Any clinical outcome Treatment Recommendation (2019)

• Time frame: July 2019 to December 12, 2023 We recommend the use of any type of physical counter-
pressure maneuver by individuals with acute symptoms
Summary of Evidence
of presyncope due to vasovagal or orthostatic causes
This PICO question was transferred from the BLS
in the first aid setting (strong recommendation, low-
Task Force to the FA Task Force after 2020. Since the
certainty and very low–certainty evidence).
last SysRev in 2020, 356 new titles were screened.
We suggest that lower body physical counter-pressure
No new evidence was identified, and an update to the
maneuvers are preferable to upper body and abdominal
SysRev is not indicated. The current ILCOR practice
physical counter-pressure maneuvers (weak recommen-
is to use good practice statements in place of treat-
dation, very low–certainty evidence).
ment recommendations for cases in which there is in-
sufficient evidence for a treatment recommendation,
but the task force thinks guidance is warranted. The Unintentional Injury From Laypersons Providing
previous treatment recommendation based on expert Chest Compressions to Patients Who Are Not
consensus from 2020 has therefore been changed to in Cardiac Arrest (FA 7670, BLS 353, SysRev
a good practice statement.
2025)
Good Practice Statement (2020) Rationale for Review
We suggest CPR be started without delay in any uncon- Delivery of high-quality chest compressions is a key
scious person not breathing normally and that naloxone step in the Chain of Survival for patients in cardiac ar-
be used by lay rescuers in suspected opioid-related re- rest. Immediate CPR initiated by laypersons is associ-
spiratory or circulatory arrest (good practice statement). ated with improved outcomes. However, there may be
a reluctance among laypersons to initiate CPR for fear
Prevention of Syncope With Counter-Pressure of causing unintentional injuries. Since the last review84
Maneuvers (FA 7550, FA 798, EvUp 2025) in 2020, the topic has been moved from the ILCOR
BLS Task Force to FA Task Force, prompting a new
Population, Intervention, Comparator, Outcome, and SysRev85 focusing on layperson rescuers. The term
Time Frame harm was changed to unintentional injury. The SysRev
• Population: Adults and children with signs and was registered before initiation (PROSPERO Registra-
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symptoms of faintness or presyncope of suspected tion CRD42023476764). The complete CoSTR can be
vasovagal or orthostatic origin found online.86
• Intervention: Interventions such as counter-pressure
maneuvers, body positioning, hydration, or other Population, Intervention, Comparator, Outcome, and
• Comparator: No intervention or any other Time Frame
intervention • Population: Adults and children outside of a hospital
• Outcomes: Avoiding or preventing syncope or who are not in cardiac arrest
transient loss of consciousness, resolution of • Intervention: Provision of chest compressions by
symptoms or symptoms response, hemodynamic laypersons
status (including systolic and diastolic blood pres- • Comparator: No use of chest compressions
sure, change in heart rate, cardiac output, stroke • Outcomes: Survival with favorable neurological out-
volume, or blood flow velocity), recurrences of come at discharge, 30 days, 60 days, 180 days, or 1
presyncope or syncope, time to resolution of year; unintentional physical injury (previously harm)
symptoms, adverse events, admission to hospital, (eg, rib fracture, bleeding); risk of unintentional
quality of life injury (eg, aspiration, rhabdomyolysis)
• Time frame: December 2, 2021, to December 2, • Time frame: All years to September 17, 2024
2023
Consensus on Science
Summary of Evidence Since the last SysRev, 1 new study87 was identified. In
Since the 2019 CoSTR summary,78,79 2 SysRevs80,81 were the total of 5 studies,87–91 including 1031 patients not in
identified on the use of physical counter-pressure ma- cardiac arrest who received CPR, 7 (0.7%) experienced
neuvers for the prevention of syncope. Additionally, 1 unintentional physical injury. Additionally, 2 (0.2%) pa-
RCT82 was found assessing counter-pressure maneu- tients had a risk of unintentional injuries and a further 24
vers during dental extraction in patients with a history of (2%) had symptoms such as chest pain or discomfort.
dental anxiety and previous syncope. The SysRevs and No deaths caused by CPR were reported, but 61 (6%)
single RCT support the conclusions of the 2019 SysRev patients died before being discharged from the hospital.
and CoSTR.78,79,83 An updated SysRev is not indicated at The included studies were too heterogeneous to perform
this time. a meta-analysis.

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 Djärv et al First Aid: 2025 CoSTR

Prior Treatment Recommendations (2020) • The incidence and pattern of injuries from CPR
We recommend that laypersons initiate CPR for pre- given to children not in cardiac arrest.
sumed cardiac arrest without concerns of harm to pa- • Few aspects of equity were reported in studies.
tients not in cardiac arrest (strong recommendation, very
low–certainty evidence).
Spinal Motion Restriction for Possible
Treatment Recommendations (2025) Traumatic Cervical Spinal Injury (FA 7311, FA
We recommend that laypersons initiate CPR for pre- 7312, FA 1547, ScopRev 2025)
sumed cardiac arrest without concerns of causing un-
intentional injury (strong recommendation, low-certainty Rationale for Review
evidence). In many countries, spinal motion restriction protocols are
We recommend that other rescuers (eg, trained used by emergency medical service professionals, but
bystanders, health care professionals, and those with similar guidance for first aid providers continues to be
a duty to respond) initiate CPR for presumed cardiac debated. There is ongoing controversy around the use of
arrest without concerns of causing unintentional injury to cervical collars and other devices by both trained emer-
persons not in cardiac arrest (good practice statement). gency medical service providers and lay first aid provid-
ers and concern regarding the evidence of harm from
Justification and Evidence-to-Decision Framework cervical collars, as well as the risk of secondary spinal
Highlights cord injury after the initial trauma. Manual stabilization of
The complete evidence-to-decision table is provided in spinal injury (FA 7312, FA 1547) was included in this new
Appendix A. PICO. This ScopRev92 encompasses literature published
In making this discordant recommendation, the FA Task in the last 25 years, including previous work done by the
Force placed a higher value on the potential survival ben- 2015 FA Task Force.7,93 The full report of the ScopRev
efits of CPR initiated by laypersons for patients in cardiac can be found online.
arrest and a lower value on the low risk of injury in patients
not in cardiac arrest. The intention of this recommenda- Population, Intervention, Comparator, Outcome, and
tion is to strongly encourage and support laypersons who Time Frame
are willing to initiate CPR in any setting when they believe • Population: Adults and children with possible trau-
someone has suffered a cardiac arrest. matic cervical spinal injury
The included studies focused on laypersons and not • Intervention: Cervical spinal motion restriction per-
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on other persons, such as health care professionals or formed by a trained first aid provider
those with a duty to respond, but the task force believes • Comparator: No cervical spinal motion restriction, or
that the benefit of starting CPR outweighs the harm another type of cervical spinal motion restriction
and used the indirect evidence to make a good practice • Outcome: Any clinical outcome
statement. • Time frame: January 1,1999, to July 31, 2024
The incidence of chest wall bone fractures was sub-
Summary of Evidence
stantially lower than the incidence reported after CPR in
We included 66 studies, including 22 RCTs,94–115 19
patients who were in cardiac arrest. This could be because
non-RCTs,116–134 8 cohort studies,135–142 3 interrupted
of the shorter duration of CPR (most often <5 minutes)85
time series,143–145 7 case series,146–152 and 7 retrospec-
initiated by laypersons and stopped by professional res-
tive chart reviews.153–159 Out of a total of 46 experimental
cuers. However, the possibility of underreporting due to
studies, 36 (78%) were performed in live human volun-
nonsystematic diagnostic studies cannot be excluded.
teers, 94–99,101–103,105–116,119–124,126,128–130,133,134,144,145,150,152
The task force discussed how the use of a structured
and 5 primarily used human cadaver mod-
equity assessment, such as the PROGRESS Plus tool,5
els117,118,127,131,132 to assess range of cervical motion and
might increase equity-focused reporting. The proportion
adverse effects of spinal motion restriction. The 20
of men and women were roughly equal in the included
observational studies135–143,146–149,153–159 mainly investi-
studies. However, in 3 studies, the layperson often had
gated the risk of secondary spinal injury, functional out-
some kind of relationship with the patient, as either a fam-
comes, and adverse effects of spinal motion restriction
ily member or personnel at a nursing home. Both types of
in trauma patients.
relationships might be accompanied by fear of causing
Evidence for the effectiveness of spinal motion
an injury, and still they most likely would be more willing
restriction compared with no spinal motion restric-
to cause an unintentional injury if it comes with survival.
tion was provided in 46 studies,94,97,99–101,105,107–111,114–118,
Task Force Knowledge Gaps 120,121,123–125,127,130,131,133,135,136,138,139,143–157,159
with most
• More studies are needed with robust methodology (n=35) comparing cervical collar use with no cervical
to identify unintentional injuries and provide follow- collar use. Together, these studies indicated that cervical
up after hospital discharge. collars decrease the range of cervical motion but lead to

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 Djärv et al First Aid: 2025 CoSTR

impaired respiratory and swallowing function as well as This ScopRev provides a comprehensive overview
increased intracranial pressure. of the available evidence and may serve as a basis for
Twenty-nine studies94,97–100,102–104,106–113,115,117,120,121,123,126, future SysRevs on one or more narrowly defined PICO
128,131–134,140,146
compared multiple types of spinal motion questions, which will be discussed in the upcoming year
restriction. Four studies compared soft foam with rigid within the task force. Currently, the 2015 treatment rec-
collars,117,120,131,146 suggesting that the use of soft foam ommendation remains unchanged.
collars allows significantly more cervical motion117,120,131
Treatment Recommendation (2015)
but is not associated with an increased risk of secondary
We suggest against the use of cervical collars by first
spinal injury.146 One study106 showed no significant dif-
aid providers (weak recommendation, very low–certainty
ferences in range of cervical motion between improvised
evidence).
(eg, a folded fleece jacket) and commercially available
collars. Five studies98,99,103,108,113 showed that in com- Task Force Knowledge Gaps
parison with 2-piece rigid collars, one-piece rigid collars • The potential benefits and harms of spinal motion
result in greater restriction of cervical motion and cause restriction in conscious or unconscious persons,
significantly lower increases in jugular venous pressure performed by untrained or trained first aid providers
but create higher interface pressures. • Optimal methods for spinal motion restriction that
The effectiveness of spinal motion restriction meth- could be applied specifically in low-resource set-
ods or devices during simulated extrication from vehicles tings (eg, a folded fleece jacket as an improvised
was assessed in 4 studies.95,96,122,129 These suggested collar, a folded towel wrapped around the neck and
that collar application in combination with unassisted crossed around the chest)
self-extrication, whereby a person is asked to leave the • Whether selective spinal immobilization by trained
vehicle themselves without further instructions, creates first aid providers using a protocol results in benefi-
the least range of cervical motion. cial or harmful clinical outcomes
Finally, 5 studies135,137,141,142,158 found no significant
difference in the incidence of spinal cord injuries or
Cryotherapy for Epistaxis (FA 7151, ScopRev
functional outcomes of trauma patients before and
after the implementation of spinal motion restriction 2021)
protocols. Cryotherapy, or cooling, has been suggested to shrink
nasal mucosa and cause vasoconstriction as a method to
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Task Force Insights

aid hemostasis. For 2021, the FA Task Force prioritized
Most of the evidence comes from experimental stud-
the topic for a ScopRev to identify the scientific evidence
ies in healthy young adult volunteers or human cadav-
behind such recommendations for the use of cryotherapy
ers. Therefore, the findings may not be generalizable to
for epistaxis. Details of this ScopRev160 can be found in
adults and children with possible traumatic cervical spine
the 2021 CoSTR summary.161
injury. Also, 40% of all included studies were conducted
in the United States. Population, Intervention, Comparator, Outcome,
Only 2 studies106,120 looked at improvised devices Study Design, and Time Frame
for spinal motion restriction, which may be particularly • Population: Adults and children receiving first aid for
useful for first aid in low-resource settings. In contrast, acute epistaxis
many experimental studies included direct comparisons • Intervention: Cryotherapy alone or cryotherapy with
of multiple commercially available cervical collars. There nose pinching
was marked heterogeneity across studies in the different • Comparator: Nose pinching alone
brands or specific features of cervical collars, including • Outcome: Time to hemostasis control (minutes),
in their design (1-piece or 2-piece) and structure (rigid, hemostasis (yes/no), reduction of nasal blood vol-
semirigid, soft, improvised). ume (volume), reduction of pain, need for follow-up
The task force recognizes that trained first aid provid- care (yes/no), adverse events (yes/no), recovery
ers in selected circumstances (eg, ski patrols and life- time (days/min), reduction of swelling (volume)
guards) might be capable of using cervical collars but • Study designs: In addition to the standard criteria,
concluded that formal data synthesis and determination gray literature was available for inclusion. Further,
of the certainty of the vast evidence base is required to we examined ILCOR’s 8 member councils’ and their
confidently withdraw the existing treatment recommen- subcouncils’ websites.
dation or to formulate any further treatment recommen- • Time frame: All years to January 14, 2021; a gray
dation or good practice statement. A future systematic literature search was conducted December 28,
review of protocol-based selective spinal motion restric- 2020
tion may provide additional evidence for a good practice There was insufficient evidence to support a good prac-
statement. tice statement.

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 Djärv et al First Aid: 2025 CoSTR

Manual Pressure and Pressure Devices for Population, Intervention, Comparator, Outcome, and
Bleeding (FA 7331, FA 530, SysRev 2021, EvUp Time Frame
• Population: Adults and children with severe, life-
2025) threatening external bleeding from an extremity
Population, Intervention, Comparator, Outcome, and • Intervention: Improvised tourniquets, direct manual
Time Frame pressure or direct pressure to the wound with a
• Population: Adults and children with severe, life- compression dressing, compression bandage or
threatening external bleeding from an extremity compression device, hemostatic dressings
• Intervention: Direct pressure to the wound with a • Comparator: Manufactured tourniquets
compression dressing, compression bandage, com- • Outcomes:
pression device, wound clamp, application of a junc- – Critical: Mortality due to bleeding; cessation of
tional pressurize, proximal manual pressure bleeding or achieving hemostasis; time to achiev-
• Comparator: Direct manual pressure ing hemostasis
• Outcomes: – Important: Mortality from any cause, decrease
– Critical: Mortality due to bleeding; cessation of in bleeding, complications/adverse effects (eg,
bleeding, achieving hemostasis; time to achieving wound infection, limb loss, rebleeding, pain
hemostasis related to an intervention)
– Important: Mortality from any cause; decrease • Time frame: November 22, 2019, to June 29, 2024
in bleeding; complications/adverse effects
(eg, wound infection, limb loss, rebleeding, pain Summary of Evidence
related to an intervention) Since the last SysRev162 in 2021, 29 articles170–198
• Time frame: November 22, 2019, to July 2, 2024 were identified regarding the use of tourniquets for life-
threatening extremity bleeding. The data support the use
Summary of Evidence of tourniquets compared with no use of a tourniquet for
Since the 2021 SysRev,162 7 studies163–169 were identified life-threatening extremity hemorrhage. Studies demon-
on the use of pressure devices or pressure points compared strate reduced in-hospital mortality and a lower incidence
with direct manual pressure. While findings in these studies of shock when tourniquets are used. Evidence supports
suggest some potential benefits for the use of pressure the use of commercial tourniquets compared with im-
points or pressure devices in some settings, the results are provised tourniquets because commercial tourniquets
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confounded by the indirect nature of the evidence and po- achieve better arterial occlusion and are simpler to apply.
tential bias. Given these limitations, a ScopRev or SysRev Therefore, based on this EvUp, a SysRev on tourniquet
is not warranted at this time. Future ScopRev or SysRev use in children was undertaken and is included here.
should clarify the definitions of devices for manual pres-
sure versus limb tourniquets. After discussion, wording was Treatment Recommendation (2020)
added to the existing 2021 treatment recommendations to We suggest that first aid providers use a tourniquet in
clarify that the recommendation for direct manual pressure comparison with direct manual pressure alone for severe,
is specific to bleeding from an extremity. life-threatening external bleeding that is amenable to the
application of a tourniquet (weak recommendation, very
Treatment Recommendation (2021) low–certainty evidence).
We recommend that first aid providers use direct manual We suggest that first aid providers use a tourni-
compression compared with the use of external com- quet rather than a hemostatic dressing for severe, life-
pression devises or pressure dressings/bandages for se- threatening external bleeding that is amenable to the
vere life-threatening external bleeding from an extremity use of a tourniquet (weak recommendation, very low–
(strong recommendation, very low–certainty evidence). certainty evidence).
We recommend against the use of pressure points
compared with the use of direct pressure by first aid
providers for severe, life-threatening external bleeding Types of Pediatric Tourniquets (FA 7333, FA 768,
(strong recommendation, very low–certainty evidence). SysRev, 2021 CoSTR Summary)
A SysRev of the use of tourniquets in the children (<19
Type of Tourniquets Alone or in Combinations years of age) was conducted for the 2021 CoSTR sum-
With Other Methods of Achieving Hemostasis mary.161
(FA 7333, FA 768, SysRev 2021, EvUp 2025) Population, Intervention, Comparator, Outcome,
The original PICO was a mega-PICO with several sub- Study Designs, and Time Frame
PICOs.162 The EvUp below focused on one of the sub- • Population: Children (<19 years of age) with severe,
PICOs. life-threatening bleeding from an extremity wound

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 Djärv et al First Aid: 2025 CoSTR

• Intervention: Commercial elastic wrap tourniquet or continue to be indirect, data continue to suggest that
commercial ratcheting tourniquet hemostatic dressings decrease the duration of bleeding
• Comparator: Commercial windlass rod–type and improve survival when compared with conventional
tourniquet gauze used to stop life-threatening bleeding. There con-
• Outcome: Mortality, control of bleeding (includ- tinues to be a low reported rate of side effects. The new
ing surrogate outcome of obliteration of Doppler studies identified support the existing recommendations.
pulses), blood loss, shock/hypotension, and adverse Therefore, based on this EvUp, no additional ScopRev or
events SysRev is warranted.
• Study designs: In addition to standard criteria, mod-
Treatment Recommendations (2020)
eling studies, studies of tourniquets applied solely to
We suggest that first aid providers use a hemostatic
maintain a bloodless surgical field, and those relat-
dressing with direct pressure as opposed to direct
ing only to education were excluded.
pressure alone for severe, life-threatening external
• Time frame: All years to October 1, 2020
bleeding (weak recommendation, very low–certainty
Treatment Recommendations (2021) evidence).
We suggest the use of a manufactured windlass tour- For the treatment of severe, life-threatening external
niquet for the management of life-threatening extremity bleeding by first aid providers, due to very limited data
bleeding in children (weak recommendation, very low– and very low confidence in effect estimates, we are
certainty evidence). unable to recommend the use of any one specific type of
We are unable to recommend for or against the use hemostatic dressing compared with another.
of other tourniquet types in children because of lack of
evidence.
For infants and children with extremities that are too
Duration of Cooling With Water for Thermal
small to allow the snug application of a tourniquet before Burns (FA 7371, FA 770 SysRev 2021)
activating the circumferential tightening mechanism, we This topic was prioritized by the ILCOR FA Task Force
recommend the use of direct manual pressure with or because of a lack of international consensus about the
without the application of a hemostatic trauma dressing optimal duration for cooling of thermal burns with run-
(good practice statement). ning water in the first aid setting and because of newly
identified relevant studies since the topic was last re-
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viewed in 2015. A SysRev204 was undertaken on behalf

Hemostatic Dressing (FA 7334, FA 769, EvUp of the FA and Pediatric Task Forces and was included in
2025) the 2021 CoSTR summary.161
Population, Intervention, Comparator, Outcome, and
Population, Intervention, Comparator, Outcome, and
Time Frame
Time Frame
• Population: Adults and children with severe, life-
• Population: Adults and children in first aid settings
threatening external bleeding
with a thermal burn
• Intervention: Hemostatic dressings with or without
• Intervention: Active cooling using running water
direct pressure (manual or pressure to the wound
for 20 minutes or more as an immediate first aid
with a compression dressing, compression ban-
intervention
dage, or compression device)
• Comparator: Active cooling using running water
• Comparator: Direct manual pressure or direct pres-
for any other duration as an immediate first aid
sure to the wound with a compression dressing,
intervention
compression bandage, or compression device
• Outcome: Size of burn, defined as percentage of
• Outcomes:
total body surface area at any reported time point;
– Critical: Mortality due to bleeding; cessation of
depth of burn, defined as any degree of deep partial
bleeding, achieving hemostasis; time to achieving
or full thickness burn depth; pain, defined as any
hemostasis
measurement of pain or administration of pain relief
– Important: Mortality from any cause; decrease
medications; adverse outcomes, defined as any
in bleeding; complications/adverse effects
adverse outcome, including hypothermia; wound
(eg, wound infection, limb loss, rebleeding, pain
healing, defined as time to re-epithelization in days;
related to an intervention)
and complications within 24 hours, defined as organ
• Time frame: November 1, 2019, to November 2024
dysfunction, ICU care, infections (within 7 days),
Summary of Evidence bleeding, and rhabdomyolysis as well as the need
Since the 2020 SysRev, 5 articles199–203 were identified for surgical procedures such as skin grafting, fasci-
regarding the use of hemostatic dressings for the con- otomy, or escharotomy
trol of life-threatening bleeding. While much of the data • Time frame: All years to February 10, 2021

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 Djärv et al First Aid: 2025 CoSTR

Treatment Recommendations (2021) (sodium chloride) for temporary storage of an avulsed

We recommend the immediate active cooling of thermal tooth (weak recommendation, very low–certainty evi-
burns using running water as a first aid intervention for dence).
adults and children (strong recommendation, very low– There is insufficient evidence to recommend for or
certainty evidence). against temporary storage of an avulsed tooth in saliva
Because no difference in outcomes could be dem- compared with alternative solutions.
onstrated with the different cooling durations studied, a There is insufficient evidence to recommend for or
specific duration of cooling cannot be recommended. against temporary storage of an avulsed tooth in probi-
Young children with thermal burns being actively otic media, epigallocatechin-3-gallate, Dentosafe box, or
cooled with running water should be monitored for signs egg white compared with cow’s milk.
and/or symptoms of excessive body cooling (good prac-
tice statement).
Compression Wrap for Closed Extremity Joint
Injuries (FA 7381, FA 511, EvUp 2025)
Dental Avulsion (FA 7361, FA 794, EvUp 2025) Population, Intervention, Comparator, Outcome, and
Population, Intervention, Comparator, Outcome, and Time Frame
Time Frame • Population: Adults in the prehospital setting with a
• Population: Adults and children in any setting (in- closed extremity joint injury
hospital or out-of-hospital) with an avulsed perma- • Intervention: Compression wrap, elastic wrap
nent tooth • Comparator: No compression wrap or elastic wrap
• Intervention: Any storage media, container, or • Outcomes:
technique – Critical: Reduction of pain and reduction of
• Comparator: Storage in whole milk or the patient’s swelling/edema
saliva – Important: Recovery time, range of motion,
• Outcomes: adverse effects
– Critical: Success of replantation and tooth sur- • Time frame: January 1, 2020, to September 30, 2024
vival or viability
– Important: Color of the tooth, infection rate, mal- Summary of Evidence
function (eating, speech) and pain Since the SysRev209 in 2020, no new studies were identi-
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• Time frame: July 1, 2019, and updated to December fied.

2, 2023 Treatment Recommendations (2019)
Summary of Evidence We suggest either application of a compression bandage
Since the last SysRev205 in 2020, 3 studies206–208 were or no application of a compression bandage for adults
identified regarding the use of a storage medium, con- with an acute closed ankle joint injury (weak recommen-
tainer, or technique for an avulsed permanent tooth. The dation, very low–certainty evidence).
evidence suggests that storage in a cooler tempera- Due to a lack of identified evidence, we are unable to
ture favored viability of periodontal ligament fibroblasts recommend for or against use of a compression bandage
for all storage media, except for Hanks’ Balanced Salt for closed joint injuries on other joints besides the ankle.
Solution (a buffered salt solution). Propolis (a natural
product made by bees by mixing resin, wax, and oils), Preservation of Traumatic, Completely
cow’s milk, and almond milk can be alternative storage Amputated or Avulsed Body Parts (FA 7391,
mediums. Based on this EvUp, an updated SysRev is ScopRev 2025)
not warranted.
Rationale for Review
Treatment Recommendation (2020) Complete amputation of extremities or digits is a physi-
We suggest the use of Hanks’ Balanced Salt Solution, cally and emotionally traumatic experience that can
propolis (0.04–2.5 mg per mL 0.4% ethanol), oral rehy- lead to long-term disability and disfigurement. Globally,
dration salt solutions including Ricetral (oral rehydration the incidence and prevalence of traumatic amputations
salt solutions containing sodium chloride, glucose, potas- reached 11.37 million and 552.45 million respectively in
sium chloride, citrate [or extruded rice]), or cling film com- 2019. Nonfreezing cold storage of an ischemic ampu-
pared with any form of cow’s milk for temporary storage tated limb or digit is essential to improve the potential
of an avulsed tooth that cannot be immediately replanted for successful replantation and revascularization, par-
(weak recommendation, very low–certainty evidence). If ticularly when transport times are prolonged. Only 35%
none of the above choices are available, we suggest the of patients with traumatic amputations present to the
use of cow’s milk, any percent fat or form, compared with emergency department with properly preserved ampu-
tap water, buttermilk, castor oil, turmeric extract, or saline tated body parts, making it difficult for surgeons to offer

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 Djärv et al First Aid: 2025 CoSTR

replantation when it would otherwise be an option.210-211 The observational studies assessed factors poten-
The full report of this ScopRev can be found online.211a tially associated with successful replantation and func-
tional recovery, including the method of preservation of
Population, Intervention, Comparator, Outcome,
the amputated part prior to hospital arrival and the total
Study Designs, and Time Frame
ischemic time. Three cohort studies240,243,244 reported an
• Population: Adults and children with a traumatic
association between cold preservation for up to 6 hours
complete amputation or a complete avulsion of an
and successful replantation of major upper extremity,
external body part (eg, digit, hand, arm) or soft tis-
although replantation of upper extremities was reported
sue in the out-of-hospital setting
in a fourth study245 to be successful after 7 to 13 hours
– Excluded: Adults and children with a partial
without cold preservation but with limited functional out-
amputation or avulsion, an internal avulsion, or a
comes. A complete overview of experimental and obser-
surgical amputation
vational studies with key findings is presented in Table 3.
• Intervention: Any approach to preservation of the
Three SysRevs with meta-analysis (Table 4) assessed
amputated body part or avulsed tissue for possible
clinical outcomes for amputated parts preserved with
replantation/attachment
cooling compared with no cooling of tissue, but in most
• Comparator: Another approach to preservation of
cases failed to describe the actual method of cooling or
the amputated body part or avulsed tissue for pos-
other factors such as cold or warm ischemia times.246–248
sible replantation/attachment
Care for amputated body parts was found in guide-
• Outcomes: Any clinical outcome; the task force
lines from St. John Ambulance and from several National
further specified a priori the critical outcome of
Societies of the International Federation of Red Cross
attempted and successful replantation of ampu-
and Red Crescent.249–251 The guidelines249–251 describe
tated body parts or reattachment of avulsed tissue.
wrapping the amputated part in moist gauze and plac-
• Study designs: In addition to standard criteria, the
ing it in a watertight container, which is then placed in
gray literature search included relevant guidelines
another larger container with ice or a mixture of ice and
from ILCOR-member organizations.
water.
• Time frame: All years to April 17, 2024
Task Force Insights
Summary of Evidence Following a traumatic amputation or avulsion, the pri-
This review212 identified 37 studies from 23 countries ority is to care for the patient, including control of life-
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with various study designs: 23 case reports,213–235 2 case threatening bleeding. However, care of the amputated
series,236,237 2 experimental studies using animal mod- or avulsed part is sometimes overlooked or delayed. Our
els,238,239 1 prospective observational study,240 6 retro- ScopRev found that in 9 out of 23 case reports, there
spective observational studies,210,241–245 and 3 SysRevs was a delay in retrieving the amputated part due to the
with meta-analyses.246–248 part being lost, intentionally discarded, or intentionally
All studies included human subjects except for the 2 withheld in a hostage situation (Table 2).
experimental studies. The experimental studies assessed More distal amputated parts (such as digits) without
replantation success following storage of amputated parts skeletal muscle appear to tolerate longer periods of isch-
for between 21 and 24 hours at room temperature, 4 °C emia without cold preservation (eg, up to 12 hours) while
and minus 5 °C. Case reports213–235 and series described cold preservation appears to extend the tolerable isch-
varying degrees of successful replantation with revas- emic time before successful replantation to 24 or more
cularization of completely amputated or avulsed body hours. Observational studies of major upper extrem-
parts that, before hospital arrival, were cooled by differ- ity amputations note successful replantation and func-
ent means or stored without cooling. Total ischemic time tion when cold preservation techniques were used, with
between amputation and replantation ranged from 2 extension of time to replantation to 12 hours versus 6
hours to 15 days. Successful replantation was reported in hours without cold preservation.
nearly all case reports and series with amputations involv- Guidelines identified provide a reasonable approach
ing body parts without skeletal muscle (eg, digits) and in to providing cold but nonfreezing storage of amputated
those cases with longer ischemic times when the part(s) or avulsed body parts. Wrapping the part in gauze or cloth
were preserved with cold storage.215,219,228,234 Unsuccessful is intended to prevent freezing of the tissue. Moistening
replantations were described in cases of prolonged (eg, up the cloth with saline or water is intended to prevent des-
to 30 hours) ischemia without cooling or cleaning/soaking iccation of exposed tissues. Some guidelines also sug-
the part in water for 2 hours. The process described for gest labeling the container holding the body part with the
cooling varied widely but often involved wrapping the part name of the person, time of injury, and time the ampu-
in moist gauze, placing it in a plastic bag and then placing tated part was placed in cold storage.
the bag in another container with ice or an ice-water mix. Most evidence identified in this review appears to
A complete overview of characteristics and key findings support the prehospital cold storage of amputated or
from the case reports and series is presented in Table 2. avulsed body parts, when feasible, especially when

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 Djärv et al First Aid: 2025 CoSTR

Table 2. Preservation of Traumatically Amputated/Avulsed Parts Characteristics of Case Reports and Series

First author, year,

country Population Preservation technique Main findings for patient outcomes
Akyurek, 2020,
213
72-year-old female, Avulsed scalp left under snow for 4 hours be- Uncomplicated/complete survival of replanted scalp, normal
United States equestrian accident, fore being located appearance at 4 years
scalp avulsion
Borenstein,214 2 female teenagers Case 1: Scalp with 2 auricles wrapped in wet Case 1: 95% of the scalp and left auricle survived; new hair
1990, Israel with complete avul- gauze, placed in a plastic bag surrounded by growth, eyebrow movement at 3-months post-op
sion of the scalp and ice; hospital arrival 2 hours postinjury Case 2: Partial survival of scalp, some grafting required; no
3/4 ears Case 2: Total avulsion of scalp and left auricle; survival of replanted ears
preservation technique not described
Braga-Silva,215 55-year-old female, Patient presented without amputated part; Survival of cold-preserved replanted finger despite 15-day
2016, Brazil amputation of distal finger located later, placed in sealed jar, delay; good function, cosmesis and 2-point discrimination at
ring finger from knife refrigerated at 4 °C for 15 days 8-year follow-up
deLagausie,216 4-year-old male, Placed in container with ice without direct Successful replantation of penis after cold ischemic time 6
2008, France amputated penis contact, 6 hours hours; normal function at 8-year follow-up
Dvořák,217 38-year-old male, Ear wrapped in moistened gauze and stored on Successful replantation despite frozen avulsed/amputated ear;
2020, Czech avulsed ear dry ice, arrived frozen/rigid cosmetic changes and cold intolerance on long-term follow-up
Republic
Elsahy,235 14-year-old male, Tissue lost for 2 hours; at hospital, immersed in Successful grafting 4 hours after injury following 2 hours warm
1974, Canada avulsed left nasal ala saline, refrigerated at 7 °C for 2 hours ischemia and 2 hours cold ischemia; normal skin color at 7
from dog bite months
Facio,218 30-year-old male, No cooling of amputated part for initial 5 hours, Successful replantation of transplanted penis after 5 hours
2015, amputated penis then stored 1 hour in a clean plastic container warm ischemia; erectile function, urinary pattern, cosmesis ac-
Brazil with saline and ice cubes ceptable at 2-year follow-up

Fernandez- 28-year-old male, Hand stored in a plastic bag on ice inside an Successful replantation at 13 hours postinjury; posttransplant
Palacios,219 2009, hand amputation at isothermal box; prolonged transport time due to infection; recovery at 3 weeks
Spain sea remote (ocean) location
Firdaus,220 8-year-old male, above “A witness immediately buys an ice bag from Successful replantation of cold-preserved arm; good circula-
2017, Malaysia elbow amputation shop nearby and the amputated part was well tion in the immediate post-op period; no further follow-up
from motorcycle preserved.” described
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accident
García-Murray,221 27-year-old female Both ears unpreserved for 2 hours, then Failed replantation after 2 hours warm ischemia, 52 hours cold
2009, Mexico hostage, bilateral ear wrapped in moist gauze, placed in sterile plastic ischemia; successful salvage procedure with reattachment
helix amputations bag, kept in a bucket filled with ice/water then of ears, reconstruction and free flap; good cosmesis at 12
refrigerated 3 hours months
Gunasagaran,222 42-year-old female, Amputated thumb found on side of road Successful replantation despite 2 hours storage directly on ice
2022, Malaysia left thumb amputation (unknown time interval after injury), placed in followed by ice water; no frostbite or maceration of the ampu-
from machete plastic bag with ice; on arrival 2 hours later, tated thumb observed after storage on ice/in ice water; good
ice had melted, thumb immersed in ice water; motion/function of thumb at follow-up
thumb then wrapped in moist gauze, stored in
“ice box”
Henry,223 34-year-old male, No preservation for 15 hours, then put on ice/ Survival of penile transplant despite 15 hours warm ischemia
2020, UK amputated penis transported with patient time; debridement and skin graft needed at 2 months, normal
function at 6 weeks
Kyrmizakis,224 47-year-old male and For both cases, auricles placed in plastic bag Case 1: Successful replantation after 4 hours cold ischemia
2006, Greece 20-year-old male, with saline, surrounded by ice, transported with time as composite graft but required revision at 3 months; no
amputated ears patient complications at 6 months except 10% decrease in size
Case 2: Successful replantation after 3 hours of cold ischemia
time, composite graft, revision at 3 months
Li,225 3-year-old male, right No specific care of the amputated leg before Successful replantation of leg after 2 hours of warm ischemia
2020, China leg amputation at knee hospital arrival (warm ischemia time: 2 hours); time, <6 hours cold ischemia; partial motor and sensory func-
level by sword leg then wrapped in saline-soaked gauze, tions 6 months after surgery; during follow-ups, the patient
placed in a plastic bag with ice for 400 km underwent sustained rehabilitation and recovered well
transfer to hospital (cold ischemia time <6
hours)
Liang,226 30-yr-old male, left ear Auricle retrieved 5 hours postamputation; at Successful replantation 10 hours after complete amputation
2004, China amputation by knife hospital auricle cleaned and “preserved in ice” of auricle; warm ischemia time 5 hours, 5 hours cold ischemia
for 5 hours time in-hospital; 1-year follow-up showed color, contour, tem-
perature similar to right ear

(Continued )

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 Djärv et al First Aid: 2025 CoSTR

Table 2. Continued
First author, year,
country Population Preservation technique Main findings for patient outcomes
Makki,227 Case 1: 43-year-old Avulsed lips both wrapped in saline-soaked At the 8-day follow-up, both patients had 100% healed cleft lip
2020, Denmark male, amputation of gauze and placed on ice in a bag and flap survival; at the 12-month follow-up, case 1 had a cos-
upper lip by human metically acceptable result with full movement in the upper lip
bite
Case 2: 30-year-
old male, upper lip
amputated in bicycle-
motor vehicle collision
May,228 28-year-old male, Digits placed in plastic bag surrounded by iced Because of the time required to replant all digits, a cold isch-
1981, United amputation of 4 saline (unclear if cooling occurred before arrival emia time of up to 28 hours was recorded for the final digit; all
States fingers of the left hand at hospital; patient presented with amputated digits survived replantation; the case suggests that the margin
from a paper cutting parts soon after injury) of safety in digit replantation may be greater than previously
machine thought
Musa,229 15-year-old male, Initially resuscitation at local hospital; Patient presented 30 hours after injury with the penis mummi-
2016, Nigeria avulsion of penis from amputated penis wrapped in gauze at hospital fied, precluding replantation
a grinding machine, and sent with patient to higher level of care,
with scrotal laceration arrived 30 hours postinjury; no cooling of
and devitalized tissues amputated tissue
Salem,230 23-year-old male, Amputated penis kept dry in plastic bag, double Successful replantation after 2 hours cold ischemia, 5 hours
2009, Egypt penile amputation bagged in ice and slush for 2 hours warm (intraoperative) ischemia
Selmi,231 11-year-old male, Testicle found in muddy water, cleaned with No testicular replantation attempted due to storage in water
2018, Turkey amputation of right soap/water, placed in jar of water for 2 hours and condition of testicle
testicle from bicycle before arrival at ER
Szlosser,232 82-year-old male, Amputated fingers “cooled” and “stored 2/4 amputated fingers were replanted, 4 hours warm isch-
2015, Poland transmetacarpal appropriately” 3 hours prior to arrival at hospital emia (operative) time; at 8 months, minimal movement of fin-
amputation of 4 gers; however, because the thumb was uninjured, hand grasp
fingers by circular saw was preserved, and patient was satisfied with the result; age
alone should not be an absolute contraindication to finger
replantation
Usui,233 14-year-old male, left Cooling of the amputated part in ice water; Successful replantation, 5 hours cold ischemia time; at
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1979, Japan distal one third leg 5-hour transportation time to the hospital 4-year follow-up, no joint contracture or deformity; child able
amputation from a to walk and run as fast as other children his age; success
mower was attributed to the patient’s youth, ideal conditions for
nerve repair, and the prearrival preservation of the amputated
part in ice water
Wei,234 24-year-old female, Prearrival: All 8 digits wrapped in normal saline- All replantations were successful following 76-hour transport
1988, Taiwan amputations of 8 soaked gauze and preserved in an ice bag; 76- time with cold preservation and total cold ischemia times of
fingers by a paper hour transportation time to the hospital 84, 86, and 94 hours for the left thumb, right thumb and left
cutting machine index finger; at 8 months post-op, the patient was able to per-
form most routine household tasks
Berger,236 33 patients with 27 Prearrival method of preservation or cooling Functional replantation not achieved in 9 of 11 cases; warm
1977, Austria complete amputations, not described except for 4 cases described as ischemia time of more than 8 hours felt responsible for failure
41 incomplete ampu- “improper first aid contributing to failed replant of replantation in 2 cases; review did not clearly describe the
tations procedure,” including: specific prearrival method of preservation or cooling technique
- Liquid-filled glass (1) other than for 4 cases; cold ischemia times of up to 12 hours
and a warm ischemia time of up to 6 hours considered the limit
- Floating in ice water (1) for replantation, although consideration of injury mechanism
- No cooling (2) and storage technique were both necessary for exclusion of
replantation
O’Brien,237 8 patients, complete The amputated fingers were “cooled in ice” Of 14 digital amputations, 11 survived replantation (83%),
1973, Australia amputation of total 14 (n=3), “cooled by ice in a plastic bag” (n=4), with ischemia times of 7 to 14 hours; for preservation methods
digits and not reported (n=1) linked to replantation failures due to complications, one was
“cooled in ice,” one not reported

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 Djärv et al First Aid: 2025 CoSTR

Table 3. Preservation of Traumatically Amputated/Avulsed Parts-Characteristics of Experimental and Observational Studies

Author, year, Main findings for preservation

country Population Preservation technique technique Other outcomes
Hayhurst, 238
10 Macaque monkeys 1.5 hours of warm ischemia Preservation for 21 hours at 4 °C did not The first 3 amputated fingers had com-
1974, Aus- with surgically ampu- during amputation proce- produce enough damage to preclude a plete necrosis; 1 subject died unexpect-
tralia tated index fingers, dure; fingers then wrapped reasonable chance of survival in digital edly with normal appearing replanted
replanted at 24 hours in saline-moistened surgical replantation finger; 1 finger had bleeding and necro-
sponge, kept at ~4 °C for sis felt due to anticoagulant overdosage
~21 hours; finger allowed to or trauma; the final 5 finger replants
return to room temperature were successful with survival of replants
for up to 2.5 hours for re- at up to 35 days
plantation
VanGiesen,239 40 amputated rabbit 1. Room air storage and 1. 5/5 replants survived All replants failed to survive after 24
1983, United ears replanted at 24 replanted within 1 hour 2. 5/5 replants survived hours of storage at room temperature
States hours (control) 3. 5/5 replants survived or at minus 5 °C; 2 other failures were
2. Immersed in lactated 4. 5/5 replants survived recorded: 1 stored at 4 °C wrapped
Ringer’s at 4 °C (24 5. 4/5 replants survived in a moistened normal saline surgical
hours) 6. 0/5 replants survived sponge, and 1 stored 2 hours at room
3. Nonimmersed, ear 7. 0/5 replants survived temperature followed by 22 hours of
wrapped in lactated Ring- 8. 4/5 replants survived storage at 4 °C; no difference was
er’s moistened sponge at shown when the amputated part was
4 °C (24 hours) stored in either lactated Ringer’s or nor-
4. Immersed in normal saline mal saline solution at 4 °C
at 4 °C (24 hours)
5. Nonimmersed, ear The author suggests that the best meth-
wrapped in saline moist- od for preservation would be to wrap
ened sponge at 4 °C (24 the amputated part in saline-moistened
hours) gauze and place this packet in a plastic
6. Immersed in lactated bag to be floated in an iced saline solu-
Ringer’s and wrapped in a tion. No difference among conventional
sponge at room tempera- methods of storage were noted if the
ture (24 hours) amputated part is not frozen or allowed
7. Frozen, nonimmersed, to become normothermic for more than
wrapped in lactated Ring- 2 hours.
er’s moistened sponge at
0° to –5 °C (24 hours)
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8. Nonimmersed wrapped in
lactated Ringer’s moist-
ened sponge for 2 hours
at room temperature and
4 °C for 22 hours
Li,242 2008, 211 patients (117 male 1. Dry storage at room tem- Compared with immersion in saline or Binary logistic regression analysis for
China and 94 female, mean perature (n=84 digits) ethanol, dry storage at room temperature predictor of digit survival found that
age 26.2 years [range, 2. Dry storage at 2–6 °C was associated with increased survival injury mechanism, platelet count, preser-
1–67 years]) with 211 (n=106 digits) rates in a nonstatistically significant man- vation of amputated part before admis-
complete fingertip am- 3. Immersed in saline or ner (aOR, 0.314; 95% CI, 0.041–2.399; sion, vein grafting, and smoking after the
putations undergoing ethanol (n=21 digits) P=0264); compared with immersion operation were independent prognostic
replantation surgery in saline or ethanol, dry storage at 2–6 variables that influence the survival of
°C was significantly associated with the replanted fingertip
increased survival (aOR, 0.028; 95% CI,
0.003–0.270; P=0.002); no statistical
difference between room- and low-
temperature (2–6 °C) preservation, sug-
gesting that the amputated fingertip could
withstand longer warm ischemia time
Chen,241 2017, 896 amputated fingers 1. Freeze-dried (n=536) 1. 518 (60.9%) survived versus 18 851/896 (94.98%) of amputated
China (average patient age, 2. Room temperature/dry (40.0%) did not survive fingers were successfully replanted;
22.0 ± 3.8 years) (n=273) 2. 257 (30.2%) survived versus 16 univariate analysis showed successful
3. Soaking liquid (n=87) (35.6%) did not survive replantation correlated with ischemic
Specifics of how and when 3. 76 (8.9%) survived versus 11 (24.4%) time, etiology of injury, age, plane of
preservation performed not did not survive severed finders, ways of preservation,
described artery reconstruction, platelet level and
incidence of vascular crisis (P<0.05)

(Continued )

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 Djärv et al First Aid: 2025 CoSTR

Table 3. Continued
Author, year, Main findings for preservation
country Population Preservation technique technique Other outcomes
Okumuş, 243
14 patients (14 male; All amputated parts but one Replantation of amputated extremity Overall satisfaction, recovery of active
2020, Turkey mean age, 29.6 years; arrived at hospital “in prop- in 11/14 cases (withheld in multilevel motion of digits and thumb opposition,
age range 11–45 erly prepared cold ischemic crush); “recommended ischemia times wrist and elbow joints, recovery of
years) with work- conditions”; one without for reliable success with replantation are sensitivity in the median and ulnar nerve
related amputations of cooling had “appropriate” 12 hours of warm and 24 hours of cold distribution, and ability of the surviving
an upper extremity warm ischemic time ischemia for digits, and 6 hours of warm hand or forearm to perform daily work
and 12 hours of cold ischemia for major were all judged satisfactory in hand
replants; the amputated part should be replantations; some distal ulnar nerve
wrapped in a saline-moistened gauze motor function problems reported in 3
sponge and placed in a plastic bag; the cases with replantation at the elbow
plastic bag should be sealed and placed
on ice; the amputated part should not be
placed directly on ice”
Tark,244 1989, 261 replantations of “Hypothermic” preservation Survival of replanted amputated parts 140 of 176 (80%) complete amputa-
Korea amputated digits and (no description given of how was assessed based on a warm or cold tions were successfully replanted;
hands in 153 patients; “hypothermic preservation” ischemia time of ≤12 or ≥13 hours; there clean-cut proximal level amputations
176 were complete was accomplished, and if was no significant relationship between and hypothermic-preserved amputation
amputations performed before arrival to a survival of the replant and length of isch- parts had the highest survival rate; a
hospital) emic time in the cold ischemia amputated higher survival rate seen with repair of
parts group; success rate of replantation both digital arteries and 2 veins rather
within 12 hours of warm ischemia was than only 1
higher than that after 13 hours of warm
ischemia
The Hoang,245 10 male patients with None of the amputated arms Ischemia times ranged from 7 to 13 All patients arrived at the hospital within
2009, Vietnam complete forearm were “properly preserved” hours; 1 illustrative case described the 2–8 hours postinjury; none of the ampu-
amputations, ages 14 amputated arm wrapped in a towel, tated parts were properly stored; overall
months–42 years transported with the patient 3 hours to survival of replanted limbs was 100%;
the hospital; no prehospital storage/ functional outcomes of replanted fore-
preservation of the amputated part was arms at 20 months rated from “excel-
performed, beyond one case in which the lent” to “fair” in 70% of patients
arm was wrapped in a towel
Sinatro,210 91 patients with trau- Prearrival “proper preserva- Most patients (60/91, 65.9%) arrived Replantation was attempted at a sig-
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2022, United matic amputation and tion” assessed, defined as without proper preservation of their nificantly lower rate (n=14, 23.3%) in
States documented modality “wrapping the part in saline amputated parts; of 74 patients trans- patients with improperly preserved parts
of preservation seen at soaked gauze inside a wa- ported by EMS, only 35.1% had proper than in those with properly preserved
a single tertiary center tertight bag and placing it preservation of their amputated part; only parts (n=18, 58.1%) (P=0.001)
on ice” 25.5% of patients presenting from home
had proper preservation of their ampu-
tated part(s)
Waikakul,240 186 patients (137 “Good preservation” defined Prearrival preservation by cooling of the There were 167 successful replantations
1998, male, 39 female; as “cooling” without further amputated part showed a significant and 16 failed replantations; of 102 ampu-
Thailand age range, 19–38 description effect on the outcome and was a better tated extremities that were cooled, 3 re-
years) with upper limb predictor than ischemic time plantations failed; 99 were successful; for
amputations: 24 am- amputated parts with “poor” preservation,
putations at the palm, 13 replantations failed, and 68 were suc-
75 at the wrist, 50 at cessful (P <0.05, Χ2 8.14); total ischemic
the forearm, and 28 time, sex and age did not affect results;
through the upper arm the type and severity of injury were also
and 9 disarticulations good predictors of successful replantation
at the elbow and functional outcome at 2 years

aOR indicates adjusted odds ratio.

transport of the part to a replantation center may be Replantation outcomes may be improved by cooling
delayed or take up to 6 hours. A SysRev of this topic without freezing the amputated or avulsed part as soon
is planned. as possible and throughout transportation to a health
care facility. If feasible, this can be accomplished by
Good Practice Statements (2025)
wrapping the part in a moist clean cloth or gauze and
Success in replantation is time dependent; complete-
sealing it in a watertight bag or container prior to cooling
ly amputated and avulsed external body parts such as
(good practice statement).
fingers, hands, arms, and legs should be retrieved and
transported as soon as possible, preferably to the same Task Force Knowledge Gaps
health care facility as the injured person (good practice • The optimal techniques for the provision of cold
statement). storage for an amputated or avulsed body part in

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 Djärv et al First Aid: 2025 CoSTR

the first aid/out-of-hospital setting, including cool- moval of an attached tick in the first aid setting and a
ers and freezer packs, instant cold packs, cool water, lack of prior SysRevs of this topic by ILCOR. This CoSTR
battery-powered coolers, and their association with was created with the adolopment process255 by using a
successful replantation recent SysRev. Details of this review can be found in the
• Systematic collection and reporting of data on the 2021 CoSTR summary.161
methods of prehospital preservation by first aid provid-
ers and prehospital professionals specifically should Population, Intervention, Comparator, Outcome,
be performed by both clinicians and researchers.
and Time Frame
• Population: Individuals in the first aid setting with a
Exertion-Related Dehydration and Rehydration tick attached to the skin
(FA 7241, FA 584, SysRev 2021) • Intervention: Any tick-removal method, including
During prolonged exercise, sweat losses generally ex- heat, chemical, commercial tick removal apparatus,
ceed fluid intake, and even low levels of dehydration can or tweezers/forceps
lead to impaired physical and cognitive performance. In • Comparator: Any other method of tick removal
such situations, it is of utmost importance to promote • Outcome: Transmission of disease, removal of (parts
postexercise drinking to restore fluid balance,252 yet of) the tick, damaged or broken-off mouth parts
there is no clear endorsement regarding the specific type • Time frame: 2017 (date of the adoloped SysRev) to
of rehydrating fluid. Therefore, a SysRev253,254 was under- February 14, 2021
taken on behalf of the FA Task Force and was included in
the 2021 CoSTR summary.161 Treatment Recommendations (2021)
Population, Intervention, Comparator, Outcome, and We recommend against the use of chemicals, heat, or ice
Time Frame in comparison with mechanical methods for the removal
• Population: Adults and children with exertion-related of a tick (strong recommendation, very low–certainty evi-
dehydration dence).
• Intervention: Drinking oral carbohydrate-electrolyte We suggest either pulling with tweezers or using com-
or alternative rehydrating liquids mercial devices according to the manufacturer’s instruc-
• Comparator: Drinking water tions to remove a tick rather than removal by hand (weak
recommendation, very low–certainty evidence).
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• Outcomes: Volume/hydration status (measured as

cumulative urine volume, net fluid balance, hemato-
crit, hemoglobin, plasma volume change), vital signs Treatment of Jellyfish Stings (FA 7211, SysRev
(measured as heart rate), development of hypona-
2025)
tremia (measured as serum sodium concentration,
serum/plasma osmolality), need for advanced medi- Rationale for Review
cal care, and patient satisfaction (measured as thirst This topic was prioritized by the FA Task Force based
perception, perceived intensity of stomach fullness, on the morbidity that jellyfish stings cause through-
nausea, stomach upset, abdominal discomfort) out the world. Jellyfish envenomation is common in
• Time frame: All years to February 21, 2021 coastal areas. While most jellyfish stings have local-
ized effects only, stings by some species of jellyfish can
Treatment Recommendations (2021) cause systemic illness or death. In 2023, an updated
We recommend the use of any readily available rehydra- Cochrane SysRev256 on interventions for the treatment
tion drink or water for treating exertion-related dehydra- of jellyfish stings was published, and an ILCOR sys-
tion in the first aid setting (good practice statement). tematic reviewer was a member of the author team.
We suggest rehydration for exertion-related dehy- That Cochrane review included randomized controlled
dration with a 4% to 9% carbohydrate-electrolyte drink. trials only, and because of the very low certainty of the
Alternative rehydration options include 0% to 3.9% evidence, the authors concluded that the effectiveness
carbohydrate-electrolyte drinks, water, coconut water, or of the treatments evaluated was uncertain. The FA
skim or low-fat cow’s milk (weak recommendation, very Task Force undertook this review,257 including random-
low–certainty evidence). ized and nonrandomized research, to identify a broader
There is insufficient evidence to recommend for or range of evidence and help in the formulation of treat-
against rehydration with beer (0%–5% alcohol). ment recommendations. The full CoSTR can be found
online.258
METHODS OF TICK REMOVAL Population, Intervention, Comparator, Outcome,
(FA 7231 SYSREV 2021) Study Design, and Time Frame
This topic was prioritized by the FA Task Force because • Population: Adults and children with a suspected
of a lack of international consensus in guidelines for re- jellyfish sting

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 Djärv et al First Aid: 2025 CoSTR

Table 4. FA7391 Preservation of Traumatic Amputated/Avulsed Body Parts. Systematic Review Characteristics and Findings

Author,
year, Primary Findings for cold
country Population Intervention Comparison outcome preservation Other factors assessed
Shaterian,248 2 studies with 6000 digit “Cold” preservation “Warm” Replant The method of Meta-analysis showed the number
2018, Unit- amputation and replantation or room survival preservation was of venous anastomosis (0 versus
No description was
ed States cases temperature not statistically 1 versus 2), the number of arterial
provided in this
preservation associated with anastomosis (0 versus 1 versus 2),
Note: One of the 2 stud- review of how or
replant survival (OR, and mechanism of injury (sharp ver-
ies was excluded from this when cooling of the
0.94; P >0.05). sus blunt cut versus avulsion versus
scoping review as it did not amputated part oc-
crush) to influence replant survival
provide any description of curred or how long
(P <0.05). No significant association
how prehospital cooling was cooling took place.
between survival and age, sex, zone
accomplished or time interval
of injury, digit number, tobacco use,
between injury, cooling and
ischemia time, method of preserva-
replantation.
tion, and use of vein graft.
Ma,247 22 observational studies with Cold (“ice”) preser- Compression Survival of Meta-analysis of Sex and ischemia time had no signif-
2016,China 2641 patients (aged 1–75 vation bandage replanted survival rates sug- icant influence on the survival rate of
years) with 4678 amputated digit gested that cold amputation replantation (P >0.05).
digits in total; studies con- preservation is as-
Age, injured hand, injury type, zone,
ducted in Brazil, China, Yugo- sociated with better
and the method of preservation
slavia, Korea, United States, replantation survival
the amputated digit significantly
Japan, Singapore, Italy, and rates than emer-
influence the survival rate of digital
India gency compression
replantation (P <0.05).
(OR, 4.89; 95%
CI, 2.14–11.20;
P =0.0002).
Huawei,246 3 studies included in meta- Storage in an ice No storage in Survival Cold storage Amputated digits stored in low
2015,China analysis of preservation tech- bag an ice bag rate of improves the sur- temperature more likely to survive
nique and survival rate, total replanted vival rate; specific than that in common temperature
of 979 patients with 1755 fingers methods used to (OR, 4.89; 95% CI, 2.14–11.20;
amputated digits (no refer- cool the amputated P =0.0002)
ences provided in the review) part in the included
There was no significant association
studies were not
between ischemia time ≤12 hours
detailed.
and ≥12 hours and replantation
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survival rate (no skeletal muscle in

finger).

OR indicates odds ratio.

• Intervention: Any pain-reducing or harm-minimizing all studies was of very low certainty and heterogenous,
technique (or combination of techniques) appropri- therefore no meta-analysis was possible. In the 2023
ate for first aid, such as vinegar, seawater, topical Cochrane SysRev, interventions were characterized into
anesthetics, meat tenderizer, cold packs, urine, wet hot or cold treatments, topical treatments, and parenteral
sand rubs, aloe, other commercial topical products treatments. The overall evidence for all outcomes was
(eg, Sting No More), or pressure bandaging with of very low certainty and data were conflicting on the
immobilization efficacy of heat and cold therapy. The RCT data sug-
• Comparator: Heat or cold treatment in any form gested that heat (eg, hot water) may reduce pain when
appropriate for first aid (hot/cold water, hot rocks, compared with cold after stings from Physalia. However,
hot packs, cold packs) or no treatment heat may not be superior to cold in reducing pain for the
• Outcomes: Pain reduction (yes/no or amount), time jellyfish Carybdea alata and Chironex fleckeri. Further, the
to pain reduction, survival, need for hospitalization, RCT data did not find a significant difference in outcomes
adverse effects/complications (hypothermia, burns, between different topical treatments (ie, application of
worsening of pain, anaphylaxis, Irukandji syndrome) seawater, fresh water, sting aid, Adolph’s meat tenderizer,
• Study designs: In addition to the standard criteria, isopropyl alcohol, heated water, acetic acid, lidocaine, or
unpublished scientific abstracts were eligible for sodium bicarbonate). The Cochrane authors concluded
inclusion. that because of the very low certainty of evidence, the
• Time frame: All years to October 1, 2024 effectiveness of any of the treatments evaluated in the
review was uncertain. The Cochrane SysRev included a
Consensus on Science patient who sustained a first-degree burn following appli-
The 2023 Cochrane SysRev256 included 9 studies259–266 cation of 10% ammonia.256 The Cochrane SysRev did not
that were RCTs and quasi-RCTs. The current task force report any cases of increasing pain or redness of skin af-
SysRev included the Cochrane data and identified 5 ter treatment with vinegar (5% acetic acid). This current
additional nonrandomized studies.267–271 Evidence from task force SysRev identified 5 additional nonrandomized

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 Djärv et al First Aid: 2025 CoSTR

Table 5. Jellyfish Stings (FA 7211). Included Studies for the Critical Outcome Pain Relief and Adverse Effects/Complications

Outcome Study, year Finding

Pain reduction McGee,256 2023 Heat may reduce pain when compared to cold following stings from Physalia (at 1 hour RR 2.66, 95% CI 1.71–
(relief): critical 4.15; at 6 hours RR 2.25, 95% CI 1.42–3.56; at the end of treatment RR 1.63, 95% CI 0.81–3.27). However, heat
may not reduce pain for the Carybdea alata and Chironex fleckeri (at 1 hour RR 1.16, 95% CI 0.71–1.89; at 6 hours
RR 1.66, 95% CI 0.56–4.94; pain at the end of treatment RR 3.54, 95% CI 0.82–15.31). Topical application of
seawater, fresh water, sting aid, Adolph’s meat tenderizer, isopropyl alcohol, heated water, acetic acid, lidocaine, or
sodium bicarbonate resulted in no significant difference in overall improvement between the different treatments.
Lopez,267 2000 Hot water demonstrated a benefit in pain reduction as participants receiving hot water immersion (110 °F) had a
relative risk of 1.600 (95% CI, 0.9354–2.7367) for pain relief compared to those with ice pack therapy.
Knudsen,268 2016 Following treatment, VAS regarding pain for hot water immersion was 0.5 and for topical lidocaine 5% was 1.3 at 30
minutes (P<0.05).
Yoshimoto,269 2002 An odds ratio of 11.5 (95% CI, 1.007–131.28) was found regarding pain relief for heat therapy (hot shower, hot
pack, hot wet compress) application versus parenteral analgesics. An odds ratio of 22.0 (95% CI, 1.40–378.90)
was obtained for pain relief in heat application versus parenteral benzodiazepines.
Birsa,270 2010 Application of lidocaine concentrations of 10% and 15% produced immediate relief; 4% and 5% solutions pro-
duced relief after approximately 1 minute, while 1, 2, and 3% solutions required 10–20 minutes provide noticeable
relief. Benzocaine provided some relief but took 10 or more minutes.
Pyo,271 2016 Sea salt water and 10% lidocaine provided pain relief and less erythema in Nemopilema nomurai stings. Pain and
erythema were increased by treatment with topical application of 4% acetic acid, ethanol (70%) and isopropanol
compared with sea salt water. In Carybdea mora stings, seawater and 10% lidocaine reduced pain and erythema.
Ethanol (70%) and isopropanol increased pain and erythema compared with sea salt water.
Adverse effects/ McGee,256 2023 Ammonia treatment resulted in a first‐degree burn in 1 participant.
complications:
Birsa,270 2010 Areas of redness were observed after treatment with benzocaine. More areas of skin redness were observed after
important
treatment 5% acetic acid, or ethanol (70%) than in control (no treatment).
Pyo,271 2016 Erythema developed with 4% acetic acid, ethanol (70%) and isopropanol following sting by Nemopilema nomurai.
Erythema developed with ethanol (70%) and isopropanol following sting by Carybdea mura tentacles.

RR indicates relative risk; and VAS, visual analog scale.

studies that reported the critical outcome of pain reduc- Justification and Evidence-to-Decision Framework
Highlights
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tion. Details of study findings are provided in Table 5.

In these studies, heat therapy provided benefit The complete evidence-to-decision table is provided in
compared with ice pack therapy. Topical lidocaine also Appendix A.
appeared beneficial compared with parenteral analge- In making these recommendations, the FA Task Force
sics and benzodiazepines.267–269 The use of seawater and considered the following:
topical lidocaine also provided pain relief and reduced Seawater should be available at the setting where
erythema compared with no treatment.270,271 Faster pain envenomation occurs and requires no additional cost.
relief and fewer areas of redness on skin were achieved Seawater should preferentially be used to wash the area
with higher concentrations of topical lidocaine compared to remove remaining tentacles or nematocysts that are
with benzocaine.270 In contrast, pain was increased by stuck to the skin.
treatment with acetic acid, ethanol, or isopropanol com- While hot water appears to demonstrate a bene-
pared with controls using sea salt water.271 fit in the non-RCTs compared with other treatments,
access to hot water may not be feasible in many parts
Treatment Recommendations (2025) of the world. Hot water may also lead to skin burns if
Following a jellyfish sting, we recommend rinsing the the temperature is too hot. In some locations, solar-
area of the sting with seawater (strong recommendation, heated water bags and instant hot packs are available
very low–certainty evidence). at beach lifeguard stations for treatment of jellyfish
For non–life-threatening jellyfish envenomation, stings. Fresh water may activate nematocysts remain-
we suggest the use of heated water (40–45 °C ing on the skin,272 therefore, it is preferred to rinse the
[104–113 °F] (immersion, irrigation or shower) or hot area of the sting with seawater prior to application of
pack application compared with application of a cold hot fresh water.
pack, topical lidocaine, benzocaine, acetic acid, Adolph’s The included studies used a water temperature
meat tenderizer, sting aid, or sodium bicarbonate to range of 40 °C to 45 °C (104–113 °F); 1 study used
relieve pain from a jellyfish sting (weak recommendation, hot packs that were reported to be 43 °C (109 °F),
very low–certainty evidence). and 1 study used a “hot shower” without reporting the
We recommend against the use of topical 10% ammo- water temperature. It may be most practical to use
nia, isopropanol, or ethanol for the treatment of jellyfish water as warm as the person can safely and comfort-
stings (weak recommendation, low-certainty evidence). ably tolerate.

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 Djärv et al First Aid: 2025 CoSTR

In the Cochrane SysRev,256 1 study showed that etha- First Aid for Trauma Emergencies
nol resulted in increased pain following jellyfish stings • Thermal injury dressing (FA 7251, FA 1545,
compared with seawater while 2 other studies reported ScopRev 20201)
less reduction in pain with ethanol and isopropyl alcohol • Open chest wound dressings (FA 7321, FA 525,
compared with seawater. EvUp 202212)
The efficacy of first aid treatment may depend on the • Foreign body in eye (FA 7351, FA 1544, EvUp
species of jellyfish causing the envenomation and the 2015273)
benefit of heat therapy was evaluated in stings due to • Single-stage scoring systems for concussion (FA
Physalia, Cyanea capillata, and Marine cnidaria. However, 7341, FA 799, EvUp 202212)
in many instances, it is not feasible for lay first aid provid-
First Aid for Environmental Emergencies
ers to know the type of jellyfish, resulting in the enven-
• Pressure immobilization following snake bite (FA
oming before beginning treatment.
7221, EvUp 2021161)
Task Force Knowledge Gaps • Heatstroke cooling (FA 7242, FA 1548, SysRev
• Whether the effect of jellyfish sting treatments dif- 2020,274 EvUp 202212)
fers by species of jellyfish
• The effect of different jellyfish sting treatments on
survival or need for hospitalization ARTICLE INFORMATION
The American Heart Association requests that this document be cited as follows:
Djärv T, Douma MJ, Carlson JN, Singletary EM, Berry DC, Bradley RN, Cassan P,

Topics Not Included in the 2025 Review Chang W-T, Charlton NP, Cimpoesu D, Goolsby CA, Lim SH, Pek JH, Klaassen B,
Kule A, Laermans J, Macneil F, Martinez-Mejias A, Meyran D, Okubo M, Orkin AM,
The following topics have not been reviewed by a SysRev Raitt J, Shahaed H, Subic AM, Thilakasiri K, Williamson F; on behalf of the ILCOR
First Aid Task Force Collaborators. First aid: 2025 International Liaison Committee
or ScopRev since 2020. on Resuscitation Consensus on Science With Treatment Recommendations. Circu-
lation. 2025;152(suppl 1):S250–S282. doi: 10.1161/CIR.0000000000001358
General Principles This article has been copublished in Resuscitation. Published by Elsevier Ire-
• Optimal position for shock (FA 7131, FA 520, EvUp land Ltd. All rights reserved.

20201) Acknowledgments
The Writing Group acknowledges Trude Thommesen for her advice as a content
First Aid for Medical Emergencies expert on the topic of postpartum hemorrhage and Jaylen I. Wright for his as-
Downloaded from [Link] by on October 27, 2025

• Supplemental oxygen for stroke (FA 7031, SysRev sistance with editing supplemental materials and providing administrative support
throughout the manuscript preparation process.
20201)
• Bronchodilators for acute asthma exacerbation (FA Collaborators
7121, FA 534, EvUp 202212) The authors thank the following individuals (the First Aid Task Force Collabora-
• Oral dilution with milk or water for poisoning with tors) for their contributions: Vere Borra, Domhnall O’Dochartaigh, Jonathan L. Ep-
stein, Gustavo E. Flores, Grete Heitmann, Teruko Kishibe, Ella MacKenzie, Peter
caustic substance ingestion (FA 7421, FA 537, T. Morley, Gene Yong-Kwang Ong, Tina L. Palmieri, Christopher Picard, Jessica
EvUp 202212) Rogers, Tetsuya Sakamoto, Willem Stassen, Lloyd Visser, Michelle Welsford

Disclosures
Writing Group Disclosures

Writing Other Speakers’

Group Research Research Bureau/ Expert Ownership Consultant/
Member Employment Grant Support Honoraria Witness Interest Advisory Board Other
Therese Karolinska Institutet and None None None None None None None
Djärv Karolinska University
Hospital (Sweden)
Matthew J. Alberta Health Services None None None None None None None
Douma University of Alberta
(Canada)
David C. Saginaw Valley State None None None None None None None
Berry University
Richard N. Texas A&M University None None None None None None None
Bradley School of Medicine
Jestin N. Allegheny Health Net- None None None None None None None
Carlson work
Pascal International Federation None None None None None None None
Cassan of Red Cross and Red
Crescent National Soci-
eties (Switzerland)

(Continued )

Circulation. 2025;152(suppl 1):S250–S282. DOI: 10.1161/CIR.0000000000001358 October 21, 2025 S273

 Djärv et al First Aid: 2025 CoSTR

Writing Group Disclosures Continued

Writing Other Speakers’
Group Research Research Bureau/ Expert Ownership Consultant/
Member Employment Grant Support Honoraria Witness Interest Advisory Board Other
Wei-Tien National Taiwan Universi- None None None None None None None
Chang ty Hospital and College
of Medicine (Taiwan)
Nathan P. University of Virginia None None None None None None None
Charlton
Diana Harbor-UCLA Medical None None None None None None None
Cimpoesu Center
Craig A. Harbor-UCLA Medical None None None None None None None
Goolsby Center
Barry Ninewells Hospital and Emergency None None None None Honorary Consultant in British Red Cross†;
Klaassen Medical School (United Medcine- Emergency Medicine*; DK/Penguin Ran-
Kingdom) Malawi Proj- Chief Medical Adviser dom House pub-
ect†; member British Red Cross†; co- lisher*
ERC First Author First Aid Manual
Aid Writing 11th Edition StJohn/St
Group* Andrew/BRC*; Con-
sultant for Superhero
First Aid Manual*
Amy Kule Loyola University Medi- None None None None None None None
cal Center
Jorien Belgian Red Cross- None None None None None None Belgian Red Cross-
Laermans Flanders (Belgium) Flanders†; ILCOR
First Aid Task
Force*; Cochrane
First Aid*; Co-
chrane Acute and
Emergency Care*
Swee Han Singapore General Hos- None None None None None None None
Lim pital (Singapore)
Downloaded from [Link] by on October 27, 2025

Finlay Australian and New None None None None None None None
Macneil Zealand Committee on
Resuscitation (Australia
and New Zealand)
Abel Hospital Universitari de None None None None None None None
Martinez- Terrassa, CST. (Spain)
Mejias
Daniel French Red Cross None None None None None None None
Meyran (France)
Masashi University of Pittsburgh NIH† None None None None None None
Okubo
Aaron M. University of Toronto None None None None None None None
Orkin (Canada)
Jen Heng Sengkang General Hos- None None None None None None None
Pek pital, Singapore (China)
James Raitt Thames Valley Air Ambu- None None None None None None None
lance (United Kingdom)
Heba Sha- University of Toronto None None None None None None None
haed (Canada)
Eunice M. University of Virginia None None None None None None None
Singletary
Anna University of Toronto None None None None None None None
Maria Subic (Canada)
Kaushila Ministry of Health (Sri None None None None None None None
Thilakasiri Lanka)
Frances Wil- Royal Brisbane and Wom- None None None None None None None
liamson en’s Hospital (Australia)
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

S274 October 21, 2025 Circulation. 2025;152(suppl 1):S250–S282. DOI: 10.1161/CIR.0000000000001358

 Djärv et al First Aid: 2025 CoSTR

Reviewer Disclosures

Other Speakers’
Research Research Bureau/ Expert Ownership Consultant/Advisory
Reviewer Employment Grant Support Honoraria Witness Interest Board Other
Elizabeth Hewett UPMC Children’s Hospital of None None None None None American Red Cross† None
Brumberg Pittsburgh
Division of Pediatric Emergency
Medicine
Matthew J. Levy Johns Hopkins University None None Stryker None None None None
School of Medicine Emergency Medical
Medicine Education†
Jeffrey L. Pellegrino University of Akron None None None None None International Journal of None
First Aid Education*; In-
Emergency Management/
ternational Red Cross/
Homeland Security
Red Crescent*; Ameri-
can Red Cross*
Samuel Robert University of Pittsburgh None None None None None American Red Cross* None
Seitz

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-
tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any
12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of
the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

9. Greif R, J EB, Djarv T, I RD, H GL, Ng KC, Cheng A, M JD, B RS, Smyth
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S282 October 21, 2025 Circulation. 2025;152(suppl 1):S250–S282. DOI: 10.1161/CIR.0000000000001358